Health inspection·June 4, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's Progress Note (IDT Event Review), dated 4/30/25, revealed .New interventions suggested following current IDT review: Recommendation to assess patient for proper footwear to accommodate foot size and width. RP was called by Activities Director to advise of updates and will provide recommendations for footwear options .[family member] will buy proper shoes for resident . Author: [DON] . Residents Affected - Some Record review of Resident #3's Progress Note (Therapy), dated 4/30/25, revealed .Recommendation to assess patient for proper footwear to accommodate foot size and width. RP was called by Activities Director to advise of [sic] updates and will provide recommendations for footwear options. Author: [DOR] . Record review of Resident #3's Care Plan, initiated 5/20/25 and revised 5/28/25, revealed: [Resident #3] had an unwitnessed fall related to unsteady gait and improper shoes. Interventions initiated 5/28/25 included: Assess and encourage [Resident #3] on proper non-skid shoes. Assure that lighting is adequate. Call light within easy reach and answer timely. Encourage to use call light for staff assistance. Refer to physical/occupational therapy for strengthening exercises, gait training to increase mobility, need for adaptive equipment. Further review of the care plan revealed the document did not include resident falls on 4/6/25, 4/17/25, 4/20/25, and 4/30/25. During an interview on 5/30/25 at 3:09 pm, CNA A said interventions in place for Resident #3 to help reduce/prevent falls included her shoes (which she thought were special made for the resident), leaving the restroom door open so that she was able to find it at night to avoid accidents and falls, supervision while Resident #3 used the restroom and was out of bed, and asking every two hours if she needed to use the restroom. Observation on 5/30/25 at 3:33 pm revealed Resident #3 walking to the dining room independently. Resident #3 refused an interview with the state investigator. Resident #3 was observed wearing black sport shoes with white rubber soles, the resident was supervised by a staff who provided touch assistance to the resident's right shoulder. During an interview on 5/30/25 at 3:41 pm, the DOR said ultimately the administrator was responsible for ensuring care plans were updated. The DOR said RN B updated care plans, but she was not at the facility full time, so management assisted with updating the care plans. The DOR further stated the IDT met every morning and reviewed any changes including falls. The DOR said Resident #3 was at a high risk for falls r/t to safety awareness and did not know when she needed rest. The DOR further stated Resident #3 needed lots of cues to take rest breaks, adding this was being implemented. The DOR said the staff ensured Resident #3's environment was well lit and free of clutter. The DOR said the facility bought a device to measure Resident #3's feet to get accurate measurements for the family. The DOR further stated Resident #3 did receive new shoes from her family after the fall on 430/25 because she had wide feet and a deformity. The DOR said Resident #3 was constantly supervised to ensure she was wearing her shoes. The DOR said Resident #3 pulled off the hipster and so they were discontinued. The DOR said the care plans were updated as a team, the interventions were individualized, and RN B was responsible for updating the care plan along with herself (DOR) and the DON when RN B was not at the facility. The DOR further stated the care plans should be updated after the risk management meetings, which were held every morning. The DOR said it was important that care plans be updated to reflect the residents' performance at that time because their needs fluctuate and to provide instruction for staff on the needs of the resident. The DOR said if care plans were not updated the residents' may not receive the care they needed or can receive care that was no longer recommended by their provider or healthcare team. During the interview, the DOR updated Resident #3's care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675502 If continuation sheet Page 2 of 4 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 675502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton North Nursing and Rehabilitation 404 Goodwin St Pleasanton, TX 78064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the care plan revised 5/30/25 revealed: .Family has provided new, appropriate width and sized shoe to reduce risk of falls .Encourage frequent rest breaks, including assisting patient to seated position, to reduce risk of falls . Further review of the care plan revealed the document did not include resident falls on 4/6/25, 4/17/25, 4/20/25, and 4/30/25. During an interview on 5/30/25 at 4:13 pm, RN B said staff, which included: the Administrator, DON, therapy department, and herself if she was at the facility, had meetings to discuss interventions that can help reduce or prevent falls. RN B further stated resident care plans were updated with any new interventions and staff were made aware of what the new interventions were. RN B said resident care plans were updated after every fall. RN B said any member of the IDT could update care plans and she was responsible for ensuring comprehensive care plans were accurate. RN B further stated there were no audits per se, but she audited care plans after the comprehensive assessments were completed. RN B said it was important that care plans were updated so everyone knew what interventions were in place for the residents' safety and wellbeing. RN B said she did know why Resident #3's care plan was not updated after the falls on 4/6/25, 4/17/25, 4/20/25, and 4/30/25. RN B further stated she was only at the facility two days a week (Tuesdays and Thursdays) and that was probably why Resident #3's care plan was not updated after the falls. During an interview on 5/30/25 at 4:34 pm, the Administrator said new interventions to help reduce/prevent falls were reviewed during the daily meetings. The Administrator further stated, most of the time, care plans were updated during the meeting and other times RN B updated them when she was at the facility. The Administrator said she expected care plans be updated within the week the fall happened. The Administrator further stated RN B pulled the interventions from the IDT meeting when she was at the facility to update the care plans. The Administrator said usually RN B was responsible for updating care plans, but any nurse could update them. The Administrator said most of time care plans were audited by the IDT after an incident occurred for accuracy. The Administrator further stated the DON was responsible for ensuring care plans were updated and accurate. The Administrator said it was important to update care plans in a timely manner for continuity of care and so that staff knew what the residents' needs were. During an interview on 6/4/25 at 9:32 am, the DON said resident care plans were supposed to be updated after every fall. The DON further stated falls were discussed during morning meeting and the care plans updated afterward. The DON said she notified RN B (MDS nurse) after the meetings so that she could update the care plans and when RN B was not at the facility, she updated the care plans herself. The DON said RN B was responsible for updating resident care plans and she (DON) was responsible for ensuring RN B updated care plans as needed. The DON said that herself, the ADON, and RN B audited care plans monthly for accuracy. The DON said it was important that care plans were updated for the residents' safety to ensure staff knew what interventions were in place for the residents and were implemented. The DON further stated, for example, if staff did not know Resident #3 needed special shoes and they were not worn she could have had additional falls. The DON said she did not review Resident #3's care plan to ensure the recommended interventions were added to the care plan. The DON further stated she was sure it was the facility's policy to update care plans after falls. Record review of facility's policy, titled Fall Prevention Program dated 2024, revealed: .9. When a resident experiences a fall, the facility will .e. Review the resident's care plan and update as indicated . Record review of facility's policy, titled Comprehensive Care Plans dated 2025, revealed: .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675502 If continuation sheet Page 3 of 4 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 675502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton North Nursing and Rehabilitation 404 Goodwin St Pleasanton, TX 78064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675502 If continuation sheet Page 4 of 4