Health inspection·December 21, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #158's face sheet dated 12/20/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of senile degeneration of brain, down syndrome (genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability, and dementia). A record review of Resident #158's MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. Resident #158's functional abilities for eating was not yet completed. A record review of Resident #158's care plan last revised on 12/20/2023 reflected he was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. During an observation and interview on 12/19/2023 at 12:38 p.m., Resident #3 was observed lying in bed with a meal tray by her side. CNA L stated, she's a feeder and stated she would feed Resident #3. During an interview on 12/19/2023 at 1:13 p.m., RN C stated, our other two feeders are in the dining room. An observation on 12/20/2023 at 8:49 a.m. revealed Resident #158 was lying in bed sleeping. During an interview on 12/20/2023 at 1:22 pm., LVN E stated she used the word feeder to refer to residents who needed help eating. LVN E stated she thought she had learned that term through a training at the facility. During an interview on 12/20/2023 at 2:27 p.m., CNA H stated Resident #158 was a feeder and she had learned that term while working in the facility. An observation on 12/20/2023 at 2:34 p.m. revealed Resident #46 was lying in bed making incomprehensible noises. Resident #46 was non-interviewable. During an interview on 12/20/2023 at 2:36 p.m., RN B stated Resident #46 was a feeder and said she learned the term way back at another facility. During an interview on 12/21/2023 at 2:53 p.m., The DON stated she had started an in-service on how to refer to residents who needed assistance with eating because I figured out what you were talking about. The DON stated staff got into the habit of using the word feeder and said they should instead use total assist. The DON stated the term feeder was not supposed to be used by the staff. The DON stated she thought staff were trained on resident rights and dignity via computer-based trainings. The DON stated staff were monitored for resident rights and dignity through interviews and rounding by management staff. The DON stated prior to 12/20/2023, staff had not been trained specifically on not using the term feeder. The DON stated, it's just not nice to say and said that was why they completed an in-service. During an interview on 12/21/2023 at 3:47 p.m., the Administrator stated she expected staff to refer to residents with appropriate language that showed respect. The Administrator stated they had been in-servicing staff on appropriate language as of yesterday (12/20/2023). The Administrator stated staff were trained on resident rights and dignity via computer-based trainings. The Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 2 of 16 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 12/21/2023 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 0557 stated herself and the DON monitored staff for resident rights and dignity. If residents were referred to as feeders, it was not the most dignified way to refer to them. Level of Harm - Minimal harm or potential for actual harm A record review of the facility's policy titled Resident Rights dated December 2016 reflected the following: Residents Affected - Some Policy Statement Team members shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 3 of 16 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 12/21/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that meets a resident's medical, nursing, mental, and psychosocial needs for two of two residents (Resident #55 and Resident #33) reviewed for pressure ulcers. 1. Resident #55 had three wounds which did not appear on the most recent comprehensive are plan last revised on 12/05/2023. 2. Resident #33 had a right buttock Stage II Pressure Ulcer (partial thickness skin and underlying tissue loss) which was not included in the comprehensive Care Plan revised on 12/20/2023. These failures could place residents at risk for pain from the wound, pain from any debridement procedures (sharp instrument or chemical excision of dead tissue often used to promote healing of pressure ulcers) and pain from the wound care required to promote healing. Residents with a pressure ulcer without an appropriate plan of care and interventions in place are at increased risk for infection, increasing dimensions/worsening of current ulcers, difficulty obtaining comfort in common positions (sitting, heels touching a bed mattress), increased financial expenditure for supplies and wound care consultation, and increased burden of care at discharge when obtaining supplies, specialist consultations/treatment, skilled wound care providers are needed at discharge. The record review on 12/20/2023 of Resident #55 current face sheet revealed a [AGE] year-old female resident who initially admitted to the facility on [DATE]; the face sheet indicated that the primary initial diagnosis for Resident #55 included fracture of left femur. The record review of other diagnoses listed on face sheet included orthopedic aftercare and dementia. The record review of the MDS assessment (an assessment required by Medicare/Medicaid for a nursing facility to complete on admission, periodically, and when there is a change in condition on each resident) dated 12/08/2023 reflected that Resident #55 had a quantity of one pressure ulcer. The MDS dated [DATE] reflected that the one pressure ulcer was an unstageable pressure ulcer. Further record review of the MDS reflected that the site of one pressure ulcer was on one of Resident #55's feet (it is not specified whether it is left foot or right foot). A record review of the MDS (Medicare/Medicaid assessment) dated 12/08/2023 reflected that Resident #55 required extensive assistance of two or more persons for bed mobility, transfers from bed to chair, and toilet use. The record review of the MDS reflected that Resident #55 had a pressure reduction device for her bed (a low air loss and/or alternating air pressure mattress system which helped to prevent skin breakdown) and dressings applied to her feet three times weekly. A record review of the care plan revised on 12/05/23 reflected that Resident #55 had potential/actual impairment to skin integrity related to immobility; the goal had been established that Resident #55 would maintain or develop clean and intact skin by the review date. The record review of the interventions, revised on 12/06/2023 included: treatment administered as ordered by physician, weekly treatment documentation which included measurements of wounds, documentation of notable changes/observations, and documentation of exudate (drainage). The remaining additional interventions included observation of dressing to left heel every shift, dressing changes to left heel with recorded observations of the site three times weekly, and identified and documented causative factors that could be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 4 of 16 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 12/21/2023 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 0656 eliminated or resolved. Level of Harm - Minimal harm or potential for actual harm A record review of the Centers for Medicare Services form 802, Resident Matrix, dated 12/19/2023, reflected that there were no Stage IV pressure ulcers on any residents in the facility. The record review of the Centers for Medicare Services form 802 reflected that Resident #55 had a Stage II pressure ulcer and an unstageable pressure ulcer. Residents Affected - Few A record review of the active Physician's Orders reflected that wound care treatments were ordered daily on 12/20/2023 on the Stage II left ischium wound, daily on the Stage IV sacrococcygeal Pressure Ulcer as ordered on 12/14/2023, and daily on the bilateral heel deep-tissue injuries, as ordered on 11/29/2023. A record review of the weekly nurses' skin assessments from 10/18/2023 through 12/20/2023 reflected that the pressure ulcers and the deep-tissue injuries were not addressed on the weekly nurses' skin assessments. The record review of the Wound Care Physician's Notes dated 12/20/2023 reflected that the sacrococcygeal area had a Stage IV pressure ulcer measuring 8.5 cm x 5.0 cm x 1.0 cm (length x width x depth), that the left ischium had a Stage 2 pressure ulcer measuring 0.6 cm x 0.8 cm x 0.1 cm (length x width x depth). The record review of the Wound Care Physician's Notes dated 12/20/2023 reflected that the heels had deep-tissue injuries; the right heel wound measured 3.0 cm x 3.5 cm x 0 cm and the left heel wound measured 2.0 cm x 1.5 cm x 0 cm. An interview with the DON on 12/19/2023 at 2:14 PM revealed that there was one resident with a Stage IV Pressure Ulcer in the facility. The DON stated that Resident #55 had a Stage IV Pressure Ulcer to the sacrococcygeal area. The DON stated that she changed the dressing on Resident #55 daily and functioned as the wound care nurse for the more serious facility wounds. The DON stated that Resident #55's Stage IV sacrococcygeal pressure ulcer had been facility-acquired and formed not long after Resident #55 was admitted (on October 18, 2023). An observation of wound care was conducted on 12/20/2023 at 09:11 AM, performed on Resident #55 by the DON. A deep-tissue injury was observed to both heels and were treated as ordered by the physician on 12/20/2023. A Stage II left ischium pressure ulcer was observed and treated as ordered by the physician on 12/20/2023. A Stage IV sacrococcygeal pressure ulcer was observed and treated as ordered by the physician on 12/20/2023. The wound care measurements appeared consistent with the measurements documented on the Wound Care Physician Notes dated 12/20/2023. An interview with the DON on 12/20/2023 at 09:11 AM revealed that the Wound Care Physician had seen Resident #55 and performed a debridement procedure (removal of dead tissue within the pressure ulcer site using a sharp instrument; the area was first numbed with a topical anesthetic spray) earlier that morning. An interview with the DON was conducted on 12/21/2023 at 1:38 PM. The DON was asked how current staff and/or new staff and/or agency staff were made aware of the interventions required for Resident #55. The DON stated that the report was given orally at shift change and a [NAME] (a nursing tool which involved a summary of care interventions and medical information which is kept current and updated each shift) was not used. An interview with the DON was conducted on 12/21/2023 at 2:23 PM. The DON stated that care plans (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 5 of 16 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 12/21/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were updated quarterly. For issues that had arisen that needed to be care-planned prior to a quarterly update, a morning meeting had been held which included the MDS Coordinator (the nurse who documented the Medicare required assessment findings and had the main facility responsibility to make certain the care plan was kept current). The DON stated that while the Wound Care Physician orders were updated, the care plan should have been. The DON stated that a lot of care had been provided for Resident #55 and it should have been care-planned. The DON stated that the interventions that Resident #55 received that should have been care-planned included: Resident #55 had been turned every two hours when in bed, had been provided a special wheelchair cushion (which reduced pressure to the area of the Stage IV Pressure Ulcer), had been provided an air mattress (a mattress which reduced pressure to the sacrococcygeal, heels, and the left buttock pressure ulcer sites), had received a dietary consultation (to ensure that Resident #55 was getting proper caloric intake, nutrients, and protein for wound healing), had received daily wound care by the DON and other nurses, and had been seen weekly by a Wound Care Physician. An interview was conducted with the MDS Coordinator on 12/21/2023 at 2:45 PM and the MDS Coordinator stated that she has requested that nursing staff notify her within three days when there was a change in a resident that needed to be care-planned. The MDS Coordinator stated that she would wait to care plan a wound if a Wound Care Physician would be seeing the resident, so that the correct type of wound and correct staging of the wound was included in the care plan. The MDS Coordinator stated that she was not made aware of the progression of Resident #55's pressure wounds. The MDS Coordinator stated that any licensed nurse could have updated the care plan. The MDS Coordinator stated that an inaccurate care plan could have caused problems with completion of Activities of Daily Living, pain, mobility issues, and progression of the wound. A record review of Resident #33's face sheet dated 12/21/2023 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of ileus (gut paralysis), type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol), dysphagia (difficulty swallowing), adult failure to thrive, squamous cell carcinoma of skin, scalp and neck (skin cancer), and COVID-19. A record review of Resident #33's MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderately impaired cognition. Section M of Resident #33's MDS assessment reflected he had on unhealed stage 2 pressure ulcer. A record review of Resident #33's care plan last revised on 12/20/2023 reflected he had a resolved stage 4 sacral pressure injury. The care plan reflected the following: RESOLVED 5/17/21: Sacrum r/t Stage 4 Pressure Ulcer Date Initiated: 10/31/022 Revision on: 08/31/2023 Resident #33's care plan did not reflect his current wound. A record review of Resident #33's wound care assessment titled Weekly Wound Progress authored by LVN E dated 11/29/2023 reflected he had a stage 2 pressure ulcer to his right buttock measuring 1.0 x (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 6 of 16 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 12/21/2023 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 0656 1.5 x 0.1 cm. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #33's wound care assessment titled Weekly Wound Progress authored by the DON dated 12/06/2023 reflected he had a stage 2 pressure ulcer to his right buttock measuring 1.5 x 1.0 x 0.1 cm. Residents Affected - Few A record review of Resident #33's wound care assessment titled Weekly Wound Progress authored by the DON dated 12/13/2023 reflected he had a stage 2 pressure ulcer to his right buttock measuring 1.2 x 1.7 x 0.1 cm. A record review of Resident #33's wound care assessment titled Weekly Wound Progress with an unknown author dated 12/20/2023 reflected he had a stage 2 pressure ulcer to his right buttock measuring 2.3 x 1.5 x 0.1 cm. During an observation and interview on 12/19/2923 at 10:09 a.m., Resident #33 was observed lying in bed. Resident #33 stated he had a small wound on his bottom that he got while in the facility. Resident #33 stated the wound had been getting better and the wound care physician followed him. During an interview on 12/21/2023 at 3:16 p.m., the MDS Coordinator stated she had worked at the facility for one year and it was her responsibility as well as other nurses' responsibility to revise care plans. The MDS Coordinator stated other nurses should know it was also their responsibility. The MDS Coordinator stated of course it could affect residents' ADLs if wounds were not care planned. The MDS Coordinator stated if the staff went in to do a resident assessment and they were unaware of a wound, it could cause pain or mobility issues. The Administrator was interviewed on 12/21/2023 at 3:30 PM. The Administrator stated that the MDS Coordinator, the Social Worker, and the Activities Director have updated the care plans. The Administrator stated that the care plans and any needed updates were discussed in the Monday through Friday morning clinical meetings. The Administrator stated that many care plan issues have been reviewed during Quality Assurance Performance Improvement meetings. The Administrator stated that the care plans are a tool used as resident care was provided. A record review of the Pressure Ulcers/Skin Breakdown Clinical Protocol Policy dated 04/2018 reflected that the physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. A record review of the Pressure Ulcers/Skin Breakdown Clinical Protocol Policy dated 04/2018 reflected that the nurse shall describe and document/report the following: full assessment of pressure sore, pain assessment, resident's mobility status, current treatments, and all active diagnoses. A record review of the Care Plan, Comprehensive Person-Centered Policy, dated 12/2016 reflected that the care plan would be formulated in conjunction with the resident and his or her legal representative and are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. A record review of the Care Plan, Comprehensive Person-Centered Policy, dated 12/2016, reflected that the comprehensive care planning process will include measurable objectives and timeframes, describe the services to be furnished to attain the highest practicable physical, mental, and psychosocial well-being, incorporate identified problem areas. The comprehensive person-centered care plan will be developed within seven days of the completion of the required comprehensive assessment (MDS; a Medicare required assessment for nursing facilities). The Policy also states that the Interdisciplinary Team must review and update the care plan when there is a significant change in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 7 of 16 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 12/21/2023 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 0656 resident's condition and when the desired outcome is not met. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 8 of 16 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 12/21/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 review the facility failed to ensure all residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 5 of 8 (Resident #35, Resident #55, Resident #52, Resident #27 and Resident #108) residents reviewed for activities of daily living. Residents Affected - Some 1. The facility failed to ensure Resident #35 received regular showers or baths. 2. The facility failed to ensure Resident #55 and Resident #52 received nail care. 3. The facility failed to ensure Resident #27 and Resident #108 received a shave. These failures placed residents at risk of not receiving help with activities of daily living. Findings included: 1. A record review of Resident #35's face sheet dated 12/21/2023 reflected an [AGE] year-old male admitted on [DATE] with diagnoses of heart failure, gastro-esophageal reflux disease (acid reflux), peripheral vascular disease (circulation disorder), Alzheimer's disease (type of dementia), and atrial fibrillation (irregular heartbeat). A record review of Resident #35's MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated cognition was intact. Section G reflected Resident #55 had total dependence and required two+ persons physical assist with toilet use and transfers. ADL assistance for bathing was not reflected in Resident #35's MDS assessment. A record review of Resident #35's care plan last revised on 12/11/2023 reflected he required extensive assistance by 1-2 staff with bathing. A record review of Resident #35's physician order dated 11/07/2023 reflected he was discharged from hospice services. A record review of Resident #35's bathing record titled ADL - Bathing dated 11/22/2023-12/20/2023 reflected he had received a shower or bath on 11/29/2023 and on 12/11/2023. There were three documented refusals on 11/27/2023, 12/01/2023, and 12/04/2023. A record review of Resident #35's progress notes dated 10/29/2023-12/202/23 reflected no documents showers, baths, or refusals of baths. A record review of Resident #35's progress note dated 12/09/2023 reflected he had tested positive for COVID-19. During an observation and interview on 12/19/2023 at 11:10 a.m., Resident #35 was observed sitting in his wheelchair in his room. Resident #35 stated hospice gave him his last bath, then the day after that the facility gave him another bath, but he had not received a shower or bath since then. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 9 of 16 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 12/21/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #35 could not recall the timeframe for when he had last been bathed. Resident #35 stated hospice had not been by to see him in a while. During an interview on 12/19/2023 at 11:14 a.m., RN C stated Resident #35 was admitted to the facility on hospice but due to his improvement in health, he had been discharged from hospice. RN C stated Resident #35 was discharged from hospice about three weeks prior. During an interview on 12/20/2023 at 8:50 a.m., RN C stated she was familiar with Resident #35, he [NAME] never refused anything from me ever and he lets me do everything. RN C stated the CNAs documented baths/showers and they had their own tab on the electronic records system. RN C stated the facility did not do shower sheets and yes the documentation for baths and showers were all electronic. RN C stated when Resident #35 was on hospice, he had the same hospice aide come in to provide showers for him. RN C stated, he could have missed some during Covid and that's the only reason I can see as to why Resident #35 would have missed showers/baths. RN C stated she thought staff knew Resident #35 was off hospice and she was pretty sure staff knew Resident #35 had not been receiving showers from hospice. RN C stated maybe staff were worried about Resident #35 being on droplet isolation. RN C stated she had never known him to refuse a shower except for one time a few weeks prior. RN C stated when residents refused showers, they were supposed to tell a charge nurse, and the CNAs needed to mark refusals in their electronic records system. RN C stated Resident #35 received showers on the afternoon shift, she was not familiar with the aides, and did not know why they would not have documented on the 2:00-10:00 p.m. shift because she left work at 2:00 p.m. An observation on 12/21/2023 at 8:42 a.m. revealed the shower schedule for the 100-hall was posted on the inside door of the shower room. The shower schedule reflected Resident #35 was to receive showers on Mondays, Wednesdays, and Fridays on the 2:00 p.m.-10:00 p.m. shift. A note by Resident #35's name reflected no longer hospice, we have to shower him. 2. A record review of Resident #55's face sheet dated 12/21/2023 reflected a [AGE] year-old female admitted on [DATE] with unspecified dementia, dehydration, COVID-19, subsequent encounter for closed fracture with routine healing, and thrombocytosis (elevated blood platelets). A record review of Resident #55's MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated cognition was intact. Section G reflected Resident #55 required extensive assistance and a two+ persons physical assist with bed mobility, transfer, and toilet use. ADL assistance required for personal hygiene was not reflected. A record review of Resident #55's care plan last revised on 12/05/2023 reflected she had an ADL self-care performance deficit related to immobility. Interventions included that staff were to check nail length and trim and clean on bath day and as necessary. A record review of Resident #55's progress notes dated 11/21/2023-12/21/2023 reflected no documented attempts or refusals to perform nail care. A record review of Resident #52's face sheet dated 12/21/2023 reflected an [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer's disease (type of dementia), unspecified glaucoma (damaged optic nerve), unspecified severe protein-calorie malnutrition, and hypertension (high blood pressure). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 10 of 16 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 12/21/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #52's MDS assessment dated [DATE] reflected a BIMS score of 8, which indicated moderately impaired cognition. Section G reflected Resident #52 required supervision and a one-person physical assist with bed mobility. ADL assistance required for personal hygiene was not reflected. A record review of Resident #52's care plan last revised on 10/09/2023 reflected he had ADL self-care performance deficit related to advanced dementia and mobility issues. Interventions reflected Resident #52 required substantial assistance by one staff with bathing. A record review of Resident #52's progress notes dated 11/23/2023-12/18/2023 reflected no documented attempts or refusals for nail care. During an observation and interview on 12/20/2023 at 8:23 a.m., Resident #52 was observed lying in bed. Resident #52's nails were long and with dirt underneath. Resident #52 was non-interviewable and said, I don't care where they're at anymore. During an observation and interview on 12/20/2023 at 8:26 a.m., Resident #55 was observed lying in bed with a family member present. Resident #55 stated the care was okay and then closed her eyes. Resident #55's family member stated she had been in the facility since October of 2023 after having a fall and was there for rehabilitation. Observed Resident #55's fingernails to be very long and Resident #55's family member stated we haven't gotten around to asking about that-whether they could be trimmed. Resident #55's family member stated he thought Resident #55's fingernails looked long and that Resident #55 did not like to keep them that long when she took care of them herself. Resident #55's family member stated Resident #55 had planned to go to the nail salon to get her fingernails done before she fell in October of 2023. Resident #55's family member stated Resident #55's nails had not been trimmed since September of 2023. During an observation and interview on 12/21/2023 at 3:36 p.m., Resident #55's fingernails were observed to still be long. Resident #55's family member stated he had seen someone who looked like a nail person, he was going to ask about getting Resident #55's nails done, but he forgot to mention it. During an interview on 12/21/2023 at 8:28 a.m., CNA G stated nail care was supposed to be done by the CNAs during showers because nails got wet and were easier to clip. CNA G stated for the residents with diabetes, nurses clipped their nails, but Resident #55 and Resident #52 were not diabetic. CNA G stated he did not know when Resident #55's or Resident #52's nails were last trimmed because they were scheduled for showers in the afternoon, and he worked mornings. During an observation and interview on 12/21/2023 at 8:31 a.m., CNA G was observed entering Resident #52's room. CNA G observed Resident #52's fingernails and stated, there's some dirt there and they need to be trimmed. During an observation and interview on 12/21/2023 at 8:34 a.m., CNA G was observed entering Resident #55's room. CNA G observed Resident #55's fingernails and said, they look like press on nails, this one is really big, it needs to be clipped, and she shouldn't have press on or long nails because she could scratch herself. CNA G stated, they should be clipped. An observation on 12/21/2023 at 8:42 a.m. revealed the shower schedule for the 100-hall was posted on the inside door of the shower room. The schedule reflected Resident #52 and Resident #55 were to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 11 of 16 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 12/21/2023 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 0677 receive showers on Mondays, Wednesdays, and Fridays on the 2:00-10:00 p.m. shift. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Some A record review of Resident #27's face sheet dated 12/21/2023 reflected a [AGE] year-old female admitted [DATE] with diagnoses of unspecified dementia, chronic atrial fibrillation (irregular heartbeat), major depressive disorder (depression), anxiety disorder, hypertension (high blood pressure), hypothyroidism (disorder of thyroid gland), sick sinus syndrome (abnormal heart rhythm), and malignant neoplasm of unspecified part of unspecified bronchus or lung (abnormal lung growth). A record review of Resident #27's MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated cognition was intact. Section G reflected Resident #27 required extensive assistance and a two+ persons physical assist with personal hygiene including shaving. A record review of Resident #27's care plan last revised on 12/05/2023 reflected she had an ADL self-care performance deficit related to generalized debility and dementia. Interventions reflected Resident #27 required extensive assistance by one staff with personal hygiene. A record review of Resident #108's face sheet dated 12/21/2023 reflected an [AGE] year old female admitted on [DATE] with diagnoses of malignant neoplasm of bladder (bladder cancer), secondary malignant neoplasm of bone (bone cancer), hypertension (high blood pressure), and muscle weakness. A record review of Resident #108's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 9, which indicated moderately impaired cognition. Section GG reflected Resident #108 required moderate assistance with personal hygiene including shaving. A record review of Resident #108's care plan last revised on 12/15/2032 reflected she had an ADL self-care performance deficit related to assessment. Interventions reflected Resident #108 required extensive assistance of one staff for personal hygiene. During an observation and interview on 12/19/2023 at 9:52 a.m., Resident #108 was observed lying in bed. Resident #108 stated staff were rushed, haphazard, and did not have time. Resident #108 was observed to have chin hair and stated staff had not offered her a shave since she came to the facility. Resident #108 stated a friend of hers trimmed her facial hair for her. Resident #108 stated if staff offered her a shave, absolutely she would accept it. An observation on 12/19/2023 at 1:00 p.m. revealed Resident #27 was sitting in the dining room. Resident #27 was observed to have facial hair on her chin. During an interview on 12/19/2023 at 3:12 p.m., Resident #27 stated of course she would like to have her facial hair trimmed if staff offered. Resident #27 stated she had been at the facility for three years and staff had never offered to trim her. Resident #27 stated yes she used to trim her facial hair herself when she lived at home. Resident #27 stated she had never asked staff for a trim, but she would say yes if they had. Resident #27 stated she had more liberty with her hands in the past, and she could no longer move her hands around. An observation on 12/20/2023 at 3:24 p.m. revealed Resident #27 still had hair on her chin. During an interview on 12/21/2023 at 8:37 a.m., CNA G stated the CNAs took care of facial hair on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 12 of 16 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 12/21/2023 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 0677 women during showers. CNA G stated [Resident #27] is a morning shower. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 12/21/2023 at 8:39 a.m., CNA G was observed entering Resident #27's room. CNA G stated, to be honest, she has a little chin hair. CNA G stated he did not know when the last time was that Resident #27 received a shave. CNA G stated Resident #27 had COVID-19 and during that time she received bed baths. CNA G stated some CNAS don't like to do their jobs and said some staff did not want to go into the rooms of residents with COVID-19. CNA G stated yes it could have been missed between Resident #27 having COVID-19 and receiving bed baths. Residents Affected - Some During an interview on 12/21/2023 at 8:41 a.m., CNA G stated Resident #108 received showers on the 2:00-10:00 p.m. shift. He did not know when the last time her shower was but, I know she requested one this morning. During an observation and interview on 12/21/2023 at 8:43 a.m., CNA G was observed entering Resident #108's room and he said, you can see that she still has whiskers. An observation on 12/21/2023 at 8:42 a.m. revealed the shower schedule for the 100-hall was posted on the inside door of the shower room. The schedule reflected Resident #55 was to receive showers on Mondays, Wednesdays, and Fridays between 6:00 a.m.-1:00 p.m. and Resident #108 was to receive showers on Tuesdays, Thursdays, and Saturdays on the 2:00-10:00 p.m. shift. During an interview on 12/21/2023 at 2:41 p.m., the DON stated showers should be done on time. The CNAs did nail care on Sundays, and for women with facial hair, she asked families for permission to shave. The DON stated showers, nail care, and shaving was done by the CNAs, except for diabetic residents. She stated nurses checked diabetic residents nails. The DON stated women were shaved on shower days as needed only if families requested staff to shave the resident. The DON stated showers were three days a week and nail care was done anytime it was needed. The DON stated Resident #108 was new with us and she had not yet requested permission from the family to shave her facial hair. The DON stated family had not notified the facility that Resident #108 had a special area that needed to be shaved. The DON stated Resident #27 was alert and orientated so she would tell us if she wanted to be shaved. The DON stated the CNAs were monitored to ensure they provide care via the ADL report. The DON stated, we all do monitor the CNAs, including the MDS Coordinator, and management. When asked how staff were trained on providing showers, nail care, and shaves for women, the DON stated, there is not a specific day because shower days are shower days. The DON stated yes she meant that those areas should be monitored during shower days. The DON stated if the residents did not receive showers, it could affect their well-being, health, and it could be an infection control issue as well as a skin issue. The DON stated not having nail care was a hygiene issue. The DON stated Resident #108 and Resident #27 could communicate whether they wanted a shave and that she had not had a chance to see them that week. The DON stated having unwanted facial hair was a body image and dignity issue and I won't allow it. The DON stated she had not seen Resident #52 and Resident #55's nails that week either. During an interview on 12/21/2023 at 3:47 p.m., the Administrator stated her expectation for showers, nail care, and shaves for female residents was people who request it get it done. The Administrator stated shaving for women was ad hoc and for men, it was part of their regimen. The Administrator stated the CNAs provided the ADL care, showers were three times a week, and nail care was offered weekly or as needed. The Administrator stated if a female resident came in and they knew they needed a shave, they would request it. The Administrator stated if there was heavy facial hair presence she would expect staff to offer them a shave. The Administrator stated the CNAs were monitored via the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 13 of 16 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 12/21/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some point of care tab on their electronic medical records system. The Administrator stated they could pull a report indicating performance, that observation was another way, and we do room rounds. The Administrator stated management staff rounded on residents everyday Monday-Friday to check ADLs. The Administrator stated staff were trained on providing ADLs through school and competency checks. The Administrator stated she was not sure if there was a staff ADL box that had a place to check off for facial hair and nail care. She said it was not built into their routine. The Administrator stated for Resident #35,this is not a family that wouldn't let him have showers. The Administrator stated if showers were not documented, she would have to have a conversation with the caregiver. If Resident #35 had not received a shower, she would have learned about it through his family. When asked how having long fingernails could affect residents, the Administrator stated, I would ask them if they like them. The Administrator stated if residents did not receive showers as often as they wanted, their needs would not be met. For women with unwanted facial hair, the Administrator said, I would want residents to be confident enough to ask. A record review of the facility's untitled in-service training dated 10/02/2023 reflected nursing staff were trained to check fingernails as residents scratch thin skin can cause skin tears. A record review of the facility's policy titled Activities of Daily Living (ADLs), Supporting dated March 2018 reflected the following: Policy Statement Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. 7. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 14 of 16 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 12/21/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 3 (100, 300, and 400 hallway medication cart) of 5 medication carts reviewed for medication storage. LVN E failed to ensure that the Medication Cart for the 100 Hallway was not left unattended and unlocked. RN A failed to ensure that the Medication Cart for the secured 300 Hallway was not left unattended and unlocked. MA F failed to ensure that the Medication Cart for the 400 Hallway was not left unattended and unlocked. These failures could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed and over-the-counter medications. Findings included: Observation on 12/19/2023 at 10:16 AM revealed that the 100 Hallway Medication Cart (a large rolling cart with an outer lock which was used to store medications and supplies for medication administration for multiple residents; it also contained an inner locked compartment which stored controlled substances) was unsecured and unattended in the hallway outside a resident's room, which had a closed door. At 10:17 AM, LVN E exited the resident's room and secured the cart before turning it away from the door. Interview on 12/19/2023 at 10:18 AM, LVN E stated that she thought she secured the 100 Hallway Medication Cart before entering the resident's room. LVN E stated the cart may not have locked because of a drawer that sticks at times preventing it from locking. LVN E stated that the medication cart was to be always secured when not in direct view. LVN E stated that failure to secure the cart could allow a resident access to medications within the cart resulting in allergic reactions and drug interactions. Observation on 12/19/2023 at 2:28 PM, revealed that the 300 Hallway Medication Cart was unsecured and unattended in the 300 hallway just off the large gathering area for residents within the facility's secure unit. RN A was observed in the gathering area providing residents with drinks and snacks. While the medication cart was unsecured and unattended, four residents passed within arm's reach of the unsecured medication cart. At 2:41 PM, RN A opened the bottom left drawer of the medication cart and retrieved a straw for a resident. RN A pushed the drawer closed and pushed the cart lock to secure it, but it did not lock. RN A pushed the drawer in again and was then able to secure the cart. The 300 Medication Cart contained prescription and over-the-counter medications. Interview on 12/19/2023 at 2:45 PM, RN A stated that she retrieved a pair of gloves from the cart prior to the state surveyor entry into the secure unit and failed to secure the medication cart. RN A stated that the medication cart was to be always locked when not in direct view. RN A stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 15 of 16 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 12/21/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some failure to secure the medication cart could result in a resident gaining access to medications within the cart leading to allergic reactions, drug interactions, overdose, and / or resident illness. Observation on 12/20/2023 at 8:18 AM, MA F left the 400 Hallway Medication Cart unsecured and unattended in the 400 hallway as she provided care for a resident. MA F returned to the 400 Hallway Medication Cart at approximately 8:22 AM and locked the medication cart after obtaining medications for another resident. Interview on 12/21/2023 at 8:27 AM, RN C stated that medication carts were to be kept locked when not in use. RN C stated that a resident could access medications in the unlocked cart resulting in possible allergic reaction. RN C stated that some residents have dementia and may not have awareness that what they were doing could hurt them. Interview on 12/21/2023 at 12:20 PM, MA F stated that she was trained to keep her medication cart locked when she is away from it, even if only for a short time. MA F stated that the medication cart should be locked when they are in the hallways, if it was not being used. MA F stated that a resident could get into the medication cart and take medications out that could be harmful to them. Interview on 12/21/2023 at 2:40 PM, the DON stated that the medication carts were to be always locked. The DON stated that RN A notified her of the failure on 12/19/2023 to secure the 300 Hallway Medication Cart, which she stated cannot occur. The DON stated that failure to secure medication carts could result in a resident gaining access to medications which could be ingested or applied resulting in possible allergic / drug reactions. The DON stated that failure to secure the medication carts also posed a risk of drug diversion. The DON was unable to recall the last in-service that was provided to staff for medication storage. Interview on 12/21/2023 at 3:41 PM, the ADMINISTRATOR stated that medication carts in the facility were to be always locked to prevent residents from gaining access. The ADMINSTRATOR was advised of observations and stated that an immediate in-service needed to be completed for medication storage due to risk of drug diversion. Review of facility in-service for Narcotics on 4/14/2023, all shifts and new hires, which was conducted by the DON revealed, Objectives of the Inservice: *Narcotics will stay in lock box at all times. The signature sheet indicated that both RN A and LVN F were in attendance. Review of the facility's Identifying Exploitation, Theft, and Misappropriation of Resident Property Policy, dated April 2021 revealed, 5. Examples of misappropriation of resident property include: f. drug diversion (taking the resident's medication). Review of facility's undated Delivery, Receipt, and Storage of Medication Policy revealed, 6.3 Storage of Medication, The facility should ensure that only authorized facility staff should have access to the medication storage areas. Authorized facility staff should include nursing staff and those authorized to administer medications. Scheduled medications should be stored in a separate locked area within the medication carts or medication room. The facility should ensure the medications requiring refrigeration are stored appropriately, and the food is not stored with refrigerated medications. Topical medications should be stored separately from oral medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675649 If continuation sheet Page 16 of 16