Health inspection·April 13, 2023

F 0692 12.6 % change to 04/06/2023 to indicate severe weight loss in less than two weeks. Level of Harm - Actual harm 14.8 % change to 04/13/2023 to indicate severe weight loss in less than two weeks. Residents Affected - Few In a follow-up observation and interview on 04/10/2023 at 8:15 AM, Resident #1 stated he guessed he was alright. When asked additional questions, he would answer yeah, yeah. He was pleasantly confused. In an observation on 04/10/2023 at 8:12 AM, Resident #1's breakfast tray was on the tray cart on the 100 hallway. At 8:14 AM CNA L set Resident #1's tray on his bedside table and asked him if he felt like eating to which he replied yes. CNA L took the plate cover off of the plate and placed Resident #1's drinks within reach and then left the room. At 8:16 AM the DON and CNA L entered the room and the DON said Resident #1 required assistance with eating and instructed CNA L to assist Resident #1 with eating. CNA L fed Resident standing up beside his bed. In an interview on 04/10/2023 at 8:30 AM, CNA L stated this was her first day back at work and had not worked with Resident #1 before today. She stated the DON educated her that Resident #1 required assistance with eating. She stated she left the room earlier to see if Resident #1 required a clothing protector but realized he was not wearing clothing and went to get a suitable cover . In an interview on 04/10/2023 at 9:00 AM, Resident #1's RP stated she had to feed Resident #1 on the day he was admitted [DATE]. She stated she was unable to visit him again until 04/04/2023 and when she returned he was not himself due to increased confusion because Resident #1 had not been receiving his lactulose which caused him to not be able to identify himself or her as his RP. She stated he was unable to feed himself and staff were unaware that he required assistance. She said when she returned on 04/04/2023 she told staff they could not just set his tray in front of him and not feed him. She said she believed Resident #1 did not eat for almost three days and was losing weight. Review of Resident #1 weight records in the EMR dated 04/10/2023 revealed no weight records for Resident #1. Review of Resident #1 hospital discharge records dated 04/01/2023 revealed Resident #1 weighed 186 lbs. In an interview on 04/10/2023 at 10:06 AM, the DON stated Resident #1 should have had his weight taken on admission and then weekly for four weeks. She stated his weight was completed on 04/06/2023 and it was 162.5 lbs but it had not been recorded in the EMR and was only documented in the weekly weight book. She stated she was unsure of weight loss due to him not being weighed when he arrived on 04/01/2023. She stated when Resident #1 was admitted he was able to feed himself. She stated Resident #1's RP did report to her on 04/06/2023 concerns of Resident #1 not being able to feed himself and that he required assistance. She stated the Resident #1's RP would assist with him eating and would bring outside food for him when she visited. She stated Resident #1 did not like the pureed food as much as the food brought from outside, but due to concerns of dysphagia (difficulty swallowing) and esophageal varices (enlarged veins in the esophagus, the tube the that connects the throat and stomach) his diet could not be upgraded. She stated they educated their staff regarding Resident #1 requiring feeding assistance on 04/06/2023. In an interview on 04/10/2023 at 2:00 PM, the ADON stated he came in to help with Resident #1's admission on [DATE]. He stated when Resident #1 was admitted he was NPO (no food by mouth) but then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 2 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 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 0692 upgraded to a pureed diet. He stated Resident #1 was able to feed himself upon admission but would only take a bite or two and required assistance to eat more. Level of Harm - Actual harm Residents Affected - Few In an interview on 04/11/2023 at 9:30 AM, LVN M stated Resident #1 was very tired when he was admitted on [DATE] and Resident #1's RP fed him his meals. She stated Resident #1's RP insisted on feeding him and wanted to staff to assist that day as well. She stated Resident #1 was asking for milkshakes or health shakes when he first arrived and they did offer him a health shake. She stated she was unaware of a physician order or other recommendations for Resident #1's diet to be supplemented when his intake was poor. She stated anytime a resident doesn't eat well they offer an alternative or a health shake. She stated later in the week after she was off for a few days she was educated that Resident #1 required assistance with eating at each meal. In an interview on 04/13/2023 at 12:05 PM, the DON stated the facility took a new weight on Resident #1 and he weighed weight 158.5 lbs and was weighed using the mechanical lift. She stated his weight on 04/06/2023 was also completed with the mechanical lift. She stated the dietitian had not evaluated him at this time because she had not returned to the facility and the DON was not aware of any interventions put into place to prevent weight loss. She stated they did implement weekly weight for four weeks. Review of Resident #1 Amount eaten records dated 04/03/2023 - 04/09/2023 revealed Resident #1 ate: 04/03/2023 at 3:47 PM: 76%-100% 04/03/2023 at 3:49 PM: 51%-75% 04/03/2023 at 5:00 PM: Resident Refused 04/04/2023 at 9:13 AM: Resident Refused 04/04/2023 at 1:10 PM: Resident Refused 04/04/2023 at 6:27 PM: Resident Refused 04/08/2023 at 10:21 AM: Resident Refused 04/09/2023 at 1:48 PM: 76%-100% 04/09/2023 at 1:19 PM: 51%-75% 04/09/2023 at 5:00 PM: 76%-100% There were no records for 04/01/2023, 04/02/2023, 04/05/2023-04/07/2023. Review of Complaint/Grievance Follow-up Report dated 04/06/2023 and completed by the DON revealed Resident #1's RP made a complaint regarding multiple issues including Resident not able to feed himself. The resolution was for staff to be educated to feed Resident #1. Review of Complaint/Grievance Follow-up Report dated 04/06/2023 and completed by the ADMIN revealed Resident #2's RP made a complaint regarding multiple issues including Resident #1 needs assistance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 3 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 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 0692 feeding. The resolution was resident added to feeder list and staff inserviced. Level of Harm - Actual harm Review of Inservice Training Report dated 04/06/2023 revealed education with staff in regarding to feeding Resident #1. The summary of the training session included please encourage Resident to get out of bed and come to dining room for meals - resident needs assistance feeding all meals whether that is in dining room or in resident room. Residents Affected - Few Review of Weight Management System policy (undated) revealed residents are weighed at admission, readmission and per physician orders. In addition the policy noted residents are to be weighed on admission and readmission. These weights are to be completed within 24 hours of admission/readmission. Weight how obtained (standing, lift or wheelchair) is to be recorded in the HER clinical record. It further noted residents with a significant weight loss or gain (5%, 7.5% or 10% or more) will be placed on weekly weights x 4 weeks or until weight is stable . If weight concerns are noted/weights are not stable , implement interim nutrition interventions, notify RDN/NTR via referral form and continue weekly weight until stable .All weight changes are considered unplanned unless the MD has documented a plan for desired weight change and the facility has care planned PRIOR to the weight change occurring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 4 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of 12 residents reviewed. Residents Affected - Few The facility failed to ensure Resident #1 received effective treatment of pain which resulted in Resident #1 having untreated pain of 10/10. These failures resulted in an Immediate Jeopardy (IJ) situation on 04/10/2023. While the IJ was removed on 04/13/2023 the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place the resident at risk of medical complications, untreated pain and harm. Findings included: Review of Resident #1's face sheet dated 04/10/2023 revealed Resident #1 was admitted to the facility on [DATE] with a diagnoses of alcoholic cirrhosis of the liver without ascites (alcohol-induced liver disease that does not have fluid build-up in the abdomen), liver cell carcinoma (liver cancer), esophageal varices with bleeding (enlarged veins in the esophagus, the tube the that connects the throat and stomach) and dysphagia (difficulty swallowing). Review of Resident #1's Baseline Care Plan dated 04/03/2023 revealed Resident #1 had an ADL self-care performance deficit related liver cell carcinoma and pain. Resident #1 required extensive assistance for bathing/showering, bed mobility, personal hygiene and toileting. Resident #1 was noted to be under the care of hospice and his level of consciousness was noted to be alert and cognitively intact. Resident #1 was on pain medication therapy (SPECIFY medication) related [not specified] with a goal of the resident will be free of any discomfort or adverse side effects from pain medications through the review date. Interventions included administer analgesic medications as ordered by physician, monitor and document side effects and effectiveness every shift. In addition, Pain Care Planning the goal was the resident will voice a level of comfort from pain through the review date with the intervention to monitor/document for side effects of pain medication and signs/symptoms of non-verbal pain. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/09/2023 hydrocodone-acetaminophen 10-325 MG tablet with instructions to give one tablet every four hours as needed for pain. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/07/2023 hydrocodone-acetaminophen 10-325 MG tablet with instructions to give one tablet four times a day for pain. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/02/2023 morphine sulfate (concentrate) oral solution with instructions to give 0.25 ml by mouth every 1 hours as needed for pain and shortness of breath. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 5 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/02/2023 morphine sulfate (concentrate) oral solution with instructions to give 0.5 ml by mouth every 1 hours as needed for pain and shortness of breath. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/02/2023 morphine sulfate (concentrate) oral solution with instructions to give 0.75 ml by mouth every 1 hours as needed for pain and shortness of breath. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/02/2023 morphine sulfate (concentrate) oral solution with instructions to give 1.0 ml by mouth every 1 hours as needed for pain and shortness of breath. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/05/2023 acetaminophen suppository 650 mg with instructions to insert one suppository rectally every 12 hours as needed for pain. In an observation on 04/10/2023 at 8:11 AM, Resident #1 was in bed lying on his side facing the wall and was not wearing clothing. Resident #1's backside was visible from the doorway of the room. TX Nurse adjusted Resident #1's catheter and then closed the door to his room. In a follow-up observation and interview on 04/10/2023 at 8:15 AM, Resident #1 stated he guessed he was alright. When asked additional questions, he would answer yeah, yeah. He was pleasantly confused. In an interview on 04/10/2023 at 9:00 AM, Resident #1's RP's stated Resident #1 was treated horribly since being admitted to the facility. She stated staff do not care if Resident #1 dies with dignity. She stated there have been issues that she reported and were still unresolved. She stated Resident #1 was admitted under hospice care on 04/01/2023 and she stayed with him throughout that day. She stated she was unable to return to visit Resident #1 until 04/04/2023 and found him lying in his feces with no clothes on and he was very confused. She stated she met with facility administration on 04/06/2023 and thought issues with Resident #1's care was resolved. She said over the past weekend on 04/08/2023 Resident #1 fell and the facility notified the hospice nurse who then notified her. She called up to the facility and asked for information about what happened and LVN A said Resident #1 fell and that Resident #1 was fine. She stated she asked for additional information and LVN A would not give her any additional information about the circumstances around the fall. She stated the facility lost Resident #1's cell phone and she was unable to check on him. She stated she kept trying to call back to the facility find out if Resident #1 was okay as he was on hospice and Resident #1's RP was worried about whether he was comfortable. She stated she called the on call HOSPICE NURSE B and asked that HOSPICE NURSE B check on Resident #1. She stated HOSPICE NURSE B called back and LVN A refused to speak with Resident #1's RP anymore. She stated she became very upset and HOSPICE NURSE B agreed at 10:30 PM on 04/08/2023 to check on Resident #1 at the facility. She stated HOSPICE NURSE B called her later that night around 11:30 PM and said Resident #1 was in 10/10 pain upon arrival at the facility. HOSPICE NURSE B told her LVN A offered a Tylenol suppository for his pain which was not indicated for 10/10 pain. Resident #1's RP said she did not understand why the facility would not treat Resident #1 for pain in the last days of his life when Resident #1 was dying of liver cancer. She stated Resident #1 was a former veteran and deserved to die with dignity with no pain. She said she felt like the facility was trying to get her to move him to a different nursing home by not treating Resident #1 well. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 6 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on 04/10/2023 at 9:18 AM, HOSPICE NURSE B stated she went to the facility on [DATE] around 11:00 PM after Resident #1's RP requested she check on Resident #1 because Resident #1 had a fall at the facility earlier that day. She stated upon arrival at the facility Resident #1 reported to be in pain at a 10/10 level. She told LVN A of his pain level and LVN A said all they had available to him was Tylenol suppository. She told LVN A the hospice physician would give an order for a stronger PRN pain medication as Resident #1 had PRN liquid morphine ordered but the family members did not want the liquid morphine given. She stated LVN A told even if HOSPICE NURSE B got the order for the PRN pain medication it would be tomorrow (04/11/2023) before the facility had the medication from the pharmacy. HOSPICE NURSE B stated she asked if LVN A could use the facility's medication e-kit for the PRN pain medication and LVN A said yes. HOSPICE NURSE B stated she did not know why LVN A had to be reminded that if a resident experienced 10/10 pain a doctor should be notified and PRN newly ordered medication could be given from the e-kit. She stated LVN A did not seem to take Resident #1's report of 10/10 pain seriously. She stated it felt like pulling teeth to get LVN A to administer the PRN pain medication to Resident #1. She stated she gave the order to LVN A and had to say please go to e-kit and get it. She stated the Tylenol suppository would never be indicated for 10/10 pain, especially in a resident dying of terminal liver cancer. In an interview on 04/10/2023 at 10:25 AM, the DON stated in regard to the issues with Resident #1 being in pain on the night of 04/08/2023 she stated LVN A told her she was the one to suggest an order for PRN medication from the e-kit and not HOSPICE NURSE B. The DON stated LVN A said when she assessed Resident #1 for pain that night, Resident #1 said to LVN A he had no pain. She stated she did not know why LVN A refused to speak with Resident #1's RP and his condition after the fall on 04/08/2023. She stated a Tylenol suppository would not be indicated for a 10/10 pain level. In an interview on 04/10/2023 at 2:00 PM, the ADON stated he assisted with Resident #1 care when Resident #1 was admitted to the facility. He stated HOSPICE NURSE B gave them a set of written orders for pain management and other comfort medications. He stated in regards to pain medication for Resident #1, if Resident #1 expressed a 10/10 pain level a Tylenol suppository would not be indicated. He stated a resident's physician will give guidelines regarding what type of pain medication would be indicated for varying levels of pain, for instance at a pain level of four or above a narcotic medication may be indicated. He stated if the resident did not have an appropriate PRN pain medication for 10/10 pain level then the nurse should page the doctor and the medication can be obtained from the e-kit. He stated morphine could have been used for Resident #1 but the family did not want morphine used unless absolutely necessary for Resident #1. An Immediate Jeopardy (IJ) was identified on 04/10/2023 at 4:30 PM, due to the above failures. The Administrator and the DON was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. In an observation on 04/11/2023 at 10:25 AM, HOSPICE NURSE E took the vital signs of Resident #1 and Resident #1 said his bottom and belly hurt bad. Resident #1 stated to HOSPICE NURSE E he was having bad bone pain and it was 10/10. He stated to HOSPICE NURSE E he would like a heating bad pad or warm towel. HOSPICE NURSE E went to nurse's station and notified LVN F of Resident #1 reporting 10/10 pain. In an observation on 04/11/2023 at 10:42 AM, Resident #1 was calling out nurse please help me I'm in real bad pain. In an observation on 04/11/2023 at 10:55 AM, LVN F administered Hydrocodone 10mg/325 mg crushed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 7 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 applesauce to Resident #1. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 04/11/2023 at 10:57 AM, RNC G stated Resident #1's pain medication regimen would need to be reviewed again because his scheduled pain medication was not lasting between doses. She stated they were planning to speak with Resident #1's family about his possible need for morphine. Residents Affected - Few In an observation on 04/11/2023 at 11:04 AM, Resident #1 was sitting up in bed calling for help due to the bad pain. In an interview on 04/11/2023 at 11:06 AM, the DON stated they contacted Resident #1's RP about giving morphine due to his high pain level at this time and Resident #1's RP gave consent for the morphine to be given. In an observation on 04/11/2023 at 11:12 AM, LVN F administered 1 ml of liquid morphine to Resident #1. In an interview on 04/11/2023 at 11:46 AM, RNC G stated Resident #1's mentation (mental activity) was changing throughout the day and it was difficult to tell when he was in pain. She said he would say he was in 10/10 pain and but later tell his RP he was not in pain. She stated regardless nurses should assess and address any reported pain and notify hospice if current pain regimen was not effective. In an observation and interview on 04/11/2023 at 12:23 PM, Resident #1 was sitting up in his wheelchair and showed no signs of distress. ST stated Resident #1 was to complete a bed side evaluation with his lunch and did not report any pain or appear to be distressed. Review of Resident #1 Nursing Pain Evaluation dated 04/03/2023 revealed Resident #1 complained of pain the last five days and interventions were effective. Resident #1 experienced pain score of 5 out of 10 and had general pain to all extremities, abdomen and buttocks. Review of Complaint/Grievance Follow-up Report dated 04/06/2023 received by the DON revealed Resident #1's RP expressed concern regarding multiple issues including Resident #1's pain medications not helping. The final resolution was hospice increased pain medication hydrocodone 10/325 mg from three times per day to four times per day. Review of Social Services progress note dated 04/06/2023 revealed Resident #1's RP requesting changes in pain medication stating Resident #1 is in pain and feels current regimen needs review. Resident #1 states he does not like morphine and feels most in pain around 4-5 PM. Hospice Nurse H alerted and came to facility to visit with this writer, RP and resident. During visit with Hospice Nurse H, Resident #1 denied any current pain. Review of Complaint/Grievance Follow-up Report dated 04/06/2023 received by the ADMIN revealed Resident #1 RP2 expressed concern Resident #1 was in a lot of pain, wants more pain medications. Review of Resident #1 Nursing progress notes dated 04/08/2023 at 8:15 PM revealed heard Resident #1 yelling for help. Upon entering room noted resident lying on floor mat with blanket behind head. Asked if resident had any pain. Repeated he was fine. No moaning, groaning, grimacing, or guarding noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 8 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident #1 Nursing Pain Evaluation dated 04/08/2023 at 8:15 PM revealed Resident #1 had not complained of pain in the last five days. No further questions were answered on the evaluation. Review of Resident #1 Nursing Pain Evaluation dated 04/10/2023 revealed Resident #1 had not complained of pain the last five days. Review of Resident #1 Nursing progress notes dated 04/09/2023 at 12:40 AM documented by LVN A, revealed HOSPICE NURSE B in facility for follow up visit related to fall. Per HOSPICE NURSE B during assessment resident reporting 10/10 to bottom. Received new order for: Hydrocodone/apap 10/325 mg one tablet orally (crushed) every four hours for pain. RP aware of order currently on phone with HOSPICE NURSE B at time of visit when order given . Upon the nurse assessment resident declined bottom hurting 10/10. Although resident did report all over body pain. Administered PRN medication as per MD order. Review of Medication Administration Policy dated 10/24/2022 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of Pain Management Policy dated 08/15/2022 revealed the facility must ensure that pain management is provided to resident who require such services . 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain . The Plan of Removal was accepted on 04/13/2023 at 8:10 AM and is as follows: LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On April 10, 2023, at approximately 4:30pm the Administrator was notified by the surveyor that an Immediate Jeopardy had been called for Resident #1. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag: 760 Significant Medication Error Identify residents who could be affected Fourteen residents with orders for Lactulose Problem: The facility did not administer Lactulose to resident #1. Action Taken: Effective immediately on 4/10/2023, the DON reviewed orders for resident #1 to ensure order for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 9 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Lactulose was in place. Fourteen residents are noted with orders for Lactulose. Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Few The DON/designee will review and be responsible for monitoring new orders including those for admissions/readmissions and validating that orders are transcribed correctly during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing Effective immediately on 4/10/2023, DON audited resident #1's chart to ensure an order for prn Hydrocodone- Acetaminophen was in place. o The DON/designee reeducated facility nurses on obtaining prn orders when indicated, medication administration, medication reconciliation, and facility emergency kit. The DON/designee will be responsible for continued reeducation of facility nurses on topics above. Start date 4/10/2023 and ongoing. ? Reviewed and monitored by Administrator and DON. Start date 4/10/2023 and ongoing. o The DON/designee will review and be responsible for monitoring administration of prn medication use during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/11/2023 and ongoing. ? Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing. Effective immediately on 4/10/2023, the DON/Assessment Nurse conducted medication order reconciliation for all thirteen residents on hospice services to ensure all medications were accounted for and match physician's orders. Medication order reconciliation was started on 4/10/2023 and finished on 4/11/2023 in the am. o The DON/designee will review and be responsible for monitoring new orders including those for admissions/readmissions during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing Effective immediately on 4/10/2023, the Assessment Nurse completed a pain evaluation on resident #1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 10 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 o Level of Harm - Immediate jeopardy to resident health or safety The DON/designee reeducated facility nurses assessing a resident for pain and providing consideration for administering pain medications for prn use. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/10/2023 and ongoing Residents Affected - Few Effective immediately on 4/10/2023, the Administrator/Assessment Nurse reeducated contracted hospice companies on process for sending orders via fax and confirming receipt via phone. Five hospice companies are noted to be contracted with the facility and were all reeducated on the above process. Reeducation started 4/10/2023 and was completed 4/11/2023. o The Administrator/designee will educate any new hospice company onboarded in the future and will monitor compliance with above process. Start date 4/11/2023 and ongoing Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 4/10/2023. The Administrator will review the follow up findings from this plan with the Medical Director weekly. Involvement of QA: On 4/10/2023 an Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, Regional Clinical Specialist, Assistant Director of Nursing, Assessment Nurse, Regional [NAME] President of Operations, and Pharmacy Consultant to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the new process. The new process/system was started on 4/11/2023. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 4/10/2023. Monitoring was completed from 04/13/2023 and was as follows: In an interview on 04/13/2023 at 10:09 AM, LVN D stated she received education regarding physician order process at the facility. She stated she would read and confirm the order and confirm the right patient, right time, right route etc before administering medication. She stated if a resident was out of medication or needed a PRN medication immediately, they could use medication from the e-kit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 11 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Immediate jeopardy to resident health or safety LVN D stated she was educated for assessing a resident for pain and administering pain medications for PRN use. LVN D stated she was educated regarding medication reconciliation and ensuring physician orders matched the prescription order. In an observation and interview on 04/13/2023 at 10:15 AM, Resident #1 was in bed wearing clothes with no visible signs of distress. He reported no pain and did not need anything. Residents Affected - Few In an interview on 04/13/2023 at 10:25 AM, LVN J stated he received education regarding medication administration, medication reconciliation and use of the e-kit medication if a medication was unavailable. He stated he received education on assessing a resident's pain level and using non-verbal cues if needed. In an interview on 04/13/2023 at 11:24 AM, LVN K stated she received education regarding pain assessments and paging doctor if a PRN medication was indicated. She stated if they did not have the medication she would use the e-kit. She received education regarding medication reconciliation in comparison with physician orders to ensure residents received the medication they needed. Interviews with additional medication aides on 04/13/2023 revealed they would notify charge nurse if a resident complained of pain. Staff would notify charge nurse if a resident was out of a medication and the nurse could access the medication from the e-kit. Review of Resident #11 Nursing Pain Evaluation dated 04/11/2023 revealed Resident #1 complained of pain the last five day and interventions were effective. Review of QAPI Action Team Report dated 04/10/2023 revealed QAPI team members held an ad hoc QAPI meeting regarding F-tag 760. Summary of data collection included: Medication administration audit report Medication summary report for all resident currently on hospice Medication cart audit to ensure medication availability Steps to resolution included: Medication cart audit Medication order reconciliation (with hospice) Staff education on medication reconciliation Medication Administration and Ekit Hospice companies educated on process for calling in/receiving medication orders Auditing of new orders for admissions/readmissions during daily clinical meetings Goal: To maintain compliance of pharmacy services and ensure that residents are free of any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 12 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety Projected completion date: 04/11/2023 Residents Affected - Few Review of Inservice Training Report dated 04/10/2023 - 04/13/2023 revealed Nursing training on Emergency Kit with summary of while waiting for ordered medications to arrive from pharmacy, nurses may use medication from e-kit on hand and follow-up with pharmacy until the medication is at hand. Utilize electronic e-kit for emergency control medication for control meds. Review of Inservice Training Report dated 04/10/2023 - 04/13/2023 revealed Nursing training on medication reconciliation and signed by nursing staff. There were a total of 50 staff who attended the training. Review of Inservice Training Report dated 04/10/2023 revealed Nursing training on medication administration and reconciliation policy and procedure. Completed by the DON. There were a total of 50 staff who attended the training. Review of Inservice Training Report dated 04/10/2023 revealed the ADMIN was educated on monitoring the facility's medication administration and reconciliation system. Review of Inservice Training Report dated 04/10/2023 revealed nursing staff educated regarding monitoring of medication administration/order process. Review of Inservice Training Report dated 04/11/2023 revealed education completed by nursing facility staff with hospice companies regarding if faxing orders call facility for confirmation of received. Preferred method is a telephone order or written order. On 04/13/2023 at 12:30 PM, the administrator was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated, due to the facility need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 13 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents are free from any significant medication error for one resident (Resident #1) out of 12 residents reviewed for significant medication errors. Residents Affected - Few The facility failed to ensure Resident #1 received lactulose as ordered by the physician which caused a rise in ammonia levels which was exhibited by Resident #1 having increased confusion and decreased cognition. These failures resulted in an Immediate Jeopardy (IJ) situation on 04/10/2023. While the IJ was removed on 04/13/2023 the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place the resident at risk of medical complications, not receiving the therapeutic effects of their medications and harm. Findings included: Review of Resident #1's face sheet dated 04/10/2023 revealed Resident #1 was admitted to the facility on [DATE] with a diagnoses of alcoholic cirrhosis of the liver without ascites (alcohol-induced liver disease that does not have fluid build-up in the abdomen), liver cell carcinoma (liver cancer), esophageal varices with bleeding (enlarged veins in the esophagus, the tube the that connects the throat and stomach) and dysphagia (difficulty swallowing). Review of Resident #1's Baseline Care Plan dated 04/03/2023 revealed Resident #1 had an ADL self-care performance deficit related liver cell carcinoma and pain. Resident #1 required extensive assistance for bathing/showering, bed mobility, personal hygiene and toileting. Resident #1 was noted to be under the care of hospice and his level of consciousness was noted to be alert and cognitively intact. Resident #1 was on pain medication therapy (SPECIFY medication) related [not specified] with a goal of the resident will be free of any discomfort or adverse side effects from pain medications through the review date. Interventions included administer analgesic medications as ordered by physician, monitor and document side effects and effectiveness every shift. In addition, Pain Care Planning the goal was the resident will voice a level of comfort from pain through the review date with the intervention to monitor/document for side effects of pain medication and signs/symptoms of non-verbal pain. Review of hospice physician orders dated 04/01/2023 revealed Resident #1 ordered Lactulose 10g/15 mL syrup effective date 04/01/2023 with instructions to give 15 mL by mouth twice a day. Review of fax confirmation page dated 04/01/2023 revealed physician orders faxed to [FACILITY FAX NUMBER] on 04/01/2023 with transmission complete 04/01/2023 at 7:33 PM with Job ID 838944911 and the status as Success. The document further revealed new orders for Lactulose 10g/15mL syrup effective date 04/01/2023 with instructions to give 15 mL by mouth twice a day. Review of Resident #1's physician orders dated 04/10/2023 revealed Resident #1 was ordered on 04/05/2023 lactulose oral solution 10GM/15ml with instructions to give 15 ml by mouth two times per day for cirrhosis (used to treat high blood levels of ammonia resulting from impaired liver function). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 14 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 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 - Immediate jeopardy to resident health or safety In an observation on 04/10/2023 at 8:11 AM, Resident #1 was in bed lying on his side facing the wall and was not wearing clothing. Resident #1's backside was visible from the doorway of the room. TX Nurse adjusted Resident #1's catheter and then closed the door to his room. In a follow-up observation and interview on 04/10/2023 at 8:15 AM, Resident #1 stated he guessed he was alright. When asked additional questions, he would answer yeah, yeah. He was pleasantly confused. Residents Affected - Few In an interview on 04/10/2023 at 9:00 AM, Resident #1's RP's stated Resident #1 was treated horribly since being admitted to the facility. She stated staff do not care if Resident #1 dies with dignity. She stated there have been issues that she reported and were still unresolved. She stated Resident #1 was admitted under hospice care on 04/01/2023 and she stayed with him throughout that day. She stated she was unable to return to visit Resident #1 until 04/04/2023 and found him lying his feces with no clothes on and he was very confused. She stated Resident #1 was not aware of his name and was not himself. She asked the charge nurse about his medications and thought maybe Resident #1 was given some type of sedative making him more confused. She said after reviewing Resident #1's medication list with the charge nurse she realized he was not receiving his lactulose medication and had not been receiving it since he was admitted to the facility. She said his increased confusion was due to the ammonia buildup from not having the lactulose medication. She said she was upset about him not receiving his medications as now he did not recognize her or other loved ones in the last days of his life. She stated the charge nurse said they did not receive the order for him to receive lactulose. She said Resident #1 suffered a fall with head laceration that required a trip to the ER on [DATE]. Resident #1's RP said Resident #1 not having the lactulose likely caused him to fall due to increased confusion. She said he did not eat for three days from what the staff told her because he was so confused. She said she felt like the facility was trying to get her to move him to a different nursing home by not treating Resident #1 well. In an interview on 04/10/2023 at 9:18 AM, HOSPICE NURSE B was the on call nurse who admitted Resident #1 to the hospice agency on 04/01/2023 at the same time that he was admitted to the facility. She had the physician order the standard comfort medications for hospice residents and then texted the hospice physician about whether to order lactulose due to Resident #1 having liver failure. She stated Resident #1 was on lactulose at the hospital when he was discharged to the facility on [DATE]. She stated the hospice physician sent back to order the lactulose and she faxed the orders to the facility and called to confirm they received the orders. HOSPICE NURSE B stated the lactulose was ordered through the pharmacy and the medication wasn't time stamped when it was delivered but the order did say 04/01/2023. She said she did not know why Resident #1 did not receive the lactulose from 04/01/2023 - 04/04/2023. In an interview on 04/10/2023 at 10:25 AM, the DON stated she was unaware of the issues with Resident #1's lactulose not being given when he was admitted . She said the order was not received from the hospital or hospice for the lactulose to be given. She stated when a new resident was admitted the charge nurse reviewed the orders from the hospital and then entered the orders into the EMR. In an observation and interview on 04/10/2023 at 11:10 AM, CMA C stated there was no order for lactulose for Resident #1 when he was first admitted . She stated when she administered medications, the order would have popped up for the lactulose as she administered medications. She stated one day last week one of the hospice nurses wanted to review Resident #1's orders because he did not receive lactulose. She stated the hospice nurse was able to clarify with nursing staff the order for the lactulose with Resident #1 that day. The medication cart contained one bottle of lactulose dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 15 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 04/02/2023 prescribed to Resident #1. CMA C stated this was the second bottle of lactulose as the bottle was observed to be nearly full. In an interview on 04/10/2023 at 12:12 PM, the ADMIN stated they did not receive the order for the lactulose until 04/04/2023. She stated she brought a copy of the hand written orders that had not been scanned into the EMR from the admitting hospice nurse on 04/01/2023 and lactulose was not on the orders. She stated she was not aware of additional orders being sent over by the hospice nurse. She said if the hospice nurse did not follow their protocol for how orders were to be sent it was not their fault that a physician order was not received. She said she did not know whether the hospice nurse had followed the facility's protocol. She said all hospice providers know how to send physician orders either hand written in facility or a verbal over the phone. She said if they fax the order they should call afterward to verify it was received. She stated she and the DON were in the process of setting up a care plan meeting with Resident #1's RP because Resident #1's RP expressed multiple concerns regarding Resident #1's care. In an interview on 04/10/2023 at 12:29 PM, LVN D stated Resident #1's RP visited on Tuesday 04/04/2023 and thought Resident #1 was sedated because Resident #1 did not recognize Resident #1's RP and did not know his own name. She stated Resident #1's RP wanted to know what medications Resident #1 had been given. She stated there was no order for lactulose and they paged the hospice nurse who gave the order LVN D for the lactulose. She stated she was not at the facility when the lactulose was delivered. She said she was not sure when the first bottle of lactulose was delivered for Resident #1 to the facility. In an interview on 04/10/2023 at 12:53 PM, the HOSPICE MD stated lactulose was used to treat hepatic encephalopathy (loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage) caused by liver failure which causes a build up of ammonia in a resident's blood. He stated the buildup of ammonia causes severe and rapid decline in cognition but can be reversed with the administration of lactulose. He stated symptoms of the build up of ammonia in the blood were confusion, poor memory/cognition and possibly hallucinations. He stated he remembered giving the physician order for Resident #1 to have lactulose when he was admitted [DATE] to hospice as Resident #1 received lactulose while hospitalized . He stated HOSPICE NURSE B would have been responsible for relaying the order to the facility. In an interview on 04/10/2023 at 2:00 PM, the ADON stated he assisted with Resident #1 care when Resident #1 was admitted to the facility. He stated HOSPICE NURSE B gave them a set of written orders for pain management and other comfort medications. He stated there confusion with Resident #1's orders upon admission because the hospital sent no medication orders for Resident #1. He stated HOSPICE NURSE B did not arrive until later in the day on 04/01/2023 to give orders. He stated normally if a new resident was admitted without orders they would contact the hospital for orders. He stated they waited for the hospice agency to provide the orders since sometimes medications were not approved when a resident was on hospice. He stated there was not an order received for the lactulose upon admission. He stated he was unaware of fax received with the physician order for lactulose. He stated physician orders were received as verbal, written in person or by fax. An Immediate Jeopardy (IJ) was identified on 04/10/2023 at 4:30 PM, due to the above failures. The Administrator and the DON was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. Review of Resident #1's MAR dated April 2023 revealed Resident #1 received the first dose of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 16 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 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 lactulose at the facility on 04/05/2023 at 8:00 PM. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 04/11/2023 at 1:32 PM, the MED DIR stated physician order clarification can take time and lactulose was not a critical medication. He stated increased ammonia levels caused confusion from hepatic encephalopathy and caused a change in baseline mentation. He stated he could not say the importance of whether a resident at end of life might want to have less confusion and clearer mentation. He stated he could not say what impact it may have for Resident #1 and his family members visiting when it was noted Resident #1 could not recognize himself or them in the final stages of Resident #1's life after being admitted to the facility. He stated the facility was also starting Resident #1 on physical therapy and he did not see the point in that either when Resident #1 was on hospice. Residents Affected - Few Review of Medication Administration Policy dated 10/24/2022 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of Hospice and Nursing Facility Service Agreement dated 04/01/2018 revealed all physician orders communicated to the nursing facility on behalf of Hospice in connection with Hospice Plan of Care shall either be in writing and signed by applicable attending physician, consulting physician, or hospice medical director or be communicated by the attending physician, consulting physician or hospice medical director orally or by facsimile transmission and promptly confirmed in writing thereafter. Review of Lactulose Medication from National Library of Medicine from the National Center of Biotechnology Information dated 07/11/2022 revealed Lactulose is used in preventing and treating clinical portal-systemic encephalopathy. Its chief mechanism of action is by decreasing the intestinal production and absorption of ammonia. It further revealed treatment with lactulose will reduce ammonia levels to decrease symptoms of encephalopathy which include confusion, decreased cognition and personality or mood changes. The Plan of Removal was accepted on 04/13/2023 at 8:10 AM and is as follows: LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On April 10, 2023, at approximately 4:30pm the Administrator was notified by the surveyor that an Immediate Jeopardy had been called for Resident #1. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag: 760 Significant Medication Error Identify residents who could be affected Fourteen residents with orders for Lactulose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 17 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 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 Problem: Level of Harm - Immediate jeopardy to resident health or safety The facility did not administer Lactulose to resident #1. Residents Affected - Few Effective immediately on 4/10/2023, the DON reviewed orders for resident #1 to ensure order for Lactulose was in place. Fourteen residents are noted with orders for Lactulose. Action Taken: o The DON/designee will review and be responsible for monitoring new orders including those for admissions/readmissions and validating that orders are transcribed correctly during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing Effective immediately on 4/10/2023, DON audited resident #1's chart to ensure an order for prn Hydrocodone- Acetaminophen was in place. o The DON/designee reeducated facility nurses on obtaining prn orders when indicated, medication administration, medication reconciliation, and facility emergency kit. The DON/designee will be responsible for continued reeducation of facility nurses on topics above. Start date 4/10/2023 and ongoing. ? Reviewed and monitored by Administrator and DON. Start date 4/10/2023 and ongoing. o The DON/designee will review and be responsible for monitoring administration of prn medication use during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/11/2023 and ongoing. ? Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing. Effective immediately on 4/10/2023, the DON/Assessment Nurse conducted medication order reconciliation for all thirteen residents on hospice services to ensure all medications were accounted for and match physician's orders. Medication order reconciliation was started on 4/10/2023 and finished on 4/11/2023 in the am. o The DON/designee will review and be responsible for monitoring new orders including those for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 18 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 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 - Immediate jeopardy to resident health or safety admissions/readmissions during the daily morning clinical meeting attended by the Interdisciplinary Team including the Director of Nursing or designee. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing Effective immediately on 4/10/2023, the Assessment Nurse completed a pain evaluation on resident #1. Residents Affected - Few o The DON/designee reeducated facility nurses assessing a resident for pain and providing consideration for administering pain medications for prn use. Start date 4/10/2023 and ongoing. Reviewed and monitored by Administrator and DON. Start date 4/10/2023 and ongoing Effective immediately on 4/10/2023, the Administrator/Assessment Nurse reeducated contracted hospice companies on process for sending orders via fax and confirming receipt via phone. Five hospice companies are noted to be contracted with the facility and were all reeducated on the above process. Reeducation started 4/10/2023 and was completed 4/11/2023. o The Administrator/designee will educate any new hospice company onboarded in the future and will monitor compliance with above process. Start date 4/11/2023 and ongoing Reviewed and monitored by Administrator and DON. Start date 4/11/2023 and ongoing. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 4/10/2023. The Administrator will review the follow up findings from this plan with the Medical Director weekly. Involvement of QA: On 4/10/2023 an Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, Regional Clinical Specialist, Assistant Director of Nursing, Assessment Nurse, Regional [NAME] President of Operations, and Pharmacy Consultant to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the new process. The new process/system was started on 4/11/2023. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 19 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 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 on 4/10/2023. Level of Harm - Immediate jeopardy to resident health or safety Monitoring was completed from 04/13/2023 and was as follows: Residents Affected - Few In an interview on 04/13/2023 at 10:09 AM, LVN D stated she received education regarding physician order process at the facility. She stated she would read and confirm the order and confirm the right patient, right time, right route etc before administering medication. She stated if a resident was out of medication or needed a PRN medication immediately, they could use medication from the e-kit. LVN D stated she was educated for assessing a resident for pain and administering pain medications for PRN use. LVN D stated she was educated regarding medication reconciliation and ensuring physician orders matched the prescription order. In an observation and interview on 04/13/2023 at 10:15 AM, Resident #1 was in bed wearing clothes with no visible signs of distress. He reported no pain and did not need anything. In an interview on 04/13/2023 at 10:25 AM, LVN J stated he received education regarding medication administration, medication reconciliation and use of the e-kit medication if a medication was unavailable. He stated he received education on assessing a resident's pain level and using non-verbal cues if needed. In an interview on 04/13/2023 at 11:24 AM, LVN K stated she received education regarding pain assessments and paging doctor if a PRN medication was indicated. She stated if they did not have the medication she would use the e-kit. She received education regarding medication reconciliation in comparison with physician orders to ensure residents received the medication they needed. Interviews with additional medication aides on 04/13/2023 revealed they would notify charge nurse if a resident complained of pain. Staff would notify charge nurse if a resident was out of a medication and the nurse could access the medication from the e-kit. Review of Resident #11 Nursing Pain Evaluation dated 04/11/2023 revealed Resident #1 complained of pain the last five day and interventions were effective. Review of QAPI Action Team Report dated 04/10/2023 revealed QAPI team members held an ad hoc QAPI meeting regarding F-tag 760. Summary of data collection included: Medication administration audit report Medication summary report for all resident currently on hospice Medication cart audit to ensure medication availability Steps to resolution included: Medication cart audit Medication order reconciliation (with hospice) Staff education on medication reconciliation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 20 of 21 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 675434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Pines Nursing and Rehabilitation Center 503 Old Austin Highway Bastrop, TX 78602 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 Medication Administration and Ekit Level of Harm - Immediate jeopardy to resident health or safety Hospice companies educated on process for calling in/receiving medication orders Residents Affected - Few Goal: To maintain compliance of pharmacy services and ensure that residents are free of any significant medication errors. Auditing of new orders for admissions/readmissions during daily clinical meetings Projected completion date: 04/11/2023 Review of Inservice Training Report dated 04/10/2023 - 04/13/2023 revealed Nursing training on Emergency Kit with summary of while waiting for ordered medications to arrive from pharmacy, nurses may use medication from e-kit on hand and follow-up with pharmacy until the medication is at hand. Utilize electronic e-kit for emergency control medication for control meds. Review of Inservice Training Report dated 04/10/2023 - 04/13/2023 revealed Nursing training on medication reconciliation and signed by nursing staff. There were a total of 50 staff who attended the training. Review of Inservice Training Report dated 04/10/2023 revealed Nursing training on medication administration and reconciliation policy and procedure. Completed by the DON. There were a total of 50 staff who attended the training. Review of Inservice Training Report dated 04/10/2023 revealed the ADMIN was educated on monitoring the facility's medication administration and reconciliation system. Review of Inservice Training Report dated 04/10/2023 revealed nursing staff educated regarding monitoring of medication administration/order process. Review of Inservice Training Report dated 04/11/2023 revealed education completed by nursing facility staff with hospice companies regarding if faxing orders call facility for confirmation of received. Preferred method is a telephone order or written order. On 04/13/2023 at 12:30 PM, the administrator was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated, due to the facility need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 21 of 21