Health inspection·November 15, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few providing care to Resident #1 yesterday 9/24/2023 around 7:30 AM. In the video, CNA A can be seen changing the resident's brief, appearing frustrated/impatient. Then, at one point, the CNA was putting on the resident's shirt, and as she did this, the resident was fidgety with her arms. The resident grabbed the CNA's arm with her left hand, and at this point, the CNA took her own left hand and slapped/swatted the resident's left hand/wrist area and said let go. After viewing this, the administrator initiated protocols immediately. Facility Action-Initiated investigation -RP aware -MD notified -Administrator and DON aware -Perpetrator CNA A was terminated immediately -Head to toe assessment conducted on Resident #1 - no visible injuries noted, no redness, bruising, swelling, or marks noted. -X-rays ordered of resident's left wrist/hand end results negative -police department notified and officer arrived on site -Continuous monitoring of resident - no signs or symptoms of emotional or physical distress -Interviews conducted with residents- no other reports of abuse -Skin assessments conducted on all residents- no injuries, new issues, or signs of abuse noted ConclusionIt is confirmed that abuse occurred toward Resident #1. Review of a video provided on 11/13/23 by FM for Resident #1 reflected the following. CNA A was placing socks on then shoes as Resident #1 lay in her bed and said, Come on, get up, we're going to get in your chair. She tried to pull Resident #1's legs around to the side of the bed and then pulled the legs harder when Resident #1 did not move the first time. CNA A took Resident #1 by the shoulder with her left hand and the neck with her right hand, and said Come on, sit up. Sit up. I know you can. CNA A put Resident #1's shirt on, during which Resident #1 continued to try to place her own hands together, and CNA A pulled Resident #1's hands apart quickly and forcefully. As CNA A was putting on the shirt, Resident #1 placed her hand on CNA A's wrist, and CNA A said, let go, yanked her hand away, and looked up to the ceiling for a moment. Resident #1 placed her hand on CNA A's wrist again, and CNA A slapped Resident #1's arm and said, let go much louder. CNA finished getting Resident #1 dressed and assisted her into the wheelchair without warmth or tenderness but without further incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 2 of 5 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 11/15/2023 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 0600 Review of a skin assessment for Resident #1 dated 09/25/23 reflected no new skin issues. Level of Harm - Minimal harm or potential for actual harm Review of x-ray findings for Resident #1 dated 09/25/23 reflected the following: Findings: no fracture, dislocation, lytic or blastic process (types of bone lesions) is demonstrated. No significant degenerative changes noted. Residents Affected - Few Review of safe resident surveys conducted 09/25/23 reflected no residents disclosed any additional abuse. Review of in-services from August 2023 through November 2023 reflected an in-service on abuse, neglect, and reporting procedures conducted on 09/25/23. Review of nursing progress notes for Resident #1 dated 09/25/23 reflected the following documented by LVN B: Observation: resident continues day at baseline behaviors, no, crying, no facial, grimacing, no clenching, no body tensing. Resident was assisted out of bed and closed via nurse aids times to staff. Resident consumed breakfast without baseline. Meal consumption change observed. Resident administered morning medication's without complications. 9/25 stat x-rays of left hand and left. Wrist resulted and communicated out for MD review. Spoke with family, nurse practitioner made aware, no new orders received. Progress notes also reflected that Resident #1 was assessed for psychosocial harm daily by the SW from 09/25/23 to 09/29/23 with no findings of psychosocial harm. Review of a physician progress note dated 09/29/23 reflected the following: (Resident #1) denies new complaints and is minimally responsive, profound cognitive debility. Discussed concern for maltreatment isolated episode. To my knowledge and according to what I've witnessed, she is generally well cared for and loved within the facility. Review of a psych services note dated 10/12/23 reflected Resident #1 was not exhibiting any latent signs of trauma. Review of activity notes for Resident #1 from September 2023 through 11/15/23 reflected she participated in activities 4-7 times a week both before the incident on 09/25/23 and after with no documented decline in participation. Review of seven undated personnel files for floor staff, including CNA A, reflected required background checks, reference checks from previous jobs, and orientation/training on abuse/neglect/exploitation, resident rights, and dementia care. Observation on 11/13/23 at 10:42 AM revealed Resident #1 seated in her high-backed wheelchair in the dining room. She did not reply to efforts to interview her but did not demonstrate fear or agitation. During an interview on 11/13/23 at 11:01 AM, a detective from the local police department stated that CNA A had been arrested for Injury to an Elderly Person after he viewed the video of CNA A slapping Resident #1 on 09/25/23. He stated his investigation was complete, and the matter was now in the hands of the district attorney. During an interview on 11/13/23 at 01:21 PM, a FM for Resident #1 stated he watched the video from Resident #1's room in the facility on 09/25/23. He stated the video was of her being dressed for breakfast on 07:30. The FM stated he had watched the video often for the first several weeks they had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 3 of 5 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 11/15/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few installed it, but he had stopped watching it so often. He stated he wanted to see the staff put Resident #1 to bed, and so he went on the site and then jumped around a little and happened to see CNA A working with Resident #1, and it made him concerned so he kept watching. He stated CNA A seemed agitated going back and forth in the video, and her agitation made him keep watching. The FM stated CNA A was yanking on Resident #1's clothes to undress her and telling Resident #1 what to do. The FM stated Resident #1 had a habit of picking at things and placing her hands on things, and she also liked to hold her hands together and withdraw as part of her normal posture. The FM stated he kept watching and saw CNA A slap Resident #1's hands and brought the video to the ADM. The FM stated he was very satisfied with how the ADM handled the situation. The FM stated he was not sure if he wanted Resident #1 to be seen by a psychologist after the incident, but he finally agreed to it after thinking about it for a while. He stated he had seen no difference in Resident #1's demenor since the incident. A telephone interview was attempted on 11/13/23 at 2:05 PM with CNA A. She did not answer, and no return contact had been initiated as of 11/22/23. During an interview on 11/15/23 at 02:13 PM, the ADM stated the FM for Resident #1 came to her office on 09/25 with his computer tablet and wanted to show her something to see if she thought it was concerning or if he was overreacting. She stated the FM brought up the video and she watched it. The ADM stated CNA A was getting Resident #1 up for the day and changed her brief and then sat her up and began to put clothes on her. The ADM stated she noticed CNA A seemed impatient with the resident just looking at CNA A's body language. The ADM stated CNA A was putting on Resident #1's shirt, and Resident #1 had her hands up, which was very normal for her. The ADM stated Resident #1 gently grabbed onto CNA A's right wrist and at that point the CNA released her hand from Resident #1, slapped Resident #1's hand, and said, let go. The ADM stated she immediately sent LVN B to assess Resident #1 and called CNA A to come in. The ADM stated she called the police and asked LVN B to order an x-ray to be on the safe side. The ADM stated the police officer took statements from her and the FM of Resident #1 and visited with Resident #1, taking some pictures of her. The ADM stated CNA A arrived at the facility at that time, and the ADM interviewed her. The ADM stated CNA A denied that she had slapped Resident #1, and the ADM stated the slap was on video and CNA A was being terminated. The ADM stated the next thing she did was begin safe surveys of interviewable residents and skin assessments for everyone. She stated they referred Resident #1 to psych services, and the SW monitored her daily. The ADM stated they provided Resident #1 a baby doll to hold during care. The ADM stated they did an in-service with the aides about the baby doll and in-serviced all staff on Abuse/Neglect and handling residents with dementia. The ADM stated they had not noticed any decline in Resident #1. The ADM stated she monitored to ensure there was no abuse of residents by training the staff well and interview residents frequently. The ADM stated they also discussed changes in demeanor or baseline at their morning meetings. The ADM stated a potential negative outcome of staff physically abusing a resident was a resident could have physical injury and/or emotional distress and withdraw from usually activities. During an interview on 11/15/23 at 02:05 PM, the AD stated she had not seen any changes or decline in Resident #1 since the episode of abuse on 09/25/23. The AD stated Resident #1 had been smiling and vocal like normal in activities. The AD stated Resident #1 loved her baby doll and kept it with her. The AD stated Resident #1 will still reach out to her and did not seem afraid. During interviews on 11/13/23 from 10:12 AM to 12:41 PM and 11/19/23 from 09:51 AM to 12:05 PM, six CNAs and three LVNs reported they had been in-serviced monthly on abuse/neglect/incident reporting and providing care for residents with dementia. They were each able to correctly identify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 4 of 5 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 11/15/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete abuse/neglect/reporting protocols and strategies to assist residents with dementia who were being resistant or combative. Two housekeepers and two dietary staff reported they had been trained on abuse/neglect/incident reporting and were able to accurately state the identity of the abuse coordinator, definitions of abuse and neglect, and procedures for reporting abuse and neglect. Review of facility policy dated 08/15/22 and titled Abuse, Neglect and Exploitation reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations, in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual resident's care needs, and behavioral symptoms. Event ID: Facility ID: 675434 If continuation sheet Page 5 of 5