Health inspection·March 28, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm anxiety disorder, insomnia, sleep apnea, high blood pressure, hernia, brain disease, heart attack, irregular heartbeat, inflammation of the lungs due to food and vomit, and weak and brittle bones. Review of Resident #139 Face Sheet dated 03/27/2024 revealed she was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnosis included Alzheimer's disease with late onset. Residents Affected - Some Review of Resident #188 Face Sheet dated 03/27/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included lack of coordination, communication deficit, asthma, type 2 diabetes, sleep apnea, high blood pressure, heart disease, repeated falls, surgical wound, long term use of insulin, and brief stroke attacks. Observation of the dining services on 03/26/2024 at 12:18pm revealed that Resident #46 and Resident #58 did not receive their meal tray until 18 minutes after their table mate received her tray. Resident #7 did not receive his meal tray until 20 minutes after his table mate received his tray. Observation of dining services on 03/27/2024 at 7:38am revealed Resident # 52 and Resident #188 did not receive their meal tray until 15 minutes after their table mate got her tray. Observation of dining services on 03/27/2024 at 11:34am revealed Resident #139 did not receive his meal tray until 10 minutes after his tablemates. An interview with CNA F on 03/28/2024 at 10:54am revealed the policy for dining tray pass was that all residents at the same table are to receive their meal tray before staff move on to the next table. She stated the aides, and the nurses were responsible for ensuring all residents were served at the same table. CNA F stated that by not feeding the residents at the same table at the same time could make the resident feel like he or she were forgotten and get upset. She also stated residents may feel like he or she is not as important as the other residents. Interview with LVN D on 03/28/2024 at 11:40am revealed the policy for tray pass in the dining room was they start with one table ensure all residents had their food before moving to the next table. She stated that by not giving a resident his/her tray at the same time as others at the table could result in the resident getting upset, resident may feel like staff are picking on them, or feel like he/she is being looked over or not important. LVN D stated there was miscommunication that occurred and that is not a valid excuse for residents to not be served their trays at the same time. Interview with the DON on 03/28/2024 at 1:49pm revealed the policy was when passing trays, they complete one table at a time and ensure residents at the same table are eating at the same time. She stated if residents are not given his/her tray at the same time the resident that did not get their tray may get upset or angry, frustrated. She stated the resident may also wonder why they have not gotten their tray or if they are even going to eat. The DON stated it was evident that the trays were not checked, staff did not communicate to the kitchen staff which residents in the dining room did not have a tray. An interview conducted with the Dietary Manager on 03/28/2024 at 2:00pm revealed the policy on passing trays in the dining room was that staff could not pass meal trays to another table until everyone at the previous table were served. She stated the nurse in the dining room is responsible for ensuring all residents at a table are served before moving to the next table. Stated if a resident did not get his/her tray at the same time as other residents at their table could result in the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 2 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0550 Level of Harm - Minimal harm or potential for actual harm feeling upset and if the resident is hungry the resident does not want to watch others eat. The Dietary Manager stated that on 03/26/2024 she was given order of where residents were seated. She stated she pulled those meal tickets and when residents were seated for lunch the list, she was given was incorrect. She stated it got better on 03/27/2024 because she came out of the kitchen and made a list of the residents in the dining room and pulled those meal tickets. She stated it was a hit and miss when the trays came. Residents Affected - Some An interview with the Administrator on 03/28/2024 at 2:52pm revealed he did not know if there was a policy, but the expectation was for all residents at the same table be served at the same time. Stated whoever is passing trays was responsible for ensuring all residents at the same table were served at the same time. He stated by not giving the residents at the same table their meals together were a dignity issue and the resident may feel left out. Stated he did not know why the residents were not served at the same time. The Administrator stated staff may not of had the correct order of residents. He stated his expectation is the meal trays come off the line in order. Record Review of Meal Service Policy dated 2018 revealed all residents at one table will be served at the same time prior to serving resident at other tables. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 3 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 accommodate the needs and preferences of five of 24 residents (Residents #4, Resident #22, Resident #41, Resident #55, and Resident #64) reviewed for accommodation of needs. Residents Affected - Few The facility failed to place Residents #4, 22, 41,55, and 64's call-lights within reach. This failure affected five residents and placed an additional twenty-five residents who reside at the facility at risk of not having their needs and preferences met and a decreased quality of life. Findings include: Review of Resident #4 Face Sheet dated 03/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included dementia, morbid obesity, insomnia, overactive bladder, atrial fibrillation, breast cancer, major depressive disorder, anxiety disorder, COVID 19, adjustment disorder, high blood pressure. Review of Resident #4s Quarterly MDS assessment dated [DATE] revealed her BIMS score was seven. The MDS also revealed that Resident #4 needs limited assistance with transfers, toileting, and bed mobility. Record review of Resident #4''s care plan dated 3/20/2024 revealed in part (Resident #4) is at risk for falls related to: impaired mobility, poor safety awareness and psychotic medication use. Further review of above plan revealed Encourage use of call light and keep call light within reach at all times while in room. Observation and interview on 3/26/2024 at 9:41 AM, Resident #4 sitting in wheelchair, dressed and well groomed. Resident was sitting approximately three feet away from her bed, along the side of her bed. Resident's call-light was hanging straight down from the wall on the floor and out of reach of reach of the resident. Resident #4 said she did not know where her call light was. Review of Resident #22 Face Sheet dated 03/26/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included dementia, muscle weakness, kidney failure, heart failure, vitamin D deficiency, high blood pressure, COVID 19, problems swallowing, water retention, mild cognitive impairment, and allergies. Review of Resident #22's Quarterly MDS assessment dated [DATE] revealed her BIMS score was two. The MDS also revealed that Resident #22 needs extensive assistance with transfers, toileting, and bed mobility. Record review of Resident #22's care plan dated 1/20/2021 revealed in part (Resident #22) is high risk for falls related to: right side weakness, and poor safety awareness. Further review of above plan revealed Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation and interview on 3/26/2024 at 9:51 AM, Resident #22 sitting in wheelchair, dressed and well groomed. Resident was sitting approximately two feet away from her bed, toward the foot of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 4 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bed. Resident's call-light was laying on the bed behind the resident out of her reach. Resident stated everything was fine and she was good. Review of Resident #41 Face Sheet dated 03/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included dementia, type 2 diabetes, morbid obesity, and high blood pressure. Review of Resident #41's Quarterly MDS assessment dated [DATE] revealed her BIMS score was two. The MDS also revealed that Resident #41 needs extensive assistance with transfers, and bed mobility. Resident #41 needs limited assistance with toileting. Record review of Resident #41''s care plan dated 1/10/2023 revealed in part (Resident #41) is moderate risk for falls related to dementia. Further review of above plan revealed Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation and interview on 3/26/2024 at 10:06 AM, Resident #41 sitting in wheelchair, dressed and well groomed. Resident was sitting approximately two feet away from her bed, toward the foot of the bed. Resident's call-light was hanging straight down on the wall to the floor. Resident #41 stated that she had to look for her call light most of the time. Resident #41 stated she did not know where her call light was, because call light was behind her on the floor. Review of Resident #51 Face Sheet dated 03/26/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included bleeding of the brain, instability, muscle weakness, lack of coordination, need for assistance with personal care, aphasia, major depressive disorder, high blood pressure, overactive bladder, other fatigue, high level of fat particles in the blood, difficulty swallowing, functional quadriplegia. Review of Resident #51's Quarterly MDS assessment dated [DATE] revealed her BIMS score was zero. The MDS also revealed that Resident #41 is total dependent with transfers, and bed mobility and toileting. Record review of Resident #41's care plan dated 1/10/2023 revealed in part (Resident #51) is high risk for falls related to quadriplegia. Further review of above plan revealed Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation on 3/27/2024 at 2:26 PM, Resident #51 sitting in wheelchair, dressed and well groomed. Resident was sitting in her wheelchair at the foot of her bed, Resident #51's call light was laying in the middle of her bed under the sheet. Resident #51 would not respond to questions about call light. Review of Resident #64 Face Sheet dated 03/26/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included dementia, anemia, hypothyroidism, retention of urine, COVID 19 hip fracture, and low levels of blood cells. Review of Resident #64's Quarterly MDS assessment dated [DATE] revealed her BIMS score was eight. The MDS also revealed that Resident #64 is supervision with transfers, and bed mobility. Resident #64 is limited assistance with toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 5 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #64's care plan dated 3/13/2024 revealed in part (Resident #64) is moderate risk for falls related to dementia and muscle weakness. Further review of above plan revealed Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation on 3/26/2024 at 10:12 AM, Resident #64 was dressed and well groom. Resident #64 was lying in bed, call light was on the bedside table out of reach of the resident. When asked Resident #64 about call light, resident stated looking around for it and stated she uses it when she needs help. Observation on 2/27/2024 at 2:26 PM revealed Resident #64's call light was in the same place it was the day before. Resident #64 call light was still on the bedside table out of reach of the resident. Resident #64 was lying in bed resting. An Interview conducted with CNA F on 03/28/2024 at 10:35 a.m., revealed the policy was call lights are to be within reach of the resident if on the bed or in a chair. She stated all staff are responsible for ensuring the call lights are always within reach of the resident when in the room. CNA F stated that if the call light is not within reach it puts the resident at risk of not getting help if they fall or need something. She stated she did not know why the call lights on the residents were not within their reach. She stated someone may have changed the resident and forgot to put it back. An Interview conducted with LVN D on 03/28/2024 at 11:28 a.m., revealed the policy was call lights should always be within reach of the resident. She stated that everyone is responsible for answering and ensuring the call light is within reach of the resident. She stated it was important to ensure the call light was within reach because the resident has the right to get assistance when they need it. LVN D stated if a resident has an emergency, they could not call for help if the call light is not within reach. She stated she did not know why the call lights were not in reach of the resident. She stated there is never an excuse for the call light not to be within reach of the resident. An interview conducted with the RCN on 03/28/204 at 12:22 p.m., revealed the facility did not have a policy on call lights. An interview conducted with CNA G on 03/28/2024 at 1:26 p.m., revealed the policy was the call light should be put on the bed next to the resident or within his/her reach. She stated the aides are responsible for answering the call lights and ensuring they are in reach of the resident. CNA G stated if a call light is not within reach of the resident the staff do not know if the resident needs help unless they yell out for help. An interview conducted with DON on 03/28/2024 at 1:55 p.m., revealed her expectation is to put the call light in the place where the resident can reach it. She stated they do skill check off and answering call lights is covered in orientation. She stated she did the training verbally with staff and did not have anything in writing. She stated that the call lights should always be within the reach of the resident. The DON stated she did not know why the call lights were not within reach of the resident, but she would educate, and exhibit call light placement with staff. An interview conducted with the Administrator on 03/28/2024 at 2:30 p.m., revealed he did not know if there was a policy, but he does have expectations. He stated his expectation is that the call light was always within reach of the resident. The Administrator stated that all staff were responsible for answering call lights and the placement of the call lights. He stated he did not know why the call lights were not within the reach of the residents . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 6 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0558 Asked for call light policy never received it. 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: 675937 If continuation sheet Page 7 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to manage the personal funds of the resident deposited with the facility for 3 (Resident #2, Resident #4, and Resident #20) of five residents reviewed for trust funds. Residents Affected - Some The facility failed to ensure Resident #2, 4, and 20 had ready access to his personal funds on the weekends. This failure could place twenty-seven residents whose funds are managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings Included: Interview on 03/27/2024 at 9:00 AM in the Resident Group Meeting revealed Resident #2, Resident #4, and Resident #20 did not have access to their funds on the weekend or after 5 pm. Resident #2 stated that the residents can only get their money when the business office manager was there. Resident #4, and Resident #20 both stated that they had trouble getting their money because they had a lot of turnovers in the office, and there was not a business office manager to give them their money. Review of Resident #2 Face Sheet dated 03/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Face Sheet revealed she was responsible for herself and received her own financial statements. Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed her BIMS score was fifteen and her active diagnoses included diabetes, Parkinson's disease, pneumonia, asthma, and respiratory failure. Review of Resident #4 Face Sheet dated 03/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Face Sheet revealed she was responsible for herself and received her own financial statements. Review of Resident #4s Quarterly MDS assessment dated [DATE] revealed her BIMS score was seven and did not have any diagnoses. Review of Resident #20 Face Sheet dated 03/27/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Face Sheet revealed she her sister was her responsible party and received her financial statements. Review of Resident #20's Quarterly MDS assessment dated [DATE] revealed her BIMS score was fourteen and her active diagnoses included Sepsis, Parkinson's disease, and respiratory failure. Parkinson's disease, pneumonia, asthma, and respiratory failure. Interview on 03/28/2024 at 1:23 PM with DON revealed the BOM was responsible for maintaining the resident's trust fund. She stated that residents could schedule an appointment or just go up to the BOM's office and get what they needed. The DON stated that if the BOM was not in, she or the Administrator could get the residents their funds. She also stated that the residents have access Monday through Friday from 8 to 5 pm. She also revealed her, the Administrator or the BOM is not at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 8 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0567 facility on the weekend. Level of Harm - Minimal harm or potential for actual harm Interview on 03/28/2024 at 2:34 PM with the Administrator revealed that he revealed worked Monday through Friday. He stated that residents would get money from their trust fund from the business office manager. He stated the only time residents would not be able to get money is if they do not have the funds the resident is requesting in the facility. He said at that point they would do a reconciliation of the cash box send it to corporate to approve; corporate would send them a check to cash to replenish the cash box funds. He stated sometimes the process to replenish the funds could take a few days. The Administrator stated that the residents could get their funds if someone who can give out the cash was at the facility. Residents Affected - Some Interview on 03/28/2024 at 2:58 PM with the BOM revealed residents are allowed to get their funds when they want, however she stated she has Trust Fund Hours normally from 9 am to 5 pm. She stated that the residents could request their funds anytime they want but she does have a 300-dollar cap. She revealed that if a resident wants the funds to pay a bill, she will tell the resident to bring her the bill and she will pay it for the resident. The BOM also stated that if the resident wants money for a field trip that is on the weekend the resident knows to ask before Friday. She also revealed that if a family showed up and decided last minute to take the resident out on a weekend or after 5 pm that the resident family can bring her a receipt and she will reimburse them for the residents' items purchased on the outing. She stated there is no one at the facility on the weekends to give the residents money. The BOM stated that by residents' not having access to their money on the weekends could make them feel excluded, disappointed, or cheated because they could not participate. Record Review of Personal Funds Policy dated 03/2021 revealed the facility is to provide the resident access to funds of fifty dollars or less with in twenty-four hours, and access to funds of fifty dollars or more within three banking days. Record Review of Resident Rights signed by the Administrator, DON, and BOM revealed the resident has the right to have access to money and property deposited with the facility. Review of the list with the number of residents whose funds were managed by the facility provided by the Assistant Business Office Manager on 02/28/2024 reflected twenty-seven residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 9 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents had the right to participate, discontinue or refuse to participate in experimental research for 4 of 4 residents (Resident #2, Resident #16, Resident #65 and Resident #67) reviewed for participation in experimental research. The facility failed to review and maintain in residents' chart signed consents for a sleep study for Residents #2, #16, #65, and #67 This failure placed residents at risk of not knowing how their personal information was used and being unaware of their right to refuse to participate in the study. Findings included: A record review of Resident #2's face sheet dated 3/27/2024 reflected an [AGE] year-old female readmitted on [DATE] with diagnoses of unspecified dementia, chronic obstructive pulmonary disease (lung disease), type 2 diabetes (uncontrolled blood sugar), epilepsy (seizure disorder), hypertension (high blood pressure), chronic diastolic (congestive) heart failure, chronic kidney disease, bipolar disorder (mood disorder), dysphagia (difficulty swallowing), and sleep disorder. A record review of Resident #2's 5-day Medicare MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. A record review of Resident #2's care plan last revised on 3/18/2024 reflected she had a mood problem related to her diagnosis of bi-polar disorder and was to be observed for any changes in need for sleep. Resident #2's care plan did not reflect her participation in the sleep study. A record review of Resident #2's electronic medical record on 3/27/2024 reflected no signed consent for her participation in the sleep study. A record review of Resident #16's face sheet dated 3/27/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis of one side of the body), aphasia (difficulty communicating), dysphagia (difficulty swallowing) following cerebral infarction (stroke), alcohol dependence, uncomplicated, depression, anxiety disorder, other insomnia (difficulty sleeping), hypertension (high blood pressure), osteoporosis (bone disease), and personal history of traumatic brain injury. A record review of Resident #16's quarterly MDS assessment dated [DATE] reflected a BIMS score of 11, which indicated moderately impaired cognition. A record review of Resident #16's care plan last revised on 3/22/2024 reflected he had potential for pain related to physical disability, depression and disease process, and staff were to observe and report any changes in his usual sleep patterns. Resident #16's care plan did not reflect her participation in the sleep study. A record review of Resident #16's electronic medical record on 3/27/2024 reflected no signed consent for her participation in the sleep study. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 10 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #65's face sheet dated 3/27/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia, anemia, hypertension (high blood pressure), and benign prostatic hyperplasia (enlarged prostate). A record review of Resident #65's quarterly MDS assessment dated [DATE] reflected a BIMS score of 14, which indicated minimally impaired cognition. A record review of Resident #65's care plan last revised on 3/13/2024 reflected he was at risk for pain related to fracture and staff were to observe and report changes in sleep patterns. Resident #65's care plan did not reflect his participation in the sleep study. A record review of Resident #65's electronic medical record on 3/27/2024 reflected no signed consent for his participation in the sleep study. A record review of Resident #67's face sheet dated 3/27/2024 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of unspecified dementia , muscle weakness, hyperlipidemia (high cholesterol), heart disease, anemia, major depressive disorder (depression), hypertension (high blood pressure), atherosclerosis (narrowing of arteries), and peripheral vascular disease (poor circulation). A record review of Resident #67's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12, which indicated moderately impaired cognition. A record review of Resident #67's care plan last revised on 9/14/2023 reflected she had ADL self-care performance deficit and was bedfast all or most of the time. Resident #67's care plan did not reflect his participation in the sleep study. A record review of Resident #67's electronic medical record on 3/27/2024 reflected no signed consent for her participation in the sleep study. During an interview on 3/27/2024 at 9:35 a.m., the Administrator stated the experimental research began in June or July of 2023. The Administrator stated residents participating wore a wrist band which sensed the amount of light in the room and tracked their vitals. The Administrator stated part of the study was to implement environmental interventions with residents to improve sleep quality. The Administrator stated the DON would have residents' consents for the study. During an interview on 3/27/2024 at 12:50 p.m., the DON stated the facility obtained soft consents for the sleep study by calling residents' families. The DON stated the facility then fielded the consents to the University conducting the experimental research. During an observation and interview on 3/28/2024 at 10:34 a.m., Resident #16 was observed sitting in her room and she stated the sleep study started a couple months prior, she was not sure how long it went on for, and she had no concerns about it . An observation on 3/28/2024 at 10:36 a.m., revealed Resident #67 was sleeping and was unable to be interviewed regarding the sleep study. During an observation and interview on 3/28/2024 at 10:42 a.m., Resident #65 was observed sitting at the nurse's station. Resident #65 did not respond when asked how the sleep study had gone, but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 11 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0578 stated they're cutting it off Friday and pointed to a black wristband on his left wrist. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 3/28/2024 at 11:12 a.m., Resident #2 was observed on the 100 hall and she stated she was not sure how long the study had lasted but it had not bothered her in any way. Residents Affected - Some During an interview on 3/28/2024 at 2:47 p.m., the DON stated no that prior to 3/27/2024, Resident #2's, Resident #16's, Resident #65's and Resident #67's signed consents were not stored at the facility because it's external. The DON stated no she had not reviewed the signed consents and what all they entailed. The DON stated herself, RN C, the SW and the RNC were involved in obtaining consents for the study through doing a soft check off, informing families what the study consisted of, and allowing the University to follow up with families who initially consented to the study. The DON stated RN C was affiliated with the University conducting the research study, and the facility hired her to coordinate the study. The DON stated there would be no outcome of failing to store signed consents in the facility. During an interview on 3/28/2024 at 2:48 p.m., the RNC stated RN C was the point person for the study and oversaw everything with families. RNC stated RN C had the hard copies of the consents at her house and on her computer. During an interview on 3/28/2024 at 4:11 p.m., the Administrator stated he had not read the consents for the experimental research but they were reviewed by the facility's corporate team before the research started. The Administrator stated generally speaking, provider consents would be uploaded into residents' charts at some point, but they did not house consents for all treatments with outside entities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 12 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0583 Keep residents' personal and medical records private and confidential. 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 resident rights for personal privacy for 7 of 7 residents (Resident # 4, Resident # 18, Resident #36, Resident # 44, Resident #50, Resident #65, Resident #68, and Resident #69) reviewed for personal privacy. Residents Affected - Some The facility posted personal incontinent information on the inside of Resident #4, 36, 44,50,65, and 68's closet. The facility posted Resident #69's incontinent information on the outside of his bathroom door that was visible by anyone walking past the resident's room. The deficient practice could affect all residents in the facility who are incontinent and could result in the resident being humiliated and cause embarrassment to the residents. Findings included: Review of Resident #4 Face Sheet dated 03/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included dementia, morbid obesity, insomnia, overactive bladder, atrial fibrillation, breast cancer, major depressive disorder, anxiety disorder, COVID 19, adjustment disorder, high blood pressure. Review of Resident #36 Face Sheet dated 03/28/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included Dementia, muscle weakness, protein-calorie malnutrition, multiple sclerosis, weak and brittle bones due to age, nerve malfunction, urinary tract infection, joint replacement, low platelet level, circulation disease, bladder infection, fast heart rate, repeated falls, altered mental state, weakness, COVID 19 and feeling of discomfort. Review of Resident #44 Face Sheet dated 03/28/2024 revealed she was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnosis included Dementia, muscle weakness, difficulty communicating, respiratory failure, cirrhosis of liver, type 2 diabetes, pneumonia, cellulitis, anemia, high blood pressure, instability, shortness of breath, difficulty walking, lack of coordination, low red and white blood cells, inflammation of bone, high level of fat particles in the blood, excess fluid in the kidneys, and COVID 19 Review of Resident #50 Face Sheet dated 03/28/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included Dementia, muscle weakness, expressive language disorder, lack of coordination, difficulty communicating, protein-calorie malnutrition, reflux disease, depression, urinary tract infection, sepsis, bladder infection, light headedness and dizziness, difficulty walking, repeated falls, fainting and collapse, and COVID 19 Review of Resident #65 Face Sheet dated 03/28/2024 revealed she was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnosis included Dementia, anemia, high blood pressure, prostatic cancer, and fluid filled sac around the testicle. Review of Resident #65 Face Sheet dated 03/28/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included anemia, high blood pressure, type 2 diabetes, protein-calorie malnutrition, vitamin D deficiency, seasonal allergies, high levels of fat particles in the blood, low potassium, narrowing of heart valve, and inflammation of the colon. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 13 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0583 Level of Harm - Minimal harm or potential for actual harm Review of Resident #68 Face Sheet dated 03/28/2024 revealed she was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnosis included dementia. Observation of residents' rooms on 03/26/2024 at 9:39 am revealed a sign that was visible from the hall that stated, resident # 69 wears pull ups only no brief/diaper. Residents Affected - Some An Interview conducted with MA M on 03/27/2024 at 1:44 pm revealed policy was that staff and family cannot post personal information about a resident. He stated by posting incontinent information about a resident violated the resident's privacy, and that the resident might feel embarrassed by the information posted. He stated if family put person information up about a resident the CNA and Med Aides would let the charge nurse know so the nurse can talk to the family. MA M stated he has not noticed the sign on Resident #68's door. He stated the resident's family must have posted the information. He did not think the DON was aware of the posting on the resident's door. An interview with Resident # 69 on 03/27/2024 at 1:56 pm revealed the resident was embarrassed by the sign that was posted stating he wore pullups. Resident wanted the sign to be taken down. Resident's wife (who is also a patient) stated surveyor needed to talk to her daughter. An interview on 03/27/2024 at 2:14 pm was attempted with Resident #69's daughter. Left daughter a message and did not get an answer or a call back. An interview with CNA F on 03/28/2024 at 10:39 am revealed the policy was that the sign about briefs must be posted inside the resident's closet. She revealed all residents that were incontinent had a sign on the inside of their closet door that stated the resident's name, and brief size. CNA F stated the Medical Records put the signs up so that staff will know what size the resident wears when doing rounds. She stated on the outside of the door it is more visible to anyone that walks by but when it is on the inside it is less visible. She stated most visitors will not go into a resident's closet so they would not see the sign. CNA F stated that most of the residents do not know the signs are there but if they did, they would want them to be taken down. She also stated that some residents might be okay with it being there because the resident would get the right brief. Observation of the signs CNA F mentioned above on 03/28/2024 at 10:49 am revealed that Resident #4, Resident # 36, Resident #44, Resident #50, Resident #65, and Resident #68 all had signs posted inside their closet that said What do I wear? The (resident's name), room number, brief or pull up, and size. An interview with LVN D on 03/28/2024 at 11:32 am revealed staff is not to hang signs on residents' doors and visitors should not have access to any personal information about a resident. She stated that the Medical Records is the one who puts signs up in resident's rooms. She stated if a sign were posted with resident personal information, it becomes a dignity and privacy issue, and the resident could be embarrassed. She stated when family members put up signs the staff try to educate them on residents' rights. She stated no one would want personal information about them posted and they would want it taken down. Observation on 03/28/2024 at 11:38 am while talking to a nurse in the hall a friend of Resident #44 came by and said she was going to go into the resident's closet to get him a jacket because he was cold. An interview on 03/28/2024 at 11:55 am with Medical Records revealed that the signs about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 14 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0583 Level of Harm - Minimal harm or potential for actual harm incontinent care cannot be posted where they can be seen, stated the signs are posted on the inside of the resident's closet or inside the resident's bathroom. She stated that the signs being posted inside the residents' closets were implemented by the previous administrator. She stated if the information was misused the resident could be offended by the sign or be embarrassed. Medical Records stated that visitors typically do not go into a residents closet but could see the sign being posted in the bathroom as an issue. Residents Affected - Some An interview with the DON on 03/28/2024 at 1:23 pm revealed that posting information about the resident is a dignity issue. She stated if the sign has the resident's name on it then it could not be visible to the public and that the old administration was the one who initiated the signs being posted in the closet. She stated the resident might get embarrassed or depressed if the signs are posted with incontinent information. The DON stated the sign on Resident #69's bathroom door should have been taken down when the staff did the quality-of-life rounds. She stated staff have a quality-of-life check list that is supposed to be done daily. An interview with the Administrator on 03/28/2024 at 2:41 pm revealed hanging signs with personal information about a resident was not allowed at all in their rooms depending on what was being posted. He stated that the signs were posted by Medical Records. The Administrator stated that if personal information about incontinent care is posted it messes with the resident's dignity and can make the resident sad, depressed, or embarrassed. He stated he has not had residents' family post personal information in a resident's room and did not think there was a policy against family posting personal information. Record Review of the quality-of-life checklist could not be done due to the facility not providing the checklist. Record Review of Statement of Resident Rights signed by the Administrator, DON, Medical Records revealed residents have the right to privacy, to have facility information about the resident maintained as confidential. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 15 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 6 of 8 residents (Resident #47, Resident #58, Resident #2, Resident #16, Resident #65, Resident #67) reviewed for comprehensive care plans. The facility failed to revise Resident #47's care plan to reflect interventions for her diagnosis of lymphedema. The facility failed to revise Resident #58's care plan to reflect interventions for her diagnosis of diabetes mellitus. The facility failed to revise Resident #2's, Resident #16's, Resident #65's, and Resident #67's care plan to reflect their participation in an experimental research study. These failures placed residents at risk of not having interventions in place to meet their needs. Findings included: A record review of Resident #47's face sheet dated 3/28/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, bipolar disorder (mood disorder), anxiety disorder, post-traumatic stress disorder, insomnia (difficulty sleeping), lymphedema (a condition that results in swelling of the leg or arm), hypertension (high blood pressure), gastroesophageal reflux disease (acid reflux), seborrheic dermatitis (skin disorder), and unspecified osteoarthritis (joint disease). A record review of Resident #47's admission MDS dated [DATE] reflected a BIMS score of 9, which indicated moderately impaired cognition. A record review of Resident #47's care plan last revised on 3/11/2024 reflected she had diabetes mellitus (uncontrolled blood sugar), cardiac disease, dehydration or potential fluid deficit and potential for pain. Resident #47's care plan did not reflect her diagnoses of lymphedema and there were no interventions to treat this problem. A record review of Resident #58's face sheet dated 3/28/2024 reflected an [AGE] year-old female readmitted on [DATE] with diagnoses of cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), type 2 diabetes (uncontrolled blood sugar), dysphagia (difficulty swallowing), anxiety disorder, hypertension (high blood pressure), primary insomnia (difficulty sleeping), hyperlipidemia (high cholesterol), obstructive sleep apnea (breathing disorder), encephalopathy (disease of the brain), and unspecified atrial fibrillation (irregular heartbeat). A record review of Resident #58's annual MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated minimally impaired cognition. A record review of Resident #58's care plan last revised on 3/20/2024 reflected she was resistive to insulin therapy and staff were to allow the resident to make decisions about her treatment regimen to provide a sense of control. Resident #58's care plan did not reflect her diagnosis of diabetes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 16 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 or any interventions to treat potential problems related to the diagnosis. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #2's face sheet dated 3/27/2024 reflected an [AGE] year-old female readmitted on [DATE] with diagnoses of unspecified dementia, chronic obstructive pulmonary disease (lung disease), type 2 diabetes (uncontrolled blood sugar), epilepsy (seizure disorder), hypertension (high blood pressure), chronic diastolic (congestive) heart failure, chronic kidney disease, bipolar disorder (mood disorder), dysphagia (difficulty swallowing), and sleep disorder. Residents Affected - Some A record review of Resident #2's 5-day Medicare MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. A record review of Resident #2's care plan last revised on 3/18/2024 reflected she had a mood problem related to her diagnosis of bi-polar disorder and was to be observed for any changes in need for sleep. Resident #2's care plan did not reflect her participation in the sleep study. A record review of Resident #16's face sheet dated 3/27/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis of one side of the body), aphasia (difficulty communicating), dysphagia (difficulty swallowing) following cerebral infarction (stroke), alcohol dependence, uncomplicated, depression, anxiety disorder, other insomnia (difficulty sleeping), hypertension (high blood pressure), osteoporosis (bone disease), and personal history of traumatic brain injury. A record review of Resident #16's quarterly MDS assessment dated [DATE] reflected a BIMS score of 11, which indicated moderately impaired cognition. A record review of Resident #16's care plan last revised on 3/22/2024 reflected he had potential for pain related to physical disability, depression and disease process, and staff were to observe and report any changes in his usual sleep patterns. Resident #16's care plan did not reflect her participation in the sleep study. A record review of Resident #65's face sheet dated 3/27/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia, anemia, hypertension (high blood pressure), and benign prostatic hyperplasia (enlarged prostate). A record review of Resident #65's quarterly MDS assessment dated [DATE] reflected a BIMS score of 14, which indicated minimally impaired cognition. A record review of Resident #65's care plan last revised on 3/13/2024 reflected he was at risk for pain related to fracture and staff were to observe and report changes in sleep patterns. Resident #65's care plan did not reflect his participation in the sleep study. A record review of Resident #67's face sheet dated 3/27/2024 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of unspecified dementia , muscle weakness, hyperlipidemia (high cholesterol), heart disease, anemia, major depressive disorder (depression), hypertension (high blood pressure), atherosclerosis (narrowing of arteries), and peripheral vascular disease (poor circulation). A record review of Resident #67's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12, which indicated moderately impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 17 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #67's care plan last revised on 9/14/2023 reflected she had ADL self-care performance deficit and was bedfast all or most of the time. Resident #67's care plan did not reflect his participation in the sleep study. During an observation and interview on 3/26/2024 at 9:51 a.m., Resident #47 was observed sitting in her room and both of her calves were swollen. Resident #47 stated she had lymphedema and it hurt her to do anything. During an observation and interview on 3/27/2024 at 9:51 a.m., Resident #58 was observed wheeling herself down the 200 hall. Resident #58 reported the menu had a lot of bread, sweets and potatoes. Resident #58 stated she was diabetic and said her diabetes was well controlled through her diet, so she did not take medication. During an observation and interview on 3/28/2024 at 10:34 a.m., Resident #16 was observed sitting in her room and she stated the sleep study started a couple months prior, she was not sure how long it went on for, and she had no concerns about it. An observation on 3/28/2024 at 10:36 a.m. revealed Resident #67 was sleeping and was unable to be interviewed regarding the sleep study. During an observation and interview on 3/28/2024 at 10:42 a.m., Resident #65 was observed sitting at the nurse's station. Resident #65 did not respond when asked how the sleep study had been going on but stated they're cutting it off Friday and pointed to a black wristband on his left wrist. During an observation and interview on 3/28/2024 at 11:12 a.m., Resident #2 was observed on the 100 hall, and she stated she was not sure how long the study had lasted but it had not bothered her in any way. During an observation and interview on 3/28/2024 at 11:16 a.m., the MDS Coordinator stated the facility's policy on comprehensive care plans was to revise them quarterly. The MDS Coordinator stated they looked at care plans during care plan meetings with family and changes would be made as needed. The MDS Coordinator stated ultimately herself was responsible for revising care plan but said each department did their part. The MDS Coordinator stated that since she had the entire facility, she had a PRN person, LVN Q, who assisted with revising care plans. The MDS Coordinator stated yes she expected to see diagnoses of lymphedema and diabetes on residents' care plans. The MDS Coordinator stated she had not care-planned residents' participation in experimental research and it just didn't occur to me. The MDS Coordinator stated she thought it was a good idea to care plan residents' participation in the sleep study. The MDS Coordinator stated, they switch who they're doing the study with so often. The MDS Coordinator stated she ensured care plans were person-centered and comprehensive through knowing the residents and from asking floor staff their opinion on good interventions. The MDS Coordinator stated she had worked there a long time. The MDS Coordinator stated when they reviewed care plans, they had one person looking at diagnoses while another person looked at the care plan and it was a team effort. Observed the MDS Coordinator look at her computer and then said it got missed in regard to Resident #47's and Resident #58's diagnoses of lymphedema and diabetes, respectively, not being on their care plans. The MDS Coordinator stated if orders were in place and the care was there, she did not think there would be any outcome on residents. During an interview on 3/28/2024 at 2:40 p.m., the DON stated care plans were reviewed every 90 days and if things need adjusted, they should be reviewed. The DON stated the MDS Coordinator was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 18 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some responsible for ensuring care plans were person-centered and comprehensive. The DON stated she expected to see a diagnosis of diabetes on a resident's care plan but no not with a diagnosis of lymphedema, because we don't treat it. The DON stated with the experimental research with Resident #2, Resident #16, Resident #65, and Resident #67, since there was no medication involved and it did not affect their emotional status, she did not think it needed to be in the care plan. The DON stated if there were something the facility could do for quality of life or to manage needs, if they did not update it in the care plan, it could cause a bad outcome. During an interview on 3/28/2024 at 4:11 p.m., the Administrator stated care plans were updated as needed or quarterly, and any nurse could update the care plan but generally the MDS Coordinator monitored care plans. The Administrator stated diagnoses such as diabetes mellitus and lymphedema should be in the care plan and he was not sure whether participation in experimental research should be included. The Administrator stated if there were no orders there to monitor and it were not being addressed, there could be a negative affect on residents. A record review of the facility's policy titled Care Plans, Comprehensive Person-Centered dated March 2022 reflected the following: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables lo meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. The care plan interventions arc derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that arc to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but arc not provided due to the resident exercising his or her rights, including the right to refuse treatment; (3) which professional services arc responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 19 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 c. reflects currently recognized standards of practice for problem areas and conditions. Level of Harm - Minimal harm or potential for actual harm 9. Care plan interventions arc chosen only after dnta gathering, proper sequencing of events. Careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Residents Affected - Some 10. When possible, interventions address the underlying source(s) of the problem [NAME](s), not just symptoms or triggers. 11. Assessments of residents arc ongoing and care plans arc revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 20 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 and oral hygiene for 3 of 8 (Resident #32, Resident #57 and Resident #58) residents reviewed for ADL's. Residents Affected - Some The facility failed to ensure Resident #32 received nail care. The facility failed to ensure Resident #57 and Resident #58 received shaving care. These failures placed residents at risk of poor personal hygiene. Findings included: A record review of Resident #32's face sheet dated 3/28/2024 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of dementia, muscle weakness, type 2 diabetes (uncontrolled blood sugar), cognitive communication deficit (difficulty communicating), hypertension (high blood pressure), cerebral infarction (stroke), and major depressive disorder (depression). A record review of Resident #32's annual MDS assessment dated [DATE] reflected a BIMS score of 9, which indicated moderately impaired cognition. Section GG (Functional Abilities and Goals) reflected Resident #32 required partial/moderate assistance with personal hygiene. A record review of Resident #32's care plan last revised on 3/07/2024 reflected she had ADL self-care performance deficit and required supervision by one staff with personal hygiene. Resident #32's care plan also reflected nails should always be cut straight across, never cut corners. A record review of Resident #32's bathing schedule reflected she was last bathed on 3/27/2024. A record review of Resident #32's progress notes dated 2/27/2024-3/28/2024 reflected no refusals of nail care. A record review of Resident #57's face sheet dated 3/28/2024 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of Alzheimer's disease (type of dementia), paraphilias (a condition characterized by abnormal sexual desires), unspecified severe protein-calorie malnutrition (unintended weight loss), anxiety disorder, and Parkinson's disease (Chronic degenerative disorder). A record review of Resident #57's quarterly MDS assessment dated [DATE] reflected a BIMS score of 02, which reflected severely impaired cognition. Section GG (Functional Abilities and Goals) reflected Resident #57 required partial/moderate assistance with personal hygiene. A record review of Resident #57's care plan last revised on 3/18/2024 reflected she had ADL self-care performance deficit and required extensive assistance by one staff with personal hygiene. A record review of Resident #57's bathing schedule reflected she was last bathed on 3/26/2024. A record review of Resident #57's progress notes dated 2/27/2024-3/28/2024 reflected no documented refusals of shaving care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 21 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 #58's face sheet dated 3/28/2024 reflected an [AGE] year-old female readmitted on [DATE] with diagnoses of cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), type 2 diabetes (uncontrolled blood sugar), dysphagia (difficulty swallowing), anxiety disorder, hypertension (high blood pressure), primary insomnia (difficulty sleeping), hyperlipidemia (high cholesterol), obstructive sleep apnea (breathing disorder), encephalopathy (disease of the brain), and unspecified atrial fibrillation (irregular heartbeat). A record review of Resident #58's annual MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated minimally impaired cognition. Section GG (Functional Abilities and Goals) reflected Resident #58 required supervision or touching assistance with personal hygiene. A record review of Resident #58's care plan last revised on 3/20/2024 reflected she had ADL self-care performance deficit and required extensive assistance by one staff with personal hygiene. A record review of Resident #58's bathing record reflected she was last bathed on 3/27/2024. A record review of Resident #58's progress notes dated 2/27/2024-3/28/2024 reflected no documented refusals of shaving care. An observation. During an observation and interview on 3/26/2024 at 10:40 a.m., Resident #32 was observed in her room with fingernails which had about 3 mm of whites showing. Resident #32 stated yeah they were long and said she was not sure when the last time they were trimmed. Resident #32 stated her last shower was Friday 3/22/2024 and staff did not trim her nails that day. An observation and interview on 3/27/2024 at 9:58 a.m., revealed Resident #58 was in her wheelchair in the 200 hall and had facial hair on her chin about 2-3 mm long. Resident #58 stated she used to have an electric razor at home and would take care of her facial hair. Resident #58 stated she had a shower that morning and no staff had never offered to shave her. Resident #58 stated yes she would like to be offered a trim. During an observation and interview on 3/27/2024 at 2:28 p.m., Resident #32 was observed in bed and her fingernails were observed to have about 3 mm of whites showing. Resident #32 stated no staff had not offered to trim her nails. During an observation and interview on 3/28/2024 at 8:56 a.m., CNA K stated, on shower days we trim their nails. CNA K stated CNAs did shaves and nail trimming on shower days at least three times a week or if you see they're not looking good. CNA K stated Resident #58 did not usually refuse shaves. CNA K stated he was not sure when the last time Resident #32 had been offered a nail trim. CNA K entered Resident #32's room and stated her fingernails needed to be trimmed. CNA K then entered Resident #58's room and stated she had little spikes of hair and said Resident #58 told him she wanted to be shaved. During an observation and interview on 3/28/2024 at 9:11 a.m., Resident #58 was observed in the 200 hall with small patches of hair on her chin. Resident #58 stated someone had shaved her, but they missed a spot and she could still feel facial hair on her chin. An observation on 3/28/2024 at 9:17 a.m. revealed Resident #57 was on the 300 hall mumbling to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 22 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 herself. Resident #57 had facial hair on her chin which was about 3-4 mm long. Resident #57 was non-interviewable. During an observation and interview on 3/28/2024 at 9:17 a.m., CNA L stated she worked for a staffing agency and it was her first time working on the 300 hall. CNA L stated if she saw female residents with facial hair, she would shave them. CNA L stated Sundays were when residents were given shaves. CNA L stated she did not know when Resident #57 had been bathed last. Observed CNA L walk over to Resident #57 and CNA L stated, she has hair and yes she could use a shave. During an interview on 3/28/2024 at 2:40 p.m., the DON stated residents' nails should be checked and shaves should be done as needed and on shower days. The DON stated CNAs provided this care. The ODN stated the expectation was that CNAs knew how to provide the care and if they had questions, they needed to get with their charge nurse. The DON stated staff were trained on providing personal hygiene during CNA school and during orientation at the facility. The DON stated she had not seen Resident #57's or Resident #58's facial hair, and she had not seen Resident #32's fingernails. The DON stated if residents did not receive nail care or shaves, it could cause embarrassment or residents could scratch themselves. During an interview on 3/28/2024 at 4:09 p.m., the Administrator stated CNAs should check for nails and facial hair during showers. The Administrator stated CNAs were monitored by the DON and nurse management. The Administrator stated if residents did not receive shaving or nail care, it could affect dignity or quality of life. A record review of the facility's policy titled Activities of Daily Living (ADLs), Supporting dated March 2018 reflected the following: Policy Statement Residents will [be] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities or daily living (ADLs). 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 or 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 or the problem and not just assume the resident is refusing or declining care. Approaching (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 23 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 the resident in a different way or al a different time, or having another staff member speak with the resident may be appropriate. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 24 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 all residents received treatment and care in accordance with professional standards of practice for 1 of 8 (Resident #47) residents reviewed for edema care. Residents Affected - Few The facility failed to obtain orders and provide treatment for Resident #47's lymphedema. This failure could place residents at risk for untreated medical issues and diminished quality of care. Findings included: A record review of Resident #47's face sheet dated 3/28/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, bipolar disorder (mood disorder), anxiety disorder, post-traumatic stress disorder, insomnia (difficulty sleeping), lymphedema (a condition that results in swelling of the leg or arm), hypertension (high blood pressure), gastroesophageal reflux disease (acid reflux), seborrheic dermatitis (skin disorder), and unspecified osteoarthritis (joint disease). A record review of Resident #47's admission MDS dated [DATE] reflected a BIMS score of 9, which indicated moderately impaired cognition. A record review of Resident #47's care plan last revised on 3/11/2024 reflected she had diabetes mellitus (uncontrolled blood sugar), cardiac disease, dehydration or potential fluid deficit and potential for pain. Resident #47's care plan did not reflect her diagnoses of lymphedema and there were no interventions to treat this problem. A record review of Resident #47's physician orders reflected no orders to apply compression stockings, use compression device, or monitor her lymphedema. A record review of Resident #47's progress note dated 2/16/2024 authored by the DON reflected the following: Left pedal/ankle edema: None Right pedal/ankle edema: None A record review of Resident #47's progress note dated 2/17/2024 authored by an unknown author reflected the following: Wanderguard placed on rollator d/t resident's arms and legs being edematous. A record review of Resident #47's progress note dated 2/19/2024 authored by the NP reflected the following: 11. Lymphedema (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 25 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0684 Bilateral lower and upper lymphedema. Level of Harm - Minimal harm or potential for actual harm Has compression device from home. Residents Affected - Few A record review of Resident #47's physician orders reflected no orders for compression socks or devices and no orders to monitor her lymphedema and associated symptoms. During an observation and interview on 3/26/2024 at 9:51 a.m., Resident #47 was observed sitting in her room and both of her calves were swollen. Resident #47 stated she had lymphedema and it hurt her to do anything. During an interview on 3/28/2024 at 8:41 a.m., Resident #47's family member stated Resident #47 had a compression device in her room which should be used for one hour a day to squeeze the fluid out of Resident #47's legs. Resident #47's family member stated Resident #47 did not take medication for her lymphedema, but a physical therapist at the hospital wanted Resident #47 to wear compression stockings. Resident #47's family member stated she was not sure what the compression device was called, but Resident #47 would put stockings on and then wrap her legs around a sleeve, and the device would squeeze fluid up out of her. Resident #47's family member stated she visited the facility ever day and had never seen the machine being used on Resident #47 and had not seen Resident #47 wearing compression stockings. During an interview on 3/28/2024 at 11:27 a.m., the MDS Coordinator stated that as an LVN, she would expect there to be monitoring in place for residents with lymphedema. In regard to Resident #47, the MDS Coordinator stated, I believe she has compression stockings. The MDS Coordinator stated yes she would expect to see an order to monitor the edema and to notify nursing staff when to apply and remove compression stockings. The MDS Coordinator stated she did not see any orders in Resident #47's chart to treat or monitor her lymphedema. The MDS Coordinator stated the NP or MD put in orders but if they were not in the facility, nurses called them to get the orders and put them in when resident were admitted . The MDS Coordinator stated yes if Resident #47 had a compression device from home, she would expect to see orders associated with its use. The MDS Coordinator stated she saw a progress note in Resident #47's chart which reflected she had a compression device and said I do not see an order for when to use the device. During an observation and interview on 3/28/2024 at 11:36 a.m., PT N was walking with Resident #47 and said I haven't seen her wear them when asked whether Resident #47 wore compression stockings. During an observation interview on 3/28/2024 at 11:46 a.m., LVN E was observed working on Resident #47's hall (200 hall). LVN E stated the process for admitting residents included receiving a folder from the admissions coordinator with the resident's information and then having the ADON or charge nurse input orders after they were approved by the NP. LVN E stated yes Resident #47 had compression stockings, but he was not sure whether she had them on at that moment. LVN E stated he was not aware Resident #47 had a compression device and they probably use it at night. When asked how staff would know when to apply the stockings or use the compression device, LVN E stated, it would be in the orders. During an interview on 3/28/2024 at 11:47 a.m., RN B stated when residents were admitted Monday through Friday, we bring it to the NP, and she approves it when asked how orders were entered. RN B stated if orders were needed and not on the discharge orders from the hospital, she would ask the NP or doctor for the order. RN B stated for a diagnosis of lymphedema, she would expect to see an order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 26 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few specifying when to apply compression wraps. RN B stated no Resident #47 did not have wraps, she was not too familiar with Resident #47 and she usually worked 100 and 300 halls. RN B stated yes she had admitted Resident #47 from home. When asked why she had not contacted the NP about inputting orders related to Resident #47's lymphedema, RN B stated I think I forgot. An observation on 3/28/2024 at 12:01 p.m. revealed Resident #47 was walking down the hall with PT N and she was not wearing compression stockings. During an observation and interview on 3/28/2024 at 3:46 p.m., Resident #47's family member stated she brought the pressure relieving device into the facility the day Resident #47 was admitted and told everyone who was there about the device. Resident #47's family member stated she showed RN A how to use the device and she was not sure whether staff were using it. Resident #47's family member stated Resident #47 had lymphedema for years, and a physical therapist at the hospital said she needed to wear it for an hour a day as well as pressure stockings. Resident #47's family member stated Resident #47's legs were so big they did not fit normal compression stockings. Resident #47's family member stated Resident #47 used to receive lymphedema therapy through the hospital, who provided her with a type of compression bandage that fit Resident #47-Resident #47's family member stated she had brought this to the facility and had told everyone at the facility about the wraps. Resident #47's family member stated she had requested Resident #47's PT records be sent to the facility, but she did not know whether the facility had received them. Observed a roll of bandage and a compression sleeve device sitting inside a bag in Resident #47's room. During an interview on 3/28/2024 at 3:57 p.m., RN A stated as of right now, the pressure machine is not being used. RN A stated when Resident #47 first arrived at the facility, she let the NP know Resident #47 had a pressure relieving device and she was not sure why it had not been used. RN A stated yes she needed an order to use the device and she said she had sent a message to the NP to request an order when Resident #47 arrived. RN A stated she did not think the NP responded to this message. RN A stated Resident #47 would need an order for the compression socks as well, no she had not asked the NP for an order for that, and I try to catch what I can. RN A stated without these orders, Resident #47's situation would not be improved, managed, and maintained the way it was supposed to. RN A stated she had not gone to the DON regarding this matter. During an interview on 3/28/2024 at 2:45 p.m., the DON stated the process for admitting residents involved the admissions coordinator providing hospital discharge orders, the NP checking off medications, the ADON placing medication orders, the admitting nurse doing a head-to-toe assessment, and then we add vital signs and other orders. The DON stated herself, the ADON, or charge nurses were responsible for adding these orders. The DON stated there was an admissions checklist they used. The DON stated she would not expect to see orders for lymphedema if we're not treating it. The DON stated she had not seen the compression device Resident #47's family brought it, and she was not sure when it was brought to the facility. The DON stated pain was monitored through pain assessments and Resident #47's legs looked the same as when she came in. During an interview on 3/28/2024 at 2:50 p.m., the RNC stated standing or queued orders could be entered by anyone but usually nurse managers put them in because there were a lot of agency nurses. The RNC stated she had spoken with the NP who said there was not a reason to treat the lymphedema. The RNC stated, you can't just put a wrap on and said they needed a special order for it. The RNC stated not having orders to treat lymphedema could be a quality-of-life issue if it were painful but said Resident #47 had not mentioned pain with anyone. The RNC stated there was not a policy on admitting residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 27 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/28/2024 at 4:28 p.m., the Administrator stated he could not say for sure what happened with Resident #47 but said that the NP said orders for lymphedema did not come with her primary orders and they can only go off what they were given. The Administrator stated providers made decisions based on diagnoses and he was not sure whether it was investigated as to why Resident #47 came in with equipment and what to do with it. The Administrator stated he did not know enough clinically to say what a potential negative outcome could be. During an interview on 3/28/2024 at 5:08 p.m., the NP stated she did not know why an order had not been placed for Resident #47's compression device and she was not aware of Resident #47's compression stockings. The NP stated she had seen Resident #47 when she first came in, and she had just seen her once more that day (3/28/2024). Polices on quality of care and edema were requested on 3/28/2024 at 3:39 p.m. and were not provided prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 28 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents received food that accommodated the resident's preferences for 1 of 8 (Resident #58) residents reviewed for food preferences. The facility served Resident #58 food items she disliked as reflected on her meal ticket. This failure placed residents at risk of decreased appetite and oral intake. Findings included: A record review of Resident #58's face sheet dated 3/28/2024 reflected an [AGE] year-old female readmitted on [DATE] with diagnoses of cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), type 2 diabetes (uncontrolled blood sugar), dysphagia (difficulty swallowing), anxiety disorder, hypertension (high blood pressure), primary insomnia (difficulty sleeping), hyperlipidemia (high cholesterol), obstructive sleep apnea (breathing disorder), encephalopathy (disease of the brain), and unspecified atrial fibrillation (irregular heartbeat). A record review of Resident #58's annual MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated minimally impaired cognition. A record review of Resident #58's care plan last revised on 3/20/2024 reflected she was resistive to insulin therapy and staff were to allow the resident to make decisions about her treatment regimen to provide a sense of control. A record review of Resident #58's orders reflected an order dated 3/06/2024 for a low concentrated sweets (LCS) diet. During an observation and interview on 3/27/2024 at 9:51 a.m., Resident #58 was observed wheeling herself down the 200 hall. Resident #58 reported the menu had a lot of bread, sweets and potatoes. Resident #58 stated she was diabetic and said her diabetes was well controlled through her diet, so she did not take medication. During an observation and interview on 3/27/2024 at 1:26 p.m., Resident #58 was observed eating lunch. Resident #58's tray ticket reflected the cheese stuffed shell with marinara & parmesan, broccoli florets, and garlic bread were struck through. Resident #58's tray ticket reflected her dislikes/intolerances included bread, broccoli, brussel sprouts, caked, cucumber, lactose, potatoes and sausage. Resident #58's meal tray contained the stuffed cheese shell with marinara & parmesan, broccoli, garlic bread and rice. Resident #58 stated, oh, it's all bread. During an observation and interview on 3/28/2024 at 12:03 p.m., Resident #58 was eating lunch in the dining room. Resident #58's meal ticket reflected the pineapple upside down cake was struck through. Resident #58 stated she had been served it anyway, and she ate it because it was there on her tray. Resident #58 stated she did not like cake because she knew she was not supposed to have it. Resident #58's lunch ticket reflected cake was still listed under her dislikes/intolerances . During an interview translated by HHSC's translating services on 3/28/2024 at 12:21 p.m., CK O (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 29 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she had served lunch that day (3/28/2024) and the day prior (3/27/2024). When asked how she ensured residents did not receive items they disliked, CK O stated, the ticket says. CK O stated no she was not familiar with Resident #58. However, when asked why Resident #58 received cake, pasta and bread on 3/27/2024 when her ticket reflected she was not to receive those items, CK O stated she puts what the resident asks for. CK O stated that on 3/27/2024, DA P told her Resident #58 wanted a regular plate. When asked why on that day (3/28/2024) Resident #58 received cake when her ticket had it crossed through, CK O stated another lady put the dessert on the tray. During an interview on 3/28/2024 at 12:35 p.m., the Dietary Manager stated Resident #58 liked broccoli despite her meal ticket indicating otherwise. During an interview on 3/28/2024 at 2:40 p.m., the DON stated she wanted to make sure they gave residents food they were wanting. The DON stated the dietary department checked trays and nurses should confirm the tickets to make sure diets were correct. The DON stated it should be common sense when asked how nurses were trained on checking tray tickets. The DON stated if Resident #58 received foods she did not like it could cause decreased intake and stated yes receiving more carbohydrates than she wanted could affect blood sugar. During an interview on 3/28/2024 at 4:18 p.m., the Administrator stated nurses were supposed to check trays and his expectation was for residents to not receive what they did not want. The Administrator stated Resident #58 receiving foods she did no want could ruin her appetite. A record review of the facility's policy titled Alternate Food Choices and Substitutions and Honoring Preferences dated 2018 reflected the following: Policy: The foci lily believes that adequate nutrition is essential to each resident's well-being and good health. An alternate entrée and vegetable will be offered at each meal. The facility also supports resident choice and allowing residents to choose foods by honoring their food preferences. Other substitutions will also be available in the event a resident does not choose the main meal or the alternate. 2. The Nutrition & Food service Manager or designee will obtain the resident's food preferences upon admission and record preferences in the tray card system. 4. If a resident's preferences indicate they dislike the main meal, the alternate will be served unless the resident requests a substitution. 7. The Nutrition & Food service Manager will be informed by the Nutrition & Food service staff or the resident's request so that the resident's preferences can be updated. 8. If a resident consistently ref uses meals, alternates and substitutions for three or more meals, the Nutrition & Food service Manager will be notified. The Nutrition & Food service Manager will visit the resident to determine if a change in diet or preferences is appropriate. A record review of the facility's policy titled Diet Order Accuracy dated 2018 reflected the following: Policy: The facility will conduct routine audits of the diet orders to ensure that residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 30 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 0806 receive the diet as ordered by the physician. Level of Harm - Minimal harm or potential for actual harm 4. 4. Any discrepancies will be investigated. If the tray card system is in error, it will be updated. If the diet noted on the diet roster is incorrect. the Nutrition & Foodservice Department will request that Nursing write a clarification order to have the diet changed on the physician's order sheet. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 31 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 review, the facility failed to 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 disease and infection for 2 of 7 residents (Resident #85 and Resident #26) reviewed for infection control, in that: Residents Affected - Some 1. The facility failed to ensure Resident #26 received peri-care by not following infection control techniques such as handwashing and changing gloves, and 2. The facility failed to place a barrier between Resident #85's left heel wound and her mattress while providing wound care. These deficient practices placed residents at risk for infections and diminished quality of life. Findings include: A record review of undated face sheet for Resident #85 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Osteomyelitis, cognitive communication deficit, chronic obstructive pulmonary disease, diabetes mellitus type 2, chronic pain, urinary tract infection, hypertension, and cellulitis of right lower limb. A record review of Quarterly MDS assessment for Resident #85 dated 3/05/24 reflected a BIMS score of 08, which indicated severely impaired cognition. Resident #85 required extensive assistance with ADLs and was a 2-person transfer with mechanical lift. A record review of undated face sheet for Resident #26 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia, hypertension, chronic obstructive pulmonary disease with exacerbation, diabetes mellitus type 2, depression, chronic pain, muscle weakness. A record review of Quarterly MDS assessment dated [DATE] for Resident #26 reflected a BIMS score of 11, which indicated mildly impaired cognition. Resident #26 required moderate assistance from another person and had bowel and bladder incontinence. A record review of Care Plan dated Resident #26's Care Plan dated 1/03/24 reflected one person assist required for ADL's, including personal hygiene and toileting. An observation on 03/27/24 at 02:30 PM of Resident #26 receiving peri-care with CNA-I revealed gloves were donned, but no hand hygiene or glove change observed when going from cleansing peri-area to cleansing bottom. CNA-I was observed not changing her gloves throughout peri-care process. Interview on 03/27/24 at 2:46 PM revealed CNA-I had been nervous and forgot to change her gloves and conduct hand hygiene when providing peri-care for Resident #26. CNA-I further stated she did not gather all of her supplies to conduct peri-care. 2. Record review of Resident #85's wound doctor's notes, dated 3/06/24, reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 32 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 Wound location- Right heel, Stage 4 pressure injury, pressure ulcer Level of Harm - Minimal harm or potential for actual harm measuring 6 cm x 6 cm x 0.4 cm, no tunneling and no undermining noted. exudate: heavy amount of purulent drainage Residents Affected - Some Dressing used: Bactroban, Calcium Alginate Wound location- Left heel, unstageable pressure injury, pressure ulcer Measuring 3 cm x 2.5 cm x 0.3 cm, no tunneling and no undermining noted. Exudate: moderate amount of purulent drainage An observation on 3/28/24 at 10:22 am of wound care for Resident #85 provided by Treatment Nurse. The wound was documented in physician orders and skin assessment as a deep tissue injury and located on left and right heel. Interview with Treatment Nurse revealed Resident #85 admitted to facility with right heel wound. Facility had her on low air loss mattress and she developed left deep tissue injury. Resident #85 had diagnosis of vascular issues, cellulitis, and open areas on right lower extremity. Treatment nurse further stated the wound care doctor saw Resident #85 on 3/27/24 and prescribed Doxycycline. Observed Resident #85 in bed with bolsters on both heels and air loss mattress. Resident #85 denied need for pain medication. All supplies were gathered before the dressing change. Supplies were handled in a way to prevent contamination. Supplies were dedicated to and labeled for one individual. Multi-dose medications were used appropriately. Hand hygiene was performed properly before preparing to clean field. Clean field was prepared. Surface was cleaned with antiseptic wipes following manufacturer guidelines. Surface barrier was applied on top of clean field. Supplies were placed on surface barrier in aseptic manner. Hand hygiene was performed properly before starting the procedure. Clean gloves and PPE were donned according to Standard or Contact precautions. Surgical mask was not used for wound care. A barrier was not positioned under the left heel wound prior to wound care being provided. Left foot was over bare air loss mattress with resident positioned on her right side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 33 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 The old dressing left heel was removed and discarded immediately. Level of Harm - Minimal harm or potential for actual harm The old dressing left foot did display the date 3/27/24 and initials JD. Residents Affected - Some Observed Left foot over air loss mattress with resident on her right side. Soiled Coban wrap applied over kerlix wrap to left foot/ankle. Right heel and lower leg bandage removed, soiled Coban wrap rolled up, Treatment nurse stated they use the Coban wrap for one week. Left heel did not have a barrier during wound care, right heel did not until foil was placed under right heel. Dirty gloves were removed and discarded. Hand hygiene was performed properly before accessing clean supplies. Clean gloves were donned prior to cleansing wound using aseptic non-touch technique* Dirty supplies were discarded in trash receptacle. Gloves were removed and hand hygiene performed after dressing change is complete. Reusable equipment was cleaned and/or disinfected appropriately. Wound cart was cleaned and utilized appropriately. During an interview on 01/04/24 at 01:46 PM with LVN E revealed she should have brought hand sanitizer to the bedside while conducting wound care for Resident #314, and an adverse outcome of not sanitizing hands when changing gloves would be a possible wound infection. During an interview on 1/5/24 at 10:30 am, CNA G stated that she was trained on infection control and resident items on the floor would concern her. She stated that she would sanitize them first before residents handle them. She stated that a nasal cannula on the floor should be trashed and replaced with a new one. If it could not be replaced, she stated it should be sanitized. Failing to sanitize could lead to an infection for the resident. During an interview on 3/28/24 at 03:47 PM, the DON revealed her expectation of hand hygiene while providing peri-care to residents was handwashing/hand hygiene and glove change should be conducted when going from dirty to clean, such as after removing and disposing of the old dressing, and after going from clean to dirty, such as gathering and setting up wound care field and then removing old dressing. DON further stated an adverse outcome of staff not following infection protocol while providing resident care would be a possible wound infection. During an interview on 3/28/24 at 04:15 PM, the ADM revealed his expectation for infection control protocol while providing resident care was for staff to conduct handwashing before and after to prevent spread of infection. ADM further stated the potential adverse outcome of staff not following infection control protocol during resident care would be placing residents at risk of infections. A record review of the facility's policy titled Infection Control dated October 2017 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 34 of 35 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 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 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 general public and To prevent, detect, investigate, and control infections in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 35 of 35