Health inspection·March 14, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch, and taste). Resident #1 had an ADL self-care performance deficit related to Parkinson's (a movement disorder that initially causes tremor in one hand, stiffness or slowing of movement). On 03/05/2024 Resident #1 was assessed to have delirium (a serious change in mental abilities) related to change in condition, UTI (an infection in the urinary system), schizoaffective disorder (a mental illness or disorder that causes disturbances in though, perception, and behavior, and makes it hard to distinguish reality from imagination. It may involve hearing voices, having false beliefs, or showing emotional lack of emotion about a human being, a thing, or an activity), had visual hallucinations (seeing objects, shapes, people, animals, or lights that are not real) Interventions: monitor resident's safety, provide medications to alleviate agitation as ordered. Resident #1 was also assessed of being at risk for falls. Resident #1 had an infection of the urine (problem initiated on 03/09/20240. Interventions: Administer antibiotics as ordered. Resident #1 had depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). She was assessed to disconnect urine collection bag. Intervention: educate resident not to pick at wafer (skin- safe adhesive to attach to the skin on one side, while the other side is attached to the ostomy pouch). Record review of Resident #1's Physician Orders was last reviewed on 02/15/2024 reflected Resident #1 had an order with a start date of 03/11/2024 and end date of 04/01/2024 of meropenem intravenous solution reconstituted one GM (administration of antibiotics into a vein by means of a steel needle). Resident #1 also had an order with a start date of 03/14/2024 and an end date of 03/15/2024 physician ordered lactated ringers (use to treat dehydration- do not drink enough water) intravenous solution (administration of fluids into a vein by means of a steel needle). Record review of ADON LVN A's intravenous therapy skills checklist orientation dated 05/26/2023 reflected she was educated on intravenous (IV) meds on 05/30/2023 by an employee no longer working at the facility. Record Review of facility IV Education in-service, dated 12/13/2024, reflected IV procedure as follows: 1. Verify order in electronic medical record. 2. Compile supplies (IV start kit, catheter tubing, medication, and pole). 3. Place IV per aseptic techniques, date/label/time/initial medication, and hang. ADON LVN A signature was on the sign in sheet for the in-service on 12/13/2024 related to IVs. Observation on 03/14/2024 at 11:57 AM, Resident #1 was in her room sitting in her wheelchair. She had an IV in her arm. The tubing on the IV was long and was a safety hazard due to almost tripping over the tubing. The tubing was coming from the IV with a clothes hanger stretched for part of the clothes hanger to go through the hole of the IV bag and part of the clothes hanger was bent to hang on the privacy curtain rod. Where the IV was hanging on the privacy curtain rod was closer to the door when you entered Resident #1's room than on the side where Resident #1 resided. The IV bag was not secure on the privacy curtain rod and when the tubing moved the IV bag and the coat hanger on the privacy curtain rod moved a little. In an interview on 03/14/2024 at 11:59 AM, Resident #1 stated she had been on IV's due to having an UTI. She stated she did not prefer to drink very much water and the staff would remind her to drink (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 2 of 6 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few water due to the staff did not want her to become dehydrated. She stated she did not listen to the staff and refused water and now she is dehydrated. Resident #1 stated it was her fault for not drinking water or drinking very much of anything but coffee at breakfast. She stated she knew the consequences if she did not drink enough fluids. Resident #1 stated she did not know why the nurse put the IV on the curtain rod. She stated they had a pole in here last night and put the IV on the pole. She stated it did not embarrass her or bother her that it was on the curtain rod. Resident #1 also stated she started fluids in the IV this morning (AM of 03/14/2024). In an interview on 03/14/2024 at 12:05 PM, ADON LVN A stated she entered Resident #1's room and did not see an IV pole. She stated she worked at emergency services and if an IV pole was not available, she would improvise (create spontaneously or without preparation) and prepare an IV and put it on anything she could find. LVN A stated she did not see an IV Pole in Resident #1's room and she saw clothes hanger in the closet and thought she could hand IV on a clothes hanger. She stated this was not unusual for her to do when she worked for emergency services. She stated she had hung IVs on nails before or anywhere when it was an emergency. LVN A stated this was the first time she used anything but an IV pole to hang an IV. LVN A stated she did not see anything wrong to hang IV on clothes hanger when the IV needed to be hung and she did not see an IV pole in Resident's #1 room. She also stated she assumed most of the supplies she needed was in Resident #1's room including IV pole. In an interview on 03/14/2024 at 12: 20 PM, the Administrator stated hanging an IV on a clothes hanger and the clothes hanger was on a privacy curtain rod was not acceptable nursing protocol. She stated the nurse was expected to alert another nurse, DON if she needed an IV pole. In an interview on 03/14/2024 at 12:40 PM, the DON stated the following is the facility's protocol for hanging an IV: 1. Verify physician order. 2. Obtain supplies such as the medication, IV start kit (alcohol pad, a tegarderm (transparent medical dressing). 3. Obtain tourniquet (a device, such as a strip of cloth or band of rubber, that is wrapped tightly around a leg or an arm to prevent the flow of blood to the leg or the arm for a period of time). 4. Obtain IV catheter, tubing for IV and the IV pole. 5. The nurse would enter the resident's room and explain what type of care they would be doing on the resident. 6. The nurse would follow infection control hand hygiene protocol- wash their hands and donn (place on gloves) gloves. 7. The nurse would hang the IV bag on the IV Pole. 8. The nurse would obtain their IV site and follow connection protocol. 9. The nurse would label, date, and sign the IV bag when the IV was administered. The DON also stated it was not her expectations of an IV to be hung on a clothes hanger and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 3 of 6 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clothes hanger hung on the curtain rod. The DON stated this was not the facilities protocol. She stated there were IV poles in the facility and they were in some of the residents' rooms. She also stated ADON LVN A did not follow protocol if she went to Resident #1's room without all the supplies she needed including an IV Pole. She stated if ADON LVN A had of followed the protocol prior to entering Resident #1's room she would have known the IV pole was not in Resident #1's room. The DON stated it was not an emergency for Resident #1 to receive the IVs immediately. She stated LVN A could have discontinued the IV administration and exited the room to find an IV pole or request another nurse to bring her one (IV Pole). She also stated no one informed her, another nurse, or the Administrator of the IV hanging on a clothes hanger until it was brought to our attention after surveyor observed it in Resident #1's room. After she viewed the pictures of Resident #1's IV hanging on the clothes hanger from the curtain rod, she stated the IV was not secure and could have fallen. The DON stated if the IV had fallen there was a possibility it could have jerked the IV out of Resident #1's arm or the hanger could have fallen on the resident causing a skin tear. She stated this was not proper use of equipment to hang an IV. DON also stated using a clothes hanger was not a safe equipment for giving care. She stated there had been in services on IV protocol but did not recall the last time the in-service was given to the staff. The DON stated again Resident #1 was not in any distress and there was no medical emergency when ADON LVN A administered the IV on a clothes hanger. She stated Resident #1 had an UTI and was refusing to drink water. She needed extra fluids and this is when the IV fluids were ordered on 03/14/2024 for a preventive measure. Interview on 03/14/2024 at 1:05 PM, ADON LVN A stated during the morning meeting she discussed Resident #1 needed extra fluids. She stated Resident #1 was beginning to refuse to drink water or a lot of fluids. She stated she received the order from the Physician. She stated Resident #1 had an UTI and was on antibiotics for UTI. ADON LVN A stated she did everything wrong this AM (3/14/2024 AM) when administering Resident #1's IV. She stated it was all her fault and she did not report to anyone she needed an IV pole or she hung the IV on a coat hanger. She stated her brain went to what had she used before when she did not have an IV pole and this is when she began looking around the room to find something to improvise to hang the IV on and she saw coat hanger and she stated she thought this will work and she stated she began to straighten out the coat hanger and put it through the hole of the IV bag and bent part of the IV bag to hang over the privacy curtain rod. ADON LVN A stated she worked for Emergency Medical Services and she knew this facility did not follow same protocols as EMS. She stated she was thinking as a nurse working under conditions that did not have the proper medical equipment. She stated the facility did have IV poles and there was one in Resident #1's room when she gave the IV around 10:38 AM today (03/14/2024). ADON LVN A stated the IV pole was hidden around the curtain on the other side of the room and not where Resident #1 resided. She stated she did not see the IV pole it was wrapped around the privacy curtain. ADON LVN A stated she had very poor judgement on hanging the IV without an IV pole. She stated she was expected to gather all the supplies needed to start an IV and not assume the supplies was already in Resident #1's room. ADON LVN A also stated after the questions asked of me this morning about the IV on the coat hanger, this is when she realized she had made a mistake and reported the incident to the DON. She stated she was trained on administer medications/ fluids with IV's when she began working at this facility in May 2023. She stated she was trained on the facility protocol during her orientation before beginning to work at this facility. She also stated she did not do anything correct when hanging Resident #1's IV bag. She stated she did not use the proper medical equipment to give care to Resident #1. ADON LVN A also stated she had been in serviced on IV's December 2023. She stated there was a possibility the IV could have fell off the privacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 4 of 6 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 03/14/2024 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 0689 curtain rod and the IV could have disconnected from resident arm causing skin concerns to Resident #1. Level of Harm - Minimal harm or potential for actual harm Interview on 03/14/2024 at 2:58 PM, ADON RN B stated she entered Resident #1's room after 12:00 PM and saw Resident #1's IV bag hanging on a coat hanger from the privacy curtain rod. She stated she immediately removed the IV bag, asked for an IV pole, and placed the IV on an IV pole. She stated hanging an IV on a coat hanger was not the facility's protocol. ADON RN B stated before you enter a Residents room to administer an IV you are required to obtain all the necessary supplies and equipment. She stated a nurse was expected to view the physician order. She also stated the nurse was to go into the supply room and gather everything needed to administer the IV and not assume the supplies are already in the room. She stated it is better to have extra supplies than not have the supplies needed to begin IV. ADON RN B stated the facility had all the supplies in the facility to begin IV. She stated there was an IV pole in Resident #1's room hidden around privacy curtain and it was difficult to see until the privacy curtain was pulled and this is when she saw the IV pole in Resident #1's room. She also stated there was a potential for the IV to fall from the curtain rod and if it had fallen on Resident #1, she may have a skin tear from the clothes hanger and there was a possibility the IV could have been pulled out of resident's arm. She also stated Resident #1 was not in an emergency where the IV had to be administered immediately. ADON RN B stated the IV could have waited until ADON LVN A obtained an IV pole. She also stated an in-service was given to all nurses in December 2023 on administering IVs. Residents Affected - Few Interview on 03/14/2024 at 3:20 PM, LVN C stated the facility protocol for administering IVs were as follows: 1. Verify the physician order. 2. Ensure all the items are available to administer the IV (she stated whenever she administered IV's supplies are always available.) 3. Obtain: IV catheter, IV start kit (gauze, Tape sheer, alcohol pads, tourniquets (sued to dilate the veins, making them larger to find a vein for the needle), hep lock (another name for IV locking device), the medication and the IV pole. 4. Enter the resident room with all the supplies needed. A nurse cannot assume all the supplies to administer IV is already in a resident's room. She stated explain to resident the process of administering IV. After the resident understands the process begin the protocol of administering the IV. She also stated there was no circumstance in this facility where an IV would be hung on a coat hanger. She stated the facility had IV poles. LVN C stated if there was not the right size IV pole a nurse needed someone can obtain the correct IV pole from a sister facility approximately five hundred feet from this facility. She also stated she had been in serviced on administering IVs in December 2023. Interview on 03/14/2024 at 4:00 PM, LVN D stated once the IV is ordered and the order was reviewed by the nurse administering the IV, the nurse would obtain the IV supplies. He stated a nurse never assumes the supplies are in the resident room. LVN D stated it was nursing protocol to obtain all the supplies needed prior to entering a resident room to administer IV. He also stated he would gather all the IV supplies including IV pole and enter the resident's room. LVN D stated he would explain to the resident the process of administering an IV. LVN D stated using a coat hanger was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 5 of 6 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 03/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appropriate equipment to use when hanging an IV. LVN D also stated a coat hanger was not a safe medical equipment to use when providing care to a resident. He stated he would deem the coat hanger as being unsafe. He stated there was a potential a coat hanger may fall from the privacy curtain rod and pull out the IV from resident arm or partially pull out the IV. He stated if Resident #1 was sitting under the coat hanger and the coat hanger fell there was a potential the coat hanger may fall on Resident #1's head and cause a skin tear or any type of skin injury. Interview on 03/14/2024 at 4:35 PM, the Regional Corporate Nurse stated before a nurse enters a resident room to administer an IV the nurse was expected to obtain all pertinent supplies and equipment including an IV pole, IV tubing, the medication, and IV starter kit. She stated the nurse cannot assume these items were in the resident's room. She also stated a coat hanger was not an appropriate medical device to give care of any type especially hanging an IV bag. She stated there was a potential the resident may injure themselves if the bag had fallen from the privacy curtain rod. She also stated in the facility policy it does not specifically say obtain an IV pole but this is something nurses already knows if they have been trained at this facility to obtain an IV pole prior to entering a resident room. Record review of the Facilities Policy on Overview of IV Therapy, 05/01/2020, reflected and IV start kit contained the supplies to clean and dress peripheral (used to draw blood) IV site. Usually contains tourniquet (a device, such as a strip of cloth or band of rubber, that is wrapped tightly around a leg or an arm to prevent the flow of blood to the leg or the arm for a period of time), sterile tape, gloves, transparent dressing, antiseptic cleaning solutions, label, and dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675434 If continuation sheet Page 6 of 6