Health inspection·August 9, 2023

F 0558 not being within reach would be the resident would not be able to notify staff if they needed care. Level of Harm - Minimal harm or potential for actual harm Record review of the policy Answering call lights, dated July 2023 revealed Purpose: The purpose of this procedure is to ensure timely responses to the residents' request and needs. General Guidelines: 5. Ensure that the call light is accessible to the resident when in bed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 2 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents' right to formulate an advance directive for 1 of 11 residents (Resident #24) reviewed for advanced directives, in that: The facility failed to ensure Resident 24's Out-of-Hospital Do Not Resuscitate (OOH-DNR) was executed correctly. This failure could place residents at-risk for residents' rights not being honored. The findings were: Record review of Resident #24's face sheet, dated [DATE], revealed the resident was re-admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia, and protein-calorie malnutrition. Record review of Resident #24's quarterly MDS assessment, dated [DATE], revealed the resident was not able to complete Cognitive interview and therefore a staff assessment was completed, which indicated severe cognitive impairment. Record review of Resident #24's physicians orders, dated [DATE], revealed an order entered on [DATE] that read: ADC: Do Not Resuscitate - DNR. Record review of Resident #24's care plan, last reviewed [DATE], revealed [Resident #24]/legal guardian chooses to have death with dignity, advanced directive established. Individual wishes include: No CPR, DNR Code Status . Record review of Resident #24's OOH-DNR, signed [DATE], revealed [name of] Notary signed under the section Notary in the State of Texas with a valid notary stamp. Further record review revealed [name of] notary was not signed under Notary's Signature located in the bottom section titled All persons who have signed above must sign below, acknowledging that this document has been properly completed. During an interview and record review on [DATE] at 6:26 p.m., the SW stated the form was not signed by the notary in the bottom section. The SW was not able to recall why it was not signed at the bottom. The SW stated she ensured the DNR was signed completely and then nurse administration was whom entered the DNR order in the resident's EHR. The SW stated the potential harm to Resident #24 was staff would do CPR instead of following the resident's wishes. During an interview on [DATE] at 6:45 p.m., ADMN AA stated Resident #24's DNR was not valid if it was not signed at the bottom. He stated the SW was ultimately responsible for the DNR forms but that it was an IDT effort in the end. ADMN AA stated the potential harm was the facility not following Resident #24's wishes. During an interview on [DATE] at 7:01 p.m., the DON stated the SW was responsible for DNR's being completed correctly. She stated all resident's code status were reviewed during the quarterly care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 3 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0578 Level of Harm - Minimal harm or potential for actual harm plan meetings. The DON believed there was no potential harm to this resident because the DNR order was in Resident #24's EHR. Record review of facility policy titled Do Not Resuscitate Order, revised 03/2021, revealed nothing about the actual signed DNR form. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 4 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 must inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of, Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services for 4 of 5 (Residents #42, #3, #59, #38) residents reviewed for NOMC (Notice of Medicare Non-Coverage) services in that: Residents Affected - Some 1 Resident #42 was discharged from therapy services on 04/7/2023 and did not receive/documentation of the cost if he would resume therapy. 2. Resident #3 was discharged from therapy services on 07/14/2023, and did not receive/documentation of the cost if she would resume therapy 3. Resident #59 was discharged from therapy services on 07/18/2023 and did not receive/documentation of the cost if he would resume therapy 4. Resident #38 was discharged from therapy services on 05/24/2023, and did not receive/documentation of the cost if he would resume therapy This failure could result in residents not receiving therapy services. The Findings were: 1. Record review of Resident #42 admission record dated 8/4/2023 revealed he was admitted to the facility on [DATE], readmitted on [DATE], discharged on 8/2/2023 and had Medicare health insurance. Resident #42 was diagnosed with diabetes II, dysphagia (Unspecified. It is a disorder characterized by difficulty in swallowing), dementia, anxiety, cognitive communication deficit, lack of coordination, muscle weakness, and anorexia(eating disorder). Review of Resident 42's Quarterly MDS dated [DATE] revealed his BIMs score was 5/15 (severely impaired). Record review of Resident #42's NOMNC revealed the effective dated coverage of the current SNF services would end: 4/7/2023. The form was signed by Resident #42 and dated on 4/4/2023. Resident #42's ABN revealed D. skilled nursing, E. Reason Medicare may not pay: no skill need, F. Estimated cost: was blank. The form was signed by Resident #42 and dated 4/4/2023. 2. Record review of Resident #38's admission record dated 8/4/2023 revealed she was admitted to the facility on [DATE], discharged home on 7/15/2023 and had Medicare health insurance. Resident #38 was diagnosed with diabetes II, muscle weakness, dysphagia, heart failure, anemia, cognitive communications deficit, and anxiety. Review of Resident 38's Quarterly MDS dated 6/20/2023 revealed her BIMs score was 7/15 (severely impaired). Record review of Resident #38's NOMNC revealed effective date coverage exhausted for SNF services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 5 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would end: 7/14/2023. The form was signed by Resident #38 and dated on 7/12/2023. Resident #38's ABN revealed D. skilled services, E. Reason Medicare may not pay: exhausted days, F. Estimated cost-was blank. The form was signed by Resident #38 and dated 7/12/2023. 3. Record review of Resident #59's admission record dated 8/4/2023 revealed he was admitted to the facility on [DATE], discharged on 7/19/2023 and had Medicare health insurance. Resident #59 was diagnosed with muscle weakness, age related physical debility, dysphagia and lack of coordination. Review of Resident 59''s admission MDS dated [DATE] revealed his BIMs score was 10/15 (moderately impaired). Record review of Resident #59's NOMC effective date coverage exhausted of your current SNF services will end: 7/18/2023, this form was signed by Resident #59 and dated on 7/14/2023. Resident #59's Advanced Beneficiary Notice of Non-Coverage (ABN) D. skilled services, E. Reason Medicare may not pay: exhausted days, F. Estimated cost-was blank, this form was signed by Resident #59 and dated 7/14/2023. 4. Record review of Resident #3's admission record dated 8/4/2023 revealed he was admitted to the facility on [DATE] and had Medicare health insurance. Resident #3 was his own responsible party and was diagnosed with muscle wasting and atrophy, respiratory failure, dysphagia, dementia, cognitive communications deficit, anxiety disorder, major depressive disorder, and repeated falls. Review of Resident 3's Annual MDS dated [DATE] revealed his BIMs score was 13/15 (cognitively intact). Record review of Resident #3's NOMC effective dated coverage exhausted of your current SNF services will end: 5/24/2023, this form was signed by Resident #3 and dated on 5/19/2023. Resident #3's Advanced Beneficiary Notice of Non-Coverage (ABN) D. skilled services, E. Reason Medicare may not pay: no skill need, F. Estimated cost-was blank, this form was signed by Resident #3 and dated 5/19/2023. Interview on 8/2/2023 at 4:14 PM revealed Resident #3 was confused and did not understand the surveyor. Interview on 8/3/2023 at 3:49 PM the BOM stated she started working as BOM on 7/5/2023. She stated she completed the NOMC for Resident #59 and was not aware that a cost should be documented and discussed with the resident. The BOM before her did the rest of the residents' NOMC/ABN letters with no cost, so, she followed that and she stated she was not trained before this week when Regional Account received resource was training her this week. Interview on 8/2/2023 at 1:02 PM ADMN AA stated he was made aware of residents not receiving the cost for services by the BOM. Administrator AA stated the risk would be residents would not receive services. Record review of the policy Medicare Advance Beneficiary and Medicare Non-Coverage Notices (ABN/NOMC) dated 9/2022 revealed 2c. termination- in the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that is physician had ordered and the beneficiary would lie to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated. 3. The resident (or representative) is informed that they may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 6 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0582 choose to continue receiving the skilled serviced that may not be paid for by Medicare and assume financial responsibility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 7 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to support resident rights to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 29 residents (Resident #1) and 5 of 8 months (January, February, March, April, May, June, July, August) reviewed for grievances, in that; 1. RN R did not initiate a grievance report on behalf of Resident #1 when Resident #1 reported mistreatment by CNA V. 2. The facility did not document and resolve grievances for residents for the months of April, May, June, July, August 2023. This failure could place residents at risk by denying their right to make and have grievances heard and contributed to feelings of not being heard and have unresolved issues. The findings included: 1. A record review of Resident #1's admission record dated 08/05/2023, revealed an admission date of 04/23/2023 with diagnoses which included muscle wasting and atrophy, asthma [a chronic (long-term) condition that affects the airways in the lungs], and edema [swelling caused by too much fluid trapped in the body's tissues]. A record review of Resident #1's quarterly MDS dated [DATE], revealed Resident #1 was a [AGE] year-old female admitted for rehabilitation with the first day of Medicare covered stay as 04/24/2023. Further review revealed Resident #1 was assessed as a BIMS of 15 out of 15 indicating no mental cognition impairment. A record review of Resident #1's care plan dated 08/05/2023, revealed, wishes to return home upon completion of therapy goals . Evaluate and discuss with resident the prognosis for independent or assisted living. Identify, discuss, and address limitations, risks, benefits, and needs for maximum . Make arrangements with required community resources to support independence. During an interview on 08/01/23 at 11:10 AM Resident # 1 stated on 07/31/2022 [Monday] in the mid-morning she had asked CNA V for her linens to be changed due to her linens were not changed in a week and were soiled. Resident #1 stated she spent the day in her wheelchair and after she was provided a shower and then CNA V returned her [Resident #1] to bed, but that evening, Resident #1 recognized her linens were still soiled and only the bed cover had been changed. Resident #1 stated she complained to RN R that CNA V did not change her linens and was rough and rude to her during care. Resident #1 stated CNA V came in her room turned off the call light and never returned. Resident #1 stated she re-ignited the call light and CNA V returned and stated it was not Resident #1's turn for care and would return later on, Resident #1 stated she complained to RN R. During an interview on 08/01/23 at 03:10 PM RN R stated she usually worked the 02:00 PM to 10:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 8 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some PM. RN R stated Resident #1 had made a complaint to her last night 07/31/2023, concerning CNA V. RN R stated Resident #1 did not want CNA V to care for her. RN R stated she made a mental note to not have CNA V care for her that evening. RN R stated she had not reported the complaint to anyone and had not documented the complaint. 2. During a record review of the facility's grievances report binder revealed scant grievance reports for the months of January thru March 2023 and no grievances reported for the months of April, May, June, July, and August 2023. During (an interview) while in the resident group meeting, where 10 residents were in attendance, on 08/02/2023 at 10:00 a.m., A resident stated he did not know how or where to file a grievance and a few other resident's shook their heads yes, which agreed with him. A resident stated she was told by an unknown staff member that they would return with a written up grievance, but that unknown staff member never returned with said grievance form. Some of the residents, who attended, stated they were not aware of the actual grievance form. During an interview on 08/02/2023 at 10:45 AM the DON and ADMN AA stated there were no grievances for the months of April, May, June, July, and August 2023. ADMN AA stated he was the Administrator since 07/17/2023 and the previous ADMN (ADMN Z) was the ADMN from January 2023 to 07/14/2023. ADMN AA, further stated, he had no comment regarding ADMN Z's grievance reported work. The DON stated ADMN Z was responsible for overseeing grievances. The DON stated there were no grievances reported for Resident #1. A record review of Resident #1's nursing progress notes revealed the DON documented on 08/02/2023, it was brought to my attention that [Resident #1] had a concern, upon speaking with [Resident #1], she reported that she had a concern with [CNA V]. [Resident #1] stated that on Monday, 07/31/2023, [Resident #1] told [CNA V] that she [Resident #1] wanted a shower and would like her linens changed. She [Resident #1] said that upon returning to her room from showering her linen was not changed. She [Resident #1] stated that the top comforter was changed but the fitted sheet and pillowcase were not changed. She [Resident #1] said she knew the linen was not changed because she had a scratch on her arm that was bleeding and the sheet still had blood on it. I [DON] asked her [Resident #1] if she believed [CNA V] had malicious intent towards her [Resident #1]? She [Resident #1] said no. I [DON] asked if she [Resident #1] felt there was any tension between herself and [CNA V]? she [Resident #1]reports that there is not, but she [Resident #1] is disappointed that her linen[s] was not fully changed and prefers that [CNA V] not provide her care for her going forward. A record review of the facility's Grievance /Complaints, Filing policy dated April 2017, revealed, policy statement; residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. Policy interpretation and implementation [ .] any Resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members theft of property, are any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished., all grievances complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance and or complaint the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and or complaint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 9 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 3 of 5 (NA AC, LVN I, Housekeeper AD) new staff hired within the last 4 months review, in that: Residents Affected - Some 1. NA AC did not have her EMR/NAR checked before the hire date. 2. LVN I did not have her EMR/NAR checked before the hire date. 3. Housekeeper AD did not have her EMR/NAR checked before the hire date. This could place residents safety at risk of abuse, neglect, exploitation or misappropriation due to staff not being fully screened to determine employment eligibility. The Findings were: Record review of the policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated Aril 2021 revealed Policy Statement: Resident s have the right to be free from abuse, neglect and misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident symptoms.4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who had been found guilty, had been filed/ entered into the state nurse aide registry and a disciplinary action in effect against his or her professional license by a state licensure body as a result of finding of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Record review of the staffing list dated on 8/1/2023 with names, position, and date of hires included and review of personal files: 1. NA AC was hired on 5/12/2023. She did not have the EMR/NAR checked before the hire date. 2. LVN I was hired on 6/29/2023. He did not have the EMR/NAR checked before the hire date. 3. Housekeeper AD was hired on 3/6/2023. She did not have the EMR/NAR checked before the hire date. Record review of NA AC, LVN I and Housekeeper AD background checks dated 8/4/2023 were eligible to be hired. Interview on 8/4/2023 at 7 PM with HR confirmed NA AC, LVN I, and Housekeeper AD had to be re-checked after survey entrance due to not being able to find their original EMR/NAR checks. HR stated she was responsible for ensuring the staff had their background checks before they started working on the floor. Interview on 8/5/2023 at 1:26 PM with the ADMN AA stated he was not aware that staff were missing their background checks. ADMN AA stated the Administrator and corporate should be monitoring HR to ensure the job task and the risk would be hiring staff that were unemployable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 10 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 1 facility's reviewed for abuse, neglect, exploitation, and/or mistreatment allegations, for 1 of 8 residents (Resident #1) reviewed for reporting mistreatment, in that: 1. The facility experienced a faulty heating ventilation air conditioning [HVAC] system for the A-hall on June 26, 2023, and did not report the allegation of neglect for physical environment to the state agency. 2. RN R did not report on behalf of Resident #1 an allegation of mistreatment by CNA V. This failure could place residents at risk for harm by abuse and mistreatment, heat stress and the lack of a comfortable homelike environment during a heat crisis of 100 degrees F+ for weeks. The findings included: 1. A record review of the facility's HVAC contractors email dated 08/01/2023, revealed, original ticket for A-hall June 26, 2023 made temporary repairs for txv [an essential valve for the air conditioner] to come in from factory. Spoke with the vendor today we will have it installed next week. During an observation on 08/01/2023 at 09:00 AM revealed the facility presented with the A-hall doors closed off due to a faulty air conditioner HVAC system. A record review of the facility's Texas Unified Licensure Portal [TULIP] website account page, accessed 08/01/2023, did not reveal any reports of neglect / physical environment for the failed HVAC system. During an interview on 08/01/2023 at 10:00 AM the DON stated the facility census was 63 and no one resided in the A-hall due to the heat and the air conditioner was not functioning. A record review of the Past Weather in City of [Name of City], Texas, USA - June 2023 website accessed 08/14/2023, https://www.timeanddate.com/weather/@7174100/historic?month=6&year=2023 , revealed the temperature on 06/26/2023 was 103?F. further reviews revealed multiple days in July and August 2023 were 103 degrees F-105 degrees F. During an interview on 08/02/2023 at 09:04 AM the Maintenance Director stated the HVAC for the A-hall had been inoperative since the end of June, beginning of July 2023. The Maintenance Director stated the A-hall had no residents due to a reduced census and the A-hall was consolidated and residents were moved to the rest of the facility. The Maintenance Director stated the Administrator at the time was not the current Administrator but was the previous Administrator. The Maintenance Director stated the previous Administrator was informed of the A-hall HVAC system failure and was involved in receiving the estimate for the repairs and was fully aware of the HVAC failure. The Maintenance Director stated the repairs were delayed due to parts were on backorder. The Maintenance Director stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 11 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0609 he had no knowledge if the failure was reported to the state agency. Level of Harm - Minimal harm or potential for actual harm During an interview on 08/02/2023 at 10:45 AM the current Administrator stated he has been the Administrator since July 2023 after the previous Administrator left sometime mid-July 2023. The Administrator stated he had not reported the A-hall HVAC failure to the state agency and was not aware if the previous Administrator had reported the HVAC failure to the state agency. The Administrator stated he would generate a facility related incident report with the TULIP website. Residents Affected - Some A record review of the facility's Unusual Occurrence Reporting policy dated December 2007, revealed, policy statement: as required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, our welfare of our residents, employees, or visitors. policy interpretation and implementation; our facility will report the following events to appropriate agencies: . other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and or regulations within 24 hours of such incident or as otherwise required by federal and state regulations. a written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency and other appropriate agencies as required by law within 48 hours of reporting the event or as required by federal and state regulations. the administration will keep a copy of written reports on file. 2. A record review of Resident #1's admission record dated 08/05/2023, revealed an admission date of 04/23/2023 with diagnoses which included muscle wasting and atrophy, asthma [a chronic (long-term) condition that affects the airways in the lungs], and edema [swelling caused by too much fluid trapped in the body's tissues]. A record review of Resident #1's quarterly MDS dated [DATE], revealed Resident #1 was a [AGE] year-old female admitted for rehabilitation with the first day of Medicare covered stay as 04/24/2023. Further review revealed Resident #1 was assessed as a BIMS of 15 out of 15 indicating no mental cognition impairment. A record review of Resident #1's care plan dated 08/05/2023, revealed, wishes to return home upon completion of therapy goals . Evaluate and discuss with resident the prognosis for independent or assisted living. Identify, discuss, and address limitations, risks, benefits, and needs for maximum . Make arrangements with required community resources to support independence. During an interview on 08/01/23 at 11:10 AM Resident # 1 stated on 07/31/2022 [Monday] in the mid-morning she had asked CNA V for her linens to be changed due to her linens were not changed in a week and were soiled. Resident #1 stated she spent the day in her wheelchair and after she was provided a shower and then CNA V returned her [Resident #1] to bed, but that evening, Resident #1 recognized her linens were still soiled and only the bed cover had been changed. Resident #1 stated she complained to RN R that CNA V did not change her linens and was rough and rude to her during care. Resident #1 stated CNA V came in her room turned off the call light and never returned. Resident #1 stated she re-ignited the call light and CNA V returned and stated it was not Resident #1's turn for care and would return later on, Resident #1 stated she complained to RN R. During an interview on 08/01/23 at 03:10 PM RN R stated she usually worked the 02:00 PM to 10:00 PM. RN R stated Resident #1 had made a complaint to her last night 07/31/2023, concerning CNA V. RN R stated Resident #1 did not want CNA V to care for her. RN R stated she made a mental note to not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 12 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some have CNA V care for her that evening. RN R stated she had not reported the complaint to anyone and had not documented the complaint. During a record review of the facility's grievances report binder revealed scant grievance reports for the months of January thru March 2023 and no grievance reports for the months of April, May, June, July, and August 2023. During an interview on 08/02/2023 at 10:45 AM the DON and ADMN AA stated no one had reported an allegation of mistreatment for Resident #1. The DON stated there were no grievances reported for Resident #1. ADMN AA received a report from the surveyor Resident #1 made an allegation of mistreatment and/or neglect to RN R and the surveyor. ADMN AA stated he would initiate an investigation and report the allegation to the state survey agency. A record review of Resident #1's nursing progress notes revealed the DON documented on 08/02/2023 at 1:30 PM, it was brought to my attention that [Resident #1] had a concern, upon speaking with [Resident #1], she reported that she had a concern with [CNA V]. [Resident #1] stated that on Monday, 07/31/2023, [Resident #1] told [CNA V] that she [Resident #1] wanted a shower and would like her linens changed. She [Resident #1] said that upon returning to her room from showering her linen was not changed. She [Resident #1] stated that the top comforter was changed but the fitted sheet and pillowcase were not changed. She [Resident #1] said she knew the linen was not changed because she had a scratch on her arm that was bleeding and the sheet still had blood on it. I [DON] asked her [Resident #1] if she believed [CNA V] had malicious intent towards her [Resident #1]? She [Resident #1] said no. I [DON] asked if she [Resident #1] felt there was any tension between herself and [CNA V]? she [Resident #1]reports that there is not, but she [Resident #1] is disappointed that her linen[s] was not fully changed and prefers that [CNA V] not provide her care for her going forward. A record review of the facility's Abuse Investigating and Reporting undated policy revealed, policy statement: all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source shall be properly reported to local, state, and federal agency and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. policy interpretation and implementation: roll of the Administrator: If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the instigation to an appropriate individual [ .] reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries from an unknown source and misappropriation of property will be reported by the facility administrator or his or her designee to the following persons or agencies [ .] the state licensing certification agency responsible for surveying licensing the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 13 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 33 (Resident #46, #10, and #1) residents reviewed, in that: 1. Resident #46's care plan did not address that they were was PASRR positive. 2. The facility failed to ensure Resident #10's care plan was updated to pureed diet. 3. The facility failed to revise a comprehensive care plan for Resident #1's needs for durable medical equipment. These deficient practices could place residents at risk of receiving the incorrect care and cause health complications with subsequent illness. The findings were: 1. Record review of Resident #46's admission record dated 8/4/2023 revealed his diagnoses of moderate intellectual disabilities, unspecified intellectual disabilities, pervasive developmental disorder, fragile x chromosome (an inherited condition characterized by an X chromosome that is abnormally susceptible to damage, especially by folic acid deficiency. Affected individuals tend to have limited intellectual functions), and cognitive communications deficit. Record review of Resident #46's PASRR Level 1 dated 4/21/23 revealed he was positive for ID and DD. Record review of Resident #46's PASRR Evaluation dated 4/28/23 revealed he was positive for ID, DD. Resident #46 reveled the recommendation was service coordination. Record review of Resident #46's PSCP dated 5/10/23 revealed he refused services and the resident was only interested in HC (service coordination) services. Record review of Resident #46's admission MDS dated [DATE] revealed sections A Identification A. 1500 PASRR, A1510 Level II PASRR conditions B. intellectual disability marked yes, C. Level II PASSR conditions: other related conditions-yes. Record review of Resident #46's Quarterly MDS dated [DATE] revealed Cognition Pattern BIMS summary 12/15 (moderately impaired). Record review of Resident #46's care plan dated 4/21/2023 revealed Resident #46 had impaired cognition functions/dementia or impaired thought process related to impaired decision-making, short-term memory loss, and dx of intellectual disability. The care plan did not address Resident #46's PASRR status. Interview on 8/3/2023 at 3:18 PM MDS H stated she was not able to see PASRR positive care plan for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 14 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #46. MDS H stated she was not sure why PASRR services was not on the care plan for Resident #46. MDS H stated she was responsible for PASRR care plans and stated PASSAR should be in Resident #46's care plan Interview on 8/5/2023 at 12:31 PM MDS H stated Resident #46 did receive visits from the PASRR service agent twice a month. Interview on 8/5/2023 at 10:30 AM with ADMN AA stated he was informed that Resident #46 did not have a care plan for being a PASRR positive and the risk would be the resident not receiving a person-centered care plan. Record review of the policy Care Plans, Comprehensive Person-Centered dated 2002 revealed 3. The care plan interventions are derived form a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: 2, any specialized serviced to be provided as a result of PASRR recommendations 2. Record review of Resident #10's face sheet, dated 08/03/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: dementia, diabetes, protein-calorie malnutrition, bipolar disorder, major depressive disorder and anxiety disorder. Record review of Resident #10's annual MDS assessment, dated 06/23/2023, revealed the resident had a BIMS score of 03, which indicated severe cognitive impairment . Record review of Resident #10's physician's orders, dated 08/03/2023, revealed an order entered on 07/21/2023, that reflected Consistent Carbohydrate (CCD) diet Dysphagia (difficulty swallowing) Level 1 Puree texture, THIN (Regular) 1 consistency [ .] Record review of Resident #10's, undated, tray card, revealed Diet Txtr: Dysphagia Pureed (Level 1). Record review of Resident #10's care plan, last reviewed 06/11/2023, revealed a Focus initiated 01/23/2023 and revised on 01/02/2023, which reflected CCD mech soft, scoop plate with meals. During an interview and record review on 08/04/2023 at 6:39 p.m., the MDS Coordinator stated Residents #10's care plan was not updated for his pureed diet. She further stated she was unaware of why his care plan was not updated. The MDS Coordinator stated it was an IDT effort to ensure care plans were updated. She stated the potential harm to resident was a choking hazard. During an interview on 08/04/2023 at 6:39 p.m., ADMN AA stated the IDT was ultimately responsible for updating the residents' care plans. He further stated care plans were updated during morning meetings when the IDT went over the 24-hour reports. ADMN AA stated the potential harm was Resident #10 not receiving the correct diet. During an interview on 08/04/2023 at 6:54 p.m., the DON stated care plans were supposed to be updated when the orders were changed. She stated it was the IDT's responsibility to ensure care plans were updated correctly. The DON further stated the IDT went over any changes during their morning meetings and made changes if needed. She stated she was unaware of a potential harm to the resident because the orders were changed correctly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 15 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. A record review of Resident #1's admission record dated 08/05/2023, revealed an admission date of 04/23/2023 with diagnoses which included muscle wasting and atrophy, asthma [a chronic (long-term) condition that affects the airways in the lungs], and edema [swelling caused by too much fluid trapped in the body's tissues]. A record review of Resident #1's quarterly MDS dated [DATE], revealed Resident #1 was a [AGE] year-old female admitted for rehabilitation with the first day of Medicare covered stay as 04/24/2023. Further review revealed Resident #1 was assessed as a BIMS of 15 out of 15 indicating no mental cognition impairment. A record review of Resident #1's physician's orders, dated 06/15/2023, revealed Resident #1 was prescribed an air pump set of leg wraps, Apply lymphedema [swollen soft tissue] pump on BLE [bilateral lower extremities] every evening minimum of 40 minutes in the evening. A further review revealed the physician also ordered a set of leg wraps designed to help reduce Resident #1's swollen lower legs, Farrow [garments that are compression devices and are designed to help reduce limb swelling] wraps on in morning off at night every morning and at bedtime. A record review of Resident #1's medical records revealed a doctor's progress note, June 14th, 2023, 01:00 PM [Resident #1] needs to have her left lower extremity elevated at all times she needs to have her wraps all day especially in the morning, please place lymphedema pump in lower extremity every evening for at least 40 minutes A record review of Resident #1's care plan dated 08/05/2023, revealed it did not address Resident #1's needs to reduce her lower leg swelling. During an interview on 08/01/23 at 11:10 AM Resident #1 stated her lower legs were often swollen and painful. Resident #1 stated she was prescribed a set of leg wraps that were inflated by an air pump. Resident #1 stated she wore the leg wraps at night while she slept. Resident #1 stated the CNAs would assist her to remove the wraps in the morning and after her morning hygiene care the CNAs would help her put on the day-time leg wraps. Resident #1 stated the physician also prescribed her a set of leg wraps that helped her keep her legs from swelling too much. During an interview on 08/01/2023 at 11:20 AM RN N stated she was the day RN and was responsible for Resident #1's care. RN N stated she was not aware of Resident #1's care plan but did know about her need for leg wraps to aide Resident #1's lower leg swelling. During an interview on 08/03/2023 at 02:30 PM LVN H stated she was the MDS nurse and assisted the SW to compile and coordinate care plans. LVN H stated she was aware of Resident #1's needs for lower leg wraps. The surveyor reported to LVN H Resident #1's care plan was lacking any directions/plan to guide direct care staff on how to apply, remove, and general directions for care regarding Resident #1's needs for leg wraps. LVN H reviewed the care plan and agreed there were no care plans for Resident #1's needs for leg wraps. LVN H stated she overlooked Resident #1's needs for the leg wraps. During a joint interview on 08/04/2023 at 09:10 AM with the DON and the ADMN AA the DON stated Resident #1 did have a need and did receive leg wraps to support her needs for swollen lower legs. The DON stated she was not aware Resident #1 did not have a care plan which spoke to Resident #1's need for lower leg wraps and Resident #1's care plan should match the care provided. A record review of the facilities Care Plans, Comprehensive Person-Centered policy dated March (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 16 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 2022, revealed, policy statement a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs is developed and implemented for each Resident. policy interpretation and implementation: the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each Resident . the comprehensive, person-centered care plan .describes the services that are to be furnished to attain or maintain the residents highest practical physical mental and psychosocial well-being Further review revealed under 11 Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Event ID: Facility ID: 675428 If continuation sheet Page 17 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to provide basic life support, including CPR to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #61) of 29 residents reviewed for CPR, in that; Resident #61 was discovered unresponsive, assessed as full code, and provided CPR for 9 minutes without the use of an available an AED prior to 911 EMS's arrival at the resident's side. An IJ was identified on [DATE]. The IJ template was provided on [DATE] at 11:05 am. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because the facility is still monitoring their effectiveness of their plan of removal. This failure placed residents at risk for harm up to and including death by the denial of all life saving measures as trained. The findings included: A record review of Resident #1's admission record dated, [DATE], revealed an admission date of [DATE] and a death discharge date of [DATE], with diagnoses which included altered mental status, extended spectrum beta lactamase resistance [a bacteria that can't be killed by many of the antibiotics that doctors use to treat infections, like penicillin's and some cephalosporins for urinary tract infections], and urinary tract infection. A record review of Resident #1's admission MDS dated [DATE] revealed Resident #61 was an [AGE] year-old male admitted from an acute care hospital for support and rehabilitation related to a urinary tract infection. A record review of Resident #61's physician's order dated [DATE] revealed RN R documented a physician's order for Resident #61 to receive care as Full Code. A record review of Resident #61's care plan dated [DATE], revealed, [Resident #61] has an advance Directive as evidenced by: Full code status Date Initiated: [DATE] [ .] wishes will be honored, Date Initiated: [DATE] [ .] CPR will be performed as ordered. A record review of Resident #61's SBAR document dated [DATE] revealed, Situation [ .] the change in condition, symptoms, or signs observed, and evaluated is/are: cardiac arrest, respiratory arrest. This started on: [DATE]. Since this started it has gotten: stayed the same [ .] Resident/Patient Evaluation [ .] mental status evaluation: unresponsiveness [ .] Code Status: Full Code [ .] Appearance, summarize your observations and evaluation: CNA notified this nurse of resident being unresponsive assessed resident not responsive no pulse RN supervisor notified initiated CPR crash cart access notified 911 CPR performed until paramedics arrived emergency medical technicians continued with CPR resident transfers out with Pulse unconscious accompanied by three emergency medical technicians [ .]. A record review of the EMS TripTix EMS Patient Care Record dated [DATE] revealed, CPR was performed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 18 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few by the facility staff for 9 minutes from 09:38 AM to 09:47 AM as evidenced by, Incident Date / Times [ .] unit notified by dispatch [DATE] 09:41 [AM] [ .] Unit En Route [DATE] 09:43 [AM] [ .] Unit Arrived on Scene [DATE] 09:45 [AM] [ .] Arrived at patient [DATE] 09:47 [AM] [ .] Unit left scene [DATE] 10:04 [AM] [ .] complaints and impressions; cardiac arrest, onset date and time [DATE] 09:38 [AM], [ .] AED used prior to EMS NO [ .] Further review revealed a summary which reflected the facility had performed CPR chest compressions and oxygenated rescue breathing but had not used the AED. The EMTs provided medications and applied the EMS AED and revealed Resident #61 had regained an irregular heartbeat after EMS care and medications administered intraosseous [directly into the bone marrow]. During an interview and observation on [DATE] at 02:28 PM the DON stated sometime in [DATE] Resident #61 was discovered unresponsive and was provided emergency CPR care. The DON stated she was not certain if the AED used. The DON proceeded to demonstrate the AED to the surveyor. The AED was stored on the facility's emergency crash cart along with CPR equipment such as an oxygen tank, and oxygen delivery equipment and included a suction pump with accessories. The DON demonstrated the AED as functional and stated the AED had not been used and could not recall the last time it had been used. The DON stated she believed LVN A, LVN B, and RN C were directly involved with Resident #1's CPR care. During an interview on [DATE] at 07:10 PM the DON provided updated information and stated she recalled the [DATE] CPR event for Resident #61 and stated the AED was not utilized, and EMS services arrived at the facility after the 911 call, approximately 4-5 minutes. The DON stated she did not know why the AED was not utilized and further stated EMS arrived quickly. The DON was asked to provide any further documentation to the event and did not provide further documentation. The DON stated LVN A, LVN B , and RN C were involved in the CPR event for Resident #61. During an interview on [DATE] at 07:40 PM LVN A stated on [DATE] around 09:30 AM to 10:00 AM CNAs AB and AC reported to her Resident #61 was unresponsive. LVN A stated she told the CNAs to get RN C and immediately arrived at Resident #61's bed side. LVN A stated she assessed Resident #61 as a full code and without a pulse and not breathing. LVN A stated she began emergency CPR with chest compressions and RN C arrived at the bedside quickly. LVN A stated RN C assumed chest compressions and told her to get the crash cart and call 911. LVN A stated she ran to retrieve the crash cart and along the way told LVN B to call 911. LVN A stated she returned to Resident #61 with the crash cart and resumed chest compressions while RN C administered oxygen with rescue breaths. LVN A stated 911 EMTs were at the bedside quickly around 4-7 minutes maybe. LVN A stated EMS took over and Resident #61 was assessed with a pulse and left for the hospital with EMS. LVN A stated she was trained for CPR by the American Heart Association . LVN A stated the AED was stored on the crash cart and was immediately available upon arrival at Resident #61's bedside. LVN A stated the AED was never opened, removed from the case, or from the crash cart. LVN A stated she was so involved in providing CPR chest compressions and rescue breaths she did not think about the AED. LVN A stated her training included the use of an AED during CPR as soon as the AED was available. During an interview on [DATE] at 06:00 AM RN C stated on [DATE] she worked from 06:00 AM to 02:00 PM. RN C stated she was providing patient care when CNAs AB and AC told her LVN A needed her, and Resident #61 was unresponsive. RN C stated she ran to Resident #61's bedside and assessed Resident #61 as unresponsive and told LVN A to get the crash cart and call 911. RN C stated she began CPR chest compressions. RN C stated LVN A returned with the crash-cart, and they switched CPR roles and LVN A continued chest compressions while RN C administered oxygenated rescue breaths. RN C stated 911 EMS arrived quickly and continued CPR. RN C stated the facility's AED was stored on the facility's crash-cart and was immediately available when the crash-cart arrived but she nor LVN A gave it a thought (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 19 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few due to the high stress of providing CPR. RN C stated she and LVN A provided CPR for maybe 5 minutes and 911 arrived quickly. RN C stated she was CPR trained by the American Heart Association . RN C stated her training included the use of an AED during CPR as soon as the AED is available. A record review of the facility's Emergency Procedure Cardiopulmonary Resuscitation policy dated February 2018, revealed, Policy Statement; personnel have completed training on the initiation of cardiopulmonary resuscitation and basic life support including Defibrillation for victims of sudden cardiac arrest; general guidelines; the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival [ .] emergency procedure; cardiopulmonary resuscitation; [ .] when the AED arrives assess for need and follow AED protocol as indicated [ .]. A record review of the facility's Automatic External Defibrillator, Use and Care of, dated [DATE], revealed, Policy Interpretation and Implementation: The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected .remove the device from its case .check the battery cartridge to ensure it is in place .remove the film seals from the pads .turn on the device and follow the prompts . A record review of the American Heart Association's website Part 3: Adult Basic and Advanced Life Support; 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support, accessed [DATE], revealed, Top 10 take home messages for adult cardiovascular life support: [ .] On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest [ .] Defibrillation is most successful when administered as soon as possible [ .]. A record review of the facility's in-service train the trainer, revealed, In-service Description: Rapid Response Policy, date: [DATE], Instructor Corp RN, in-service time: 1 hour.; the Administrator; the DON received CPR / AED training. Further review of the attached printed training revealed, [ .] the chances of surviving a sudden cardiac arrest maybe increased if CPR is initiated immediately upon collapse [ .] Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival [ .] Provide periodic mock codes for training purposes [ .] instruct a staff member to retrieve the automatic external defibrillators [ .] when the AED arrives, assess for need and followed protocols as indicated [ .] continue with CPR/BLS until emergency medical personnel arrive [ .] This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 11:05 AM. ADMN AA was notified. ADMN AA was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 10:27 AM. Plan of Removal Date [DATE] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 20 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0678 To Whom it May Concern, Level of Harm - Immediate jeopardy to resident health or safety Summary of details which leads to outcomes. Residents Affected - Few On [DATE] an annual survey was initiated at [Facility name and address]. On [DATE], a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows:

F678 Quality of Life CPR The facility failed to provide Quality of life CPR care for Resident #61 in that it did not follow and provide basic life support, including CPR, to a resident requiring such emergency care prior to arrival of emergency medical personnel. Problem The Facility's Deficient practice revealed facility failed to provide basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Once the facility was made aware of the deficient practice, the Director of Nursing/designee conducted an in-service with all staff on Mock Code, Rapid Response, AED, and CPR Training with emphasis on the expectation that the AED is retrieved immediately after checking for pulse and respirations. Residents identified at risk are those with Advanced Directives of Full Code status. The facility Director of Nursing/designee completed a 100% audit of residents advanced directive. This audit was completed on [DATE]. Residents who did not have a proper advanced directive were corrected immediately. Director of Nursing/Designee initiated education with clinical staff on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with DONs direct supervision and guidance to validate staff competency and understanding. Staff completed in-service training sheet. Identification of Others: Residents identified with full code status have the potential to be impacted by the alleged deficient practice. Director of nursing/designee completed mock code reviews with clinical staff to ensure adequate knowledge of resuscitation protocol. Systemic Changes The Director of Nursing/ designee initiated immediate training on Mock Codes, Rapid Response, AED, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 21 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few CPR and documentation of code process training to nursing staff on [DATE]. All education is at 100% completion as of [DATE]. The Director of Nursing/designee completed all education and training was started on [DATE] and will continue until all clinical staff have received training prior to the start of their work shift. The facility Director of Nursing, Corporate Clinical Director and Administrator met on [DATE] to evaluate the facility policy and procedures regarding Quality of Life and CPR Care. The Director of nursing/designee will complete education and training with all clinical staff on [DATE] and newly hired clinical staff over Mock Codes, Rapid Response, AED, CPR protocols and documentation of code process. The education will be provided by DON or designee with the necessary skill set related to CPR/ Rapid Response and proper documentation. The Administrator, DON, and designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F678. Monitoring will include a system to ensure deficient practice is prevented. The monitoring and oversight system will ensure clinical staff are adequately trained to meet requirements of safe practice. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. Monitoring The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency. Monitoring will include a system to observe all clinical staff's adequate understanding of rapid response protocols on all shifts. Monitoring will be completed through direct observation, when possible, as well as through observation of mock codes. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. The Director of Nursing/ designee will also conduct a chart review of any resident who has coded to validate that charting has been completed adequately and according to the education provided. This monitoring system will begin [DATE]. Data gathered will be measurable and monitoring will occur at least monthly and include weekend days and alternate shifts over the next 3 months and quarterly following. All concerns identified during the monitoring process will be addressed timely and documented for correction. The monitoring process, findings, and corrections will be presented to the facility QAPI committee each month for a minimum of 6 months for this plan of correction. Administrator will be responsible for monitoring DON compliance with system monthly. System compliance will be documented and discussed. The Administrator/designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F678. Clinical Director of Operations will in-service Admin and DON over Rapid Response Policy and Procedure on [DATE]. Monitoring will be conducted monthly for 3 months to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 22 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented and addressed immediately. Ad Hoc QAPI meeting will be held on [DATE] with the Medical Director, Administrator, Director of Nursing, and IDT to review and validate the plan of removal. Involvement of Medical Director The Director of Nursing notified the facility's Medical Director, of the Immediate Jeopardy tag on [DATE]. The Administrator will be responsible for implementation of ensuring the adequate process regarding Mock Code Monitoring. The new process/system was initiated on [DATE]. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued [DATE]. Plan Of Removal Verification Clinical Director of Operations will in-service Admin and DON over Rapid Response Policy and Procedure on [DATE]. Monitoring will be conducted monthly for 3 months to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. A record review of the facility's in-service train the trainer, revealed, In-service Description: Rapid Response Policy, date: [DATE], Instructor Corp RN, in-service time: 1 hour.; the Administrator; the DON received CPR/AED training. Further review of the attached printed training revealed, .the chances of surviving a sudden cardiac arrest maybe increased if CPR is initiated immediately upon collapse .Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival .Provide periodic mock codes for training purposes .instruct a staff member to retrieve the automatic external defibrillators .when the AED arrives, assess for need and followed protocols as indicated .continue with CPR/BLS until emergency medical personnel arrive . The Director of Nursing/designee conducted an in-service with all nursing staff n Mock Code, Rapid Response, AED, and CPR Training with emphasis on the expectation that the AED is retrieved immediately after checking for pulse and respirations. Residents identified at risk are those with Advanced Directives of Full Code status. The Director of Nursing/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR and documentation of code process training with nursing staff on all shifts on [DATE]. All education was at 100% completion as of [DATE]. The Director of Nursing/designee-initiated education with clinical on all shifts on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with the DON's direct supervision and guidance to validate staff competency and understanding. Staff completed in-service training sheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 23 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0678 Level of Harm - Immediate jeopardy to resident health or safety The Director of Nursing/designee completed all education and training was started on [DATE] and will continue until all clinical staff on all shifts have received training prior to the start of their work shift. A record review of the facility's nursing roster revealed 22 nurses were employed by the facility over all 3 shifts, 06:00 AM to 02:00 PM, 02:00 PM to 10:00 PM, and 10:00 PM to 06:00 AM. 22 of the 22 nurses on all shifts were interviewed for AED CPR training. And were able to identify and use of AED. Residents Affected - Few During an observation of a mock CPR AED event on [DATE] at 01:06 p.m., revealed the ADMN AA called out to DON that a resident was unresponsive. The DON yelled out Code Blue and instructed RN R, LVN G, LVN Q and LVN E to follow her to the unresponsive mock resident's room. The DON then delegated responsibilities to each nurse and one nurse to go get the crash cart. The DON then proceeded to place a backboard under the mock resident while communicating out load he importance of the backboard and if there was no backboard then to place the unresponsive resident on the floor. The DON began compressions while counting out load to 30, followed by using the AMBU bag for the two breaths. The crash cart arrived during this time. The DON showed staff, while doing it, how to remove the AED from its case, opened the AED cover, which automatically began the verbal AED prompt protocols. The DON removed the AED pads from the case, attached the electrical pad leads to the AED, and placed the pads on the CPR mannequin, and continued to follow the AED verbal prompts. The DON stated to the mock CPR AED participants, Continue CPR with the AED until EMS arrives. During an interview on [DATE] at 01:08 AM LVN K stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED was presented. LVN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. Interviews done on [DATE] During an interview on [DATE] at 1:15 p.m., LVN E stated she worked 6-2 and 2-10 shifts. LVN E stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN E stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:16 p.m., LVN G stated she worked 6-2 and 2-10 shifts. LVN G stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:18 p.m., RN C stated she worked 6-2 shifts. RN C stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN C stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:19 p.m., LVN Q stated she worked 6-2 and 2-10 shifts. LVN Q stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN Q stated she received further training to include documentation to reflect the details and times of events for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 24 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0678 the CPR AED event. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 1:20 p.m., RN R stated she worked 6-2 and 2-10 shifts. RN R stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN R stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. Residents Affected - Few During an interview on [DATE] at 01:33 PM LVN P stated she had received in-person training for CPR with the use of an AED during a mock CPR code event on [DATE]. LVN P stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN P stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. During an interview on [DATE] at 1:55 p.m., LVN I stated he worked weekends and just started the previous weekend. LVN I stated he had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN I stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:56 p.m., RN K stated she was one of the ADONs. RN K stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:57 p.m., LVN L stated she worked on weekends. LVN L stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN L stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:58 p.m., RN O stated she was one of the ADONs. RN O stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN O stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:01 p.m., LVN J stated she worked 10-6 shift. LVN J stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN J stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. During an interview on [DATE] at 2:12 p.m., RN D stated she worked 10-6 shift. RN D stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN D stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:17 p.m., RN N stated she worked 6-2 shifts. RN N stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN N stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 25 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on [DATE] at 2:21 p.m., LVN H stated she was the MDS Coordinator. LVN H stated she worked weekends. LVN U stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN H stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. During an interview on [DATE] at 2:33 p.m., LVN A stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN A stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:47 p.m., LVN M stated she worked 10-6 shift. LVN M stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN M stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:50 p.m., LVN U stated she worked weekends. LVN U stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN U stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. The facility DON/designee completed a 100% audit of residents advanced directive. The audit was completed on [DATE]. Residents who did not have a proper advanced directive were corrected immediately. A record review of the facility census revealed 29 residents requested they receive CPR (CardioPulmonary Resuscitation) care and had full code orders signed by a physician. A record review of Resident #2's code status revealed Resident #2 was a full code. A record review of Resident #7's code status revealed Resident #7 was a full code. A record review of Resident #33's code status revealed Resident #33 was a full code. A record review of Resident #53's code status revealed Resident #53 was a full code. A record review of Resident #257's code status revealed Resident #257 was a full code. ADMN AA, DON, and designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in

F678. Monitoring will include a system to ensure deficient practice is prevented. The monitoring and oversight system will ensure clinical staff are adequately trained to meet requirements of safe practice. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency. Monitoring will include a system to observe all clinical staff's adequate understanding of rapid response protocols on all shifts. Monitoring will be completed through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 26 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few direct observation, when possible, as well as through observation of mock codes. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. The Director of Nursing/ designee will also conduct a chart review of any resident who has coded to validate that charting has been completed adequately and according to the education provided. This monitoring system will begin [DATE]. Data gathered will be measurable and monitoring will occur at least monthly and include weekend days and alternate shifts over the next 3 months and quarterly following. All concerns identified during the monitoring process will be addressed timely and documented for correction. The monitoring process, findings, and corrections will be presented to the facility QAPI committee each month for a minimum of 6 months for this plan of correction. Administrator will be responsible for monitoring DON compliance with system monthly. System compliance will be documented and discussed. A record review of the facility's undated, F678 Quality of Care Life Support monitoring worksheet revealed, Administrator will conduct monitoring to ensure rapid response Mock drills are conducted once a month for 3 months and once a quarter for six months; a form designed to document and follow CPR Mock Codes to include corrective actions. A record review of the facility's [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 27 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 residents (Residents #54) reviewed for respiratory care, in that: Residents Affected - Few The facility failed to ensure Resident #54's oxygen order included liter parameters This deficient practice could place residents who received oxygen therapy at risk for incorrect oxygen support being delivered and an increase in respiratory complications. The findings were: Record review of Resident #54's face sheet, dated 08/04/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: anxiety disorder, major depression, legal blindness, and chronic obstructive pulmonary disease. Record review of Resident #54's annual MDS assessment, dated 04/15/2023, revealed the resident had a BIMS score of 15, which indicated intact cognitive impairment. Record review of Resident #54's physicians orders, dated 08/03/2023, revealed an order entered on 07/05/2023 that read: Oxygen via NC qhs per resident request dx: COPD, may titrate to maintain o2 sats >88%. During an interview on 08/02/2023 at 6:17 p.m., Resident #54 stated he only used the oxygen while he was sleeping. He further stated he was on 2 liters. During an interview and observation on 08/03/2023 at 6:15 p.m., Resident #54 was not in his room, however, his roommate stated yes, he uses the oxygen only at night and that he usually get up around 3:00 am and goes to bed around 8:00 pm. During an observation and interview on 08/04/2023 at 12:34 a.m., LVN U observed Resident #54 was currently using oxygen and that he was supposed to be on two liters. During an interview and record review on 08/04/2023 at 12:37 at a.m., LVN M stated yes Resident #54 used oxygen at night and was supposed to be two liters. LVN M stated, during record review, she was not aware of why his order did not have liters on it. LVN M further stated she was not aware of a potential harm to resident. During an interview on 08/04/23 at 12:07 p.m., the DON stated she spoke with Resident #54's Dr and he agreed that resident's order should have (liter) parameters included. The DON stated that his liters changed so much so the IDT team decided to just state titrate and not specify any liters. The DON stated this allowed the resident to manage his O2 depending on how he was feeling at the time he was using the O2. The DON further stated she was not aware of a potential harm to the resident because his order still stated titrate. Record review of the facility's policy titled Medication Orders, revised 11/2014, which read 3. Oxygen Orders - When recording orders for oxygen, specify the rate of flow, route and rationale. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 28 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 3 of 29 (Resident #61) residents reviewed for CPR care and 2 of 21 nurses (LVN A and RN C) reviewed for competencies and skill sets for CPR care to include an AED, in that; The facility failed to ensure all nursing staff had competent skills in performing actual CPR, to include using the AED, as a result of Resident #61 being found unresponsive on [DATE] and the responding nurse staff (LVN A and RN C) not using the AED during the actual CPR process for this resident. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:10 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because the facility is still monitoring the effectiveness of their Plan of Removal. This failure placed residents at risk for harm up to and including death by the denial of all life saving measures as trained. The findings included: A record review of Resident #1's admission record dated, [DATE], revealed an admission date of [DATE] and a death discharge date of [DATE], with diagnoses which included altered mental status, extended spectrum beta lactamase resistance [a bacteria that can't be killed by many of the antibiotics that doctors use to treat infections, like penicillin's and some cephalosporins for urinary tract infections], and urinary tract infection. A record review of Resident #1's admission MDS dated [DATE] revealed Resident #61 was an [AGE] year-old male admitted from an acute care hospital for support and rehabilitation related to a urinary tract infection. A record review of Resident #61's physician's order dated [DATE] revealed RN R documented a physician's order for Resident #61 to receive care as Full Code. A record review of Resident #61's care plan dated [DATE], revealed, [Resident #61] has an advance Directive as evidenced by: Full code status Date Initiated: [DATE] [ .] wishes will be honored, Date Initiated: [DATE] [ .] CPR will be performed as ordered A record review of Resident #61's SBAR document dated [DATE] revealed, Situation [ .] the change in condition, symptoms, or signs observed, and evaluated is/are: cardiac arrest, respiratory arrest. This started on: [DATE]. Since this started it has gotten: stayed the same [ .] Resident/Patient Evaluation [ .] mental status evaluation: unresponsiveness [ .] Code Status: Full Code [ .] Appearance, summarize your observations and evaluation: CNA notified this nurse of resident being unresponsive assessed resident not responsive no pulse RN supervisor notified initiated CPR crash cart access notified 911 CPR performed until paramedics arrived emergency medical technicians continued with CPR resident transfers out with Pulse unconscious accompanied by three emergency medical technicians [ .]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 29 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few A record review of the EMS TripTix EMS Patient Care Record dated [DATE] revealed, CPR was performed by the facility staff for 9 minutes from 09:38 AM to 09:47 AM as evidenced by, Incident Date / Times [ .] unit notified by dispatch [DATE] 09:41 [AM] [ .] Unit En Route [DATE] 09:43 [AM] [ .] Unit Arrived on Scene [DATE] 09:45 [AM] [ .] Arrived at patient [DATE] 09:47 [AM] [ .] Unit left scene [DATE] 10:04 [AM] [ .] complaints and impressions; cardiac arrest, onset date and time [DATE] 09:38 [AM], [ .] AED used prior to EMS NO [ .] Further review revealed a summary which reflected the facility had performed CPR chest compressions and oxygenated rescue breathing but had not used the AED. The EMTs provided medications and applied the EMS AED and revealed Resident #61 had regained an irregular heartbeat after EMS care and medications administered intraosseous [directly into the bone marrow]. During an interview and observation on [DATE] at 02:28 PM the DON stated sometime in [DATE] Resident #61 was discovered unresponsive and was provided emergency CPR care. The DON stated she was not certain if the AED used. The DON proceeded to demonstrate the AED to the surveyor. The AED was stored on the facility's emergency crash cart along with CPR equipment such as an oxygen tank, and oxygen delivery equipment and included a suction pump with accessories. The DON demonstrated the AED as functional and stated the AED had not been used and could not recall the last time it had been used. The DON stated she believed LVN A, LVN B, and RN C were directly involved with Resident #1's CPR care. During an interview on [DATE] at 07:10 PM the DON provided updated information and stated she recalled the [DATE] CPR event for Resident #61 and stated the AED was not utilized, and EMS services arrived at the facility after the 911 call, approximately 4-5 minutes. The DON stated she did not know why the AED was not utilized and further stated EMS arrived quickly. The DON was asked to provide any further documentation to the event and did not provide further documentation. The DON stated LVN A, LVN B, and RN C were involved in the CPR event for Resident #61 AND reported to her Resident #61 was unresponsive. LVN A stated she told the CNAs to get RN C and immediately arrived at Resident #61's bed side. LVN A stated she assessed Resident #61 as a full code and without a pulse and not breathing. LVN A stated she began emergency CPR with chest compressions and RN C arrived at the bedside quickly. LVN A stated RN C assumed chest compressions and told her to get the crash cart and call 911. LVN A stated she ran to retrieve the crash cart and along the way told LVN B to call 911. LVN A stated she returned to Resident #61 with the crash cart and resumed chest compressions while RN C administered oxygen with rescue breaths. LVN A stated 911 EMTs were at the bedside quickly around 4-7 minutes maybe. LVN A stated EMS took over and Resident #61 was assessed with a pulse and left for the hospital with EMS. LVN A stated she was trained for CPR by the American Heart Association. LVN A stated the AED was stored on the crash cart and was immediately available upon arrival at Resident #61's bedside. LVN A stated the AED was never opened, removed from the case, or from the crash cart. LVN A stated she was so involved in providing CPR chest compressions and rescue breaths she did not think about the AED. LVN A stated her training included the use of an AED during CPR as soon as the AED was available. During an interview on [DATE] at 06:00 AM RN C stated on [DATE] she worked from 06:00 AM to 02:00 PM. RN C stated she was providing patient care when CNAs AB and AC told her LVN A needed her, and Resident #61 was unresponsive. RN C stated she ran to Resident #61's bedside and assessed Resident #61 as unresponsive and told LVN A to get the crash cart and call 911. RN C stated she began CPR chest compressions. RN C stated LVN A returned with the crash-cart, and they switched CPR roles and LVN A continued chest compressions while RN C administered oxygenated rescue breaths. RN C stated 911 EMS arrived quickly and continued CPR. RN C stated the facility's AED was stored on the facility's crash-cart and was immediately available when the crash-cart arrived but she nor LVN A gave it a thought due to the high stress of providing CPR. RN C stated she and LVN A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 30 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few provided CPR for maybe 5 minutes and 911 arrived quickly. RN C stated she was CPR trained by the American Heart Association. RN C stated her training included the use of an AED during CPR as soon as the AED is available. RN C stated she had not documented her role in Resident #61's CPR care to include times and details of care such as the use of an AED, RN C stated she believed the DON and / or LVN A had documented the CPR care. A record review of the facility's Emergency Procedure Cardiopulmonary Resuscitation policy dated February 2018, revealed, Policy Statement; personnel have completed training on the initiation of cardiopulmonary resuscitation and basic life support including Defibrillation for victims of sudden cardiac arrest; general guidelines; the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival [ .] emergency procedure; cardiopulmonary resuscitation; [ .] when the AED arrives assess for need and follow AED protocol as indicated [ .]. A record review of the American Heart Association's website Part 3: Adult Basic and Advanced Life Support; 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support, accessed [DATE], revealed, Top 10 take home messages for adult cardiovascular life support: [ .] On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest [ .] Defibrillation is most successful when administered as soon as possible [ .]. A record review of the facility's in-service train the trainer, revealed, In-service Description: Rapid Response Policy, date: [DATE], Instructor Corp RN, in-service time: 1 hour.; the Administrator; the DON received CPR / AED training. Further review of the attached printed training revealed, [ .] the chances of surviving a sudden cardiac arrest maybe increased if CPR is initiated immediately upon collapse [ .] Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival [ .] Provide periodic mock codes for training purposes [ .] instruct a staff member to retrieve the automatic external defibrillators [ .] when the AED arrives, assess for need and followed protocols as indicated [ .] continue with CPR/BLS until emergency medical personnel arrive [ .] This was determined to be an Immediate Jeopardy (IJ) on 08/072023 at 4:10 p.m. The Administrator was notified. The Administrator was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 2:10 p.m. Plan of Removal Verification Date [DATE] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, POR - Plan of Removal for Immediate Jeopardy dated [DATE] at 12:32 PM with the DON and ADMN Y: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 31 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0726 Summary of details which leads to outcomes. Level of Harm - Immediate jeopardy to resident health or safety On [DATE] an annual survey was initiated at the Facility. On [DATE], a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. Residents Affected - Few The notification of the alleged immediate jeopardy states as follows:

F726 COMPETENT NURSING STAFF The facility failed to have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident Problem The Facility's Deficient practice revealed facility staff failed to demonstrate competency related to providing basic life support, including CPR including the timely application and use of an AED to a resident requiring emergency care prior to the arrival of emergency medical personnel. Immediate Corrections Implemented for Removal of Immediate Jeopardy. o Once the facility was made aware of the deficient practice, the Director of Nursing/ designee conducted an in-service with all staff on Mock Code, Rapid Response, AED, and CPR Training with emphasis on staff competencies to include all licensed staff all shifts, with return demonstration. The facility Director of Nursing/designee completed a 100% training in person with return demonstration of all licensed staff began on [DATE] and completed on [DATE] o Director of Nursing/Designee initiated education with clinical staff on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with DONs direct supervision and guidance to validate staff competency and understanding completed began mock code Competency in-service training sheet. Identification of Others: o Residents identified with full code status have the potential to be impacted by the alleged deficient practice. o Director of nursing/designee completed mock code reviews with clinical staff to ensure adequate knowledge of resuscitation protocol. Systemic Changes o the DON/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR and documentation of code process training to nursing staff on [DATE]. All education is at 100% completion as of [DATE]. o the DON/designee completed all education and training to all clinical staff and all clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 32 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0726 staff upon hire and added to new hire checklist. Level of Harm - Immediate jeopardy to resident health or safety o the facility DON, Corporate Clinical Director and Administrator met on [DATE] to evaluate the facility policy and procedures regarding Quality of Life and staff competencies. Residents Affected - Few o the DON/designee will complete education and training with all clinical staff on [DATE] and newly hired clinical staff over Mock Codes, Rapid Response, AED, CPR protocols and documentation of code process. The education will be provided by DON or designee with the necessary skill set related to CPR/ Rapid Response, including AED use and proper documentation. Education will include return demonstration and routine mocks to validate understanding and competency of all clinical staff. o The Administrator, DON/designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in

F726. Monitoring will include a system to ensure deficient practice is prevented. The monitoring and oversight system will ensure clinical staff are adequately trained to meet requirements of safe practice. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. Monitoring o The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency by [DATE]. Monitoring will include a system to observe all clinical staff's verbalization of comprehension and return demonstration of rapid response protocols on all shifts through return demonstration q month for 3 months and quarterly for 12 months. o Monitoring will be completed through direct observation, when possible, and observation of mock codes. DON/Designee will retain record of all written mock competencies' routine and PRN. Mock codes will be run monthly for all clinical staff q month for 3 months on various shifts, then quarterly for 12 months. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. o The Administrator/ designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in

F726 o The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review the ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented and addressed immediately. o An Ad Hoc QAPI meeting was held on [DATE] with the Medical Director, Administrator, Director of Nursing, and IDT to review and validate the plan of removal. Involvement of Medical Director The DON notified the facility's Medical Director, of the Immediate Jeopardy tag on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 33 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0726 Level of Harm - Immediate jeopardy to resident health or safety The Administrator will be responsible for implementation of ensuring the adequate process regarding Monitoring of staff competency related to the provision of CPR including the use of an AED. The new process/system was initiated on [DATE]. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued [DATE]. Plan of Removal Verification Residents Affected - Few Once the facility was made aware of the deficient practice, the DON/designee conducted an in-service with all staff on Mock Code, Rapid Response, AED, and CPR Training with emphasis on staff competencies to include all licensed staff all shifts, with return demonstration. The facility Director of Nursing/designee completed a 100% training in person with return demonstration of all licensed staff began on [DATE] and completed on [DATE] DON/Designee initiated education with clinical staff on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with DON's direct supervision and guidance to validate staff competency and understanding completed began mock code Competency in-service training sheet. Identification of Others: Residents identified with full code status have the potential to be impacted by the alleged deficient practice. Director of nursing/designee completed mock code reviews with clinical staff to ensure adequate knowledge of resuscitation protocol. Systemic Changes The DON/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR, and documentation of code process training to nursing staff on [DATE]. All education is at 100% completion as of [DATE]. The DON/designee completed all education and training to all clinical staff and all clinical staff upon hire and added to new hire checklist. The facility DON, Corporate Clinical Director and Administrator met on [DATE] to evaluate the facility policy and procedures regarding Quality of Life and staff competencies. The DON/designee will complete education and training with all clinical staff on [DATE] and newly hired clinical staff over Mock Codes, Rapid Response, AED, CPR protocols and documentation of code process. The education will be provided by DON or designee with the necessary skill set related to CPR/ Rapid Response, including AED use and proper documentation. Education will include return demonstration and routine mocks to validate understanding and competency of all clinical staff. During and observation of a mock CPR AED event on [DATE] at 01:51 p.m., revealed the DON called out to that a resident was unresponsive. The DON yelled out Code Blue and instructed RN O, RN K, RN N and LVN P to follow her to the unresponsive mock-Resident's room. The DON then delegated responsibilities to each nurse and one nurse to go get the crash cart. DON then proceeded to place a backboard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 34 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few under mock resident while communicating out load the importance of this backboard and if no backboard to then place the Unresponsive resident on the floor. The DON began compressions while counting outloud to 30, followed by using the AMBU bag for the two breaths. The crash cart arrived during this time. The DON showed staff, while doing it, how to remove the AED from its case, open the AED cover, which automatically begins the verbal AED Prompts protocols, the DON removed the AED pads from the case, attached the electrical pad leads to the AED, and placed the pads on the CPR mannequin, and continued to follow the AED verbal Prompts. The DON stated to the Mock CPR AED participants, continue CPR with the AED until EMS arrives. Interview on [DATE] at 2PM the DON stated 2 nurses, LVN M and LVN J were called at first and came in for mock CPR code training. Interview on [DATE] at 2:13 PM with LVN P, T, TH doubles, Fridays 6-2PM, worked for SNF for 8 yrs. Worked all halls. DON -over weekend had a mock code, in-service, documentations, designate duties, implement AED, can participate call 911, call family, Call MD, give report to ER implement skills and continue use of AED. Interview on [DATE] at 2:18 PM- ADON K, worked for [DATE], works the floor if coverage is needed, all shifts -Did mock codes- 6 time, staff that would work different shifts, she made sure to cover all component, directed staff to do different task, call 911, call family, call MD, give report to ER, especially documentation, QAPI- monthly-don't recall talking about Resident #61, had 2 ADHOC mtg- nursing competency, areas of improvement all related to investigations management team DM, pharmacies, DON, Admin. Interview on [DATE] at 2:23 PM with RN O, ADON, m-f 8-5, prn, worked the floor, worked all halls, worked as LVN, trained on Mock code by DON-process and delegate task, call 911, family, MD and DON. Learned the delegating of task. QAPI-not sure if it was brought up, recent member to QAPI, had a emergency QAPI mtg, called MD, pharmacist, Admin, DON, department heads-discussed the incident with resident and interventions and POR. Interview on [DATE] at 2:33 PM with RN N, worked for 7 yrs. ago, worked all halls, worked days and evenings, DON mock codes-2nd, refreshes CPR training, CPR certified, process- go to resident, assess, pulse, delegate, check if resident code status, work as a team to assist resident. Make sure to sue board or on floor, make sure resident is positioned and can with out with other team member, utilize ED, document, wait for EMS. Did go to QAPI trainings. Interview on [DATE] at 2:46 PM with LVN J, worked the prn, all shifts, all halls, (nights) worked for 2 yrs., was out of town, called her on phone, yesterday did demonstration - DON in-service, CPR, all staff have a role, check pt., make sure environment after, assess, check code status, process, CNA can be involvedcalling 911, family, DON explained for nursed and CNA in detail of training, CPR, AED, QAPI-not sure. Interview on [DATE] at 2:51 PM with LVN M, night shift, worked here for 1 yr., DON-called first, then came in yesterday for mock code-going over code and procedures and react to situation, go to room, res not breathing, initiated emergency response, call 911, cart c rt, AED, document time, delegate task, document on PCC. QAPI-had training. Interview on [DATE] at 2:57 PM with LVN F, Med nurse Charge nurse, m-f 6-2, worked for 2 yrs., worked all halls, in-service - was at SNF, mock code and in-service-find resident responsive, if code (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 35 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few does not get verbal, check pulse, assess, delegate task, check res code status, crash cart, back board, AED, start on CPR and wait for EMS to come, QAPI-not sure. Interview on [DATE] at 3:16 PM with LVN E, shifts doubles 6-10pm, worked for 3 months, worked E, F B hall (left side), -DON in-service mock code-demonstrated mock code, trained, res assesses, get res code status, 30 compressions to 2 rest, AED, call 911, etc, documentation and who helped you and wait for EMS. QAPI- no A record review of the facility's nursing roster revealed 21 nurses were employed by the facility over all 3 shifts, 06:00 AM to 02:00 PM, 02:00 PM to 10:00 PM, and 10:00 PM to 06:00 AM. 21 of the 21 nurses were interviewed for AED CPR training. A record review of the facility's nursing roster revealed 2 nurses, LVN J and LVN M were not in serviced in person as of [DATE] and have since [DATE] received in person CPR, AED, Documentation, training. During an interview on [DATE] at 02:13 PM LVN P stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN P stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN P stated the training was documented on a training competency checkoff form which she signed, and the DON signed. LVN P stated she currently works 3-4 time a week doubles from 06:00 AM to 02:00 PM and continues on 02:00 PM to 10:00 PM. During an interview on [DATE] at 02:18 PM RN K stated she had received training on [DATE] to include instructions for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. RN K stated her training with return demonstration was recorded on a CRP AED competency checkoff form signed by the DON and herself. RN K stated she had attended the QAPI meeting on [DATE]. RN K stated she works Monday thru Friday 06:00 AM to 06:00 PM. During an interview on [DATE] at 02:23 PM RN O stated she had received in-person training for CPR with the use of an AED during a Mock CPR code event on [DATE]. RN O stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. RN O stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. RN O stated the DON signed her CPR AED competency checkoff list in approval of her CPR AED competency training. RN O stated she works Monday thru Friday 06:00 AM to 06:00 PM. During an interview on [DATE] at 02:33 PM RN N stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN N stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. RN N stated the training was documented on a training competency checkoff form which she signed, and the DON signed. RN N stated she received in-service training for QAPI reporting. RN N stated she currently works 3-4 time a week doubles from 06:00 AM to 02:00 PM and continues on 02:00 PM to 10:00 PM. During an interview on [DATE] at 02:50 PM LVN J stated she had received training on [DATE] to include instructions for a mock CPR code event with specific training to include the immediate use of an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 36 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few AED as soon as the AED is presented. LVN J stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN J stated her training with return demonstration was recorded on a CRP AED competency checkoff form signed by the DON and herself. LVN J stated she was in serviced on the QAPI review process. LVN J stated she is PRN and works all shifts. During an interview on [DATE] at 02:51 PM LVN M stated she had received in-person training for CPR with the use of an AED during a Mock CPR code event on [DATE]. LVN M stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN M stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. LVN M stated the DON signed her CPR AED competency checkoff list in approval of her CPR AED competency training. LVN M stated she works the night shift 10:00 PM to 06:00 AM. During an interview on [DATE] at 02:57 PM LVN F stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN F stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN F stated the training was documented on a training competency checkoff form which she signed, and the DON signed. LVN F stated she received in-service training for QAPI reporting. LVN F stated she worked the 06:00 AM to 02:00 PM shift. During an interview on [DATE] at 03:16 PM LVN E stated she had received training on [DATE] to include instructions for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN E stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN E stated her training with return demonstration was recorded on a CPR AED competency checkoff form signed by the DON and herself. LVN E stated she had attended the QAPI meeting on [DATE]. LVN E stated she works Monday thru Friday 06:00 AM to 06:00 PM. LVN E stated she currently works 3-4 time a week doubles from 06:00 AM to 02:00 PM and continued 02:00 PM to 10:00 PM. Identification of Others: Residents identified with full code status have the potential to be impacted by the alleged deficient practice. A record review of the facility census revealed 29 residents requested they receive CPR care and had Full Code orders signed by a physician. A record review of Resident #2's code status revealed Resident #2 was a full code. A record review of Resident #7's code status revealed Resident #7 was a full code. A record review of Resident #33's code status revealed Resident #33 was a full code. A record review of Resident #53's code status revealed Resident #53 was a full code. A record review of Resident #257's code status revealed Resident #257 was a full code. Monitoring The DON or designee will develop a short-term monitoring system for all areas of deficient practice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 37 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few identified for this deficiency by [DATE]. Monitoring will include a system to observe all clinical staff's verbalization of comprehension and return demonstration of rapid response protocols on all shifts through return demonstration q month for 3 months and quarterly for 12 months. Monitoring will be completed through direct observation, when possible, and observation of mock codes. DON/Designee will retain record of all written mock competencies' routine and PRN. Mock codes will be run monthly for all clinical staff q month for 3 months on various shifts, then quarterly for 12 months. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. The Administrator/ designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F726 A record review of the facility's, F726 Staffing, Sufficient and Competent Nursing policy, dated [DATE] revealed, Policy Statement: Our Facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. policy interpretation and implementation: . competent staff: competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. staff must demonstrate the skills and techniques necessary to care for residents needs FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 38 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the Nurse Staffing Information. Data requirements. The facility must post the following information on a daily basis: Resident census for 2 of 2 days in that: Residents Affected - Many The nurse staffing postings for 2 days did not have a census and the 18 months ([DATE]-August 3, 2023) of nurse staffing posting did not have a census. This could result in family and residents not being aware of the census for the day. The Findings were: Observation on 8/01/23 at 9:30AM at the front entrance revealed the nurse staffing posting was posted but did not include the census. Observation on 8/02/2023 at 9:10 AM at the front entrance revealed the nurse staffing posting was posted but did not include the census. Record review of 18 months of nurse staffing posting dated from [DATE]-August 3, 2023, revealed the census was missing. Interview on 8/02/2023 at 9:33 AM HR stated she was responsible for posting the nurse staffing information and to make sure the records were retained. HR stated she was not aware that the nurse staffing postings had to have the census included and would make sure from now on. Interview on 8/5/2023 at 10:32 AM with ADMN AA stated the HR person was responsible for the nurse staffing postings and HR made him aware that they were required to post the census. ADMN AA stated the risk would be that the residents/families were not aware of the census for the day. Record review of the policy on Staffing, Sufficient and Competent Nursing dated 2001 revealed the facility provided sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Competent Staff .6. Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 39 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5%. The facility error was 8% based on 2 errors out of 25 opportunities for 2 of 6 residents (Resident #33 and #267) reviewed for medication administration: Residents Affected - Some 1. LVN F administered Carafate [a medication used to treat and prevent ulcers in the intestines] to Resident #33 and did not follow the physicians order to administer the medication by itself at least 2 hours away from other medications. 2. MA W crushed and administered metoprolol extended release [a medication which lowers blood pressure and should not be crushed] to Resident #267. This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. A record review of Resident #33's admission record, dated 08/05/2023, revealed an admission date of 03/30/2023 with diagnoses which included gastrointestinal hemorrhage [ bleeding in the stomach and intestines]. A record review of Resident #33's quarterly MDS, dated [DATE], revealed Resident #33 was a [AGE] year-old female admitted for physical therapy rehabilitation. A record review of Resident #33's care plan dated 08/05/2023 revealed, [Resident #33] has GERD related to inappropriate diet [ .] [Resident #33] will remain free from discomfort, complications or signs and symptoms related to the diagnosis of GERD through review date [ .] 06/21/2023 [ .] Give medications as ordered. Observe/document side effects and effectiveness. A record review of Resident #33's physicians orders dated 08/03/2023 revealed the physician ordered for Resident #33 to receive Carafate 2 hours away from other medications, Carafate Oral Tablet 1 GM (Sucralfate) Give 1 tablet by mouth before meals and at bedtime related to GASTROINTESTINAL HEMORRHAGE, UNSPECIFIED; Administer 2 hours apart from other medications. During an observation and record review on 08/03/2023 from 07:32 to 07:34 AM revealed LVN F prepared and administered Carafate together with other medications to Resident #33, as follows: 1. Cholecalciferol Tablet 1000 UNIT Give 1 tablet by mouth one time a day related to vitamin d deficiency. 2. Cyanocobalamin Tablet 1000 MCG Give 1 tablet by mouth one time a day related to anemia. 3. Folic Acid Oral Tablet 1 MG (Folic Acid) Give 1 tablet by mouth one time a day for supplement. 4. Coreg Oral Tablet 3.125 MG (Carvedilol) Give 1 tablet by mouth two times a day related to secondary hypertension [high blood pressure]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 40 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0759 Level of Harm - Minimal harm or potential for actual harm 5. Divalproex Sodium Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day related to bipolar disorder. 6. Iron Oral Tablet 325 (65 Fe) MG (Ferrous Sulfate) Give 1 tablet by mouth two times a day related to anemia [low iron in blood]. Residents Affected - Some 7. Omeprazole Oral Tablet Delayed Release 20 MG (Omeprazole) Give 20 mg by mouth two times a day related to gastrointestinal hemorrhage [stomach bleeding]. 8. Sodium Chloride Oral Tablet 1 GM (Sodium Chloride) Give 2 tablet by mouth two times a day related to hypoosmolality and hyponatremia [low salt]. 9, Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth three times a day related to fibromyalgia [painful muscles]. 10. Carafate Oral Tablet 1 GM (Sucralfate) Give 1 tablet by mouth before meals and at bedtime related to GASTROINTESTINAL HEMORRHAGE, UNSPECIFIED [stomach bleeding] Administer 2 hours apart from other medications. During an interview on 08/04/2023 at 08:34 AM LVN F stated she should have administered the Carafate 2 hours prior to Resident #33's other medications. 2. A record review of Resident #267's admission record dated 08/05/2023 revealed an admission date 07/21/2023 with diagnoses which included essential (primary) hypertension [high blood pressure]. A record review of Resident #267's admission MDS dated [DATE] revealed Resident #267 was an [AGE] year-old female admitted for long term care. A record review of Resident #267's care plan dated 08/03/2023, revealed, [Resident #267] has impaired cardiovascular status related to: Hypertension [ .] Resident will not have a decline in function related to cardiac condition through next 90 days [ .] Medications as ordered by physician and Observe use and effectiveness. A record review of Resident #267's physicians orders dated 08/03/2023 revealed Resident #267 was prescribed metoprolol [a medication used to lower blood pressure] extended-release form [a pill designed with a coating to slowly dissolve and deliver a low steady dose throughout the day], metoprolol succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth two times a day . During an observation on 08/03/2023 at 03:30 PM Medication Aide W [MA W] prepared, crushed, and administered metoprolol 25mg extended release 24 hr. to Resident #267. During an interview and record review on 08/04/2023 at 08:34 AM LVN F identified the medication aide cart for Resident #267. LVN f opened the medication cart and demonstrated Resident #267's metoprolol medication card. The card revealed the label which read, metoprolol succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth two times a day . The surveyor asked LVN F if this medication could be crushed and LVN F stated, it should not be crushed. During an interview on 08/04/2023 at 08:40 PM the DON received a report from the surveyor that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 41 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete results of the medication observations revealed 2 medication errors; 1) LVN F administered to Resident #33 carafate concurrent with other medications and 2) MA W crushed and administered to resident #267 metoprolol extended-release medication. the DON stated the carafate should have been administered away from other medications and the extended-release formulation of medications should not be crushed. A record review of the facility's Adverse Consequences and Medication Errors dated February 2023, revealed, Policy Heading: The interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions and side effects. Policy Interpretation and Implementation .Medications Errors 1. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Event ID: Facility ID: 675428 If continuation sheet Page 42 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 1 of 6 residents (Resident #267) reviewed for medication administration, in that: Residents Affected - Few MA W crushed and administered metoprolol extended release [a medication which lowers blood pressure and should not be crushed] to Resident #267. This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #267's admission record dated 08/05/2023 revealed an admission date 07/21/2023 with diagnoses which included essential (primary) hypertension [high blood pressure]. A record review of Resident #267's admission MDS dated [DATE] revealed Resident #267 was an [AGE] year-old female admitted for long term care. A record review of Resident #267's care plan dated 08/03/2023, revealed, Resident #267 has impaired cardiovascular status related to: Hypertension . Resident will not have a decline in function related to cardiac condition through next 90 days .Medications as ordered by physician and Observe use and effectiveness. A record review of Resident #267's physicians orders dated 08/03/2023 revealed Resident #267 was prescribed metoprolol [a medication used to lower blood pressure] extended-release form [a pill designed with a coating to slowly dissolve and deliver a low steady dose throughout the day], metoprolol succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth two times a day . During an observation on 08/03/2023 at 03:30 PM Medication Aide W [MA W] prepared, crushed, and administered metoprolol 25mg extended release 24 hr. to Resident #267. During an interview and record review on 08/04/2023 at 08:34 AM LVN F identified the medication aide cart for Resident #267. LVN F opened the medication cart and demonstrated Resident #267's metoprolol medication card. The card revealed the label which read, metoprolol succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth two times a day . The surveyor asked LVN F if this medication could be crushed and LVN F stated, it should not be crushed. During an interview on 08/04/2023 at 08:40 PM the DON received a report from the surveyor that the results of the medication observations revealed MA W crushed and administered to Resident #267 metoprolol extended-release medication. The DON stated the extended-release formulation of medications should not be crushed. A record review of the facility's Adverse Consequences and Medication Errors dated February 2023, revealed, Policy Heading: The interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions and side effects. Policy Interpretation and Implementation .Medications Errors 1. A medication error is defined as the preparation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 43 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. A record review of the US National Library of Medicine website https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a0c8c0ac-863c-4385-94d2-f6691bee66d9 accessed 08/04/2023, revealed, Dosage and Administration: Metoprolol succinate is an extended release tablet intended for once daily administration. For treatment of hypertension and angina .metoprolol succinate extended-release tablets are scored and can be divided; however, do not crush or chew the whole or half tablet. Event ID: Facility ID: 675428 If continuation sheet Page 44 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 4 of 6 (Residents #35, #20, #2, and #53) residents reviewed for dietary services in that: The kitchen ordered unpasteurized eggs and Residents #35, #20, #2, and #53 were served soft yolks for breakfast: This failure could affect residents that was served over easy eggs and could place them at risk for food borne illnesses. 1. Record review of Resident # 35's admission record dated 8/4/2023 revealed he was admitted to the facility on [DATE] with diagnoses of muscle weakness, cellulitis (common, potentially serious bacterial skin infection.), insomnia, kidney failure, and history of falls. Record review of Resident # 35's Quarterly MDS dated [DATE] revealed section C Cognition Pattern, BIMs score was 15/15 (cognitively intact) and section G Functional Status, eating was independent. Record review of Resident # 35's care plan dated 5/11/2023 revealed Eating-Resident was able to feed self after tray set up and for Diet- Resident #35 was on a regular diet with regular texture. Record review of Resident # 35 consolidated physician's order for August 2023 revealed his diet order was a regular diet, regular texture, regular consistency. Record review of Resident # 35 's diet card revealed for breakfast it was documented he received over medium eggs. During an interview on 8/2/2023 at 1:34 PM Resident #35 stated he had asked and was served over medium (fried) eggs for breakfast and stated he had not been sick. Resident #35 stated he had over medium eggs with the soft yolk since he was admitted . 2. Record review of Resident # 20's admission record dated 8/3/2023 revealed he was admitted to the facility on [DATE] with diagnoses of anemia, unsteady on feet and osteoarthritis. Record review of Resident # 20's Quarterly MDS dated [DATE] revealed section C Cognition Pattern, BIMs score was 99 (modified independence) and section G Functional Status, eating required supervision with set up help only. Record review of Resident # 20's care plan dated 6/19/2023 revealed ADL-Eating-Resident required supervision assistance by 1 staff to eat. Resident #20 was on a regular diet. Record review of Resident # 20's consolidated orders dated August 2023 revealed a diet order of a regular diet, regular texture, regular consistency. Record review of Resident # 20's diet card revealed for breakfast it was documented he received over medium eggs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 45 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 8/2/2023 at 10:19 AM revealed LVN E checked the breakfast for the last 2 days. LVN E stated Resident # 35 had his eggs over easy, Resident #20 had over easy eggs, this morning with soft yolk. 3. Record review of Resident #2's admission record dated 08/26/2023, revealed an admission date of 10/01/2021 with diagnoses which included type II diabetes and heart failure. Record review of Resident#2's physician's orders revealed Resident #2 was ordered on 03/23/2023, to have a regular diet with regular textures. Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 was an [AGE] year-old female admitted for long term care and section C cognition BIMS was 14/15 (cognitively intact). Record review of Resident #2's care plan dated 08/04/2023 revealed, Resident #2 has nutritional problem or potential nutritional problem related to diet restrictions renal diet resident number two is exercising her right to have foods outside of her recommended diet . provide and serve diet as ordered observe intake and record every meal registered dietitian to evaluate and make diet change recommendations as needed. Record review of Resident#2's physician's orders revealed Resident #2 was ordered on 03/23/2023, to have a regular diet with regular textures. Record review of Resident # 2's diet card revealed for breakfast it was documented he received over medium eggs (soft yolk). During an interview on 08/01/2023 at 04:32 PM Resident #2 stated she had sunny-side eggs which were soft and runny for breakfast this morning . 4. Record review of Resident #53's admission record dated 08/06/2023 revealed an admission date of 06/13/2022 with diagnosis which included abnormal weight loss. Record review of Resident #53's quarterly MDS dated [DATE] revealed Resident #53 was an [AGE] year-old female admitted for long term care and section C cognition BIMS was 15/15 (cognitively intact) Record review of Resident #53's care plan dated 08/06/2023 revealed, Resident #53 has nutritional problem or potential nutritional problem .Resident #53 will maintain adequate nutritional status as evidenced by maintaining weight .provide, serve, diet as ordered. Regular diet .regular consistency. Record review of Resident #53's physician's order dated 08/06/2023 revealed Resident #53 was ordered to receive regular diet .regular consistency, ground meats, aid Resident with cutting food items. Record review of Resident # 53's diet card revealed for breakfast it was documented she received over medium eggs (soft yolks). During an interview on 08/01/2023 at 04:35 PM Resident #53 stated her preference for breakfast was sunny side up eggs. Resident #53 stated she had sunny side up eggs this morning and they were runny . Observation on 8/1/2023 at 10:17 AM during initial rounds of the kitchen revealed in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 46 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some refrigerator a box of eggs. There was no label and the eggs were not stamped as pasteurized with DM (dietary manager). During an interview on 8/01/2023 at 10:18 AM with the DM during initial rounds revealed the box of eggs were not pasteurized and stated 6 residents were served soft yolk eggs. The DM stated he was not sure if eggs were pasteurized and looked at the order from the food supply. The DM stated the order for eggs did not indicate the eggs were pasteurized. The DM stated he called the food supplier and they stated the last order of eggs were not pasteurized . During an interview on 8/02/2023 at 10:36 AM [NAME] X stated she had been working as a cook for facility for 2 yrs. [NAME] X stated Residents #35, #20, #2 and #53 had soft yolk eggs for breakfast every morning. [NAME] X stated she thought the eggs in the refrigerator were pasteurized. During an interview on 8/04/2023 at 12:50 PM ADMN AA stated he was not sure the eggs in the kitchen were not pasteurized. He stated he did round audits in the kitchen every 2 weeks with the Dietitian and DM. The ADMN AA stated the risk was low impact for resident food borne illness and stated no residents were immune comprised. Record review of the policy Food Preparation and Service dated November 2022 revealed Food and Nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Food Preparation, Cooking and Holding Time/Temperatures 12. Only pasteurized shell eggs are cooked and served when: a. residents request undercooked, soft-served or sunny side up eggs. Record review of the Food and Drug Administration, dated 2022 revealed TITLE 21--FOOD AND DRUGS, CHAPTER I--FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES, SUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION, PART 160 -- EGGS AND EGG PRODUCTS, Subpart B - Requirements for Specific Standardized Eggs and Egg Products, https://www.fda.gov/food/fda-food-code/food-code-2022, 3-202.14 Eggs and Milk Products, Pasteurized., (A) EGG PRODUCTS shall be obtained pasteurized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 47 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 1 Resident(s) (Resident #61) reviewed for accurate medical records, in that: LVN A and RN C failed to document the details of CPR care provided for Resident #61. This failure could place residents at risk for harm by inaccurate records. The findings included: A record review of Resident #1's admission record dated, [DATE], revealed an admission date of [DATE] and a death discharge date of [DATE], with diagnoses which included altered mental status, extended spectrum beta lactamase (esbl) resistance [a bacteria that can't be killed by many of the antibiotics that doctors use to treat infections, like penicillin's and some cephalosporins for urinary tract infections], and urinary tract infection. A record review of Resident #1's admission MDS dated [DATE] revealed Resident #61 was an [AGE] year-old male admitted from an acute care hospital for support and rehabilitation related to a urinary tract infection. A record review of Resident #1's death in facility MDS dated [DATE] revealed Resident #61 was an [AGE] year-old male discharged for a death in the facility. A record review of Resident #61's physicians order dated [DATE] revealed RN R documented a physician's order for Resident #61 to receive care as Full Code. A record review of Resident #61's care plan dated [DATE], revealed, Resident #61 has an advance Directive as evidenced by: Full code status Date Initiated: [DATE] .wishes will be honored, Date Initiated: [DATE] .CPR will be performed as ordered A record review of the EMS TripTix EMS Patient Care Record dated [DATE] revealed, CPR was performed by the facility staff for 9 minutes from 09:38 AM to 09:47 AM as evidenced by, Incident Date / Times .unit notified by dispatch [DATE] 09:41 [AM] .Unit En Route [DATE] 09:43 [AM] .Unit Arrived on Scene [DATE] 09:45 [AM] .Arrived at patient [DATE] 09:47 [AM] .Unit left scene [DATE] 10:04 [AM] .complaints and impressions; cardiac arrest, onset date and time [DATE] 09:38 [AM], . AED used prior to EMS NO . further review revealed a summary which documented the facility had performed CPR chest compressions and oxygenated recue breathing but had not used the AED, the EMTs provided medications and applied the EMS AED and revealed Resident #61 had regained an irregular heartbeat after EMS care and medications administered intraosseous [directly into the bone marrow]. A record review of Resident #61's medical records did not evidence any detailed documentation related to the CPR care provided, such as when Resident #61 was discovered unresponsive, if an AED was presented for care, if the AED was used, et cetera. During an interview on [DATE] at 07:40 PM LVN A stated on [DATE] around 09:30 to 10:00 AM CNAs AB (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 48 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and AC reported to her Resident #61 was unresponsive. LVN A stated she told the CNAs to get RN C and immediately arrived at Resident #61's bed side. LVN A stated she assessed Resident #61 as a full code and without a pulse and not breathing. LVN A stated she began emergency CPR with chest compressions and RN C arrived at the bedside quickly. LVN A stated RN C assumed chest compressions and told her to get the crash cart and call 911. LVN A stated she ran to retrieve the crash cart and along the way told LVN B to call 911. LVN A stated she returned to Resident #61 with the crash cart and resumed chest compressions while RN C administered oxygen with rescue breaths. LVN A stated 911 EMT's were at the bedside quickly around 4-7 minutes maybe. LVN A stated EMS took over and Resident #61 was assessed with a pulse and left for the hospital with EMS. LVN A stated she was trained for CPR by the American Heart Association. LVN A stated the AED was stored on the crash cart and was immediately available upon arrival at Resident #61's bedside. LVN A stated the AED was never opened, removed from the case, or from the crash cart. LVN A stated she was so involved in providing CPR chest compressions and recue breaths she did not think about the AED. LVN A stated she was trained for CPR by the American Heart Association. LVN A stated her training included the use of an AED during CPR as soon as the AED is available. LVN A stated she had not documented her role in Resident #61's CPR care to include times and details of care such as the use of an AED, LVN A stated she believed RN C had documented the CPR care. During an interview on [DATE] at 06:00 AM RN C stated on [DATE] she worked from 06:00 AM to 02:00 PM. RN C stated she was providing patient care when CNAs AB and AC told her LVN A needed her, and Resident #61 was unresponsive. RN C stated she ran to Resident #61's bedside and assessed Resident #61 as unresponsive and told LVN A to get the crash cart and call 911. RN C stated she began CPR chest compressions. RN C stated LVN A returned with the crash-cart, and they switched CPR roles and LVN A continued chest compressions while RN C administered oxygenated rescue breaths. RN C stated 911 EMS arrived quickly and continued CPR. RN C stated the facility's AED was stored on the facility's crash-cart and was immediately available when the crash-cart arrived but she nor LVN A gave it a though due to the high stress of providing CPR. RN C stated she and LVN A provided CPR for maybe 5 minutes and 911 arrived quickly. RN C stated she was CPR trained by the American Heart Association. RN C stated her training included the use of an AED during CPR as soon as the AED is available. RN C stated she had not documented her role in Resident #61's CPR care to include times and details of care such as the use of an AED, RN C stated she believed the DON and / or LVN A had documented the CPR care. A record review of the facility's Charting and Documentation policy dated [DATE], revealed, policy statement; all services provided to the Resident, progress towards the care plan goals, or any changes in the Residents' medical, physical, functional, or psychosocial condition, shall be documented in the residence medical record. the medical record should facilitate communication between the interdisciplinary team regarding the residence condition and response to care. policy interpretation and implementation: the following information is to be documented in the resident medical record: objective observations, medications administered, treatments or services perform, changes in the residence condition, events, incidents or accidents involving the Resident . documentation of procedures and treatment will include care specific details, including: the date and the time the procedure treatment was provided; the name and title of the individuals who provided the care; the assessment data and or any unusual findings obtained during the procedure treatment; the signature and title of the individual documenting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 49 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following: Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events for 1 of 1 Resident(s) reviewed (Resident #61) for an adverse CPR event, in that: The DON did not report Resident #61's CPR event for QAPI review. This failure could place residents at risk for adverse health outcome by denying the QAPI committee the data for review. The findings included: A record review of Resident #1's admission record dated, [DATE], revealed an admission date of [DATE] and a death discharge date of [DATE], with diagnoses which included altered mental status, extended spectrum beta lactamase (esbl) resistance [a bacteria that can't be killed by many of the antibiotics that doctors use to treat infections, like penicillin's and some cephalosporins for urinary tract infections], and urinary tract infection. A record review of Resident #1's admission MDS dated [DATE] revealed Resident #61 was an [AGE] year-old male admitted from an acute care hospital for support and rehabilitation related to a urinary tract infection. A record review of Resident #1's death in facility MDS dated [DATE] revealed Resident #61 was an [AGE] year-old male discharged for a death in the facility. A record review of Resident #61's physicians order dated [DATE] revealed RN R documented a physician's order for Resident #61 to receive care as Full Code. A record review of Resident #61's care plan dated [DATE], revealed, Resident #61 has an advance Directive as evidenced by: Full code status Date Initiated: [DATE] .wishes will be honored, Date Initiated: [DATE] .CPR will be performed as ordered A record review of Resident #61's SBAR [Situation, Background, Appearance, and Review] document dated [DATE] revealed, Situation .the change in condition, symptoms, or signs observed, and evaluated is/are: cardiac arrest, respiratory arrest. This started on: [DATE]. Since this started it has gotten: stayed the same .Resident / Patient Evaluation .mental status evaluation: unresponsiveness .Code Status: Full Code .Appearance, summarize your observations and evaluation: CNA notified this nurse of resident being unresponsive assessed resident not responsive no pulse RN supervisor notified initiated CPR crash card access notified 911 CPR performed until paramedics arrived emergency medical technicians continued with CPR resident transfers out with Pulse unconscious accompanied by three emergency medical technicians . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 50 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of the EMS TripTix EMS Patient Care Record dated [DATE] revealed, CPR was performed by the facility staff for 9 minutes from 09:38 AM to 09:47 AM as evidenced by, Incident Date / Times .unit notified by dispatch [DATE] 09:41 [AM] .Unit En Route [DATE] 09:43 [AM] .Unit Arrived on Scene [DATE] 09:45 [AM] .Arrived at patient [DATE] 09:47 [AM] .Unit left scene [DATE] 10:04 [AM] .complaints and impressions; cardiac arrest, onset date and time [DATE] 09:38 [AM], . AED used prior to EMS NO . further review revealed a summary which documented the facility had performed CPR chest compressions and oxygenated recue breathing but had not used the AED, the EMTs provided medications and applied the EMS AED and revealed Resident #61 had regained an irregular heartbeat after EMS care and medications administered intraosseous [directly into the bone marrow]. A record review of Resident #61's medical records did not evidence any detailed documentation related to the CPR care provided, such as when Resident #61 was discovered unresponsive, if an AED was presented for care, if the AED was used, et cetera. A record review of the facility's QAPI monthly meeting roster dated [DATE] which reviewed [DATE] revealed the DON's signature to indicate attendance. During an interview and observation on [DATE] at 02:28 PM the DON stated sometime in [DATE] Resident #61 was discovered unresponsive and was provided emergency CPR care. The DON stated she was not certain if the AED used. The DON stated she believed LVN A, LVN B, and RN C were directly involved with Resident #1's CPR care. The DON stated she had not completed an incident report and had not presented the CPR event to the QAPI committee. The DON stated she attended the QAPI committee meeting monthly and had attended the [DATE], QAPI meeting, the DON stated, Why would I bring it to QAPI? A record review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, policy dated February 2020, revealed, Policy Statement: this facility shall develop, implement, and maintain an ongoing, facility wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation: the objectives of the QAPI program are to: providing means to measure current and potential indicators for outcomes of care and quality of life. provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. reinforce and build upon effective systems and processes related to the delivery of quality care and services. it stablished systems through which to monitor and evaluate corrective action .Implementation: . The QAPI plan describes the process for identifying and correcting quality deficiencies . the committee meets monthly to review reports, evaluate data, and monitor QAPI related activities and make adjustments to the plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 51 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on interview and record review the facility failed to provide a minimum of 80 square feet per resident in 43 of 44 resident rooms (A2 through A8, A10, B3 through B11, C2 through C5, C7, C9, C10, D2 through D7, E3 through E8, and F2 through F8) reviewed for minimum for square footage per resident, in that: Resident rooms A2 through A8, A10, B3 through B11, C2 through C5, C7, C9, C10, D2 through D7, E3 through E8, and F2 through F8 did not have a minimum of 80 square feet per resident. This deficient practice could affect residents residing in rooms due to the reduced living space for the residents and could pose problems in the residents' activities of daily living. The findings were: During an interview on 08/08/2023 at 10:55 a.m., ADMN Y stated he would be requesting a room waiver on the same rooms from last year which did not provide residents with 80 square feet of floor space. Record review of previous room waiver revealed: Resident rooms A2, A3, A5 through A8, and A10 measured 13 feet 7 inches by 11 feet 5 inches which provided 157.55 square feet of floor space. Dividing the 157.55 square feet of usable floor space by 2 resulted in 78.77 square feet of floor space per resident in these rooms. Room A4 measured 13 feet 6 inches by 11 feet 7 inches which provided 159.12 square feet of usable floor space. Dividing the 159.12 square feet of usable floor space by 2 resulted in 79.56 square feet of floor space per resident in this room. Room B3 measured 13 feet 6 inches by 11 feet 10 inches which provided 150.96 square feet of floor space. Dividing the 150.96 square feet of usable floor space by 2 resulted in 75.48 square feet of floor space per resident in this room. Rooms B4 through B6, B8 through B11, C7, C9, D4, E4, E7 and E8 measured 13 feet 6 inches by 11 feet 5 inches which provided 156.4 square feet of floor space. Dividing the 156.4 square feet of usable floor space by 2 resulted in 78.2 square feet of floor space per resident in these rooms. Room B7, C4, D3, and F7 measured 13 feet 6 inches by 11 feet 6 inches which provided 157.76 square feet of floor space. Dividing the 157.76 square feet of usable floor space by 2 resulted in 78.88 square feet of floor space per resident in these rooms. Room C2, C3, and C5 measured 13 feet 5 inches by 11 feet 5 inches which provided 155.25 square feet of floor space. Dividing the 155.25 square feet of usable floor space by 2 resulted in 77.63 square feet of floor space per resident in these rooms. Room C10, E5, F2, F3, F5, F6. and F8 measured 13 feet 7 inches by 11 feet 5 inches which provided 158.92 square feet of floor space. Dividing the 158.92 square feet of usable floor space by 2 resulted in 79.46 square feet of floor space per resident in these rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 52 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Room D2, D5 through D7, E3. and E6 measured 13 feet 7 inches by 11 feet 6 inches which provided 157.55 square feet of floor space. Dividing the 157.55 square feet of usable floor space by 2 resulted in 78.77 square feet of floor space per resident in these rooms. Room F4 measured 13 feet 4 inches by 11 feet 4 inches which provided 152.76 square feet of floor space. Dividing the 152.76 square feet of usable floor space by 2 resulted in 76.38 square feet of floor space per resident in this room. Record review of Form 3740, Bed Classifications, signed by the ADMN AA on 08/02/2023 revealed that all resident rooms were double occupancy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 53 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 of 1 facility in that: Residents Affected - Few Resident # #39 was sitting outside on his wheelchair and a live wasp was near him, the wasp were above him under the roof soffit had holes. The facility had 7 live wasp and 7 nests in water puddles and the roof soffits had holes with wasp and wasp nest. This could effect residents sitting outside the facility and could result in residents being stung The findings were: Record review of Resident #39's admission Record dated 8/4/2023 revealed he was admitted to the facility on [DATE], age [AGE], with diagnoses of muscle wasting and atrophy, aphasia (loss of ability to understand or express speech, caused by brain damage), diabetes II ( a metabolic disease, involving inappropriately elevated blood glucose levels), hemiplegia and hemiparesis (means you can't move or control the muscles in the affected body part.) following a cerebral infarction, vascular dementia, heart failure, and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). Record review of Resident #39's Quarterly MDS dated [DATE] revealed Section C- cognition BIM score was 99 (severely impaired), and he had short and long-term memory problems. Section G Functional Status for transfer/dressing/personal hygiene and showers revealed the resident required extensive assistance with one person assistance, Record review of Resident #39's care plan dated 6/21/2023 revealed Resident #39 had a strong preference to be outdoors rather than attend activities. Resident #39 sat alone on the patio/porch for long periods of time. Interventions included: coordinate nursing for protection from environment by making sure he stayed hydrated with fluids, wore sunscreen, and proper clothing for the weather. Resident #39 had an ADL self-care performance deficit related to dementia and hemiplegia. The intervention was for transfers/personal hygiene/dressing/showers Resident #39 required extensive assistance by 1 staff to move between surfaces. Resident #39 had a communication problem related to history of stroke and was non-verbal, very unclear speech. Observation on 8/4/2023 between 9:55 AM-10:21 AM, ADMN AA revealed the perimeter (all sides) of the facility and saw 7 live wasps flying around water puddles and around soffits (the underside of an architectural structure such as an arch, a balcony, or overhanging eaves) .7 wasp nests were observed. Observation on 8/4/2023 at 10:02 AM revealed Resident #39 was sitting in front of facility, outside in his wheelchair. Further observation revealed close to the rood soffit there was a hole that a wasp was swarming around. Resident #39 was non-verbal. Interview on 8/4/2023 at 10:22 AM, ADMN AA stated when walking around the perimeter of the facility, he confirmed 7 live wasps flying around water puddles and soffits and 7 wasp nests. Interview on 8/4/2023 at 10:54 AM with the Maintenance Director revealed the pest control company (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 54 of 55 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm came to facility about 3 weeks ago and sprayed around the building for wasp and other insects. The Maintenance Director stated the pest control company came every 2 weeks. Interview on at 8/04/2023 at 12:56 PM, ADMN AA stated the risk for wasps close to the building when residents were outside was they could be stung. Residents Affected - Few Record review of the pest control log/invoice dated 7/20/2023 and August 2023 visits did indicate the pest control company had visited and sprayed wasp and other insects. Record review of the policy date May 2008 revealed Pest Control Our Facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675428 If continuation sheet Page 55 of 55