Health inspection·October 7, 2022

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some Resident #6's bowel and bladder incontinence to be accurate in her comprehensive plan of care so that other staff were aware of the care she needed. 2. Review of Resident #44's electronic face sheet dated 10/04/2022 revealed she was admitted to the facility on [DATE] with diagnoses of dementia (cognitive loss), atherosclerotic heart disease (cardiac compromise due to plague build up on vessels), overactive bladder (urinary frequency) and anxiety (nervous disorder). Review of Resident #44's significant change MDS dated [DATE] revealed she was always incontinent of bowel and bladder. Review of Resident #44's comprehensive care plan with a revision date of 09/15/2022 revealed Problem .has bladder incontinence r/t confusion, dementia and did not address she was always incontinent of bowel. Observation on 10/04/22 at 11:45 AM of Resident #44 as she received incontinent care revealed she was incontinent of bladder and bowel. Interview on 10/07/2022 at 09:58 a.m. with the MDS Nurse revealed that Resident #44 was always incontinent, and her comprehensive care plan should have been revised after each assessment. The MDS Nurse stated she did not know how it was missed. The MDS Nursestated it was important for Resident #44's comprehensive care plan to address her incontinent issues, so she received the required care to meet her needs. Interview on 10/07/2022 with the DON at 11:00 a.m., the DON stated that it was important for Resident #44's bowel and bladder incontinence to be addressed in her comprehensive plan of care so that other staff were aware of the care she needed. Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change .14. The Interdisciplinary Team must review and update the care plan: d. At least quarterly, in conjunction with the required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 2 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were assessed and had consents for bed rails for 7 of 14 residents (Residents #10, #17, #28, #30, #40, #44, and #55) reviewed for bed rails, in that: 1. Facility failed to ensure Residents #10 and #30 had informed consents for the use of bed rails. 2. Facility failed to ensure Resident #28 had assessments or informed consent for the use of bed rails. 3. Facility failed to ensure Residents #17, #40, #44 and #55 had informed consents for the use of bed rails. These deficient practices could affect residents who utilized some type of bed rails in the facility and could put the residents at risk for potential injuries. The findings were: 1. Record review of Resident #10's face sheet, dated 10/06/2022, revealed he was readmitted to the facility on [DATE] (original admission [DATE]) with diagnoses which included: cerebral infarction unspecified (referred to as a stroke, this affects your blood flow to the brain), hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction affecting left non-dominant side, and age-related physical debility. Record review of Resident #10's care plan with a revision date 06/08/2022, revealed Resident #10 had a Focus: The resident has an ADL self-care performance deficit r/t hemiparesis, left side, dementia, hx of CVA with Interventions: Side Rails: half rails up as per Dr.s order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use with date initiated 08/23/2021. Record review of Resident #10's Side Rail Assessment, dated 07/25/2022 revealed Recommendations: Side rails are indicated and serve as an enabler or promote independence. Record review of Resident #10's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 00, which indicated severe cognitive impairment, and the resident was totally dependent (full staff performance) with two-person physical assistance for transfers and bed mobility. Record review of Resident #10's clinical record revealed there was no informed consent documented for use of bed rails. Observation on 10/04/2022 at 10:55 a.m. revealed Resident #10 lying in bed, head of bed elevated and both metal side rails in the upright position. Observation and interview on 10/06/2022 at 2:27 p.m. revealed Resident #10 sleeping in his bed, head of bed elevated with both metal side rails in the upright position. The ADON stated Resident #10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 3 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some used the side rails for safety not mobility or positioning and Resident #10 was not able to use the side rails to assist with care. The ADON stated after record review Resident #10 did not have a consent for the side rails. Interview on 10/06/2022 at 3:31 p.m. the MDS coordinator stated Resident #10 did not have consent for side rails. MDS coordinator further stated nursing is responsible for ensuring consents are completed. Record review of Resident #30's face sheet, dated 10/05/2022, revealed he was readmitted to the facility on [DATE] with diagnoses which included: hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction affecting left non-dominant side, and peripheral vascular disease unspecified (slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel). Record review of Resident #30's admission MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated intact cognition, and the resident was totally dependent (full staff performance) with two-person physical assistance for bed mobility along with transfer having not occurred. Record review of Resident #30's care plan with a revision date 09/09/2022, revealed Resident #30 had a Focus: The resident has an ADL self-care performance deficit with CVA with left sided Hemiparesis. Resident is bed bound with Interventions: bilateral half rails for repositioning per MD orders with date initiated 08/19/2022. Record review of Resident #30's Order Summary Report dated 10/05/2022 revealed an order for Bilateral ½ side rails every shift for positioning with a start date of 08/19/2022. Record review of Resident #30's Side Rail Assessment, dated 08/19/2022 revealed Recommendations: Side rails are indicated and serve as an enabler or promote independence. Record review of Resident #30's clinical record revealed there was no informed consent documented for use of bed rails. Observation on 10/04/2022 at 10:40 a.m. revealed Resident #30 lying in her bed with head of bed elevated with both metal side rails in the upright position. Observation and interview on 10/06/2022 at 2:40 a.m. revealed Resident #30 asleep in her bed with both metal side rails in the upright position. The ADON stated Resident #30 had declined and was no longer able to use the side rails for position, however prior to her decline she would use them to hold as staff provided care. The ADON further stated after EMR review Resident #30 did not have consent for her side rails. The ADON stated it was nursing's responsibility to get the consents for the side rails. 2. Record review of Resident #28's face sheet, dated 10/06/2022, revealed she was admitted to the facility on [DATE] with diagnoses which included: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), repeated falls, unspecified lack of coordination, muscle weakness generalized, other abnormalities of gait and mobility, and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #28's Significant Change MDS, dated [DATE], revealed the resident's BIMS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 4 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some score was 01, which indicated severe cognitive impairment, and the resident required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with one-person physical assistance for transfers and bed mobility. Record review of Resident #28's Order Summary Report dated 10/07/2022 revealed an order for Side rails ½ for turning & positioning with order date of 10/06/2022. Record review of Resident #28's clinical record revealed there was no assessment or informed consent documented for use of bed rails. Observation and interview on 10/06/2022 at 2:40 p.m. revealed Resident #28 in bed sleeping with both metal side rails in the upright position. The ADON stated Resident #28 got out of bed independently using the side rails to assist with her transfers in and out of the wheelchair and bed. The ADON further stated assessments and consents for Resident #28's side rails could be found in her EMR. The ADON stated Resident #28 did not have an assessment or a consent after reviewing her EMR. 3. Review of Resident #17's electronic face sheet dated 10/06/2022 revealed she was admitted to the facility on [DATE] with diagnoses of anxiety (nervous disorder), bradycardia (slow heart rate), hemiplegia affecting right non-dominant side (paralysis of right side) and diabetes (blood sugar abnormality). Review of Resident #17's Quarterly MDS assessment with an ARD of 08/09/2022 revealed she scored a 3/15 on her BIMS which indicated she was severely cognitively impaired. She required extensive assistance with her ADL's. Review of Resident #17's comprehensive care plan dated 08/01/2022 revealed Problem .has an ADL self-care performance deficit .Intervention .requires extensive assistance by one staff to turn and reposition in bed. Review of Resident #17's Order Summary Report dated 10/07/2022 revealed Side Rails, use 1/2 side rails for increased positioning and mobility with a start date of 09/24/2022. Observation on 10/04/2022 at 10:00 a.m. of Resident #17's bed revealed the bed was against the wall and the alternate side had 1/2 bed rail up. Review of Resident #17's side rail assessment dated [DATE] revealed she required an 1/8 side rail for weakness. Under section Fall Risk revealed provides a sense of security. Cognitive Status revealed Poor Safety Awareness. Bilateral side rails were recommended for bed mobility, Review of Resident #17's clinical record on 10/07/2022 at 09:00 a.m. revealed no evidence of a consent form for the bedrails was obtained. Review of Resident #40's electronic face sheet dated 10/06/2022 revealed she was admitted to the facility on [DATE] with diagnoses of dementia (cognitive disorder, memory loss), anxiety (nervous disorder), contracture left ankle and right hand (muscle tightness, loss of range of motion), and Cerebral Palsy (a group of disorders that affect movement, muscle tone, balance, and posture). Review of Resident #40's Quarterly MDS assessment with an ARD of 08/30/2022 revealed she scored an 8/15 on her BIMS which indicated she was moderately cognitively impaired. She required extensive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 5 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0700 assistance with her ADL's. Level of Harm - Minimal harm or potential for actual harm Review of Resident #40's comprehensive care plan revised on 09/01/2020 revealed Problem .has an ADL self-care performance deficit r/t limited mobility, high muscle tone/spasticity .Interventions .Side rails: per MD order for safety during care provision. Residents Affected - Some Review of Resident #40's Order Summary Report dated 10/07/2022 revealed Side Rails, use 1/2 side rails for increased positioning and mobility with a start date of 09/24/2022. Review of Resident #40's side rail assessment dated [DATE] revealed she had a recommendation for bilateral siderails to be used as an enabler. Review of Resident #40's clinical record on 10/07/2022 at 09:00 a.m. revealed no evidence of a consent form for the bedrails was obtained. Observation on 10/05/22 at 11:16 a.mm. of Resident #40's bed revealed she had 1/2 length side rails up on both sides of the bed. Review of Resident #44's electronic face sheet dated 10/04/2022 revealed she was admitted to the facility on [DATE] with diagnoses of dementia (cognitive loss), atherosclerotic heart disease (cardiac compromise due to plague build up on vessels), overactive bladder (urinary frequency) and anxiety (nervous disorder). Review of Resident #44's significant change MDS dated [DATE] revealed she scored a 5/15 on her BIMS which indicated she was moderately cognitively impaired. She required extensive assistance with her ADL's. Review of Resident #44's comprehensive care plan with a revision date of 09/15/2022 revealed Problem .has an ADL self-care performance deficit r/t debility and dementia .Interventions .requires extensive assistance by 2 staff to turn and reposition in bed. Review of Resident #44's Order Summary Report dated 10/07/2022 revealed Side Rails, use 1/2 side rails for increased positioning and mobility with a start date of 09/24/2022. Review of Resident #44's side rail assessment dated [DATE] revealed she had a recommendation for bilateral siderails to be used as an enabler. Review of Resident #44's clinical record on 10/07/2022 at 09:00 a.m. revealed no evidence of a consent form for the bedrails was obtained. Review of Resident #55's electronic face sheet dated 10/07/2022 revealed he was admitted to the facility on [DATE] with diagnoses of dementia (cognitive and memory impairment), anemia (low iron level in blood) and Parkinson's Disease (chronic and progressive movement disorder that initially causes tremor, stiffness and slowing of movement}. Review of Resident #55's Quarterly MDS assessment with an ARD of 09/12/2022 revealed he scored a 14/15 on his BIMS which indicated he was cognitively intact. He required extensive assistance with his ADL's. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 6 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #55's comprehensive person-centered care plan revised on 10/6/22 revealed Problem .has an ADL self-care performance deficit r/t weakness, deconditioning, dementia and Parkinson's Disease .Interventions .Side rails per MD order for safety during care provision,to assist with bed mobility. Review of Resident #55's Order Summary Report dated 10/07/2022 revealed Side Rails, use 1/2 side rails for increased positioning and mobility with a start date of 09/24/2022. Observation on 10/04/2022 at 10:30 a.m. of Resident #55's bed revealed he had 1/2 length side rails up bilaterally. Observation on 10/07/2022 at 11:00 a.m. of Resident #55's bed revealed he had 1/2 length side rails up bilaterally. Interview on 10/07/2022 at 11:03 a.m. with Resident #55 revealed he was not asked if he wanted side rails and never consented to them. Review of Resident #55's side rail assessment dated [DATE] revealed she had a recommendation for bilateral siderails to be used as an enabler. Review of Resident #55's clinical record on 10/07/2022 at 09:00 a.m. revealed no evidence of a consent form for the bedrails was obtained. During an interview on 10/07/2022 at 10:44 a.m. the DON stated the assessment of a resident's side rails is an ongoing assessment, but it should be done quarterly. The DON further stated the facility wants to ensure the residents who use side rails benefit from the use of the side rails and if not, the side rails are removed. The DON stated the consents for residents' side rails were not present. The DON stated nursing and therapy are responsible for assessing residents for side rail use. The DON further stated consents are obtained by whomever was completing the consents when residents are admitted or when a bed with side rails was given to a resident and it could be anyone to complete the consents. During an interview on 10/07/2022 at 11:10 a.m. the ADM stated nursing was responsible for the completion of consents regarding side rails. Record review of the facility's policy titled Proper Use of Side Rails, revised December 2016, revealed under Purpose: The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: #3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet: c. Risk of entrapment from the use of side rails .#5. Consent for using restrictive devises will be obtained from the resident or legal representative per facility protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 7 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review, and interview, the facility failed to prepare and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety, in that: Residents Affected - Many 1. The shelve unit below the steamer had visible dust and dirt particles. 2. The two (2) ceiling vents in the dish room measuring approximately one (1) foot by one foot were dirty with noticeable dust build-up. The side wall in the dish room measuring approximately two (2) feet by 2 feet was dirty with chipped paint. 3. The ceiling overhead light in front of the three (3) pan sink with four (4) fluorescent bulbs did not have a light cover on. 4. The two (2) ceiling vents in the storeroom measuring approximately one (1) foot by one (1) foot were dirty with noticeable dust build-up. 5-The electrical outlet on the wall behind the milk freezer had duct tape attached to the outlet. These deficient practices could place residents at risk of consuming contaminated food and maintained an unsafe food sanitation environment. The findings include: Observations in the kitchen on 10/4/22 from 9:10 AM through 9:20 AM revealed the shelve unit below the steamer was dirty. The two (2) ceiling vents in the dish room measuring approximately one (1) foot by one foot were dirty with noticeable dust build-up. The side wall in the dish room measuring approximately two (2) feet by 2 feet was dirty with chipped paint. The ceiling overhead light in front of the three (3) pan sink with four (4) fluorescent bulbs did not have a light cover on. The two (2) ceiling vents in the storeroom measuring approximately one (1) foot by one (1) foot were dirty with noticeable dust build-up. Observation on 10/4/22 at 9:10 AM revealed the electrical outlet on the wall behind the milk freezer had duct tape attached to the outlet. Interview on 10/4/22 at 9:25 AM the Dietary Director stated that the maintenance department was aware of the noted kitchen areas needing repair. The Dietary Director stated the tape on the electrical outlet was used to keep the outlet in place on the wall. Interview on 10/5/22 at 9:40AM with the Maintenance Director stated the facility did not have a written preventative maintenance policy but did utilize the work order request protocol called where staff could make a repair request. Record review of quality assurance monitor record for kitchen/food service observation completed by facility contracted dietician dated 9/8/22 noted a negative finding for the general appearance of the kitchen for clean walls, ceilings, vents, light fixtures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 8 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Nutrition and Foodservice Policies and Procedures Manual ,dated 2019, policy number 04.003, section 4-5, revealed, non-food-contact surfaces should be cleaned at intervals as necessary to keep them free of dust, dirt, and food particles and kept otherwise in a clean and sanitary condition. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 9 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 6 residents (Resident #44) reviewed for infection control, in that: Residents Affected - Few CNA B placed Resident #44's nasal cannula onto the resident's face after it was lying on the floor. This deficient practice could affect residents who are on oxygen therapy and could result in an upper respiratory infection. The findings were: Review of Resident #44's electronic face sheet dated 10/04/2022 revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia (cognitive loss), atherosclerotic heart disease (cardiac compromise due to plague build up on vessels), overactive bladder (urinary frequency) and anxiety (nervous disorder). Review of Resident #44's significant change MDS dated [DATE] revealed she scored a 5/15 on her BIMS which indicated the residet was moderately cognitively impaired. Further review revealed the resident required extensive assistance with her ADL's. Review of Resident #44's comprehensive care plan, with a revision date of 09/15/2022, revealed, Problem .has coronary artery disease .Intervention .Oxygen per MD orders. Observation on 10/04/22 at 11:45 AM of Resident #44 as she received incontinent care from CNA B revealed the resident's oxygen concentrator was set at 1.5 L/min and her nasal cannula was lying on the floor by her bed. As CNA B completed the incontinent care, CNA B picked up the nasal cannula off from Resident #44's floor and placed it into the plastic bag hanging on the concentrator for when the oxygen tubing is not in use. When CNA B discovered she had to wait to get Resident #44 up out of bed, CNA B took the oxygen nasal cannula back out of the plastic bag and placed it onto Resident #44's face without having the nurse change it out because it had been on the floor. Interview on 10/04/2022 at 11:50 a.m. with CNA B revealed she should have told the nurse about the nasal cannula being on the floor and she should not have put the cannula back onto Resident #44's face. CNA B stated it could transfer bacteria and dirt from the floor and the resident could get an infection. CNA B stated facilty staff received ongoing training on infection control practices. Interview with the DON on 10/05/2022 at 10:00 a.m., the DON stated CNA B was trained on infection control practices, and CNA B should have notified the nurse to change out Resident #44's oxygen nasal cannula. The DON stated that CNA B was trained on cross contamination, and she was accountable for nursing practice. Review of the facility's policy and procedure titled, Policies and Practices - Infection Control, dated revised October 2018, revealed as part of their infection control program objectives, .2 b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the general public. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 10 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure conduct regular inspection of all bed frames, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for 7 of 14 residents (Residents #10, #17, #28, #30, #40, #44, and #55) reviewed for bed rails, in that: The facility failed to inspect bed frames and bed rails for Residents' #10, #17, #28, #30, #40, #44, and #55 beds that were obtained from Hospice services. This deficient practice could affect residents who utilized some type of bed rails in the facility and could put the residents at risk for potential injuries. The findings were: 1. Record review of Resident #10's face sheet, dated 10/06/2022, revealed he was readmitted to the facility on [DATE] (original admission [DATE]) with diagnoses which included: cerebral infarction unspecified (referred to as a stroke, this affects your blood flow to the brain), hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction affecting left non-dominant side, and age-related physical debility. Record review of Resident #10's care plan with a revision date 06/08/2022, revealed Resident #10 had a Focus: The resident has an ADL self-care performance deficit r/t hemiparesis, left side, dementia, hx of CVA with Interventions: Side Rails: half rails up as per Dr.s order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use with date initiated 08/23/2021. Record review of Resident #10's Side Rail Assessment, dated 07/25/2022 revealed Recommendations: Side rails are indicated and serve as an enabler or promote independence. Record review of Resident #10's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 00, which indicated severe cognitive impairment, and the resident was totally dependent (full staff performance) with two-person physical assistance for transfers and bed mobility. Observation on 10/04/2022 at 10:55 a.m. revealed Resident #10 lying in bed, head of bed elevated and both metal side rails in the upright position. Observation and interview on 10/06/2022 at 2:27 p.m. revealed Resident #10 sleeping in his bed, head of bed elevated with both metal side rails in the upright position. 2. Review of Resident #17's electronic face sheet dated 10/06/2022 revealed she was admitted to the facility on [DATE] with diagnoses of anxiety (nervous disorder), bradycardia (slow heart rate), hemiplegia affecting right non-dominant side (paralysis of right side) and diabetes (blood sugar abnormality). Review of Resident #17's Quarterly MDS assessment with an ARD of 08/09/2022 revealed she scored a 3/15 on her BIMS which indicated she was severely cognitively impaired. Further review revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 11 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0909 resident required extensive assistance with her ADL's. Level of Harm - Minimal harm or potential for actual harm Review of Resident #17's comprehensive care plan dated 08/01/2022 revealed Problem .has an ADL self-care performance deficit .Intervention .requires extensive assistance by one staff to turn and reposition in bed. Residents Affected - Some Review of Resident #17's Order Summary Report dated 10/07/2022 revealed Side Rails, use 1/2 side rails for increased positioning and mobility with a start date of 09/24/2022. Observation on 10/04/2022 at 10:00 a.m. of Resident #17's bed revealed the bed was against the wall and the alternate side had 1/2 bed rail up. Review of Resident #17's side rail assessment dated [DATE] revealed she required an 1/8 side rail for weakness. Under section Fall Risk revealed provides a sense of security. Cognitive Status revealed Poor Safety Awareness. Bilateral side rails were recommended for bed mobility, 3. Record review of Resident #28's face sheet, dated 10/06/2022, revealed she was admitted to the facility on [DATE] with diagnoses which included: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), repeated falls, unspecified lack of coordination, muscle weakness generalized, other abnormalities of gait and mobility, and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #28's Significant Change MDS, dated [DATE], revealed the resident's BIMS score was 01, which indicated severe cognitive impairment, and the resident required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with one-person physical assistance for transfers and bed mobility. Record review of Resident #28's Order Summary Report dated 10/07/2022 revealed an order for Side rails ½ for turning & positioning with order date of 10/06/2022. Observation and interview on 10/06/2022 at 2:40 p.m. revealed Resident #28 in bed sleeping with both metal side rails in the upright position. The ADON stated Resident #28 got out of bed independently using the side rails to assist with her transfers in and out of the wheelchair and bed. The ADON further stated assessments and consents for Resident #28's side rails could be found in her EMR. The ADON stated Resident #28 did not have an assessment or a consent after reviewing her EMR. 4. Record review of Resident #30's face sheet, dated 10/05/2022, revealed he was readmitted to the facility on [DATE] with diagnoses which included: hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction affecting left non-dominant side, and peripheral vascular disease unspecified (slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel). Record review of Resident #30's admission MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated intact cognition, and the resident was totally dependent (full staff performance) with two-person physical assistance for bed mobility along with transfer having not occurred. Record review of Resident #30's care plan with a revision date 09/09/2022, revealed Resident #30 had a Focus: The resident has an ADL self-care performance deficit with CVA with left sided Hemiparesis. Resident is bed bound with Interventions: bilateral half rails for repositioning per MD orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 12 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0909 with date initiated 08/19/2022. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #30's Order Summary Report dated 10/05/2022 revealed an order for Bilateral ½ side rails every shift for positioning with a start date of 08/19/2022. Residents Affected - Some Record review of Resident #30's Side Rail Assessment, dated 08/19/2022 revealed Recommendations: Side rails are indicated and serve as an enabler or promote independence. Observation on 10/04/2022 at 10:40 a.m. revealed Resident #30 lying in her bed with head of bed elevated with both metal side rails in the upright position with approximately a 4-inch gap between the side rail and the air mattress on both sides of the bed. Observation and interview on 10/05/2022 at 9:50 a.m. the MM who worked for a sister facility and had been assisting with maintenance issue at the facility measured the distance between the side rails and the air mattress with his tape measurer stated the distance was 3 ½ inches between the side rails on both sides of the bed and the air mattress of Resident #30's bed. The MM further stated the mattress of the bed should have been tight against the side rails. The MM stated the mattress was undersized for the frame and it looked like a regular mattress with a bariatric frame. The MM stated the gap could put Resident #30 at risk for entrapment. During an interview on 10/05/2022 at 12:42 p.m. the DON stated Resident #30's mattress was too small for the bed frame. The DON further stated it had more space between the mattress and side rails than other resident beds. The DON stated with the gap between the mattress and the side rail it put Resident #30 at risk of turning then getting stuck in the area between the side rails and mattress. Observation and interview on 10/06/2022 at 2:40 a.m. revealed Resident #30 asleep in her bed with both metal side rails in the upright position. The ADON stated Resident #30 had declined and was no longer able to use the side rails for position, however prior to her decline she would use them to hold as staff provided care. 5. Review of Resident #40's electronic face sheet dated 10/06/2022 revealed she was admitted to the facility on [DATE] with diagnoses of dementia (cognitive disorder, memory loss), anxiety (nervous disorder), contracture left ankle and right hand (muscle tightness, loss of range of motion), and Cerebral Palsy (a group of disorders that affect movement, muscle tone, balance, and posture). Review of Resident #40's Quarterly MDS assessment with an ARD of 08/30/2022 revealed she scored an 8/15 on her BIMS which indicated she was moderately cognitively impaired. Further review revealed the resident required extensive assistance with her ADL's. Review of Resident #40's comprehensive care plan revised on 09/01/2020 revealed Problem .has an ADL self-care performance deficit r/t limited mobility, high muscle tone/spasticity .Interventions .Side rails: per MD order for safety during care provision. Review of Resident #40s Order Summary Report dated 10/07/2022 revealed Side Rails, use 1/2 side rails for increased positioning and mobility with a start date of 09/24/2022. Review of Resident #40's side rail assessment dated [DATE] revealed she had a recommendation for bilateral siderails to be used as an enabler. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 13 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 10/05/22 at 11:16 a.mm. of Resident #40's bed revealed she had 1/2 length side rails up on both sides of the bed. 6. Review of Resident #44's electronic face sheet dated 10/04/2022 revealed she was admitted to the facility on [DATE] with diagnoses of dementia (cognitive loss), atherosclerotic heart disease (cardiac compromise due to plague build up on vessels), overactive bladder (urinary frequency) and anxiety (nervous disorder). Review of Resident #44's significant change MDS dated [DATE] revealed she scored a 5/15 on her BIMS which indicated she was moderately cognitively impaired. Further review revealed the resident required extensive assistance with her ADL's. Review of Resident #44's comprehensive care plan with a revision date of 09/15/2022 revealed Problem .has an ADL self-care performance deficit r/t debility and dementia .Interventions .requires extensive assistance by 2 staff to turn and reposition in bed. Review of Resident #44's Order Summary Report dated 10/07/2022 revealed Side Rails, use 1/2 side rails for increased positioning and mobility with a start date of 09/24/2022. Review of Resident #44's side rail assessment dated [DATE] revealed she had a recommendation for bilateral siderails to be used as an enabler. 7. Review of Resident #55's electronic face sheet dated 10/07/2022 revealed he was admitted to the facility on [DATE] with diagnoses of dementia (cognitive and memory impairment), anemia (low iron level in blood) and Parkinson's Disease (chronic and progressive movement disorder that initially causes tremor, stiffness and slowing of movement}. Review of Resident #55's Quarterly MDS assessment with an ARD of 09/12/2022 revealed he scored a 14/15 on his BIMS which indicated he was cognitively intact. Further review revealed the resident required extensive assistance with his ADL's. Review of Resident #55's comprehensive person-centered care plan revised on 10/6/22 revealed Problem .has an ADL self-care performance deficit r/t weakness, deconditioning, dementia and Parkinson's Disease .Interventions .Side rails per MD order for safety during care provision, to assist with bed mobility. Review of Resident #55's Order Summary Report dated 10/07/2022 revealed Side Rails, use 1/2 side rails for increased positioning and mobility with a start date of 09/24/2022. Observation on 10/04/2022 at 10:30 a.m. of Resident #55's bed revealed he had 1/2 length side rails up bilaterally. Observation on 10/07/2022 at 11:00 a.m. of Resident #55's bed revealed he had 1/2 length side rails up bilaterally. Review of Resident #55's side rail assessment dated [DATE] revealed she had a recommendation for bilateral siderails to be used as an enabler. During an interview on 10/07/2022 at 10:44 a.m. the DON stated the beds that currently have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 14 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some rails were provided by hospice. The DON further stated currently the facility did not have a MM so there had not been regular inspections on the side rails. During an interview on 10/07/2022 11:10 a.m. the ADM stated the facility did not have a formal log or schedule for maintenance of the side rails. The ADM further stated the noted beds with the metal side rails were provided by hospice services. The ADM stated the facility had not had a MM since April 2022, so no bed rail inspections were performed as required. Record review of the facility's policy titled, Proper Use of Side Rails, revised December 2016, revealed under Purpose: The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: #3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet: c. Risk of entrapment from the use of side rails .#12. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 15 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and public for 4 of 24 residents (Residents # 6, # 21, #46, and #49) reviewed for environment, in that: 1. The room for Resident #21 had two (2) pieces of missing floor baseboard molding in the left corner of the room entrance adjacent to the bathroom. 2. The floor entry to the memory care unit in front of the activity room had five (5) cracked floor tiles with each floor tile measuring approximately two (2) by four (4) inches. 3. Four small personal refrigerators that belonged to Residents #6, #46 and #49 which were located in their rooms were not cleaned or defrosted. This deficient practice could place residents at risk of living in an environment that is not sanitary or comfortable. The findings include: 1. Record review of Resident #21's face sheet, dated 10/7/22, revealed the resident was admitted to the facility with diagnosis of Alzheimer's disease (a brain disorder that affects memory and cognition), mood disorder (a mental health condition affecting the emotional state), and delusional disorder, (a mental illness in which a person experiences delusions as part of their thinking process). Record review of Resident #21's care plans, dated 8/16/21, revealed Resident #21 resided on the memory care unit and has a risk of falling. Observation on 10/4/22 at 10:15AM on the memory care unit noted: missing floor baseboard moulding in the bedroom for Resident #21 and 5 cracked floor tiles in front of the activity room on the memory care unit. Interview with LVN A on 10/4/22 at 10:25 AM on the memory care unit, LVN A stated she thought Maintenance was aware of the missing floor baseboard molding in the bedroom for Resident #21 and the 5 cracked floor tiles in front of the activity room in the memory care unit. Interview on 10/4/22 at 10:35AM on the memory care unit, the Administrator stated that Maintenance was aware of the missing floor baseboard molding in the room for Resident #21 and the cracked floor tiles in front of the activity room and will repair these areas. The Administrator stated the Maintenance Director position has been unfilled since March of 2022. Interview with the Maintenance Director on 10/5/22 at 9:40AM stated the facility does not have a written preventative maintenance policy but used the work request program in which staff members can request work repairs in the facility that are handled by Maintenance Directors at the facility's sister facilities. 2. Review of Resident #6's electronic face sheet dated 10/06/2022 revealed she was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 16 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE] with diagnoses of vascular dementia (cognitive deficit related to lack of blood flow), dysphagia (difficulty swallowing), peripheral vascular disease (diminished circulation to the extremities) and complete traumatic amputation at level between knee and ankle, right lower leg (loss of right lower leg). Review of Resident #6's Quarterly MDS Assessment with an ARD of 05/18/2022, Annual MDS Assessment with an ARD of 07/15/2022, and Quarterly Assessment with an ARD of 07/26/2022 revealed she scored a 4/15 on her BIMS which indicated she was severely cognitively impaired, and she required extensive assistance with her ADL's. Review of Resident #6's comprehensive care plan with a revision date of 08/10/2022 revealed Problem .has an ADL s10:00 self-care performance deficit r/t deconditioning, weakness, abnormal posture, right below the knee amputation and a history of seizures, and changes with dementia .Intervention .requires extensive assistance by 2 people. Observation on 10/04/2022 at 10:30 a.m. of Resident #6's small refrigerator in her room revealed undated partially eaten food and spillage of a brown colored substance on the interior sides and trays which resembled pudding or chocolate drink. Observation on 10/07/2022 at 11: 25 a.m. with the DON revealed Resident #6's refrigerator had undated partially eaten food and spillage of a brown colored substance on the interior sides and trays of the unit. 3. Review of Resident #46 electronic face sheet dated 10/07/2022 revealed she was admitted to the facility on [DATE] with diagnoses of unspecified dementia (cognitive loss) and delusional disorders (can't tell what's real from what is imagined), and anxiety (nervous disorder). Review of Resident #46's Quarterly MDS assessment with an ARD of 09/03/2022 revealed she scored a 14/15 on her BIMS which indicated she was cognitively intact. She required minimal to extensive assistance with her ADL's. Review of Resident #46's comprehensive person-centered care plan with a revision date of 01/13/2022 revealed Problem .have an ADL self-care performance deficit r/t deconditioning, bilateral shoulder pain and changes occurring with diagnosis of Parkinson's Disease .Interventions .At times I required extensive assistance of one staff. Observation on 10/04/2022 at 10:55 a.m. of Resident #46's small refrigerator in her room revealed it had approximately 3 inches of ice buildup on and in the freezer. Observation on 10/06/22 at 10:59 AM accompanied by the DON of Resident #46's small refrigerator in her room revealed the freezer had about 3 inches of ice on the freezer. Interview on 10/06/2022 at 10:48 a.m. with Resident #46 she stated that the amount of ice buildup makes the refrigerator work harder and it won't last as long and food will not stay cold. Resident #46 stated that she had a little drawer under the freezer and that she could not use it because of the ice buildup. Resident #46 stated that she had to remove the guitar case which she has next to the refrigerator because the side gets so hot. Resident #46 stated she did not ask any staff to help her because they were always so busy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 17 of 18 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 675649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Review of Resident #49's electronic face sheet dated 10/06/2022 revealed she was admitted to the facility on [DATE] with malignant neoplasm (cancer) unspecified dementia (cognitive loss) and depressive disorder (low mood). Review of Resident #49's Annual MDS assessment with an ARD of 09/07/2022 revealed she scored a 06/15 on her BIMS which revealed she was moderately cognitively impaired. Review of Resident #49's comprehensive person-centered care plan with a revised date of 09/21/2022 revealed Problem .has an ADL self-care performance deficit r/t generalized debility, dementia .Interventions .requires extensive assistance by two staff. Observation on 10/06/22 at 10:44 AM accompanied by the DON of Resident #49's personal small refrigerator in her room revealed it had approximately 2 inches of ice buildup on the freezer. Interview on 10/07/2022 at 11:40 a.m. with the DON revealed that CNA's check the temperatures of the refrigerator, but they are not responsible for anything else to do with it. The DON stated that the families used to help keep the refrigerators clean prior to COVID-19, and that she realized it was an environment issue. The DON stated they did not have any policies or guidelines which addressed cleaning or defrosting the residents' refrigerators; however she and the Administrator would work up a cleaning schedule and that the management staff assigned to the rooms and do rounds needed to check them. The DON stated there was a potential for health issues and safety issues if the refrigerators in the rooms were not maintained. Review of the facility's admission Packet (undated) revealed, items in resident rooms is allowed and based upon governing laws, regulations and the need to maintain a safe living environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 18 of 18