Inspection·February 9, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident # 45's quarterly MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS of 11 meaning moderate cognitive impairment; Section GG - Functional Abilities and Goals revealed Resident #45 required substantial/maximal assistance (helper does more than half the effort); Section H- Bladder and Bowel revealed Resident #45 had an indwelling catheter. Record review of Resident #45's care plan dated 02/09/2024 revealed: Focus: The resident had an indwelling catheter .Interventions: The resident had indwelling catheter. Position catheter bag and tubing below the level of the bladder and in a privacy bag. During an observation on 02/07/2024 at 9:07 a.m. Resident #45 was seen wheeling himself down the 200 halls from the dining room with the foley catheter bag hanging from the bottom of the wheelchair and not covered with a privacy bag. During an interview on 02/08/2024 at 4:31 p.m., Resident #45 stated he would prefer his catheter bag was covered. He stated he was unable to cover the catheter with a privacy bag himself. During an interview on 02/07/2024 at 9:07 a.m., LVN A stated there should be a privacy bag covering the catheter bag. LVN A stated she did not know why the catheter bags did not have a privacy bag. She stated the facility's policy was for catheter bags to be covered with privacy bags. LVN A stated not covering with a privacy bag could cause the resident to have dignity issues. During an interview on 02/08/2024 at 10:24 a.m., the DON stated catheter bags should be covered with a privacy bag. She stated it was the CNAs and charge nurses' responsibility to make sure a privacy bag was covering the catheter bags. The DON stated she monitors CNAs and charge nurses are covering catheters with privacy bags. She stated it was her expectation that privacy bags be covering catheters bags when residents were in their rooms and when they were out of their rooms. She stated not covering the catheter with a privacy bag could affect the resident's dignity. She did not know where the failure to cover had occurred. Review of facility policy titled, Catheter Care dated February 13, 2007, revealed: Review the resident's plan of care daily for changes. Review of facility policy titled, Resident Rights reviewed on 2/08/2024 revealed: The Resident has a right to a dignified existence .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 2 of 43 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 02/09/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to thoroughly investigate allegations of Abuse and Neglect and Injury of Unknown Origin for 6 of 11 residents (Resident #6, #17, #20, #37, #27 and #42) reviewed. Residents Affected - Some The facility did not have documentation that thorough investigations of allegations of Neglect for Resident #,6, #17, #20, #37, #27 and #42 were completed. This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated. Findings included: Resident #6 Record review of Resident #6's electronic face sheet dated 02/07/2024 revealed the resident was a [AGE] year-old female who was admitted on [DATE] and an original admission date of 10/28/2022 with diagnoses that included: Chronic Obstructive Pulmonary Disease (airflow blockage and breathing related problems), muscle weakness, Lack of Coordination, violent behavior, spastic hemiplegia (muscle tightness and involuntary contractions in the limbs and extremities on one side of the body) affecting left nondominant side. Review of Resident #6's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns Resident #6 had a BIMS score of 08 (moderate impairment); Section GG- Functional Abilities and Goals Resident #6 had upper and lower extremity impairment on both sides and required a wheelchair for mobility. Record review of Facility's Incident report dated 12/07/2023 revealed an allegation of Abuse of Resident #6 and Resident #37, I (was in the Human Resources and hear both resident cursing each other on the hallway. I rushed to hallway. I saw both of resident close to each other and cursing and swinging arms. I saw Resident #6 wheeling her wheelchair backward and run into Resident #37's chair. I separated them and moved Resident #37 back to his room. I ask him what happened, he was unable to verbalize the incident. He Just said Bullshit. I asked med what happened, she said just into him and he was mad. Both residents were separated with there was no physical or emotional destress. Review, on 02/06/2024, of facility's investigation revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #17 Record review of Resident #17's face sheet dated 02/09/2024 revealed: [AGE] year-old male admitted on [DATE] and an original admission date of 01/15/2016 with the following diagnosis Intermittent Explosive disorder, Moderate Intellectual disabilities, Major Depressive Disorder, and bipolar disorder. Record review of Resident #17's Annual MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns BIMS score of 5 (severe cognitive impairment). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 3 of 43 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 02/09/2024 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 0610 Resident #37 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #37's face sheet dated 02/09/2024 revealed: [AGE] year-old male admitted on [DATE] and an original admission date of 06/16/2021 with the following diagnosis Traumatic Brain injury, heart failure, anxiety disorder and Dementia. Residents Affected - Some Record review of Resident #37's Annual MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns BIMS score of 3 (severe cognitive impairment). Record review of Facility's Incident report dated 11/29/2023 revealed an allegation of Abuse of Resident #37 THE REPORTER STATED THE INCIDENT OCCURED ON 11/28/23, AT 5:00 PM, IN THE DINING ROOM. THE REPORTER STATED THERE WERE WITNESSES. Unknown Resident WAS IN THE DINING ROOM WHEN HE SAW Resident #37 STRUCK Resident #17. HE ALSO STATED THAT KITCHEN STAFF HEARD THE INCIDENT. THE REPORTER WAS NOTIFIED AND ASSISTED Resident #37 BACK TO HIS ROOM AND ASKED HIM WHAT HAPPENED. HE STATED THAT HE DIDN'T DO SHIT. THE REPORTER SPOKE WITH Resident #17 AND ASKED HIM WHAT HAPPENED. HE STATED, HE SLAPPED ME. THE REPORTER HAD BOTH RESIDENTS ASSESSED WITH NO INJURIES. THE RESIDENTS WERE NOT EMOTIONALLY DISTRESSED. Record review of Facility's Incident report dated 01/16/2024 revealed an allegation of Abuse of Resident #37 I was in the Human Resources and hear both resident cursing each other on the hallway. I rushed to hallway. I saw both of resident close to each other and cursing and swinging arms. I saw Resident #6 wheeling her wheelchair backward and run into Resident #37's chair. I separated them and moved Resident #37 back to his room. I ask him what happened, he was unable to verbalize the incident. He Just said Bullshit. I asked what happened, she said I just into him and he was mad. Both residents were separated with there was no physical or emotional destress. Review, on 02/06/2024, of facility's investigations revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #46 Record review of Resident #46's face sheet dated 02/09/2024 revealed: [AGE] year-old female admitted on [DATE] and an original admission date of 01/20/2022 with the following diagnosis Dementia and Major Depressive Disorder. Record review of Resident #46's Annual MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns BIMS score of 3 (severe cognitive impairment). Record review of Facility's Incident report dated 02/01/2024 revealed an allegation of Abuse of Resident #46 It was brought to my attention this morning that the resident has a bruise of a size of a quarter in her forehead. The resident was assessed by the charge nurse and the DON for any possible discomfort. The resident is unable to verbalize the incident. Both the MD and the responsible party were notified. There was not physical or emotional distress involved and the resident is safe. Review, on 02/06/2024, of facility's investigation revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 4 of 43 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 02/09/2024 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 0610 Resident #20 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #20's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's Disease (disease that destroys memory and other important mental functions), muscle weakness, and lack of coordination. Residents Affected - Some Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS assessment revealed a score of 0 meaning severe cognitive impairment; Section GG (Functional Abilities) revealed Resident #20 was independent in rolling left to right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Facility's Incident report dated 12/07/2023 revealed an allegation of Abuse of Resident #20 Both residents were sited on the same table in the dining room. #27 started getting agitated and swing her hand toward Resident #20's face. There was no evidence that she intentionally hit her. According to the Certified Nurse that was in the dining room at the time, it seems that she may have hit her in the face unintentionally. There was no bruise on both residents. Both residents cannot verbalize the incident. Both residents were assessed by the charge nurse and the DON. There is no bruises or emotional distress on both residents. Review, on 02/06/2024, of facility's investigation revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. Resident #42 Record review of Resident #42's face sheet, dated 02/09/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with the following diagnoses which included type-2 diabetes, hemiplegia (weakness) and hemiparesis (paralyzes) to right dominant side, stroke and lack of coordination. Record review of Resident #42's Quarterly MDS Assessment, dated 01/11/2024, revealed Section CCognitive Patterns Resident #42 had a BIMS score of 15 (cognitively intact); Section G: ADL Assistance revealed Resident #42 had functional limitation in range of motion to upper and lower extremity on one side. Record review of Facility's Incident report dated 01/25/2024 revealed an allegation of Neglect of Resident #42 The resident was schedule to see a podiatrist doctor at the beginning of the years 2024 to cut his foot nail. The podiatrist office call to reschedule the appointment later in January because their office is close of the New Year. I called both [family members] to informed them about the changes. The responsible party hanged up the phone on me while I was trying to explain the re-scheduling to her. I went and spoke with the [family member] and give her a copy of the new schedule. Review, on 02/06/2024, of facility's investigation revealed no evidence of witness interviews with residents and staff, no evidence of staffing in-services, and no evidence of resident medical information. During an interview on 02/06/2024 at 2:30 PM the ADMIN stated he had investigated each intake with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 5 of 43 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 02/09/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in-services and conclusions. He stated he did not print the investigation out for his records. He stated was not aware he had to fill out a 3613-A form. During an interview on 02/07/24 at 11:26 AM the ADO stated the ADMN should have the PIR reports on file. He stated the ADMN should have completed the initial self-report. The ADO stated the facility had protocols in place to aid in completing an investigation correctly. He stated that he expected the ADMN to follow those protocols and should have been completed within 5 days with a conclusion. He stated in completing an investigation and following those protocols, it could have helped and aid the facility staff to take steps and prevent it from happening again. The ADO stated the ADMN monitored investigations using facility program with day 5 the ADMN been reminded of the form 3613-A, submitting all supporting documents from his investigation. He stated a failure to investigate would have a negative impact for residents and visitors which would lead to further intakes. He stated in not coming up with adequate interventions, residents would not have possibly gotten the proper care. The ADO stated he felt the staff not following the policies and procedures and company's expectations led to the failure. He stated his expectations were for staff to follow the protocols with a completed investigation. Record Review of policy titled, Abuse/Neglect dated 03/29/2018, revealed: .The facility will provide and ensure the promotion and protection of Resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . .C. Prevention .6. The facility will designate an Abuse Preventionist to monitor tracking and trending data and completion of investigations as needed . .D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly . .F. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect .and injuries of unknown source will be investigated. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC. 2. After receipt of the allegation the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in the policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 6 of 43 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 02/09/2024 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 0610 3. Level of Harm - Minimal harm or potential for actual harm A report to the appropriate agency will include the following: . .g. Other pertinent information as available. Residents Affected - Some The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form. .6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s). A copy of the written report will accompany any personnel action deemed necessary. 7. The facility will report and cooperate with any and all investigations concerning reports of abuse, and neglect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 7 of 43 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 02/09/2024 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 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 interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 5 (Resident # 32, Resident #33, Resident #44, Resident #48, and Resident #49) of 5 residents reviewed for care plans. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified for Resident #32, Resident #33, Resident #44, Resident #48, and Resident #49. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified with a timeframe to achieve for Resident #32, Resident #33, Resident #44, Resident #48, and Resident #49. These failures could place residents at risk for not receiving timely interventions or interventions not individualized to meet their specific physical, mental, and/or emotional needs. Findings included: Record review of Resident #32's electronic face sheet revealed a [AGE] year-old male, initially admitted on [DATE] with a recent admission date of [DATE]. Resident #32's medical diagnoses included chronic respiratory problems, dementia, major depression, heart failure, weakness, heartburn, repeated falls, head injury, high blood pressure, and high cholesterol. Record review of Resident #32's Quarterly MDS assessment dated [DATE], Section C 1000. Cognitive Skills for Daily Decision Making revealed Resident #32 was Severely impaired - never/rarely made decisions. Record review of Resident #32's Comprehensive Care Plan reviewed and revised [DATE] revealed objectives lacking ability to be evaluated or quantified were: Mr. [resident] will not sustain serious injury . , The resident's fall risk will be reduced ., Mr. [resident] will display optimal breathing pattern daily. , Mr. [resident] will pass soft, formed stool. , Mr. [resident] will improve current level of function in ADL's. , Mr. [resident] will have no indications of psychosocial well being problem . , Mr. [resident] will identify coping mechanisms (new and old) . , Mr. [resident] will demonstrate adjustment to nursing home placement. , Mr. [resident] will not have an interruption in normal activities due to pain . , Mr. [resident] will not have discomfort related to side effects of analgesia . , Residents needs will be met . , My/RR's decision for DNR will be honored . , I will have fewer episodes of allergies . , My dignity will be maintained and fewer incidents of incontinence . , Resident will be safe from any injuries . , The resident will cooperate with care . , The resident will demonstrate effective coping skills . , The resident will seek out staff/caregiver when agitation occurs . , The resident will show decreased episodes of s/sx of depression. , The resident will be able to communicate basic needs on a daily basis . , The resident's, dignity and autonomy will be maintained at highest level . , The resident will display optimal breathing pattern daily . , and Resident will maintain ideal weight and receive proper nutrition daily . The objective lacking ability to be evaluated or quantified and did not provide a timeframe for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 8 of 43 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 02/09/2024 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 achieving was Maintain stable weight and nutritional parameters. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #33's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with medical diagnoses of heart failure, Alzheimer's disease, major depression, dementia, history of falling, placement of a cardiac pacemaker (an implanted device to regulate heart rhythm). Residents Affected - Some Record review of Resident #33's Quarterly MDS assessment dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #33 scored 1 out of 15 indicating severe cognitive impairment. Record review of Resident #33's Comprehensive Care Plan reviewed and revised [DATE] revealed objectives lacking ability to be evaluated or quantified were: Resident/responsible party's decision for DNR will be honored. , The resident will be able to communicate basic needs on a daily basis. , The resident will maintain involvement in cognitive stimulation, social activities as desired. , The resident will verbalize less difficulty breathing and be more comfortable . , The resident will not sustain serious injury . , The resident will not have an interruption in normal activities due to pain . , Dignity will be maintained and the resident will be kept comfortable . , and The resident will maintain or improve current level of function . The objective lacking ability to be evaluated or quantified and did not provide a timeframe for achieving was Maintain stable weight and nutritional parameters. Record review of Resident #44's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with medical diagnoses of Alzheimer's disease, high cholesterol, difficulty sleeping, major depression, weakness, history of head trauma, disease of the liver, and vitamin deficiency. Record review of Resident #44's Quarterly MDS dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #44 scored 4 out of 15 indicating severe cognitive impairment. Record review of Resident #44's Comprehensive Care Plan reviewed and revised [DATE] revealed objectives lacking ability to be evaluated or quantified were: My/RR's decision for DNR will be honored ., I will maintain my current level of function . , I will not have discomfort related to side effects of analgesia . , I will verbalize adequate relief of pain or ability to cope with incompletely relieved pain . , I will not sustain serious injury related to a fall . , I will have my needs met with input from my RR . , I will have fewer episodes of allergies . , The resident will demonstrate adjustment to nursing home placement . , Medication will be administers safely., The resident will develop skills to cope with cognitive decline and maintain safety . , The resident's comfort will be maintained . , The resident's dignity and autonomy will be maintained at highest level . , I will have adequate air exchange as evidenced by normal breathing patterns and usual mental status . , The resident will have fewer episodes of yelling out weekly ., and The resident will not have an interruption in normal activities due to pain . The objectives lacking ability to be evaluated or quantified and did not provide a timeframe for achieving were: I will receive medication as ordered by the Physician. while on pass., I will be offered/administered all Immunizations as ordered by his physician., and Maintain stable weight and nutritional parameters. Record review of Resident #48's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of adult-onset diabetes, shortness of breath, Alzheimer's disease, weakness, high blood pressure, difficulty swallowing, depression, and anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 9 of 43 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 02/09/2024 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 Record review of Resident #48's Quarterly MDS dated [DATE], Section C 1000. Cognitive Skills for Daily Decision Making revealed Resident #32 was Severely impaired - never/rarely made decisions. Record review of Resident #48's Comprehensive Care Plan reviewed and revised [DATE] revealed objectives lacking ability to be evaluated or quantified were: The resident will cooperate with care. , I will have adequate air exchange as evidenced by normal breathing patterns and usual mental status . , I will maintain my current level of function . , I will not sustain a serious injury related to a fall . , The resident will be able to communicate basic needs on a daily basis . , The resident will develop skills to cope with cognitive decline and maintain safety . , The resident will improve current level of cognitive function . , The resident's safety will be maintained . , The resident will demonstrate happiness with daily routine . , The resident will be able to communicate basic needs on a daily basis . , and Resident will maintain ideal weight and receive proper nutrition daily . The objectives lacking ability to be evaluated or quantified and did not provide a timeframe for achieving were Request for CPR to be initiated will be followed, Medication will be administers safety and as ordered, The resident will receive medications as ordered by the physician, The resident will be compliant with thyroid replacement therapy., and Maintain stable weight and nutritional parameters. Record review of Resident #49's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses respiratory disease, kidney disease, high blood pressure, heart failure, gout (a type of arthritis that causes pain and swelling in the joints), Sjogren syndrome (a disease that occurs when the immune system attacks the body causing dry skin, dry eyes, fatigue and joint pain), and a skin infection. Record review of Resident #49's Quarterly MDS assessment dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #49 scored 12 out of 15 indicating moderately impaired cognition. Record review of Resident #49's Comprehensive Care Plan reviewed and revised [DATE] revealed objectives lacking ability to be evaluated or quantified were: My/RR's decision for DNR will be honored . , I will maintain my current level of function . , The resident's comfort will be maintained . , I will have adequate air exchange as evidenced by normal breathing patterns and usual mental status . ,I will not have an interruption in normal activities due to pain . , I will have my needs met with input from my RR . , and The resident will have no s/sx of complications r/t fluid deficit . The objectives lacking ability to be evaluated or quantified and did not provide a timeframe for achieving were: Medication will be administers safety and as ordered, and The resident will receive medications as ordered by the physician, while on pass. During an interview on [DATE] at 10:52 AM, RCN stated goals should be measurable and include a timeframe to complete or be reviewed. She stated previous nursing leadership responsible for creating, reviewing and revising the care plans did not do their jobs. Record review of Facility policy titled Comprehensive Care Planning undated revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . Measurable objectives describe the steps toward achieving the resident's goals, and can be measured, quantified, and/or verified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 10 of 43 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 02/09/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise resident-centered comprehensive care plans within 7 days of a comprehensive assessment for 5 (Resident #13, Resident #32, Resident #44, Resident #48, and Resident #49) of 6 residents reviewed for care plans. The facility failed to review and revise Resident #13, Resident #32, Resident #44, Resident #48, and Resident #49's Comprehensive Patient-Centered Care Plan within 7 days following the completion of a comprehensive assessment. This failure could put residents at risk for not receiving the care and services needed to maintain or improve physical, mental, emotional, psychological well-being. Findings included: Record review of Resident #13's electronic face sheet revealed a [AGE] year-old female, initially admitted on [DATE] with her most recent admission on [DATE]. Resident #13 was admitted with medical diagnoses that included kidney disease, bipolar disorder, major depression, low thyroid function, drug induced involuntary muscle movement, abnormal weight loss, and history of falls. Record review of Resident #13's Annual MDS assessment dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #13 scored 5 out of 15 indicating severe cognitive impairment. Record review of Resident #13's recent comprehensive assessment revealed a completion date of 01/16/2024. Review of Resident #13's date of last care plan review completed was 11/10/2023. Record review of Resident #32's electronic face sheet revealed a [AGE] year-old male, initially admitted on [DATE] with a recent admission date of 07/04/2023. Resident #32's medical diagnoses included chronic respiratory problems, dementia, major depression, heart failure, weakness, heartburn, repeated falls, head injury, high blood pressure, and high cholesterol. Record review of Resident #32's Quarterly MDS assessment dated [DATE], Section C 1000. Cognitive Skills for Daily Decision Making revealed Resident #32 was Severely impaired - never/rarely made decisions. Record review of Resident #32's recent comprehensive assessment revealed a completion date of 11/17/2023. Review of Resident #32's date of last care plan review completed was 10/06/2023. Record review of Resident #44's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with medical diagnoses of Alzheimer's disease, high cholesterol, difficulty sleeping, major depression, weakness, history of head trauma, disease of the liver, and vitamin deficiency. Record review of Resident #44's Quarterly MDS assessment dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #44 scored 4 out of 15 indicating severe cognitive impairment. Record review of Resident #44's recent comprehensive assessment revealed a completion date of 01/16/2024. Review of Resident #44's date of last care plan review completed was 10/06/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 11 of 43 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 02/09/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #48's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of adult-onset diabetes, shortness of breath, Alzheimer's disease, weakness, high blood pressure, difficulty swallowing, depression, and anxiety. Record review of Resident #48's Quarterly MDS assessment dated [DATE], Section C 1000. Cognitive Skills for Daily Decision Making revealed Resident #48 was Severely impaired - never/rarely made decisions. Record review of Resident #48's recent comprehensive assessment revealed a completion date of 01/11/2024. Review of Resident #48's date of last care plan review completed was 10/06/2023. Record review of Resident #49's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses respiratory disease, kidney disease, high blood pressure, heart failure, gout (a type of arthritis that causes pain and swelling in the joints), Sjogren syndrome (a disease that occurs when the immune system attacks the body causing dry skin, dry eyes, fatigue and joint pain), and a skin infection. Record review of Resident #49's Quarterly MDS assessment dated [DATE], Section C 0500 BIMS Summary Score revealed Resident #49 scored 12 out of 15 indicating moderately impaired cognition. Record review of Resident #49's recent comprehensive assessment revealed a completion date of 12/15/2023. Review of Resident #49's date of last care plan review completed was 09/27/2023. Interview on 02/09/24 at 12:30 PM, the DON stated she was aware that care plans had not been updated due to the previous DON and ADON leaving without notice. The DON stated her expectation was that care plans be comprehensive and be person centered. She also stated her expectation was for care plans to be updated timely. She stated care plans should have been reviewed any time there was a change and at minimum quarterly. DON stated the team (DON, ADON, MDS, and nurses) were responsible to ensure care plans were completed and reviewed timely. Interview on 02/09/24 at 2:34 PM, the MDS Coordinator stated she was behind on updating care plans. The MDS Coordinator stated care plans should be reviewed and revised if needed within 7 days after each comprehensive assessment. She stated the failure occurred due to former nursing leadership walking out in December 2023. Record review of facility policy titled Comprehensive Care Planning undated revealed A comprehensive care plan will be developed within 7 days after completion of the comprehensive assessment, The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 12 of 43 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 02/09/2024 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 0687 Provide appropriate foot care. 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 residents received proper treatment and care to maintain mobility and good foot health for 1 of 3 residents (Resident #42) reviewed for foot care. Residents Affected - Some The facility failed to ensure Resident #42 received podiatry care since admission on [DATE]. This deficient practice could place residents at risk of overall poor foot hygiene and a decline in resident's physical condition. The findings were: Record review of Resident #42's face sheet, dated 02/09/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with the following diagnoses which included type-2 diabetes, hemiplegia (weakness) and hemiparesis (paralysis) to right dominant side, stroke and lack of coordination. Record review of Resident #42's Quarterly MDS Assessment, dated 01/11/2024, revealed Section CCognitive Patterns Resident #42 had a BIMS score of 15 (cognitively intact); Section G: ADL Assistance revealed Resident #42 had functional limitation in range of motion to upper and lower extremity on one side. Record review of Resident #42's Care Plan revised on 01/27/2024, revealed Focus: Goal: Interventions: Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness; Focus: Resident has thick, yellow toenails that require trimming by a nurse Goal : Resident will be free of pain or discomfort Interventions Nursing will perform toenails/fingernails care when needed for resident, Resident will see podiatrist when needed Record review of Resident #42's Order Summary Report revealed a start date of 07/05/2023 and May have Podiatry Consult PRN. During an observation on 02/06/24 at 10:53 AM revealed Resident #42's toenails had been trimmed and were short. Resident #42 stated he had seen the podiatrist on January 30, 2024 he had cut his toenails and he was feeling better and had no pian. During an interview on 02/06/2024 at 3:55 PM the family representative stated Resident #42's toenails had not been clipped in a long time and that he had not been seen by a podiatrist since he had been admitted to the facility. During an interview on 02/08/2024 at 9:15 AM the ADO stated his expectation was residents who were diabetic should have been on the list to be seen by the podiatrist quarterly. The ADO stated his expectation was that when staff observe residents' toenails that needed to be trimmed the nurse should have been notified and the nurse should have trimmed nails immediately. The ADO stated Resident #42 should have been seeing the podiatrist due to his diagnosis of diabetes. The ADO stated when he was made aware of Resident #42's toenails on 01/26/2024 he clipped the resident's toenails himself and attempted to get the resident's appointment moved up from January 30, 2024. The ADO stated Resident #42 had seen podiatrist on January 30, 2024 and was scheduled for routine visits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 13 of 43 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 02/09/2024 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 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 2/08/2024 at 2:30 PM the ADON stated her first day working at the facility was January 26, 2024 and she learned about Resident #42's issues with his feet. ADON stated Resident #42 was scheduled to see the Podiatrist on January 30, 2024. The ADON stated there were no open areas, redness, or infection. The ADON stated by her observation it had been at least a month since someone had trimmed his toenails. The ADON stated since he was diabetic, he should have been seen by the podiatrist quarterly. The ADON stated the social worker was responsible to schedule podiatrist appointments. The ADON stated nurses were supposed to do a weekly skin assessment and they should have been documenting toenails on the skin assessment. The ADON stated what led to the failure was the nurse was not completing an accurate assessment and lack of communication. The ADON stated the effect on the resident could have been infection or pain to the resident. During an interview on 02/09/24 at 12:30 PM the DON stated her expectation was that residents who were diabetic should have been seen by the podiatrist on a regular basis, and the nurses should have been taking care of clipping residents' nails when an issue arose. The DON stated the nurses were responsible for completing nail care and the ADON and DON were responsible to monitor. The DON stated the effect on residents could have been minor injury and/or infection. The DON stated what led to the failure was the changes in leadership the last several months left no one to monitor the nurses. Record review of facility document for residents with routine foot care for 09/23/23 and 11/30/2023 revealed no evidence of Resident #42 was seen by the podiatrist. Record review of facility policy titled, Foot Care dated 2003 revealed Become familiar with medical conditions that compromise circulation in the feet and assess or need of nail trimming. Request referral to podiatrist if nail trimming is needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 14 of 43 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 02/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 5 (Residents #3, #6, and #18) residents reviewed for smoking safety. The facility failed to ensure Residents #6 was supervised when smoking per assessment. The facility failed to ensure Residents #3, #6, and #18's lighters and cigarettes were not stored on their person. These failures could affect residents who smoke at risk of serious bodily harm, physical impairment, or death. The findings included: Resident #3 Record review of Resident #3's electronic face sheet dated 02/09/2024 revealed resident was a [AGE] year-old female who was admitted on [DATE]. Resident #3's diagnoses included: Chronic Obstructive Pulmonary Disease. Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns Resident #3 had a BIMS score of 15 (cognitively intact). Section GG-Functional Abilities and Goal: Resident #3 used a manual wheelchair. Record review of Resident #3 Electronic Health Record from 09/07/2023 through 02/09/2024 revealed she did not have any Safe Smoking Assessment. During observation on 02/07/2024 at 1:54 PM, Residents #3 were observed smoking in the designated smoking area of the facility having cigarettes and lighters on their person with no supervision. During an interview on 02/08/2024 at 9:33 AM the ADON stated there was not an assessment on Resident #3. She stated the assessment should have been done upon admission and monthly if needed. She stated herself as ADON, the DON and MDS should have monitored the resident assessments. The ADON stated the negative impact to residents who smoke and not having a smoking assessment would be an unsafe smoking environment for everyone at the facility. She stated the failure was upper management not keeping up with the assessments. Her expectations were to make sure the assessments be done for each resident that smoked. During an interview on 02/09/24 at 1:46 PM the ADO stated the smoking assessments should be done on admission or once they find out they are a smoker. The assessment would then be flagged with a monthly reminder to continue monthly assessments. The ADO also stated if a residents condition changes, an assessment would be done then as well. He stated compliance nurses would also do random auditing, but the DON was the ultimate one to monitor the smoking assessments. He stated the negative impact of not having a smoking assessment would be unsafe for residents possibly start a fire with residents getting burnt. The ADO stated the failure was having changes in upper management. His expectations were for a smoking assessment to be performed on a resident once identified as a smoker and to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 15 of 43 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 02/09/2024 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 0689 done and completed monthly. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled Smoking Policy last revised on 11/01/2017 revealed: . .2. A safe smoking assessment will be done regularly for each resident who smokes . Residents Affected - Some Resident #6 Record review of Resident #6's electronic face sheet dated 02/07/2024 revealed resident was a [AGE] year-old female who was admitted on [DATE] and an original admission date of 10/28/2022 with diagnoses that included: Chronic Obstructive Pulmonary Disease, muscle weakness, Lack of Coordination, violent behavior, spastic hemiplegia (muscle tightness and involuntary contractions on one side of the body) affecting left nondominant side. Review of Resident #6's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns Resident #6 had a BIMS score of 08 (moderately impairment); Section GG- Functional Abilities and Goals Resident #6 had upper and lower extremity impairment on both sides and required a wheelchair for mobility. Record review of Resident #6's Safe Smoking assessment dated [DATE] revealed: Resident requires direct supervision while smoking; Resident requires a fire-resistant smoking apron while smoking; Residents smoking materials will be kept at the nurses station. Record review of Resident #6's Comprehensive Care Plan last revised on 10/20/2023 revealed: Focus: The resident is a smoker and requires supervision and smoking apron due to shaking, hemiplegia and dexterity issues. Goal: Resident will be able to smoke without causing injury. Interventions: Safe Smoking Assessment every month. Record review of Resident #6's Safe Smoking assessment dated 12/28/2023 (noted assessment date) revealed: A. Evaluation-When observed, the resident cannot independently light smoking materials safely. The resident had only complete use of one hand. The resident has had past accidents/incidents with smoking materials. There were visible burn marks on the residents clothing. B. Summary-The resident requires direct supervision while smoking. The resident requires a fire-resistant smoking apron while smoking. All smoking materials will be kept at the nurses station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 16 of 43 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 02/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #6's smoking assessments were initiated on 07/06/2023. She had missing monthly assessments for 09/2023 and 01/2024. During observation on 02/07/2024 at 1:54 PM, Resident #6 was observed smoking in the designated smoking area with no apron for Resident #6 and no supervision. Residents Affected - Some Resident #18 Record review of Resident #18's electronic face sheet dated 02/09/2024 revealed resident was a [AGE] year-old male who was admitted on [DATE] and an original admission date of 03/08/2015 with diagnoses that included: heart disease, pain, mild cognitive impairment, muscle weakness, difficultly walking and lack of coordination. Review of Resident #18's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns Resident #18 had a BIMS score of 09 (moderately impaired); Section GG- Functional Abilities and Goals Resident #18 used a cane/crutch for mobility. Record review of Resident #18's Comprehensive Care Plan last revised on 07/05/2023 revealed: Focus: The resident is a smoker, and all smoking materials will be returned to charge nurse. Record review of Resident #18's Safe Smoking assessment dated [DATE] revealed: B. Summary-All smoking materials will be kept at the nurses station. During an observation and interview on 02/06/2024 at 11:50 AM, Resident #18 was observed with cigarettes in his shirt pocket. He stated he also carried his own lighter. During observation on 02/07/2024 at 1:54 PM, Residents #18 were observed smoking in the designated smoking area of the facility having cigarettes and lighters on their person with no supervision. During observation and interview on 02/07/2024 at 1:57 PM the Dietary Staff stated those 3 residents (#3, #6, #18) had their own cigarettes and lighters. The Dietary Staff stated she did not usually go out with the residents and realized they had their own cigarettes and lighters but stated she was not supervising the residents at that time. The Dietary Staff stated she did not think the residents were able to have their own. During an interview on 02/07/2024 at 2:55 PM the ADMIN stated there was a lockbox that Residents were supposed to have kept their cigarettes and lighters in after smoking. He stated when the Residents go out with the supervising aide, they would refuse to hand them back in. The ADMIN stated all of the residents who smoked had signed the smoking policy agreement. During an interview on 02/08/24 at 9:07 AM the DON stated all of the smokers were required to be educated on safe smoking in the designated smoking area and follow the policy and procedures they had signed. She stated the code to go out to the designated smoke break area from the dining room should be kept between staff, and residents should not be going out to smoke on their own. The DON stated it was the ADMIN that monitored the code and had not been changed, even though residents were smoking without supervision. She also stated they should not have cigarettes and/or lighters on their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 17 of 43 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 02/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some person and smoking supplies should have been placed in a lockbox after use. She stated if residents were found to have them, they would have been confiscated. The DON stated the negative impact for unsupervised residents could have been possibly burned, or smoke inhalation. The DON stated there were residents that were supposed to have smoking vests on but some refused most times. She stated the supervising aides were supposed to tell the nurses when they refuse to do so. The DON stated she could not say why the residents were able to smoke unsupervised, and they may have been getting cigarettes from visitors as they came in. She stated the failure occurred when the cigarettes and lighters were not being kept in the lockbox as well as with residents being allowed to keep them. The DON stated the failure also occurred with staff not reporting residents having cigarettes and lighters on their person, to the upper management. Her expectations were that staff would be more knowledgeable about the lockbox with a designated supervised person to be with them. During an interview on 02/09/24 at 1:40 PM the ADMIN stated there were no in services for staff supervising smokers. He stated they should have been in serviced before being allowed to supervise the smoking residents. Record review of facility policy titled, Uniform Smoke Free Policy undated, revealed: No storage is permitted in rooms with gas fired equipment Smoking by residents classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel Smoking tobacco, matches, lighter or other smoking paraphernalia are not permitted to be kept or stored in a resident's room. A resident, who is assessed safe to smoke unsupervised, will be instructed to obtain their smoking paraphernalia from a designated, secured area. The resident will be instructed to return the smoking paraphernalia following the smoking session. The resident may smoke at their request, unless the time interferes with resident care A resident who is assessed unsafe to smoke unsupervised must be in direct view of the smoking supervisor, in a reasonably close proximity of the supervisor, and the supervisor must be able to quickly respond in the event of an emergency. Additionally, the supervisor, whether staff or visitor, must be aware of these responsibilities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 18 of 43 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 02/09/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #40) of 4 residents reviewed for catheters. The facility failed to provide appropriate treatment and indwelling catheter services consistent with professional standards of practice by not changing Resident #40's urinary catheter as ordered and ensuring Resident #40's urinary catheter collection bag was not on the floor. This failure placed residents with urinary catheters at risk for infection threatening their physical and mental well-being. Findings included: Record review of Resident #40's electronic face sheet revealed a [AGE] year-old female admitted [DATE] with medical diagnoses of a stroke, high blood pressure, paralysis in both arms and legs, neuromuscular dysfunction of the bladder (lacking control of the muscles that control bladder function due to brain, spinal cord, or nerve problems), difficulty eating, adult-onset diabetes, inability to speak, and inability to stand or walk. Record review of Resident #40's Quarterly MDS dated [DATE] revealed in Section C 1000. Cognitive Skills for Daily Decision Making revealed Resident #40 was Severely impaired - never/rarely made decisions. Observation on 02/06/24 at 02:31 PM revealed Resident #40's urinary catheter tubing was cloudy. The tubing was not dated. Observation on 02/08/24 at 4:45 PM, revealed Resident #40's urinary catheter collection bag was lying on the floor under the right side of the bed. Observation on 02/09/24 at 07:26 AM, revealed Resident # 40's catheter was in a privacy bag, hanging below the right side of the bed. The tubing was cloudy. The tubing was not dated. Record review of Resident #40's care plan dated 07/05/2023 revealed Focus: The resident has an indwelling catheter. Goal: The resident will show no s/sx of infection through the review date. Review date: 10/22/2023. Interventions: Change the catheter as ordered. Revised 08/23/2023. Review of Physician's order dated 06/17/2023 reflected Change 16f 10 cc foley catheter q28days and PRN one time a day every 28 day(s) related to neuromuscular dysfunction of bladder. Review of Resident #40's Wound Assessment Record dated October 2023 revealed the catheter was due to be changed 10/06/23. The box to note who changed the catheter was blank. Resident #40's progress note on 10/17/23 indicated the urinary catheter was changed. Review of Resident #40's Wound Assessment Record dated November 2023 revealed the catheter was due to be changed 11/03/23. The box to note who changed the catheter was blank indicating the catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 19 of 43 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 02/09/2024 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 0690 was not changed as scheduled. Level of Harm - Minimal harm or potential for actual harm Review of Resident #40's Wound Assessment Record dated December 2023 revealed the catheter was due to be changed 12/29/23. The box to note who changed the catheter was blank indicating the catheter was not changed on 12/29/23. The record indicated the catheter was changed on 12/01/23. Residents Affected - Some Review of Resident #40's Wound Assessment Record dated January 2024 revealed the catheter was due to be changed 01/26/24. The box to note who changed the catheter was blank indicating the catheter was not changed. During an interview on 02/09/24 at 7:40 AM, MA C and CNA A stated urinary catheter collection bags should never be placed on the floor due to the risk of cross-contamination. MA C stated training on catheter care was provided by the facility about every 3 months either face-to-face or online. CNA D stated placing a catheter collection bag on the floor could put residents at risk for the bladder not draining properly, the collection bag and/or tube could become a trip hazard, the collection bag and/or tubing may get caught up and possibly pull the catheter out, and leaving the collection bag on the floor increased the potential for infection. MA C stated all staff were responsible for ensuring bags were not left on the floor. MA C stated the charge nurse was responsible for monitoring and the administrator checked all residents during morning rounds every day. During an interview on 02/09/24 at 9:28 AM, LVN B stated the physician's order for Resident # 40 was for the urinary catheter to be changed every 28 days and PRN. She stated the resident refused the recent scheduled change because the catheter had been changed a week earlier. LVN B explained a notation would be made in the Wound Administration Record or progress notes if there was an issue and the catheter was not changed when scheduled. She stated nursing personnel were responsible for monitoring proper catheter care. Her expectations were to be informed of issues with catheters such as if there was leaking or no urine output. LVN B stated Resident #40 frequently refused catheter change. She explained Resident #40 prefers only certain staff members to do certain tasks. LVN B stated a notification pops up on the computer when nursing staff access resident records and a catheter change was due. LVN B explained training for catheters was via an online program. She stated staff received notifications when training is due. LVN B could not recall how often catheter training was required. LVN B stated the consequences of placing the collection bag on the floor may be that the bag would get run over, a hole may develop in the bag, or someone may trip and pull the catheter out. She stated the collection bag could have been left on the floor after the resident was transferred to bed and staff forgot to attach the collection bag to the bed. Another reason LVN B provided was because staff often unhooked the collection bag to make it easier to empty at the end of the shift and probably forgot to rehang it. She stated not hanging the collection bag up off of the floor may affect a resident because it could cause bladder spasms from urine backflow. LVN B stated nursing personnel were responsible for monitoring proper catheter care. LVN B stated s/sx of possible infection were complaints of burning or pain from spasms and expected direct care providers to report. LVN B stated Resident #40 was not being treated for UTI. Record review of physician's orders for Resident #40 confirmed LVN B's statement. During an interview on 02/09/24 at 10:52 AM, RCN stated her expectation of catheter care was for catheters to be changed when ordered. She stated several catheter change orders had been changed to PRN only in order to decrease the risk of catheter associated infection. RCN stated the nursing staff were responsible for changing catheters and the DON was ultimately responsible to ensure the changes were done. RCN explained the risk of failing to change a catheter as ordered would be infection. RCN stated when a resident refused a catheter change the provider was notified, a care plan meeting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 20 of 43 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 02/09/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was scheduled, the resident was advised of the consequences including potential transfer to the hospital or to a urologist. She explained a Negotiated Risk Agreement would be reviewed with the resident and/or their representative and the IDT would be involved. RCN stated if the resident's primary physician ordered the catheter change, the facility would be responsible for ensuring it was done. She stated the nursing staff was required to review the WAR daily to see what treatments such as catheter change were due. She stated the nursing administration performed an audit in the electronic records system daily to make sure orders were completed. The RCN accessed Resident #40's records and acknowledged Resident #40 was scheduled for a catheter change on 01/26/24 and it was not done. She explained the electronic system popped up a screen to document a reason when a resident refused a task. She stated unfortunately too many nurses just enter refused as the explanation. RCN stated it was not appropriate for a catheter collection bag to be left on floor. She stated all staff were responsible for ensuring collection bags were off the floor. Her stated expectation was for collections bags to be kept off the floor. She explained staff received training at hire and annually. Face-to-face training was done during orientation and again if a problem was identified, and subsequent training such as annual training was done online. RCN stated staff were notified when online training was due via email and/or text message. She stated staff's notification preference was set-up during orientation. RCN stated compliance with required training was monitored by nursing leadership. Record review of facility policy titled Catheter Care, revised 02/13/07, revealed Change the catheter and drainage system as needed unless ordered otherwise by the physician. and Be sure the catheter tubing and drainage bag are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 21 of 43 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 02/09/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident who uses a feeding tube for liquid nourishment, fluids, and medications received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 (Resident #40) reviewed for gastrostomy tube. The facility failed to check the placement of Resident #40's gastrostomy tube prior to administering water flushes and medication administration via gastrostomy tube. This failure could place residents who use gastrostomy tubes at risk of aspiration pneumonia. The findings included: Record review of Resident # 40's face sheet dated 02/09/2024 revealed, [AGE] year-old female admitted on [DATE] with diagnosis: dysphasia following other cerebrovascular disease (difficulty swallowing after stroke) and dysphagia, oropharyngeal phase (difficulty swallowing). Record review of Resident # 40's quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior resident was rarely/never understood; Section GG- Functional Abilities and Goals revealed eating not attempted due to medical condition or safety concerns; Section K- Swallowing/Nutritional Status revealed Resident #40 had a feeding tube while a resident. Record review of Resident #40's care plan dated 02/09/2024 revealed; Focus: Resident is NPO and requires an alternate method of nourishment. RP agreed on no residual or placement checks .Goal: I will be free of aspiration through the review date .Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than 100cc. During an observation and interview on 02/07/2024 at 8:23 a.m., LVN A administered a water flush and antinausea medication via Resident #40's gastrostomy tube without checking for tube placement. LVN A stated Resident #40 did not like for staff to check for placement and that was why she did not perform it. LVN A did not know what the care plan stated for Resident #40. She stated not checking for placement put the resident at risk for aspiration. During an interview on 02/09/2024 at 9:08 a.m., ADON stated her expectation would be for RP to sign an associated risk consent when RP did not want the facility to check for gastrostomy tube placement prior to administering nutrition / medication into it. She stated the effect of not checking placement prior to using the gastrostomy tube could cause peritonitis (inflammation in the tissue that lines the inside of the abdominal cavity). ADON stated she and DON were responsible for monitoring staff are properly using gastrostomy tubes. She did not know why the failure occurred. During an interview on 02/09/2024 at 9:08 a.m., DON stated her expectation would be for resident's RP to sign consent and care plan be updated if resident or RP would not allow for gastrostomy tube placement prior to administering medication. She stated she was responsible for monitoring that staff perform care appropriately and did not know if there was a policy for what to do if there was a refusal of placement checks. She stated not checking placement placed resident at risk of infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 22 of 43 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 02/09/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete She does not know why consent was not gotten because she has only worked at the facility for less than one month. Review of facility policy titled Gastrostomy Tube Care dated February 13, 2007 revealed: Unplug or unclamp the tube and check the placement by aspiration or injecting air and listening to the stomach for sounds .Check its position using the markings on the tube .If the tube has moved or has come out, do not use and call the physician. Event ID: Facility ID: 675982 If continuation sheet Page 23 of 43 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 02/09/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 3 of 3 residents (Resident #20, Resident #25, and Resident #45) reviewed for bed rails. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails. These failures could place residents at risk for injury and restricted movement. The findings include: Resident #20 Record review of Resident #20's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's Disease (disease that destroys memory and other important mental functions), muscle weakness, and lack of coordination. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS assessment revealed a score of 0 meaning severe cognitively impairment; Section GG (Functional Abilities) revealed Resident #20 was independent in rolling left to right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #20's care plan reviewed on 02/09/2024 revealed Focus: The resident had an ADL self-care performance deficit related to weakness, cognition deficit, unsteady gait upon mobility, disease process .Interventions: I require limited assistance by 1-2 staff. There was no evidence of interventions for placement and/or use of bed rails. Record review of Resident #20's physician orders dated 02/09/2024 revealed no order for the use of bed rails. Record review of Resident #20's electronic records on 02/09/2024 revealed no evidence of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. During an observation on 02/06/2024 at 10:00 a.m., Resident #20's bed had quarter rails on both sides of bed. Resident #25 Record review of Resident #25's face sheet dated 02/07/2024 revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), abnormalities of gait and mobility, lack of coordination, and right sided hemiplegia and hemiparesis following cerebral infarction (right sided weakness following a stroke). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 24 of 43 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 02/09/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #25's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 9 indicated moderately impaired and Section GG (Functional Status) revealed Resident #25 needed supervision with rolling left and right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #25's comprehensive care plan reviewed on 02/07/2024 revealed the resident requires 1-2 person assist with bed mobility, she was able to use side rails to help hold self over and to help reposition self in bed. Record review of Resident #25's physician orders dated 02/09/2024 revealed order for ¼ siderails x 2 when in bed for positioning with start date of 12/21/2021. Record review of Resident #25's electronic records on 02/09/2024 revealed no evidence of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. During an observation and interview on 02/06/2024 at 10:01 a.m., Resident #25 had half rails present to bed. She stated rails help with bed mobility. Resident #45 Record review of Resident #45's face sheet dated 02/09/2024 revealed a [AGE] year-old male was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included pain, abnormalities of gait and mobility, muscle weakness, and reduced mobility. Record review of Resident #45's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 11 meaning moderately impaired and Section GG (Functional Abilities) revealed Resident #13 needed partial to moderate assistance with rolling left to right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #45's care plan reviewed on 02/09/2024 revealed he may use ½ rail for turning and positioning as necessary. Record review of Resident #45's physician orders dated 02/09/2024 revealed order for half siderails x 2 when in bed as tolerated with start date of 11/21/2022. Record review of Resident #45's electronic records on 02/09/2024 revealed bed rail consent signed on 02/08/2024 and bed rail assessment completed on 02/08/2024. During an observation and interview on 02/06/2024 at 3:15 p.m., Resident #45 had half rails on his bed. He stated the rail on the right side of his bed was loose. He stated he used rails to help him move around in the bed. During an interview on 02/09/2024 at 10:35 a.m., LVN B stated she did not do risk for entrapment, bed rail assessment, or consents for bed rails. She stated she did not know why they were not completed, and that upper management were who completed those forms. During an interview on 02/09/2024 at 10:38 a.m., the ADON stated her expectation would be that entrapment risk, bed rail assessment be performed, and consent be signed by resident or responsible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 25 of 43 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 02/09/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some party prior to bed rails being installed on a resident's bed. She did not know why these steps were not completed prior to bed rails being placed. She stated some information was lost when changing systems. She stated the effect could be that resident could potentially be harmed by entrapment if bed rails were not appropriate for that resident. During an interview on 02/09/2024 at 10:39 a.m., the RCN stated she was unsure what led to bed rail assessment, entrapment risk assessment and consent not signed. She stated the DON was given a list of residents that corporate had identified as needing these assessments and consents, but that staff member had resigned. She was unsure if assessments and consents were performed and could not provide evidence that they were. The RCN stated it was her expectation admitting nurse would perform bed rail assessment, entrapment risk assessment and get consent for bed rails. She stated these forms not being completed could lead to bed rails being used when not appropriate. She stated she was ultimately responsible for making sure the forms were completed but that ADON and DON were to start performing audits to charts to make sure appropriate forms were present after admission paperwork completed. Review of facility policy titled Bed Rails dated November 8, 2016, revealed: This facility will utilize bed rails for those residents that use them for bed mobility. The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements .Assess the resident for risk of entrapment from bed rails prior to installation .Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation .Ensure that the bed's dimensions are appropriate for the resident's size and weight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 26 of 43 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 02/09/2024 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on interviews and observation, the facility failed to ensure staffing information was posted daily, readily accessible to residents and visitors that included: the total number and the actual hours worked by the Registered nurses, Licensed Practical nurses or Licensed Vocational Nurses or Certified Nurse Aides directly responsible for resident care per shift for 3 of 3 days (02/06/2024, 02/07/2024, and 02/08/2024 reviewed for staffing information. Residents Affected - Many The facility failed to ensure the daily staffing information was posted daily on 02/06/2024, 02/07/2024, and 02/08/2024. This failure could place residents, their families, and visitors at risk of not having the staffing information readily accessible for review, residents and visitors are not able to know how many staff are currently working to provide care on all shifts. Findings Included: Observation on 02/06/2024, 02/07/2024 and 02/08/2024 of the nurses station and hallways revealed evidence of the daily staffing hours posted was last dated 01/01/2024. During an interview on 02/07/2024 at 3:48 PM the ADMN stated he was not sure where the daily nurse staffing was located. The ADMN stated someone must be taking them down as they should be posted on the wall where it was visible for visitors and residents. During an interview on 02/08/24 4:23 PM the RCN stated the nursing services postings should be posted on a daily basis. She stated she was unaware they were not being done daily. During an interview on 02/09/24 01:09 PM the ADO stated the nursing staff postings should have been posted at midnight every day. He stated he had previously discussed the staff postings with the ADMN and RCN. The ADO stated the purpose of having staff posting available would be to let residents and visitors know how many staff are scheduled for the day and that adequate staff is being provided for resident care. He stated the negative effect for residents and visitors would be a possibility of inadequate staffing. He stated the DON was responsible for monitor on a daily basis and the failure was with the new nurse management which was new to the facility and not aware of the requirements. The ADO stated his expectations were for the nurse staff posting to be posted every day regardless of holidays and/or weekends. The facility failed to provide any associated policies for Nurse staff postings before exiting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 27 of 43 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 02/09/2024 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assure accurate administering of medications for 2 of 4 medication carts (South nurse medication cart, & North nurse medication cart) reviewed. The facility failed to ensure expired medications were removed from medication carts. These failures could place residents who receive medications at risk for receiving outdated medications which could result in residents not receiving the intended therapeutic effects medications. Findings included: During an observation / interview on 02/06/2024 at 11:41 a.m. revealed the South Hall nurses' cart had diphenhydramine (medication used for itching and allergic symptoms) 25mg bottle with expiration date not visible. LVN G stated she was not able to read the expiration date on the medication bottle. She stated she did not know when medication expired, and that medication should not be stored on cart without visible expiration date. She did not know why medication was on the cart but should not be administered without knowing expiration date. During an observation / interview on 02/06/2024 at 12:07 p.m. revealed the North Hall nurses' cart had medication a bottle of hydroxyzine (medication used for anxiety, nausea, allergies, and itching) 10mg with discard by date of 12/23/2023. LVN B stated medication should not be stored on cart when expired. She stated she felt change in medication orders had led to failure to remove medication. LVN B stated the facility's policy was to remove medication from cart when no longer ordered or expired. During an interview on 02/08/2024 at 10:41 a.m. the DON stated medications that are expired should not be kept on the medication carts. She stated she and the ADON were responsible for monitoring nurses and CMAs to ensure they stored medications appropriately. She stated the effect that storing expired / discontinued medication inside medication carts could cause residents to receive medication that are no longer ordered or not effective which could lead to harm. During an interview on 02/08/2024 at 10:42 a.m., the RCN stated she expected for expired medications to be removed from cart. She stated leaving expired medication on the cart could cause residents being given medications that are not as effective causing symptoms to not be managed. She was not sure what led to the failure of expired medications being on medication carts. She stated ADON and DON were to monitor that medications were stored appropriately. Record review of the facility Medication Reconciliation revised on 10/25/2017 revealed: In addition, the pharmacist may collaborate with the facility and medical director on other aspects of pharmaceutical services including, but not limited to .Interacting with the quality assessment and assurance committee to develop procedures and evaluate pharmaceutical services including delivery and storage systems within the various locations of the facility in order to prevent. To the degree possible, loss or tampering with the medication supplies, and to define and monitor corrective actions for problems related to pharmaceutical services and medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 28 of 43 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 02/09/2024 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 - Some 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 observation, interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days and to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 2 (Resident #20) residents reviewed for unnecessary medications. The facility failed to ensure Resident #20's PRN lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms and dependence on unnecessary medications. Findings included: Resident #20 Record review of Resident #20's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's Disease (disease that destroys memory and other important mental functions), brief psychotic disorder, muscle weakness, and lack of coordination. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS assessment revealed a score of 0 meaning severe cognitively impairment; Section NMedication's resident received during the last 7 days antianxiety medication checked. Record review of Resident #20's care plan reviewed on 02/09/2024 revealed Focus: The resident uses anti-anxiety medication related to anxiety .Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Record review of Resident #20's physician orders dated 02/09/2024 revealed order for lorazepam 1mg give 1 tablet by mouth every 4 hours as needed for anxiety / restlessness with start date of 11/01/2023 and no end date. Record review of Resident #20's electronic records on 02/09/2024 revealed no evidence of documented rationale for the continued use of anti-anxiety PRN for greater than 14 days. During an interview on 02/09/2024 at 12:07 p.m., the ADON stated she was not able to fine MMR on file for PRN lorazepam. She stated her expectation would be for anti-anxiety medication used PRN would not extend for longer that 14 days unless a physician does not agree with discontinuing at that time. The ADON stated the nurse who receives the order for PRN anti-anxiety would be responsible for filling out forms for physician to review so that medications were not given past 14 days. She stated the DON and her were supposed to monitor that this process was being completed. She did not know what led to the failure since she did not work for facility in November of 2023. She stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 29 of 43 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 02/09/2024 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 - Some facility's policy stated PRN anti-anxiety medication should be discontinued if physician does not provide rational for it to continue. She stated the effect continuing medication without physician's rational would be that resident could receive medication that was no longer appropriate. During an interview on 02/09/2024 at 1:17 p.m., the DON stated her expectation was for the ordering physician to sign the form with the rational to extend the prn anti-anxiety medication past 14 days. She stated the form with the rational needed to be signed timely but she was not sure exactly what the facility's policy stated. She did not know what led to the failure as she did not work in the facility when the medication was started. She stated both her and the ADON monitor that forms are filled out and physician responded to either extend or discontinue PRN anti-anxiety medications. She stated the effect of this process not being performed depended on the resident and what type of medication was being administered. She did not feel that in this circumstance this resident was harmed. During an interview on 02/09/2024 at 1:19 p.m., the RCN stated she was aware of the regulation on PRN anti-anxiety medications. She stated it was her expectation for rational to be received from physician to extend medication past 14 days. She stated after PRN anti-anxiety rational received twice then another rational would not be needed for 6 months. The RCN stated the DON and ADON were to monitor forms were filled out and physician's response received. She stated in this circumstance this resident was not affected by PRN anti-anxiety medication not being stopped after no physician rational received. Review of facility policy titled Monitoring of antipsychotics dated February 1, 2007, revealed: 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 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. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: o anti-psychotic; o anti-depressant; o anti-anxiety; and o hypnotic. The facility must will ensure that: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 30 of 43 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 02/09/2024 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 1. Level of Harm - Minimal harm or potential for actual harm Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; Residents Affected - Some 2. Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; 3. Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; 4. 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 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. 5. PRN orders for 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 31 of 43 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 02/09/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication storage rooms (North hall medication room) and 1 of 4 medication carts (South nurse medication cart) reviewed. The facility failed to ensure that medications were secured in locked medication cart. The facility failed to ensure that medications were stored in an environment that was dry and without ice buildup. These failures could place residents who receive medications at risk for receiving the wrong medications, outdated medications or contaminated medications which could result in residents not receiving the intended therapeutic effects medications or harm. Findings included: During an observation / interview on 02/06/2024 at 10:37 a.m. revealed the South Hall medication cart sitting in front of the South Hall nurses' station unattended. On the top of medication cart had one bubble pack of trazadone (medication used for insomnia and depression) 50mg with 3 tablets in bubble pack. On the top of medication cart there was clear plastic bag with 6 tablets of cyproheptadine (medication used to relieve allergic symptoms, headaches, and motion sickness) 4mg in it. The medications were not being supervised and residents were moving around the medication cart. CMA F stated she was not supposed to leave medication sitting on top of the cart. She stated she was going to reorder medications and left them there to go into medication room. She stated residents had access to medication and that they could have taken medication that was not ordered for them. During an observation / interview on 02/08/2024 at 10:41 a.m. revealed the North Hall medication room refrigerator had insulins in bags with condensation on outside and label was wet, and ink smeared on medication label. Flu vaccines were stored on the shelf of the refrigerator had ice buildup on the outside of the box that was frozen to the shelf. The DON stated it was her expectation that nurses would report any issues with the fridge verbally to the maintenance man. She stated nurses who use the fridge were responsible for reporting issues of ice buildup or condensation inside of the fridge when performing temperature checks. Observed refrigerator temperature log with no temperatures logged that were out of range and no area for nurses to report unusual refrigerator findings. The DON stated she had not been told of any issues with the refrigerator. She stated medications should not be stored in these conditions and should be discarded. The DON stated she expected for medications to not be left unattended on top of medication cart. She stated she and the ADON were responsible for monitoring nurses and CMAs to ensure they stored medications appropriately. She stated the effect of unsupervised medication being left on top of cart could give residents access to medications that they should not have access to which could harm them. During an interview on 02/08/2024 at 10:42 a.m., the RCN stated she expected medications to be stored so that residents did not have access to them and not on top of medication cart unsupervised. She stated this would give residents access to medications that were not ordered for them and did not know what led to this failure. The RCN stated that medications should not be stored in a wet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 32 of 43 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 02/09/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete environment and not have ice buildup outside of medication box. She stated she felt the failure was caused by nurse not reporting issue to maintenance. She stated ADON and DON were to monitor that medications were stored appropriately. Record review of the facility Medication Reconciliation revised on 10/25/2017 revealed: In addition, the pharmacist may collaborate with the facility and medical director on other aspects of pharmaceutical services including, but not limited to .Interacting with the quality assessment and assurance committee to develop procedures and evaluate pharmaceutical services including delivery and storage systems within the various locations of the facility in order to prevent. To the degree possible, loss or tampering with the medication supplies, and to define and monitor corrective actions for problems related to pharmaceutical services and medications . Event ID: Facility ID: 675982 If continuation sheet Page 33 of 43 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 02/09/2024 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 provide or obtain laboratory services to meet the needs of 1 of 2 (Resident #25) residents reviewed for lab services. Residents Affected - Some The facility failed to provide or obtain lab work as ordered by the physician for Resident #25. This failure could place the residents at risk of missed labs, depriving their physician of monitoring important levels. Findings included: Record review of Resident #25's face sheet dated 02/07/2024 revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included type 2 diabetes (disease that resulted in too much sugar in the blood). Record review of Resident #25's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 9 indicated moderately impaired and Section I (Active Diagnoses) included diabetes. Record review of Resident #25's comprehensive care plan reviewed on 02/07/2024 revealed the resident had diabetes with interventions to monitor/document for side effects and effectiveness of medications. Record review of Resident #25's physician orders dated 02/09/2024 revealed: hemoglobin A1C lab (lab used to monitor the average blood sugar levels over the last 3 months) was to be performed every 3 months, in December, March, June, and September. Insulin Glargine inject 55 units subcutaneously one time a day related to type 2 diabetes. Insulin Aspart inject 12 units subcutaneously with meals related to type 2 diabetes. Insulin Aspart inject as per sliding scale: if 200-250 = 2 units; 251-300 = 4 units; 301 and above give 6 units subcutaneously before meals and at bedtime for diabetes. Record review of Resident #25's electronic records on 02/08/2024 revealed the last hemoglobin A1C lab results performed on 07/25/2023. During an interview on 02/08/2024 at 11:17 a.m., LVN A stated she did set up for labs to be drawn at the hospital when she obtained one-time orders for them. She was unsure who was responsible for making sure that scheduled labs were scheduled to be drawn but felt the DON monitors that they are done. LVN A stated the effect of a resident not having hemoglobin A1C drawn as ordered would be nurse not knowing results and not being able to report range values to physician. During an interview on 02/08/2024 at 4:10 p.m., the ADON stated lab orders should be transcribed into electronic medical record system so that there was a prompt for nurse to order. She felt the failure occurred due to the order not being transcribed correctly and no prompt to the nurse meant the lab was missed. She did not know why the lab was entered incorrectly as she did not work at the facility when the lab was originally ordered, and that nurse no longer worked for the facility. Her expectation would be for the charge nurse to make sure labs were scheduled when they received prompts that lab work due. The ADON stated hemoglobin A1C not being performed as ordered could cause resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 34 of 43 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 02/09/2024 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to not be on correct dosage of medication to control diabetes. She stated the DON and her were who monitored that charge nurses perform labs as ordered. During an interview on 02/08/2024 at 4:11 p.m., the DON stated it was her expectation that labs be scheduled to be drawn as physician orders specify. She stated she was in the process of putting together a binder to help supplement with monitoring that labs are being done as ordered. She did not know what lead to the failure of this lab not being performed as ordered. She stated the effect could have on the resident would be that her chronic condition would not be managed appropriately. Review of facility policy titled Medication Reconciliation dated 11/14/16 revealed: The Mediation Regimen Review (MRR) is an important component of the overall management and monitoring of a resident's medication regimen .Unnecessary drug is defined as any drug used: In excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 35 of 43 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 02/09/2024 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. The facility failed to ensure food was not past expiration date. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 02/06/2024 from 9:30 AM to 10:00 AM of the kitchen revealed: Refrigerator #1 1. A container of Chorizo that was opened with a use by date of 01/24/2024. 2. A container of ranch dressing not in the original container date open on 01/26/24 not labeled with use by date. 3. An open container of sour cream with a use by date of 02/02/2024. 4. A plastic container with a lid that contained three 5-pound packages of ground hamburger meat dated 01/29/2024. 5. A plastic container with a lid that contained green chilies, out of original container, labeled with an open date of 01/26 6. A plastic container of sauerkraut, out of the original container, labeled with an open date of 01/29. 7. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 36 of 43 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 02/09/2024 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 - Some A plastic bag with zipper contained packages of hard-boiled eggs, out of the original container, labeled with an open date of 01/26/2024. 8. A plastic container with lid contained mushrooms, out of original package, labeled with an open date of 12/23/23. 9. A plastic container with lid contained black olives, out of original package, labeled with an open date of 11/23/23. Dry Storage 1. A plastic bowl with a lid contained instant potatoes with an open date of 01/19/24. 2. A plastic bag with a zipper contained an open package of frosting mix that was labeled with a use by date of 01/18/24. Refrigerator #2 1. A package of broccoli salad mix with a use by date of 01/27/24. During an interview on 02/06/2024 at 10:00 AM the DM stated items needed to be thrown out after their use by date. The DM stated items that were out of the original containers needed to be dated with an open date and a use by date. The DM stated items in the original package needed to be labeled with open date and should be discarded after a week. The DM stated the hamburger meat had been placed in the refrigerator to defrost and should have been disposed of after 3 days. The DM stated she was responsible to monitor staff. The DM stated the failure was she had a lot of new staff and was still in process of training of new staff . The DM stated the effect on residents could have been residents received spoiled food or food had become less flavorful or could have gotten sick. During an interview on 02/07/2024 at 10:30 AM the Dietitian stated her expectation was that items in fridge should be labeled with just open date if in original package and need a use by date if out of the original package. The Dietician stated that food should have been disposed of if it was past the use by date and the food should have been disposed of after it had been opened for seven days. The Dietician stated the effect on residents could have been the residents could have gotten ill, especially if residents had compromised health. The Dietician stated what led to failure was the DM having to train new staff. The Dietician stated the DM was supposed to monitor staff in kitchen, and she monitored on her with monthly visits. During an interview on 02/08/2024 at 5:00 PM the ADMN stated his expectation was that staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 37 of 43 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 02/09/2024 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 - Some followed the policy and that foods should have been discarded once items were past the use by date. The ADMN stated the DM was responsible to monitor . The ADMN stated the effect on residents could have been a negative effect on residents, they could get sick. The ADMN stated what led to failure was staff not following policy. Record review of policy titled, Food Storage and Supplies dated 2012 revealed: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies .Open packages of food are stored in closed containers with covers or in sealed bags, and dates as to when open. Record review of policy titled, Storage Refrigerators dated 2012 revealed: Food must be covered when stored, with a date label identifying what is in the container. Frozen food that has been thawed will be used within three days of thawing. According to the FDA (Food and Drug Administration) Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 02/09/24), FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; . (D) . after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; . (E) After handling soiled EQUIPMENT or UTENSILS; . (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 38 of 43 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 02/09/2024 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 3 of 12 meetings (11/23,12/2023, and 01/2024) reviewed for QAPI. Residents Affected - Some The facility did not ensure the MD, or a representative attended QAPI meetings on 11/23, 12/2023, and 01/2024. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets for 11/23, 12/2023, and 01/2024 indicated the MD or a representative did not sign in for the meetings. During an interview on 02/08/2024 at 1:45 PM the ADMN stated the Physician participated the monthly QAPI meetings by telephone and they did not have any documentation. He stated he could have the physician come into the facility to sign the logs. He stated the staff would sign their name on the QAPI list but did not place their titles. He stated the Medical Director should have signed once in the facility but would not always do so. During an interview on 02/08/2024 at 1:50 PM the ADO stated his expectation was that if the physician was not able to attend in person, but by phone, it should have been documented that he participated by phone. He stated the next time the physician was in the facility he would then be provided the notes and sign the sign in sheet at that time. The ADO stated if concerns were not being discussed and identified it could have led to a negative effect for residents as they cannot track and trend. He stated the ADMN was supposed to have monitored the QAPI meetings. The ADO stated the failure occurred with the leadership and the expectations were for the department heads to complete each section and sign the committee form when attending the QAPI meetings. Record review of form titled QAA Committee Information dated 11/23, 12/2023, and 01/2024 indicated the QAA Committee members signed their names with no titles and unable to recognize who had attended the meetings. Record Review of facility policy Quality Assurance Policy and Procedure dated 03/2021 and revised 09/2022 revealed: .2. Governance and Leadership The administrator will ensure that the QAPI plan is reviewed minimally monthly by the QAA committee. Revisions will be made to the plan ongoing, as the need arises, to reflect current practices within our organization. These revisions will be made and recorded in the minutes by the QAA committee. This involves leadership working with input from facility staff, as well as from residents and their families and/or representatives. The administration of the facility is responsible for ensuring the staff is given the time and equipment that is needed to make an effective QAPI program .The QAPI committee will be made up of the Administrator, DON, Medical Director, facility direct care staff as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 39 of 43 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 02/09/2024 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 0868 well as department heads. 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: 675982 If continuation sheet Page 40 of 43 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 02/09/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to conduct regular inspections of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 4 of 4 (Residents #9, #20, #25 and #45) residents reviewed for bed rails. The facility did not conduct regular inspections of bed rails, including Residents #9, #20, #25 and #45's beds. This failure could place residents who have bed rails at risk for injury related to poor maintenance of the bed rails. The findings included: Resident #9 Record review of Resident # 9's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with an original admission date of 07/10/2020 with diagnoses which included Heart failure, Kidney failure and high blood pressure. Record review of Resident #9's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS score of 15 (cognitively intact); Section GG (Functional Abilities) revealed Resident #9 needed partial assistance for transfers. During and observation and interview on 02/07/24 at 9:03 AM Resident #9 stated her bed rail was broken and it was hard for her to get out of bed because it was not stable. Resident #9 shook her bedrail and the bedrail appeared to be loose and unstable (moved back and forth with ease). Resident stated her bedrail was not attached good and was wobbly which made it hard for her to get out of her bed. Resident #20 Record review of Resident #20's face sheet dated 02/09/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's Disease (disease that destroys memory and other important mental functions), muscle weakness, and lack of coordination. Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS assessment revealed a score of 0 meaning severe cognitively impairment; Section GG (Functional Abilities) revealed Resident #20 was independent in rolling left to right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. During an observation on 02/06/2024 at 10:00 a.m., Resident #20's bed had quarter rails on both sides of bed. Resident #25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 41 of 43 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 02/09/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #25's face sheet dated 02/07/2024 revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), abnormalities of gait and mobility, lack of coordination, and right sided hemiplegia and hemiparesis following cerebral infarction (right sided weakness following a stroke). Residents Affected - Some Record review of Resident #25's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 9 indicated moderately impaired and Section GG (Functional Status) revealed Resident #25 needed supervision with rolling left and right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. During an observation and interview on 02/06/2024 at 10:01 a.m., Resident #25 had half rails present to bed. She stated rails help with bed mobility. Resident #45 Record review of Resident #45's face sheet dated 02/09/2024 revealed a [AGE] year-old male was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with diagnoses which included pain, abnormalities of gait and mobility, muscle weakness, and reduced mobility. Record review of Resident #45's quarterly MDS dated [DATE] Section C (Cognitive Patterns) BIMS assessment revealed a score of 11 meaning moderately impaired and Section GG (Functional Abilities) revealed Resident #13 needed partial to moderate assistance with rolling left to right; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. During an observation on 02/08/2024 at 2:05 PM revealed Resident #45 had bed rails on his bed. During an interview on 02/08/2024 at 2:15 PM the Maintenance Supervisor stated he inspected resident bed rails monthly for function and as needed when bed rails were reported broken. The Maintenance Supervisor stated he had received a work slip for Resident #9 bed rail on Monday (02/05/2024) but had not had time to fix the bed rail. The Maintenance Supervisor stated Resident's not having bedrails in working condition could have led to serious health hazard. During an interview on 02/08/24 at 2:45 PM the ADMN stated his expectation was that the Maintenance should have inspected bedrails monthly and if broken they should have been fixed within less than two hours. The ADMN stated there was no excuse to why Resident # 9's bed rails were not fixed or that the monthly checks were not completed. During an interview on 02/08/2024 at 4:45 PM the DON Stated her expectation was that bed rails on patients' beds would be sturdy and stable for support. Resident monitor nurses should be checking on these with the resident and if they see something broke, they should ask maintenance to fix affect safety issues not sturdy failure no one checked or followed up on. During an interview on 02/09/2024 at 11:00 AM the ADO stated the Maintenance Supervisor was only able to provide record for the bedrails being inspected for the month of December and could not provide any evidence for any additional checks being completed during previous year. The ADO stated the Maintenance Supervisor should have inspected bed rails at a minimum on a quarterly basis. The ADO did not have a reason for what led to the failure. The ADO stated bed rails that were not working (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 42 of 43 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 02/09/2024 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 0909 correctly could have led to residents being harmed. Level of Harm - Minimal harm or potential for actual harm Record review of the maintenance log for the past year revealed no evidence that inspections occurred more than one time during the previous year for inspections for repairs of any bed rails in the facility . Residents Affected - Some Record review of the facility policy titled, Bed Safety dated 2003 revealed: In an effort to reduce/prevent death/injuries from entrapment with hospital bedside rails, the director of nursery services (or designee) and safety director (or designee) shall: Inspect all hospital bed frames, bedside rails, and mattresses quarterly as part of our regular safety program to identify potential areas of possible entrapment . Ensure that bed side rails are properly installed using the manufacture instructions to ensure proper fit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675982 If continuation sheet Page 43 of 43