Inspection·November 26, 2024

F 0550 Observation on 11/24/24 at 1:38 PM revealed Resident #93 in her room with a meal of 2 slices of pizza. Level of Harm - Minimal harm or potential for actual harm In an interview on 11/24/24 at 1:17 PM, RN B stated Resident #93 did not get her tray because the staff had lost her meal ticket. Residents Affected - Few In an interview on 11/24/24 at 1:25 PM, Resident #93 said she sent her tray back because she did not like fish. In an interview on 11/24/24 at 1:38 pm Resident #93 said she was happy with her pizza. In an interview on 11/24/24 at 2:35 PM, RN A stated that she was responsible for ensuring people at the same table received their tickets. She stated that table mates should have waited less than a minute for their food. She stated she would have talked to the kitchen directly. She stated it could make the resident's feel neglected if they did not receive their food on-time. In an interview on 11/25/24 at 1:34 PM, the DM stated that residents should be served together and relied on dining room staff to communicate who had not received their trays yet. She stated it would make residents feel bad and frustrated if they had not received their meal with the others. In an interview on 11/26/2024 at 1:30 PM, the ADM stated all trays needed to be distributed within an hour of starting meal service. Resident 93's tray was late because they printed the wrong ticket, and it took too long to get it reprinted. Review of the facility's policy titled, Resident Rights- Dignity and Respect, dated 07/23 revealed, 1) the staff shall display respect for residents when speaking with caring for or talking about them as constant affirmation of their individually [NAME] and dignity as human beings. 2) residence individual preferences regarding things such as menus, clothing, religious activities, friendships, activity programs, and entertainment are elicited and respected by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident rights for personal privacy for 4 of 15 residents (Resident #23, Resident #52, Resident #78 and Resident #93) residents reviewed for personal privacy. Residents Affected - Some The facility failed to knock on Resident #23, Resident #52, Resident #78 and Resident #93's room when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy is being invaded or the facility is not their home. Findings included: Review of Resident #23 Face Sheet dated 11/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #23's diagnoses included dementia (memory, thinking, difficulty), morbid obesity, insomnia (difficulty sleeping), hypertension (high blood pressure), major depressive disorder, cognitive communication deficit (problems with communication), muscle wasting, heart failure, muscle weakness, gout (swollen arthritis), and need for assistance with personal care. Record review of Resident #23's Quarterly MDS assessment dated [DATE] revealed that Resident #23's BIMS score was 14 which means resident was cognitively intact. Review of Resident #52 Face Sheet dated 11/26/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52's diagnoses included heart disease, hyperlipidemia (high cholesterol), hypertension (high blood pressure), cognitive communication deficit (problems with communication), repeated falls, abnormalities of gait and mobility, unsteadiness on feet, muscle weakness, hyperthyroidism (excessive production of thyroid hormones), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), and age-related physical debility. Record review of Resident #52's Quarterly MDS dated [DATE] revealed that Resident #52's BIMS score was 12 which means resident was moderately cognitively impaired. Review of Resident #78 Face Sheet dated 11/26/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52's diagnoses included dementia (memory, thinking, difficulty), hypertension (high blood pressure), depression, difficulty walking, unsteadiness on feet, Parkinson's disease (a progressive disorder that affects the nervous system), Schizophrenia (mental disorder), cognitive communication deficit (problems with communication), muscle weakness, anemia (not enough healthy red blood cells), and anxiety disorder. Record review of Resident #78's Quarterly MDS dated [DATE] revealed that Resident #78's BIMS score was 15 which means resident was cognitively intact. Review of Resident #93 Face Sheet dated 11/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #93's diagnoses included cognitive communication deficit (problems with communication), repeated falls, abnormalities of gait and mobility, unsteadiness on feet, muscle weakness, major depressive disorder, insomnia, acute pain due to trauma, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Level of Harm - Minimal harm or potential for actual harm hypertension (high blood pressure), hyperlipidemia (high cholesterol and need for assistance with personal care. Record review of Resident #93's Quarterly MDS dated [DATE] revealed that Resident #93's BIMS score was 14 which means resident was cognitively intact. Residents Affected - Some Observation on the 100 hall on 11/24/2024 at 11:10 am revealed that LVN D walked into Resident #23, Resident #52 and Resident #78's room without knocking. Observation on the 300 hall on 11/24/2024 at 01:05 pm revealed that CNA E walked into Resident #93's room without knocking. An interview with Resident #23 on 11/24/2024 at 10:27am revealed that staff do not always knock on her door before entering. She said it did not bother her that staff do not knock. She said she would like staff to knock before entering her room, so she knows someone is coming in. An interview with Resident #78 on 11/24/2024 at 11:10am revealed that staff do not always knock on his door before entering. He said it bothered him at times when staff did not knock on his door. He said he would like staff to knock all the time. An interview with Resident #52 on 11/24/2024 at 11:12am revealed that staff do not always knock on his door before entering. He said it did not bother him that staff does not knock, but he said that he would like staff to knock because he might be changing or something. An interview with LVN D on 11/24/2024 at 2:29 pm revealed she had been trained on resident rights. She stated that staff were supposed to knock on the door before going into the room. She said if staff did not hear anything, they were supposed to knock again. She said staff are supposed to knock always before entering a resident's room even if their door is open. She said that some residents may not be familiar with staff and maybe uncomfortable if staff did not knock. She stated she should have knocked but did not know why she did not knock. An interview with CNA E on 11/26/2024 at 11:12 am revealed that she had been trained on resident rights. She stated that staff were supposed to knock on the resident's door and wait a bit or wait for the resident to tell them to come in. She said staff should even knock on the resident's door when their call light was on. She said residents may not like it if staff just walk in without knocking. She said it was just like someone being at home and not knocking before coming into your house. She said she did not know why she did not knock on the resident's door before entering. An interview with the ADM on 11/26/2024 at 11:26 am revealed he had been trained on resident rights. He stated staff were supposed to knock on the resident's door anytime they were entering a resident's room to get permission to enter. He said that if staff are not knocking the resident may feel like they were losing their privacy and being treated like a patient. He said if staff were not knocking it does not create a homelike environment for the resident. He stated staff may not have knocked due to urgency or being relaxed. An interview with the DON on 11/26/2024 at 11:49 am revealed she had been trained on resident rights. She stated that staff should knock before entering and see if it was okay for them to enter. She said staff should be knocking on the door any time they wanted to enter the resident's room. She said if staff did not knock on the door before entering, the resident may get upset or not like staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 just coming in. She said she did not know why staff were not knocking on the door. Level of Harm - Minimal harm or potential for actual harm Record Review of Resident Rights Policy dated 10/04/2016 revealed residents of the nursing facility had the right to a dignified existence and had the right to exercise their rights. The residents also have the right to personal privacy. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 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 - Few 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 residents received adequate supervision to prevent accidents for 1 of 4 residents (Resident #69) reviewed for accidents and supervision. The facility failed to ensure Resident #69 was supervised while eating ice chips according to physician orders. This failure placed resident at risk for choking or aspiration due to lack of supervision. Findings included: Record review of Resident #69's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Dysphagia (difficulty swallowing), flaccid hemiplegia (one side of the body being completely and permanently paralyzed), gastroesophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the esophagus) and gastrostomy status (feeding tube insertion). Record review of Resident #69's quarterly MDS assessment, dated 11/10/2024, reflected a BIMS of 07, indicating severe cognitive impairment. Section GG (Functional Abilities) reflected he was dependent on assistance for eating, (helper does all the effort, resident does none of the effort to complete the activity). Section K (Swallowing/Nutritional Status) reflected the resident did not have a swallowing disorder, received a mechanically altered diet, and had a feeding tube. Review of Resident #69's care plan, revised 11/08/2024, reflected he had a potential nutritional problem due to being fed through a tube and dysphagia. He was to follow the diet as ordered by the physician and have a mechanical soft texture and thin liquids. The goal was the resident would be free of aspiration. Review of Resident #69's physician order , dated 11/06/2024, reflected May have ice chips. Do not leave alone with patient or at bedside d/t risk of aspiration. Every 2 hours as needed for dry mouth. Review of Resident #69's swallow study dated 11/7/2024, reflected based on the swallow test, the following strategies are recommended: small bites/sips, feed slowly and carefully, alternate bites/sips, precautions during PO feeding: small bites/sips, cueing for strategies, allow extra time, minimize distractions. Patient is currently NPO and transitioning to oral feeds. SLP will be performing skilled trials to train strategies before advancement to meals. During an observation and interview on 11/25/2024 at 9:46 AM, Resident #69 was lying in bed after receiving care from LVN F. When the state surveyor asked him how everything was going, he whispered the word ice. It was observed that Resident #69 had a quarter cup of melted ice on his bedside table. LVN F re-entered Resident #69's room with a fresh cup of ice, sat it on Resident 69's bedside table and left the room. During an interview on 11/25/2204 at 2:00 PM, LVN F stated she was not aware Resident #69 had an active physician's order that stated resident was not to be left alone with ice chips. When asked how she would know if a resident was allowed to have certain food or drink items, she stated it would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 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 - Few listed in their chart on the computer. When asked what the risks of leaving an NPO resident alone with ice, could be, she stated aspiration pneumonia and choking. During an interview on 11/25/2024 at 2:05 PM, the MDSN stated that the physician order for supervision with ice was supposed to have been discontinued by the SLP after Resident #69's swallow study on 11/07/2024. During an interview on 11/25/2024 at 3:00 PM, the ADT revealed a swallow study was done on 11/07/2024 for Resident #69 and it had been determined he could be removed from NPO and put on mechanical soft diet. This meant that the ice chip order should have been discontinued in PCC. When asked what the dangers were of residents on an NPO diet order given ice without supervision, she stated that a resident could get aspiration pneumonia or choke. She stated all LVNs should be checking the computer for residents' orders. During an interview on 11/26/2024 at 1:40 PM, the DON was asked what the expectation was for uploading documents into PCC or making changes to care plans, physician's orders, she stated that within 24 hours of a new edit, those things should be uploaded, unless records have not been received. She stated the process for CNAs and other direct care staff to know if residents are allowed certain foods or drinks was to check the binder located in the dining room, check their diets in the system, and/or check with a nurse to see if the resident's diet needed to be changed. When asked what the risks of a resident being left alone with ice chips if they are said to be on an NPO diet, she stated there could be a risk of aspiration or choking. Review of the facility's Documentation and Charting Policy, dated reviewed 7/2022, reflected the following: It is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatments. 4. Nursing service personnel with a record of the physical and mental status of the resident. 5. Assistant in the development of a Plan of Care for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 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 provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administrating of all drugs and biologicals in accordance with currently accepted practices for 1 of 4 (Cart #1,) medication carts reviewed for pharmacy services in that: Medication Cart #1 for the 100 hall was left unattended with the keys in the lock and was not locked. This deficient practice could affect residents and result in a drug diversion causing an allergic reaction or a resident taking medication not prescribed for them due to medications not being properly secured. The findings were: Observation on 11/24/2024 at 10:37 am revealed that LVN D walked away from Cart #1 on the 100 hall and left the keys in the lock and the cart unlocked. Observation on 11/24/2024 at 11:04 a.m. of Medication Cart #1 for the 100 revealed it was not locked and had the keys hanging out the lock when LVN D went into a resident's room to administer medication. Observation on 11/24/2024 at 11:06 a.m. revealed LVN D walked away from Cart #1 and left the keys hanging in the lock and left unlocked when she went down the hall to a resident's room to check on her. The medications were not in sight of LVN D's view. An interview with LVN D on 11/24/2024 at 2:36 pm revealed that she had been trained on medication storage. She said that the medication cart was to always be locked. She also said that all staff were responsible for ensuring the medication carts were locked. She stated if the medication carts were left unlocked, someone could take the medications from it. She stated that she would have to take her cart with her everywhere because she does not recall leaving the keys in the cart and the cart unlocked. An interview with the ADM on 11/26/2024 at 11:30 pm revealed that he and staff had been trained on medication storage . He stated the medication carts were supposed to be locked if staff did not have a hundred percent visibility. He stated the nurses and medication aides were responsible for ensuring the medication carts were always locked. He said that if the carts were left unlocked, it could cause a medication diversion, a resident could come by and take the medications, and someone could use the medication for their personal gain. He said that he thought that LVN D may have thought she was close enough to the medication cart or she was not paying attention. An interview with the DON on 11/26/2024 at 11:52 am revealed she and staff had been trained on medication storage . She stated that the medication carts were supposed to be locked every time staff walk away from it. She stated the charge nurse or whoever was working the cart was responsible for ensuring that the cart was locked. She said if the staff walk away from the cart and leave it unlocked someone could open the cart and take the medications. She said her and the ADM were responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 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 ensuring the carts were locked. She said that she would walk around and take the keys if they were left in the cart. She said she did not know why LVN D left the cart unlocked three times. Record Review of Medication Administration: Medication and Treatment Cart Policy revised on May 2007 revealed do not leave the medication or treatment cart unlocked or unattended in the resident care area. The cart must remain in your line of sight when it is not locked. Event ID: Facility ID: 676095 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 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 observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen and one of one nourishment room and one of one activities room reviewed for sanitation. 1. The facility failed to properly label and date perishable foods. 2. The facility failed to ensure the nourishment room was properly cleaned and items were correctly labeled and dated. 3. The facility failed to ensure employees did not wear jewelry and had removed false nails to best food service standards. 4. The facility failed to ensure employees were practicing proper hand hygiene while cooking and serving foods. 5. The facility failed to ensure meat was properly thawed under cold running water. 6. The facility failed to ensure dishwasher temperature was within standard range for disinfection. 7. The facility failed to ensure the microwave, ice machine, and ice scoop holder were cleaned. 8. The facility failed to ensure the microwave in the nourishment room was cleaned. 9. The facility failed to ensure margarine was kept at the appropriate temperature outside of refrigeration. These failures could place residents who were served from the kitchen at risk for consuming hazardous expired food, developing foodborne illnesses, and a diminished quality of life. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 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 Findings included: Level of Harm - Minimal harm or potential for actual harm Observation in the kitchen walk-in refrigerator on 11/25/24 at 9:04 AM revealed the following items were undated. Residents Affected - Some A bag of bacon A bag of solid block cheese A container of peaches A container of applesauce A box of sandwich bread A bag of shredded lettuce that emitted a foul odor and looked wilted. Observation in the kitchen walk-in refrigerator on 11/25/24 at 09:04 AM the following expired items: A container labeled Italian pasta salad with the label 11/03/24. A large pan labeled orange Jello dated 11/12/24. A bottle of mayo labeled 10/07/24. A bag of raw sausage labeled 11/10/24. An opened container of whipped topping with a label of 11/11/24. Observation on 11/24/24 at 9:05 am a large container with ground beef thawing under hot running water in a sink next to dirty dishes. Observation on 11/24/24 at 9:05 am dented cans on the can holding cart with non-damaged cans. Observation on 11/24/24 at 9:07 am an employee's personal sized soda bottle inside the reach in refrigerator containing food for the next meal. Observation on 11/24/24 at 9:07 am the low temperature dishwasher temperature was at 110 degrees with a stem thermometer in the bottom of the dishwasher. Observation on 11/24/24 at 9:07 am a black slime substance inside the ice machine near the internal dispenser. Observation on 11/24/24 at 9:10 am a pink substance splattered inside the walls of the microwave in the kitchen. Observation on 11/24/24 at 9:11 am a brown liquid at the bottom of the holder for the ice machine scoop. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 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 Observation on 11/24/24 at 10:51 AM a pan with margarine sitting out on stove; not obtaining direct heat. The temperature was 114 F when measured by a stem thermometer by the dietary manager. Level of Harm - Minimal harm or potential for actual harm Observation in the nourishment room on 11/24/24 at 9:15 am revealed the following items: Residents Affected - Some Dirty dishes were in the sink with clean dishes and a used napkin. The microwave had a red substance splattered inside. The freezer had visible dirt on the bottom and contained ice cream that was unlabeled and undated. Personal cups without names were on top of the refrigerator. Observation in the refrigerator of the activities room on 11/24/24 at 9:30 am revealed the following items: Bins of drinks containing different sodas and hydration drinks unlabeled and undated. Popsicles in the freezer unlabeled or dated. Observation on 11/24/24 at 9:59 am revealed the following while the staff making pureed foods. The DM failed to wash her hands before assisting [NAME] J in removing the cover of the food processor. Cook J failed to wash her hands before starting her tasks. She donned gloves and did not change the gloves when she wiped her station or when she washed the food processor bowls and blades. Cook J failed to take the temperature of the meatloaf that had just finished cooking and used it for her meals. Cook J had long (around 2 inches) false nails and was wearing large hoop earrings before beginning purees. Observation on 11/24/24 at 12:13 pm revealed RN B touch his face while he yawned and then grab a plate holder and the meal slip. He did not sanitize his hands. Observation on 11/24/24 at 12:20 pm RN B scratch his back under his shirt, then touched a resident's tray, and failed to sanitize his hands . In an interview with [NAME] J on 11/24/24 at 2:17 pm, she stated that she was only supposed to wear small hoops and was allowed to keep her false nails if she had a scrub brush. She stated that she carries her own scrub brush for her nails. She stated that she needs to wash and sanitize her hands every time she walked away from her prep station, and she should have changed her gloves. She thought they had done a hand hygiene in-service about a month ago. She stated that she did not keep any left-over foods, any food needed to be thrown away after 10 days, and it was a team effort to clean out expired foods. In an interview with RN B on 11/24/24 at 2:28 pm, he stated that he started a month ago and only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 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 had hand hygiene training upon orientation. He had not received training from dietary or nursing staff on how to pass trays. He did not believe it was wrong to touch his face and then touch items on the resident's tray. He did believe cross contamination can happen while passing trays. He stated he was not responsible for ensuring residents receive their same trays. He was responsible for ensuring the accuracy of the trays. In an interview with the DM on 11/25/24 at 1:34 pm, she stated that their rules follow the Texas Food Establishment Rules (TFER). They did not follow a specific diet manual. She stated the cooks were allowed to have on small hoops and a plain wedding band. She stated the cook should not have had on long false nails. She did not believe there was nail brushes around. She stated that the employees are required to place personal foods in her office and no personal food or cups were allowed in the nourishment room or in the refrigerators. She stated nursing staff was responsible for cleaning out the nourishment room. She stated that the cook was responsible for cleaning the microwave, sweeping, and mopping. She stated she cleaned the ice machine is cleaned monthly and was unsure as to why it was still dirty. She stated that the dishwasher was out of temperature and the correct temperature should have been 120 degrees . She stated the margarine on the stove should have been at 145 degrees or changed every 3 hours. In an interview with the Dietitian on 11/25/2024 at 2:35 pm. she stated that she came that month and came every two weeks . She stated she recently did an in-service on labeling and dating and following alternative diet textures. She stated that they followed the TFER for their storage and handling policies. She stated that she did quality assurance rounds and tried to observe two meals at her last visit. She left notes with the dietary manager for recommended improvements. During an interview with the ADM on 11/26/24 at 2:35 pm, he stated that the dietary manager was responsible for the cleaning of the entire kitchen expired foods. The dietary manager was to follow the Texas Food Establishment Regulations for food service policies. He believed a hand hygiene in-service was done recently but did not remember the details. He stated the kitchen staff should have been wearing a hair and beard net, no long and loose clothing was allowed, but did not know the policy for jewelry or nails. Review of 2022 Food Code states: 2-201.16 States: (A) FOOD EMPLOYEES shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. (B) Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. 2-301.14 States: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (E) After handling soiled EQUIPMENT or UTENSILS. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 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 (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Level of Harm - Minimal harm or potential for actual harm (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD. Residents Affected - Some (H) Before donning gloves to initiate a task that involves working with FOOD; and 3-304.15 states: (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 3-501.13 states: Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (B) Completely submerged under running water (1) At a water temperature of 21C (70F) or below 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5°C (41°F) or less. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #46) reviewed for indwelling catheter care. Residents Affected - Few CNA G did not remove soiled gloves and conduct hand hygiene after cleansing Resident #46's perineal area, and cleansed the suprapubic catheter with a wipe x 2 during incontinent care. This failure could place residents at risk of the spread of diseases, a decreased quality of life, illness, and hospitalization. Findings included: Review of Resident #46's face sheet dated 11/26/24, reflected a [AGE] year-old male admitted to the facility on [DATE] with admitting diagnoses that include: Dementia, cognitive communication deficit, chronic obstructive pulmonary disease, bradycardia (slower than normal heart rate), chronic pain syndrome, hypertension (elevated blood pressure), obstructive and reflux uropathy (a blockage in one or both ureters), neuromuscular dysfunction of bladder (damage to nerves that control the bladder), and need for personal assistance. Review of Resident #46's MDS assessment dated [DATE] reflected a BIMS score of 8, indicating resident had moderate cognitive impairment. The MDS also reflected in Section H - Bowel and Bladder, Resident #46 had an indwelling catheter, and more specifically, a suprapubic catheter (a device that drains urine from the bladder through the belly button). Review of Resident #46's Care Plan dated 08/29/24 reflected he had a suprapubic foley catheter, and he returned from the hospital on [DATE] with a UTI related to the catheter. The goal was for Resident #46 to remain free from catheter-related trauma. There were no relevant interventions related to cleansing the catheter tubing reflected in the Care Plan. Observation on 11/25/24 at 03:34 PM of the suprapubic catheter care and peri-care for Resident #46 with CNA G revealed she did not remove soiled gloves or conduct hand hygiene after cleansing Resident #46's perineal area before moving to Resident #46's suprapubic catheter site. CNA G then cleansed the suprapubic catheter site with a wipe and the catheter tubing with a wipe x 2. Interview on 11/25/24 03:53 PM with CNA G who stated she had forgotten to conduct hand hygiene and change her gloves between conducting peri-care and suprapubic catheter care. CNA G then stated not conducting hand hygiene or a glove change when going from peri-care to conducting suprapubic catheter care, could lead to cross-contamination. CNA G stated she had received training on infection control, hand hygiene, and catheter care when she was hired, and could not recall when she had received training since then. Interview on 11/25/24 at 4:11 PM with LVN D revealed the removal of soiled gloves, conducting hand hygiene, and donning clean gloves when going from dirty to clean during resident care was to prevent cross-contamination. LVN D stated she received a recent in-servicing on infection control and hand hygiene, and had also been trained throughout the past year. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/26/24 at 11:01 AM with the DON revealed she currently was the ICPC for the facility, as the Infection Preventionist had left facility about one month ago. The DON stated her expectation was for staff to make sure they were following all the steps in preventing the spread of infection when providing care to the residents. The DON further stated she expected her staff to practice hand hygiene and glove changes when going from clean to dirty during all resident care. The DON stated it was important to practice good hand hygiene and follow infection control protocols to prevent residents from getting infections and cross-contamination, and she would be conducting in-services on these topics with her staff. Interview on 11/26/24 at 01:34 PM with the ADM revealed the DON was responsible for infection control oversight. The ADM stated they were in the process of hiring another ADON, as the ADON with ICPC qualifications had left the position recently. The ADM stated not conducting good hand hygiene when providing resident care, could ultimately lead to an infectious situation that could lead to bigger medical issues for the residents, as well as staff contaminating themselves and other staff members. The ADM further stated his expectations were for all staff to follow the appropriate protocols for infection control to reduce the spread of infection, and he stated the facility regularly conducted a skills fair and required every nurse and aide to participate and pass to provide resident care. Review of In-Service Training Report dated 09/13/24 on Sanitizing Hands - Hands need to be sanitized before patient care and when coming out of a room, was signed by CNA G. Review of policy Hand Hygiene dated revision 10.2022 revealed the following relevant information: 1. Wash hands with soap and water when hands are visibly soiled (e.g., blood, body fluids). 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non- antimicrobial) and water for the following situations: e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites), h. before moving from a contaminated body site to a clean body site during resident care, and m. after removing gloves. Review of policy IPCP Standard and Transmission-Based Precautions dated revision 10.2022 revealed: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Review of policy Infection Prevention and Control Program dated revision 10.2022 revealed: The infection prevention and control program are a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance management program. Further it revealed the goals were to: decrease the risk of infection to residents and personnel, recognize infection control practices while providing care, identify and correct problems related to infection control, ensure compliance with state and federal regulations related to infection control and promote individual residents' rights and wellbeing while trying to prevent and control the spread of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 If continuation sheet Page 16 of 16