Inspection·January 4, 2023

F 0656 Resident #45 had no care plan for wandering. Level of Harm - Minimal harm or potential for actual harm This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. Residents Affected - Some The findings included the following: Resident #7 Review of Resident #7's admission Record dated 1/4/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included head injury, schizoaffective disorder (a mental disorder which includes abnormal thought processes) with depression, and stroke. Review of Resident #7's quarterly MDS assessment , dated 11/16/22, revealed: She had a cognitive score of 10 of 15 indicating moderate cognitive impairment. Identified medications included an antipsychotic for 7 of 7 days, an antianxiety for 7 of 7 days, and an antidepressant for 7 of 7 days. Review of Resident #7's Nurse's Notes revealed: Dated 10/29/2022 at 6:23 AM Resident is allowed to smoke out back when accompanied by roommate per DON. Dated 11/18/22 at 11:14 AM Staff concerned that resident may be under the influence of drugs or alcohol at times. Spoke to doctor. Gave verbal order for as-needed drug and alcohol labs to be drawn and to notify him for any concerns. Resident is aware of contraindications of using any substance not prescribed by physician with her current medications. Dated 12/2/22 at 11:09 PM Noted strong odor of alcohol on resident. Resident slurring words and difficult to arouse for bedtime medication and assessment. Doctor notified of resident stat us and stated it was ok to give medications as ordered tonight. Review of Resident #7's care plan last revised on 12/4/22 revealed no care plan related to her drinking behavior. The care plan initiated 12/4/22 revealed Resident #7 was a smoker. Identified interventions included the resident required supervision while smoking. Resident #13 Review of Resident #13's admission Record, dated 01/03/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a previous admission date of 06/04/18 and diagnoses which included Parkinson's Disease, pain, anxiety disorder, thyrotoxicosis, dementia, Type 2 Diabetes Mellitus, alcohol dependence, nicotine dependence, paranoid schizophrenia, schizoaffective disorder, major depressive disorder, and suicidal ideations . Review of Resident #13's Quarterly MDS Assessment , dated 12/19/22, revealed: He had a cognitive score of 11 of 15 indicating moderate cognitive impairment. He was a smoker. Identified medications included an antipsychotic 7 of 7 days and an antidepressant 7 of 7 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #13's nurse's note dated 11/06/22 at 6:42 PM: Informed by nursing staff that resident has been under the influence of alcohol or drugs. This writer called with DON on speaker phone and updated him on the resident's status. He stated to put an order in to hold medications if the resident is suspected to be under the influence. Referral placed for psychiatric services since the psychiatric provider denied the resident as a patient. MD also stated to notify him if resident is suspected to be under the influence. Noted. Charge nurse aware. Review of Resident #13's care plan, last revised 11/09/22, revealed no care plan related to his alcohol dependence or drinking behavior, no care plan related to him being a smoker, no care plan related to his history of suicidal ideations, and no care plan related to his anxiety disorder. Review of Resident #13's nurse's notes revealed: Note dated 12/02/22 at 11:01 PM: Noted strong odor of alcohol on resident. Resident slurring words & difficult to arouse for HS medication & assessment. Held Gabapentin. Afebrile at 97.6 & O2 Sat 94% RA. Dr. notified of resident status & stated OK to hold medication tonight. Monitoring in progress. Resident resting soundly, respirations even & regular. Will note to 24hr report to continue assessment follow-up. Note dated 12/10/22 at 1:05 PM: resident went out on pass and girlfriend states that he came back intoxicated. resident signed his self out and back in from oop. resident went to his room. Note dated 12/10/22 at 10:50 PM: Patient drowsy and did not rouse for medication. Dr. in building and he gave order to hold medication for drowsiness. Dr. went to patient room for evaluation. Patient had signed himself out on pass earlier in the day. Note dated 01/03/23 at 6:23 PM: Resident observed to be outside drinking alcohol. MD notified and aware. No new orders. Resident has an order to hold medication if needed. No adverse effects at this time. No behaviors observed. Charge nurse aware. Observation on 1/3/23 at 5:09 PM revealed Resident #7 and Resident #13 outside on the front porch smoking independently and drinking alcohol. Interview on 1/4/23 at 10:53 a.m. the RDO and Administrator stated there should be a care plan for both Resident #7 and Resident #13's alcohol use. The RDO stated he would make sure the care plan got started because it should be there. Surveyors attempted to interview the DON on 1/3/23 at 11:20 AM and were unable to leave a message. Interview on 1/04/23 at 3:08 PM the MDS Coordinator said she became aware of Resident #13's alcohol use yesterday. She stated usually one of the staff would come tell her about resident changes. She said she was unaware of the DON's permission for Resident #13 to go out and smoke with Resident #7 because that was not on her care plan. Resident #17 Review of Resident #17's admission Record, dated 1/3/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, cognitive disorder with Lewy Bodies, psychotic disorder with hallucinations, and depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 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 Review of Resident #17's Significant Change MDS, dated [DATE], revealed Level of Harm - Minimal harm or potential for actual harm He had a cognitive score of 8 of 15 indicating moderate cognitive impairment. He showed no behaviors. He was on an antidepressant for 7 of 7 days in the look back period. Residents Affected - Some Review of Resident #17's Order Summary Report , dated 1/3/23, revealed: Order dated 10/12/22 for Divalproex Sodium 125 twice a day for Depressive Disorder. Order dated 11/4/22 for Gabapentin 100mg at bedtime for a pinched nerve. Order dated 11/16/22 for Olanzapine 5mg at bedtime related to psychotic disorder with hallucinations. Ordered dated 11/16/22 for Ropinirole 2mg five times a day for Parkinson's Disease There was no order for the Sertraline. Review of Resident #17's Care Plan revealed: Care Plan revised 8/18/22: Focus: The resident has Parkinson's Medications Gabapentin, Divalproex Sodium. (Gabapentin was prescribed for pinched nerve and Divalproex Sodium was prescribed for depression). Care Plan revised 8/18/22: Focus: The resident was at risk for disturbed sleep pattern related to restless leg syndrome, Medication - Ropinirole. (Ropinirole was prescribed for Parkinson's Disease). Care Plan revised 8/18/22: Focus: The resident has dementia With Lewy Bodies, Medication - Olanzapine. (Olanzapine was prescribed for psychotic disorder with hallucinations). Care Plan revised 8/18/22: Focus: The resident uses psychotropic medications Olanzapine related to dementia with Lewy Bodies. (The medication was prescribed for psychotic disorder with hallucinations). Care Plan revised 8/18/22: Focus: The resident uses antidepressant medication Sertraline. (Resident #7 was not prescribed Sertraline). Interview on 1/04/23 at 3:08 PM the MDS Coordinator said Divalproex Sodium was not usually used to treat Parkinson's Disease. She said she usually went by the diagnosis on either discharge orders or the physician orders. The MDS Coordinator stated she would review the medication, the orders, and the reason the medication was given to make sure it matched up; she said she did not know how the doctor reviewed the medications for accuracy of diagnosis. She said she did not know where the care plan for the Sertraline came from. Resident #23 Review of Resident #23's admission Record dated 1/3/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, heart failure, underweight, difficulty moving, and diabetes. Resident #23 received Hospice services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 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 Review Resident #23's Significant Change MDS dated [DATE] revealed: Level of Harm - Minimal harm or potential for actual harm She had a cognitive score of 4 of 15 (indicating severe cognitive impairment). She needed extensive assistance for all activities of daily living. She was always incontinent of bladder. She had a stage II pressure ulcer (bed sore where the skin was compromised and not sealed but did not expose blood or tissues). Residents Affected - Some Review of Resident #23's Care Plan revealed: Updated 2/6/20 : Resident has potential for pressure ulcer development related to immobility and urine/ bowel incontinence. Goal was Resident #23 would have intact skin, free of redness, blisters, or discoloration through the review date. There were interventions . The care plan did not address Resident #23's history of healing and then having another sore repeatedly or what was done to prevent that . Review of Resident #23's Nurse's Notes revealed: Dated 12/13/22: Nurse noted intact blister to left popliteal and applied betadine. The nurse notified hospice and received new orders to apply betadine every shift and notify hospice when blister opens for further orders. Interview on 1/04/23 at 3:08 PM the MDS Coordinator said Resident #23 would heal and break down again and then heal. She said she would place the skin break down care plan on the care plan and then off again . She stated there was a skin care plan that was based off the Braden Scale (assessment tool used for determining how much risk a resident had to develop pressure ulcers). The MDS Coordinator said she did not know she could do a care plan for the history of resolved skin issues . Resident #34 Review of Resident #34's admission Record, dated 01/04/23, revealed she was an [AGE] year-old female admitted to the facility 11/08/22 with previous admission date of 06/28/21 and diagnoses which included generalized anxiety disorder, dysphagia (difficulty swallowing), hypertension (high blood pressure), esophageal obstruction, diverticulum of esophagus (pocket-like structures protruding outward in the lining of the throat), osteoporosis, abnormal weight loss, dependence on supplemental oxygen, chronic obstructive pulmonary disease, and dementia. Review of Resident #34's Care Plan, last revised 10/20/22, revealed no care plan for smoking, no care plan for generalized anxiety disorder, no care plan for dementia and no care plan for hypertension (high blood pressure). Review of Resident #34's Significant Change MDS Assessment , dated 11/15/22, revealed: She had a cognitive score of 10 of 15 indicating moderate cognitive impairment. She had no indications of delirium and no reported behavioral concerns. She required supervision or one person assistance for all ADLs. She used a walker for ambulation in the facility. She was a smoker. Identified medications included an antidepressant 7 of 7 days and an antibiotic 5 of 7 days. Resident #39 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 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 Review of Resident #39's admission Record, dated 01/04/23, revealed she was a [AGE] year-old female admitted to the facility 12/14/22 with previous admission date of 04/09/21 and diagnoses which included cellulitis of the left lower limb, congestive heart failure, gastro esophageal reflux, breast cancer, anxiety, mild cognitive impairment , hypertension (high blood pressure), aortic valve stenosis (narrowing of the valve in the large blood vessel branching off the heart), and osteoporosis (brittle bones). Residents Affected - Some Review of Resident #39's Order Summary revealed the following orders: Acetaminophen Capsule 500 mg give 1 capsule by mouth every 6 hours as needed for pain (start date 12/14/22) Aspirin Tablet Chewable 81 mg give 1 tablet by mouth one time a day for CHF (start date 12/15/22) Ativan Tablet 0.5 mg (Lorazepam) give 1 tablet by mouth every 24 hours as needed for anxiety (start date 12/14/22) B Complex-Minerals Tablet give 1 tablet by mouth one time a day for wound (start date 12/15/22) Benzocaine Gel 10% give 1 application orally every 8 hours as needed for pain (start date 12/14/22) Denosumab Solution Prefilled Syringe 60 mg/ml inject 60 mg subcutaneously one time a day starting on the 15th and ending on the 15th for osteoporosis for 1 administration (start date 12/15/22) Furosemide Tablet 20 mg give 1 tablet by mouth one time a day for CHF (start date 12/15/22) Gentamicin Sulfate Ointment 0.1% apply to bilateral thigh wounds topically one time a day every Monday, Friday for wound healing (start date 01/02/23) Ketotifen Fumarate Solution 0.025% instill 1 drop in both eyes every 6 hours as needed for dryness (start date 12/14/22) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 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 Lisinopril Tablet 20 mg give 1 tablet by mouth one time a day for HTN (start date 12/15/22) - Residents Affected - Some MiraLax Powder 17 GM/Scoop (polyethylene glycol 3350) give 1 scoop by mouth every 24 hours as needed for constipation (start date 12/14/22) Naphazoline-Pheniramine Solution 0.025-0.3% instill 1 drop in both eyes every 8 hours as needed for dryness (start date 12/14/22) Omeprazole Tablet Delayed Release 20 mg give 1 tablet by mouth one time a day related to gastroesophageal reflux disease (start date 01/03/22) Potassium Chloride ER Capsule Extended Release 10 MEQ give 1 capsule by mouth one time a day for GERD (start date 12/15/22) Tramadol HCL Tablet 50 mg give 1 tablet by mouth every 24 hours as needed for pain (start date 12/14/22) Vashe Cleansing Solution (wound cleansers) apply to bilateral leg topically one time a day every Monday, Wednesday, Friday for wound care (12/16/22) Review of Resident #39's admission MDS Assessment, dated 12/21/22, revealed: She had a cognitive score of 14 of 15, indicating she was cognitively intact. She had no signs of delirium and no reported behaviors. She required extensive assistance for all ADLs except for eating which only required setup. She was frequently incontinent of bowel and bladder. She used a wheelchair for mobility. She had a history of falls prior to admission. Identified medications were an antibiotic 7 of 7 days and a diuretic 7 of 7 days. CAA s triggered were ADL Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Psychosocial Wellbeing, Falls, Nutritional, Pressure Ulcers, Return to Community Referral, all of which were marked as addressed in care plan. Review of Resident #39's Care Plan , last revised 01/02/23, revealed a focus of antibiotic therapy (Gentamicin) with appropriate goals and interventions and a focus of full code status with appropriate goals and interventions. There were no other items addressed in the care plan. Interview on 1/04/23 at 3:08 PM the MDS Coordinator said that Resident #39 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 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 facility for a skilled visit. She said that for a skilled care plan she started with baseline then built onto it after 20 days. She said that all she was required to complete immediately for skilled residents was the baseline care plan in 48 hours, which she had done. RESIDENT #45 Residents Affected - Some Review of Resident #45's admission Record dated 1/3/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia. Review of Resident #45's Significant Change MDS , dated 12/24/22, revealed: She had a mental status score of 5 of 15 indicating severe cognitive impairment. She had signs of delirium including inattention which fluctuated. She wandered. Review of Resident #45's Physician Orders, dated 1/3/23, revealed an order dated 11/15/22 for a Code Alert Bracelet to alert staff of any attempts at elopement (this was an alarm attached to a resident that would sound an alarm at a door when the resident tried to exit). Review of Resident #45's Care Plan, last revised on 12/15/22, showed no care plan for the Code Alert Bracelet. Observation on 1/2/23 at 2:29 PM Resident #45 was observed wandering the 200 hall. Resident #45 would walk up to a room and stand in the doorway staring at the residents. If the resident in the room ignored her, she moved to the next room. Sometimes she would enter the room. At 2:33 p.m. Resident #45 tried to go out the emergency exit door. Observation on 1/3/23 at 9:43 AM revealed two residents walking down the hall complaining to each other about Resident #45's wandering. One resident told the other don't look at her! It will just encourage her. Resident #45 was walking the hallway staring into other resident's room. Interview on 1/04/23 at 3:08 PM the MDS Coordinator said Resident #45 wandered every day and tried to exit the door every day. She said she should have Resident #45's Code Alert Bracelet care planned. Interview on 1/04/23 at 3:08 PM the MDS Coordinator said everything needed to be care planned: code status, diet, ADL assistance, falls and fall risk, skin issues, psychotropic medications, cognition, smoking and specialized medications. She said she mainly got her cues for what to care plan from the Care Assessment Areas on the MDS. The MDS Coordinator stated that care plans were reviewed when an MDS was done and the facility made sure changes were made, especially with ADL declines. She stated the facility was cited for care plans last year and the plan of correction was that department heads would review and communicate any changes. She said she did not know why it did not work. She stated she thought having a second set of eyes on her care plans would be great and that was why the other departments were supposed to also sign off on the care plan. The MDS Coordinator stated she relied on the other departments to help assure they were accurate. She said she made the changes that she was aware of but the department heads were supposed to review the care plans they were responsible for to ensure they were accurate. The MDS Coordinator said there was no additional information to take into consideration about the care plans. Interview on 1/4/23 at 4:48 PM the RDO and Administrator were informed of the care plan deficiency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 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 The RDO said he did not know why the original plan of correction did not work. He said he thought it might be an issue of lack of internal communication. They said they had no additional information to add about the care plans. Review of undated facility policy Policy and Procedure Comprehensive Care Planning revealed, in part, the following: Every triggered CAA from Section V of the MDS will have its own specific individualized care plan written and revised/updated routinely. Every resident will have all active medical diagnosis along with medications and treatments related to the specific needs of each resident care planned and revised routinely. Every resident will have all needs/specialized services care planned such as PASRR , hospice, etc., and revised routinely. The comprehensive care plan must be written, completed, and signed within 7 days of the Z0500 RN signature date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents in 2 of 2 medication rooms (medication rooms #1 and #2) reviewed for storage in that: 1. One tube of 30gm Nystatin 100000 unit/gm ointment expired 7/2022 2. One 2 oz tube of Hemorrhoid ointment expired 10/2022 3. One tube of Hydrocortisone cream 2.5% expired 4/2022 4. Ten vials of Ipratropium Bromide 0.5mg/ Albuterol sulfate 3mg expired 12/2021 5. Fifteen 3 ml vials Albuterol sulfate inhalation suspension 2.5mg/3ml expired 4/2022 6. Ten 2 ml vials Budesonide inhalation suspension 0.5/2ml expired 6/2022 7. One Advair Diskus 250/50 expired 4/2022 8. Seven bisacodyl suppository 10 mg expired 11/2022 9. One carton of Nutren 2.0-caloric dense nutrition 250ml expired 12/2022 10. Twenty five packets of Lemon Glycerin swabsticks expired 2/2022 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 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 0755 11. Level of Harm - Minimal harm or potential for actual harm Ten 2 oz tubes of soothe and cool barrier ointment expired 8/2022 Residents Affected - Some This failure could place residents at risk of receiving medications that were expired and not producing the desired effect. Findings included: Observations of medication storage room [ROOM NUMBER] on [DATE] at 02:18PM revealed that the following medications were found to be expired: 1 tube of 30gm Nystatin 100000 unit/gm ointment exp 7/2022 1- 2 oz tube of Hemorrhoid ointment exp 10/2022 1 tube Hydrocortisone cream 2.5% exp 4/2022 10 vials of Ipratropium Bromide 0.5mg/ Albuterol sulfate 3mg exp 12/2021 15 -3 ml vials Albuterol sulfate inhalation txt 2.5mg/3ml exp 4/2022 10- 2 ml vials Budesonide inh suspension 0.5/2ml exp 6/2022 1 Advair Diskus 250/50 exp 4/2022 Observations of medication storage room [ROOM NUMBER] on [DATE] at 03:00 PM revealed that the following medications were found to be expired: 7 bisacodyl suppository 10 mg exp 11/2022 1 Nutren 2.0-caloric dense nutrition 250ml exp 12/2022 25 packets of Lemon Glycerin swabsticks exp 2/2022 10 - 2 oz tubes of soothe and cool barrier ointment exp 8/2022 Interview on [DATE] at 2:20 PM with LVN A stated that only the medication aide and the charge nurse have keys for the medication room, and according to the DON they are responsible for checking the medication room and disposing of all expired meds. LVN A stated that she does not ever think of checking the med room, as she was too busy on the floor. Interview on [DATE] at 2:30 PM with MA A stated that it is the responsibility of both Nurses and medication aides to check for expired meds and ensure that they are removed from carts and medication rooms. MA A stated that the medication aides have more time to check for expired meds and there is no excuse for why it was not done. Interview on [DATE] at 3:40 PM with Director of Clinical Operations and DON, DON stated that Med aides are responsible for checking the medication rooms for expired and discontinued medications and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some discarding them on a monthly basis. Director of Clinical Operations states that they will be increasing the monthly checks to weekly checks. DON confirmed that she has no evidence of medication room audits from the pharmacist. Record Review of the pharmacist activity log for 6/2022 to 12/2022, revealed no medication room audits performed by the pharmacist. Review of facility policy titled Storage of Medications dated 11/2020, revealed it read in part; Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Drug destruction done monthly, last in December. Who is in charge of disposing Sharps containers? The nurse brings to biohazard closet and they come monthly to dispose Review of the Pharmacist Medication Destruction Log Book showed the last destruction was in [DATE], done every three months. Records of the receipt and disposition of controlled medications were maintained to enable an accurate reconciliation. Review of the Narcotic Book Log on med cart Hall 100 And Hall 200, showed medication records were in order and controlled medications were maintained and reconciled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: Residents Affected - Many The facility failed to label and date food items. The facility failed to discard expired food items. The facility failed to properly store dishes, utensils, pans. These deficient practices could place residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination. Findings include: Observation on 01/02/23 from 10:55 AM to 12:00 PM during a walk-through inspection of the kitchen revealed: resealable plastic bag labeled churros dated 10/22 in glass front freezer clear plastic bag of what appeared to be sweet potato fries with no label and no date in glass front freezer Plates stored in dispenser/storage rack open to air with no cover or lid to prevent contamination from air borne particles 5 ladles on rack of steam table not inverted to prevent contamination from airborne particles 3 pans hanging on rack above steam table not inverted to prevent contamination from airborne particles (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 - Level of Harm - Minimal harm or potential for actual harm unopened box of 4oz pork chopped steak with no dates on box in industrial freezer - Residents Affected - Many resealable plastic bag of what appeared to be tortillas with no label and no date in dry storage resealable bag of what appeared to be hamburger buns with no label and no date in dry storage resealable plastic bag labeled Cherry Jello not sealed with foil packaging inside torn open and contents spilling out, date on bag 8/4/22 in dry storage 32oz bottle of liquid vanilla flavor with broken lid held on by tape with best by date of May 22, 2022, in dry storage 14 1-lb boxes of baking soda with best by date of June 2022 in dry storage 20 15-oz boxes of raisins with best by date of August 2022 in dry storage 4 1-lb bags of vanilla wafer cookies with best by date of 12/2022 in dry storage plastic container with lid labeled ham & cheese with date of 12/30/22 in industrial refrigerator plastic container with lid labeled ketchup dated 12/28/22 in industrial refrigerator clear plastic container with lid labeled chilies dated 12/20/22 in industrial refrigerator clear plastic container with lid labeled jelly dated 12/30/22 in industrial refrigerator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 - Level of Harm - Minimal harm or potential for actual harm 1 5-lb tub of peanut butter with no date in industrial refrigerator - Residents Affected - Many clear plastic bag of peppers with no label and no date in industrial refrigerator 2-lb tub of chopped garlic with best by date of 9/25/22 in industrial refrigerator jug labeled hot chile dated 12/20/22 in industrial refrigerator clear plastic container with lid labeled lunch meat with date of 12/2/22 in industrial refrigerator clear plastic bag of what appeared to be lettuce with no label and no date box of apples dated 9/22 in industrial refrigerator package of ground beef dated 12/21/22 in industrial refrigerator Observation on 01/03/23 at 3:40 PM during a follow up inspection of the kitchen revealed: plates continued to be stored in storage rack open to air with no cover to prevent contamination from airborne particles. Ladles continued to be stored above steam table not inverted to prevent contamination from airborne particles Pans continued to be stored above steam table not inverted to prevent contamination from airborne particles (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 01/03/23 04:15 PM with Dietary Manager, she stated that all her staff is new, and she is still working with them to get them all trained properly. She stated that she had been on vacation last week, so some things certainly had been missed. She stated that all leftover foods should be thrown out after three days. She stated that all food should be labeled and dated. Regarding the large amount of baking soda and raisins that were past their best by date she stated that the supplier always sent too much of things like that even though she will not use it. She stated that she has had problems with it in the past. She also stated that she has received deliveries with items that are very close to their best by dates before and has had to call the supplier about it because she will not be able to use the items. She stated she is not allowed to change the order for what is delivered to her. She stated that she was not aware that plates had to be stored inverted or completely covered. She also stated she was not aware that the pans and ladles had to be inverted. Interview on 01/03/23 at 4:40 PM the Administrator was informed of the deficiencies in the kitchen. He had no additional information to add. Review of facility policy Food Receiving and Storage dated 2001, revised October 2017, revealed, in part: When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 16 of 16