Inspection·September 7, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4) When resident becomes agitated: Intervene before agitation escalates .engage calmly in conversation: if response is aggressive, staff to walk calmly away, and approach later. Observation of Resident #1 was conducted on 09/05/2023 at 9:40 AM with Resident #1 sitting in her Broda chair right outside her room (in the hallway). Interview was attempted with Resident #1 smiling and touching surveyor's dress. Resident #1's primary language was Spanish but appeared to be in a pleasant mood. No visible injuries noted, and Resident #1 did not appear to be in any pain or distress. In an interview on 09/05/2023 at 10:03 AM Resident #1's Family Member (FM-1) stated that facility had informed her that Resident #1 had recently been overly aggressive with the staff, so she had been checking the video recordings from the camera in her room to see if there was a reason for behavior change. The FM-1 stated she had monitored many recordings and had not seen an issue with Resident #1's care until she watched the incontinent care provided by CNA A on 09/02/2023 at 7:30 AM. FM-1 stated she saw CNA A providing incontinent care for Resident #1 she found disturbing. FM-1 stated she contacted the DON at 4:11 PM and informed her of the concerns she had seen on the video and informed DON that she was coming to the facility. During the interview Resident #1's FM-1 stated that she had never seen any other incidents of inappropriate care prior to this and stated that, prior to this incident, CNA A had been Resident #1's advocate and would calm Resident #1 with speaking softly in Spanish. FM-1 stated that Resident #1 was placed on Hospice approximately one year ago due to Resident #1's decreased cognitive. FM-1 stated that Resident #1 was more active due to her changes with Dementia and Resident will act more aggressively towards others than she did in the past. Resident #1's FM-1 stated Resident #1 appeared to not be affected by the incident with CNA A and will still smile and reach for staff. In an interview on 09/05/2023 at 11:02 AM, Certified Medication Aide (CMA D) stated that on the morning of 09/02/2023 at 7:30 AM she was pushing the medication cart down the hall she overheard CNA A telling Resident A stop hitting me. CMA D stated she stopped and stood at the door of Resident #1's room (saw Resident #1 sitting in her Broda chair) with Resident #1 screaming and crying, and asked CNA A if she needed assistance. Stated that CNA A stated she did not need help, so she continued with her med pass. CMA D stated that Resident #1 has a history of screaming, crying out and striking out at staff and other residents (when care is being provided/not being provided). CMA D stated when she saw CNA A brushing Resident #1's hair she did not observe any inappropriate actions/care. CMA D stated later that afternoon she was informed that Resident #1's family member was in the facility, was informed that CNA A was accused of abuse, that CNA A had been escorted out of facility. Stated she was asked to write a statement of what she had witnessed this morning (interaction between Resident #1 and CNA A). CMA D stated she had never witnessed any inappropriate behaviors from staff. In a Resident Group interview on 09/05/2023 at 1:50 PM, Five resident's (that resided on hall where CNA A provided care) stated they have never been afraid of any staff and had never felt that the staff had been inappropriate with their care. In an interview on 09/05/2023 at 2:40 PM, the DON stated that she had no knowledge of any staff being rough or aggressive with any residents until Resident #1's Family Member contacted her on 09/02/2023 at 4:00 PM. DON stated that Resident #1's Family Member informed her that she felt that CNA A was abusive and rough when she provided care on 09/02/2023 at 7;30 PM. DON stated that she contacted the administrator after she heard from the Family Member and was instructed to start the investigation and that he would be coming to the facility also. DON stated that she was instructed to do the following: get an assessment on Resident #1, meet, and suspend CNA A, complete an incident report and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 2 of 12 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 09/07/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few contact CII to report incident, contact law enforcement to report incident, and perform safe surveys with all residents on hall that CNA A was working. DON stated that she arrived at the facility on 09/02/2023 at approximately 4:15 PM and went immediately to Resident #1's room and found Resident #1's Family Member's in her room. Stated that Family Member wanted her to view the video and DON informed Family Member that she would sit down with her after she took care of getting Resident #1 assessed and CNA A off the floor. DON stated that she instructed LVN A to perform a head-to-toe assessment on Resident #1 and report findings ASAP. DON stated she then instructed CNA A to come to her office (and informed other aides to cover CNA A's hall). DON stated that the administrator arrived at the facility and was in Resident #1's room with the family. DON stated that she asked CNA A of what occurred this morning with Resident #1 and stated that CNA A said Resident #1 was fighting with her during incontinent care but did not feel she had been rough or aggressive with Resident #1. DON stated that she questioned why CNA A did not remove herself from room once Resident #1 became upset with CNA A stating that she was afraid that Resident #1 would have fallen if she left the room. DON informed CNA A of allegation of abuse, had CNA A write a statement and informed CNA A that she was suspended pending investigation. DON stated she escorted CNA A to the door. DON stated that she got report from LVN A (regarding assessment) and was informed by LVN A that Resident #1 was assessed with no visible injuries and was able to perform ROM to all extremities without pain or discomfort. DON stated that she then contacted Resident #1's PCP and Hospice service provider of incident with no orders received at time of call. DON stated that she then went to Resident #1 room to review video. DON stated that after reviewing the video of incontinent care provided, she observed CNA A trying to change her brief. She observed CNA A blocking Resident #1 from hitting her and saying, Stop hitting me we cannot do this. CNA A continued to reposition Resident #1 and cleaned Resident #1 up. DON stated she observed CNA A picked Resident #1 up off the bed an put Resident #1 in the Broda chair. Observed CNA A grab Resident #1's ponytail and Resident #1 screamed. DON stated that she felt CNA A was frustrated, it looked like CNA A had to continue caring even though she was being struck by Resident #1. DON stated that she did not see Resident #1 being slammed in the chair but did see Resident #1's hair being pulled. DON stated that the behaviors that were observed by Resident #1 were not unusual (crying, screaming, hitting staff). DON stated that she felt that CNA A was frustrated during the care but did not fell that CNA A was angry with Resident #1. DON stated that she had not witnessed any staff being in appropriate with ADL care before today. DON stated that CNA A should have left the room (after making sure Resident #1 was safe) and returned later to try again. DON stated that all staff have been trained to do this and these interventions are in Resident #1's care plan. In a phone interview on 09/05/2023 at 3:10 PM CNA A stated that when she entered Resident #1's room the resident was watching TV and was informed that it was time to get up for breakfast. CNA A stated that as soon as she began to provide care Resident #1 started hitting her. Stated that she was trying to block Resident #1 from hitting her. CNA A stated that at no time did she grab Resident #1's hands or hold her down in any way, stated she was just trying to block Resident #1 from hitting her. CNA A stated that this was not the first time that Resident #1 had been aggressive when providing care and stated she was trying to do the best she could to get Resident #1 changed and cleaned up without getting hit too much. CNA A stated that she knows she should have left the room but was afraid that Resident #1 would have fallen out of bed. CNA A stated that she has had training for residents with Dementia/Alzheimer's and has been an CNA for over 23 years. Stated that she did not ask for help due to one aide calling in that morning. CNA A stated that she may have been frustrated but would never intentionally hurt any resident and that her frustration would have been towards the staffing situation and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 3 of 12 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 09/07/2023 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 0684 not Resident #1. Level of Harm - Minimal harm or potential for actual harm In an interview on 09/05/2023 at 3:40 PM LVN A stated that on the morning of 09/02/2023 she did not witness or hear incident between Resident #1 and CNA A. LVN A stated she was not aware of any issues until Resident #1's Family Member-1 arrived at the facility on 09/02/2023 at approximately 4:00 PM. LVN A state that Resident #1's Family Member-1 approach her and showed here the video of interaction with Resident #1 and CNA A recorded this morning at 7:30 AM. LVN A stated that she observed (on video) that Resident #1 is combative during incontinent care. Stated she observed CNA A trying to avoid getting hit/bit and LVN stated that CNA A was too rough while providing care for Resident #1. Stated that CNA A covered Resident #1 with a blanket and then was trying to pull the ponytail (rubber band) out of Resident #1's hair and it appears CNA A was rougher than necessary. LVN stated that Resident has a history of acting out with staff and other residents (scratching, hitting, biting, and crying out). LVN A stated that there is a history of Resident #1's behaviors increasing when staff are providing care and Resident #1 has orders for PRN Ativan (anti-anxiety) medication due to her behaviors. LVN A stated that she has not witnessed any inappropriate care from staff or had knowledge prior to the afternoon of 09/02/2023. LVN A stated that she had not observed a change with Resident #1's behavior or demeanor post incident. Residents Affected - Few In an interview on 09/05/2023 at 4:05 PM Administrator stated that he was notified of Resident #1's Family Member allegation of abuse on 09/02/2023 at 4:14 PM. Administrator stated that he immediately drove to the facility after receiving call and notified Law Enforcement of incident on 09/02/2023 between 6:00-6:30 PM. Administrator stated he notified CII on 09/02/2023 at 5:26 PM. Stated that after reviewing video with Resident #1's Family Member he asked her to complete a physical, mental and psychosocial assessment and with review the answer showed that there was no adverse reactions from Resident #1 in regards to the incident with CNA A. Administrator stated that when he interviewed Resident #1's Family Member she stated that she did not want to make a big deal out of what she observed on video but administrator informed Family Member that any form of ANE had to be reported and investigated. Administrator stated that Law Enforcement had informed him that after reviewing video and speaking with CNA A that they determined that the incident did not reach the level of a felony and it was up to the facility on the punishment of CNA A. Administrator stated that CNA A had been contacted to notify she was terminated and that she would be referred. Administrator stated that all staff have been trained on Dealing with residents with Dementia/Alzheimer's and stated that staff are taught to walk away if a resident shows signs of agitation or distress, then return in 5-10 minutes to try again. If behaviors continue staff are to get another staff to attempt care. Administrator stated that when he arrived at facility on 09/02/2023 he had 1 to 1 staffing with Resident #1 for 24 hours and then had staff perform 15 minutes checks on Resident #1. Stated that Resident #1 has not shown any adverse changes post incident. Administrator stated that CNA A should have stopped providing care as soon as Resident #1 became agitated and follow the interventions taught in training. Administrator stated that he has not witnessed or had complaints/grievances reported in regard to in appropriate care prior to the incident on 09/02/2023. In an interview on 09/06/2023 at 1:31 PM ADON stated that she worked the night shift on 09/01/2023 into the morning of 09/02/2023 and checked on Resident #1 several times due to Resident #1 having a history of wiggling herself out of bed and onto the floor. ADON stated that with her visual checks of Resident #1 and found her resting quietly throughout the night. ADON stated that Resident #1 has a history of agitation with hitting, screaming, and crying but stated that her behaviors are not as bad on the night shift and believes it due to less stimulation during the night shift. ADON stated that Resident #1 has a history of responding well to talking in a soothing voice or giving her extra time but has had experience with Resident #1 when interventions do not help. ADON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 4 of 12 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 09/07/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm stated that she has received Dementia/Alzheimer's training within the last 2-3 months (when change of ownership occurred). ADON stated that Resident #1 has an order for PRN Ativan but has not had to use it on the night shift. ADON stated that the morning of 09/02/2023 she had left the facility prior to incident that occurred between CNA A and Resident #1. ADON stated that she not witnessed or had complaints reported to her regarding inappropriate care prior to the incident on 09/02/2023. Residents Affected - Few In an interview on 09/06/2023 at 2:28 PM CNA B stated that she had experience working with Resident #1 and the resident has times when interventions (talking softly, smiling, giving her time to calm down, etc.) do not help with Resident #1's behaviors. CNA B stated that there are times when you must ask another staff to help with Resident #1's care and this sometimes help to get ADL's done without agitating Resident #1. Stated that it depends on Resident #1's mood at the time of care. CNA B stated that she has had training for residents with Dementia and Alzheimer's and is aware that one of the interventions is to walk away if a resident becomes agitated/upset and for staff to return shortly after to see if care can be continued. CNA B stated that she not witnessed or had complaints reported to her regarding inappropriate care prior to the incident on 09/02/2023. Observation of recorded video (from Resident #1's Family Member) performed on 09/07/2023 at 8:51 PM revealed [NAME] following: Video recording #1 of incident #1 that occurred on 9/02/23 from 7:25 AM to 7:29:52 AM: CNA A entered Resident #1's room, CNA A was laughing and talking to someone. It appeared as soon as CNA A started interacting with Resident #1, CNA A's demeanor changed. CNA A picked up chair mat, raises bed, pulled curtains around bed but left door open, pulled covers down never speaking to Resident #1 exposing her bare legs and brief. CNA A touched inside of Resident #1's brief as if checking to see if it was wet. CNA A proceeded to place purple pants on legs and pulled up to the level of brief. CNA A placed Broda chair beside bed. Moved white sitting cushion to Broda chair. Lowers bed rail, CNA A rolled Resident #1 to left side, obtains new brief. Resident #1 rolls onto to her back. CNA A says, I am going to change you and holds Resident #1's arm (to keep Resident #1 from striking her) and Resident #1 tried to remove her arm from CNA A's grip. CNA A held down Resident #1's arm speaking in Spanish and appeared to be removing the brief. Resident #1 raised up off the bed (sitting position). CNA A grabbed Resident #1's left arm, then the brief, and said, you are wet I got to change you, Resident #1 raised right hand to hit CNA A. CNA A held Resident #1's' right arm and turned Resident #1 over to left side rocking her at which point her head was close to the bedrail. CNA A was speaking with Resident #1, tucked the old brief and chux under Resident #1 and placed new brief under buttock. Resident #1 had hands on the wall. Resident #1 rolled onto her back slapping at CNA A. CNA A held Resident #1's left arm and pulled her over onto right side to remove other side of the old brief and chux. Resident #1 was still hitting CNA A. CNA A continued to hold Resident #1's arm while removing old brief. CNA A moved Resident #1 onto her right side with jerking movement while Resident #1 cried out. Resident #1 and CNA A are speaking Spanish throughout care. Resident #1 was placed on her back and continued to slap at CNA A with her right hand. CNA A held onto Resident #1's right arm and said stop it you do not hit me. CNA A continued incontinent care and pulled up residents' pants. First video ends. Video recording #2 that occurred on 9/02/23 at 7:29:58 AM lasting 3 minutes and 4 seconds. The time stamp were cut out of the frame because the Family Member zoomed in. Video recording #2 begins with CNA A pulling up purple pants of Resident #1. CAN A then pivots Resident #1's to the left where Resident #1's legs are hanging on the side of bed. Resident #1 continues (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 5 of 12 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 09/07/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few striking out at CNA A. CNA A grabs both of Resident #1 hands and pulls her up to sitting position on side of bed then CNA A places her hands underneath Resident #1 arms, lifts resident up and places her in the Broda chair. Resident #1 is crying the entire time. CNA A walks behind Resident #1's chair puts it into the reclining position. Resident #1 leans up and touches the side of the bed. When CNA A walks back into Resident #1's view (on the left side of chair), Resident #1 reaches out to hit CNA A. CNA A moves behind Resident #1 and begins to take the rubber band out of Resident #1's ponytail. Resident #1 begins to scream and cry. CNA A begins brushing Resident #1's hair all the while Resident #1 is screaming/crying. Resident #1 continues to try to stop CNA A by trying to grab her hand. After several minutes Resident #1 puts her hands in her lap and continues to cry. CNA A finishes brushing Resident #1's hair and pushes Resident #1 out of room. Second video ends. Record review on 09/07/2023 for CNA A revealed that she had no previous negative performance evaluations. CNA A was had no convictions on EMR registry. Records revealed CNA A had Working with Dementia and Alzheimer's residents training on 06/19/2023. No Grievances had been reported for CNA A with review of log. Review of facility policy Behavior Management, revised 04/19/2005, Revealed in part: Behavior management includes the management of anger, confusion, hallucinations, and other behavior by utilizing techniques such as area limitations, self-responsibility, group interactions, limit setting, and behavior modifications depending on individual needs. Behavior changes can be attributed to dementia disorders or psychological conflicts resulting from a loss of control over body, environment, and unmet needs such as pain, hunger, thirst, and toileting. They may include combativeness, arguing, agitation, and aggressiveness. 2) Establish a rapport with a calm approach and supportive attitude. 3) Provide structure with routines and low to moderate stimulation in the environment. 4) Provide diversion or redirect attention away from aggressive or agitated behaviors. 5) Provide quiet low stimuli environment periods if necessary. 6) Explain care to be provided prior to providing the care. 7) If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 6 of 12 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 09/07/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm later time or with different staff. Continued combativeness with care should be reported to the IDT and physician. Review of facility training titled Alzheimer's Disease and Related Disorders, provided by Relias, revealed in part: Residents Affected - Few Therapeutic Interventions or Approaches The use of any approach must be based on a careful, detailed assessment of physical, psychological, and behavioral symptoms and underlying causes as well as potential situational or environmental reasons for the behaviors. Caregivers and practitioners are expected to understand or explain the rationale for interventions/approaches, to monitor the effectiveness of those interventions/approaches, and to provide ongoing assessment as to whether they are improving or stabilizing the resident's status or causing adverse consequences. Describing the details and possible consequences of resident behaviors helps to distinguish expressions such as restlessness or continual verbalization from potentially harmful actions such as kicking, biting, or striking out at others. Individualized Approaches and Treatment: This step implements the care plan interventions to address the needs of a resident with dementia. It includes addressing the causes and consequences of the resident's behavior and staff communication and interactions with residents and families to try to prevent potentially distressing behaviors or symptoms. It is important to conduct sufficient observations in order to determine if the care plan is being implemented as written. Observations should focus on whether staff: Identify and document specific target behaviors, expressions of distress and desired outcomes and Communicate and consistently implement the care plan, over time and across various shifts FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 7 of 12 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 09/07/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reevaluate and implement non-pharmacological interventions with the use of a PRN antipsychotic drug, for 1 Resident (R#1) of 6 residents reviewed for antipsychotic medications, in that: 1) The facility administered an anti-anxiety medication (Ativan) PRN (as needed) to Resident #1, for more than 14 days, without an evaluation by Resident#1's Physician for the appropriateness of the medication. 2) Facility failed to implement behavioral interventions and assess resident reaction to interventions prior to administering anti-anxiety medication (Ativan) PRN (as needed) to Resident #1. These failures could place residents who received psychotropic medications at risk of receiving unnecessary doses of medication, experiencing undesirable side effects as well as potentially causing a physical or psychological decline in health. The Findings Include: Review of Resident #1's face sheet dated 09/07/2023 revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included vascular dementia (impaired blood flow to brain) Alzheimer's Disease and Type II Diabetes. Review of Resident #1's MDS assessment dated [DATE] revealed she had a brief interview for mental status score of 99 indicating Resident #1 was not able to complete the BIM's interview. Resident #1 has minimum difficulty hearing with unclear speech Resident #1 has physical behaviors directed towards others e.g., hitting, kicking, pushing, scratching, and grabbing. The MDS revealed Resident #1 was always incontinent of bladder and bowels and was extensive assist with ADL's. Review of Resident #1 's Care Plan dated 03/23/2023 revealed Resident #1 had a behavior problem as evidenced by being physically and verbally aggressive towards staff and other residents. Care Plan revealed Resident #1 has a behavior problem related to cries randomly even when nothing was wrong and uses anti-anxiety medications. Goals: Resident #1 will be free from discomfort or adverse reactions and will have fewer episodes of behaviors. Interventions were as follows: 1) Allow the resident to make decisions about treatment regimen, to provide sense of control. 2) Encourage as much participation by the resident as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 8 of 12 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 09/07/2023 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 0758 3) Monitor/document/report any adverse reactions to Anti-Anxiety therapy with (partial) possible side effects of hostility, rage, aggression, or impulsive behaviors. Level of Harm - Minimal harm or potential for actual harm 4) Anticipate and meet the needs of the resident. Residents Affected - Few 5) Caregivers to provide opportunity for positive interaction: Stop and Talk. 6) Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. 7) Minimize potential for the resident's disruptive behaviors (Specify) by offering tasks which divert attention. 8) Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Observation of Resident #1 was conducted on 09/05/2023 at 9:40 AM with Resident #1 sitting in her Broda chair right outside her room (in the hallway). Interview was attempted with Resident #1 smiling and touching surveyor's dress. Resident #1's primary language were Spanish but appeared to be in a pleasant mood with no behaviors at time of observation. In a telephone Interview on 09/07/2023 at 10:30 AM, Hospice LVN stated Resident #1 is seen at the facility every week and stated that she and the Hospice RN alternate weeks. Stated that she does not know when the Hospice physician was last at facility to assess Resident #1. She stated she was not aware that Resident #1 is receiving her anti-anxiety medication almost daily. Stated that she relies upon the facility nurses to inform the hospice staff of excessive usage. Hospice LVN stated that since they are at facility only one day a week the expectations are that the facility nurses would keep them informed if Resident #1 was having behaviors daily that would require a daily dose. Hospice LVN stated she was aware Resident #1 had episodes of crying, screaming, striking out but she had not experienced behaviors every time Resident #1 was seen. Hospice LVN stated she never knows what mood Resident #1 will be in when she arrives but had never witnessed behaviors that were extreme enough to warrant a dose of anti-anxiety. Hospice LVN stated standard nursing practice would be to try other interventions prior to administering PRN anti-anxiety medications such as removing her from situation that may be causing her distress, playing soft music, talking softly with resident, distracting her, etc. Hospice LVN stated the Hospice RN and herself have spoken with Resident #1's family member and they stated they do not want routine anti-anxiety medication for Resident #1's behaviors. She stated Resident #1 is on another medication daily that is indicated for anxiety and the family member is resistant to adding more medications. Hospice LVN stated that Resident #1 is evaluated for effectiveness of medications by their establishment quarterly and they report findings to the Hospice physician. Hospice LVN stated she is aware Resident #1's behaviors have worsened lately (over last 6 months) and had attributed this to Resident #1's Dementia/Alzheimer's disease. In an interview on 09/07/2023 at 2:15 PM, DON stated that when a resident is administered a PRN medication the nurse administering should be assessing for appropriate symptoms for use. DON stated her expectation was if Resident #1 had more than just typical restless and anxiety she would expect a progress note. Otherwise, she would just want nurses to document the code for the corresponding behavior on the TARs in the behavior monitoring section. DON stated that behavior documentation is done on the TAR's and each symptom has a numerical code that corresponds with it. DON stated that the nurses are to do a second entry to indicate if medication was effective. DON stated that her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 9 of 12 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 09/07/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few expectations are that side effects should be monitored and documented on the AIMs. DON stated that her expectations are the nurse should be trying non-pharmacological interventions and charting this prior to administering a PRN medication. DON stated that nurses have access to resident's care plans to review interventions and the aides have access to the [NAME] to refer to the residents likes, dislikes, and needs. DON stated that she evaluates for modifications of medications monthly and will contact the resident's physician and inform them of signs and symptoms. DON stated that she monitors the usage of PRN medications through the computer clinical dashboard and if she notices a change with the administration (increase/decrease) she will further investigate the need for the change. DON stated that she was used to Resident #1's usage increasing due to Resident #1's diagnosis and receiving Hospice services. DON stated that Resident #1's family member is contacted when each dose of PRN anti-anxiety medication is administered. DON stated that GDR and 14-day limitations are expected to be performed by the pharmacist when they come to facility monthly. In an interview on 09/07/2023 at 3:00 PM Administrator stated that his expectations are for the nurses to try non-pharmacological interventions prior to administering PRN medications. he stated that nurses should be using Nursing Judgement and should be looking at the situation, surroundings, the need for ADL care, etc. to see if there is a cause for behaviors, anxiety, pain, etc. Administrator stated that he had spoken with Hospice physician regarding using anti-anxiety medications for more than 14-days. Record Review of Resident #1's medical chart revealed that PRN anti-anxiety medication was administered daily (with occasional administration twice a day). All documentation with PRN did not include a detail progress note or entry of notifying family member of administration of PRN anti-anxiety medication. No documentation was found that non-pharmacological interventions were attempted prior to administration of PRN anti-anxiety medications. Review revealed that a physician assessment to re-evaluate PRN anti-anxiety medications was not available. Anti-anxiety (PRN) was ordered after admission to facility (December 2022). Review of facility policy Behavior Management, revised 04/19/2005, Revealed in part: Behavior management includes the management of anger, confusion, hallucinations, and other behavior by utilizing techniques such as area limitations, self-responsibility, group interactions, limit setting, and behavior modifications depending on individual needs. Behavior changes can be attributed to dementia disorders or psychological conflicts resulting from a loss of control over body, environment, and unmet needs such as pain, hunger, thirst, and toileting. They may include combativeness, arguing, agitation, and aggressiveness. 1) Establish a rapport with a calm approach and supportive attitude. 2) Provide structure with routines and low to moderate stimulation in the environment. 3) Provide diversion or redirect attention away from aggressive or agitated behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 10 of 12 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 09/07/2023 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 0758 4) Level of Harm - Minimal harm or potential for actual harm Provide quiet low stimuli environment periods if necessary. 5) Residents Affected - Few Document behavior modification and monitor effectiveness of interventions. Review of facility policy Psychotropic Drugs, revised 10/25/2017, revealed in part: The intent of this policy is that each resident's entire drug medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the facility implements non-pharmacological interventions, unless contraindicated. prior to initiating or instead of continuing psychotopic medication; and PRN orders for psychotropic medications are only used when the indication is necessary and PRN use is limited. PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45 (e) (5) if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 clays, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders (Or anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Monitoring Nurses will continually monitor for side effects and utilize the Psychotropic Monitoring forms generated by PCC. The nurse will document the behavior and/or side effects. If a medication could potentially cause involuntary movements, an AIMS assessment should be completed. Antipsychotic Medications As with all medications. the indication for any prescribed first generation (also referred to as typical or conventional antipsychotic medication) or second generation (also referred to as atypical antipsychotic medication) antipsychotic medication must be thoroughly documented in the medical record. If not clinically contraindicated. multiple non-pharmacological approaches have been attempted, but did not relieve the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 11 of 12 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 09/07/2023 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 0758 symptoms which are presenting a danger or significant distress Level of Harm - Minimal harm or potential for actual harm If antipsychotic medications are prescribed, documentation must clearly show the indication for the antipsychotic Residents Affected - Few medication, the multiple attempts to implement care-planned, non-pharmacological approaches, and ongoing evaluation of the effectiveness of these interventions. PRN Orders for Psychotropic and Antipsychotic Medications The required evaluation of a resident before writing a new PRN order for an antipsychotic entails the attending physician or prescribing practitioner directly examining the resident and assessing the resident's current condition and progress to determine if the PRN antipsychotic medication is still needed. Report of the resident's condition from facility staff to the attending physician or prescribing practitioner does not constitute an evaluation FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 12 of 12