Health inspection·March 7, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reach her call light. CNA A stated residents used the call light for getting help, letting the staff know when they were in pain or just in general need. CNA A stated Resident #68's call should have been down where she could reach it. Record review of Resident #49's face sheet, dated 03/07/2024, revealed the resident was originally admitted to the facility on [DATE] with diagnoses which included: pain in unspecified joint, unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other seizures, essential hypertension, and edema. Record review of Resident #49's Quarterly MDS assessment, dated 02/20/2024, revealed the resident's BIMS score was 5, which indicated severe cognitive impairment with resident dependent on staff with bed to chair transfers (the ability to transfer to and from a bed to a chair) helper does all of the effort and resident does none of the effort to complete the activity. Record review of Resident #49's care plan, revision date of 02/28/2024, and target date of 05/28/2024 revealed Resident #49 had a focus of The resident is risk for falls and an intervention of Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation and interview on 03/05/2024 at 11:13 a.m. revealed Resident #49 lying in bed with bed in lowest position, head of bed slightly elevated, call light going up between the headboard and the top of mattress, lying on the bed frame out of reach of resident. Resident #49 stated he did use his call light then began patting around on his bed beginning by feeling around on his pillow and then along side of him. Resident #49 then stated he could not find the call light. During an interview on 03/05/2024 at 11:16 a.m. LVN B stated where Resident #49's call light was located it could not be reached and pulled it from behind the mattress at the head of the bed and clipped it to the top of Resident #49's the blanket. LVN B then had him push the button to ensure it worked. LVN B stated Resident #49 was able to use the call light and would yell out at times when he needed assistance. LVN B further stated with call lights not being place where residents could reach the residents would not be able to call for help. During an interview on 03/07/2024 at 3:37 p.m. the DON stated residents used the call lights to call for help and should be within reach. The DON further stated it was the responsibility of the CNAs and nurses to ensure call lights were within reach of resident. The DON stated without the call light how would the staff know there was a need or an emergency. During an interview on 03/07/2024 at 4:10 p.m. the ADM stated the importance of the call light was for the resident to have access to request care. The ADM further stated the call lights should be always within reach when they were in their room. During an interview on 03/07/2024 at 5:00 p.m. the ADM stated the facility did not have a policy which addressed call lights specifically but was noted in the Quality Assurance Policy and Procedure as part of the QA team rounds and ADM provide with the policy. Record review of facility's Quality Assurance Policy and Procedure policy, revision date 09/2022, revealed under QA Team Rounds Criteria, Purpose: To utilize IDT (Interdisciplinary Team) for Survey Readiness each day of facility operation and to ensure a safe environment for residents and staff while maintaining open communications with resident, family, and all department employees. A mentoring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 2 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm process is recommended to ensure staff in all departments learn what is required by Federal Regulatory Guidelines and enhance their ability to provide safe and proper care. Section, Basic Things to look for: Section, Safety: Call light with-in reach and working. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 3 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess each resident quarterly using the Minimum Data Set form specified by the state and approved by CMS for 1 of 8 residents (Resident 58) reviewed for quarterly assessments. Residents Affected - Few Resident #58's quarterly MDS Assessment was not completed within 92 days of the previous MDS assessment. This failure could place residents at-risk of not having their assessments completed timely. The findings included: Record review of Resident #58's face sheet, dated 03/07/2024, revealed the resident was originally admitted to the facility on [DATE] and an admission date 03/29/2023 with diagnoses which included: encounter for other orthopedic aftercare, fracture of unspecified part of neck of right femur, history of falling, type 2 diabetes mellitus without complications, hyperlipidemia, essential hypertension, other chronic pain, major depressive disorder, presence of left artificial knee joint, ileus, and neuromuscular dysfunction of bladder. Record review of Resident #58's most recent MDS Assessment, dated 10/05/2023, reflected the due date of the next Quarterly MDS Assessment was to be completed on 01/05/2024. Further review reflected the Quarterly MDS Assessment due on 01/05/2024 had not been opened or started. During an interview on 03/07/2024 at 2:51 p.m. the MDS C stated she just must have missed the MDS and typically MDS assessments are done quarterly and annually. MDS C further stated by not doing the MDS assessments timely a change of condition could be missed, and it could affect payments. MDS C stated the facility follows the RAI schedule and manual when completing MDS assessments. MDS C further stated she was responsible for completing the MDS assessment for Resident #58 but, relied on the PCC program to notify her when a MDS assessments were due, yet for some reason the program was not showing Resident #58's MDS assessment being due, and it should have been done in January. MDS C stated she would add it then to be completed. During an interview on 03/07/2024 at 3:34 p.m. the DON stated typically the MDs coordinators are usually responsible for the schedule, opening, and completing of the MDS assessments. The DON who had only been with the facility for only a few weeks stated he believed MDS coordinators fell under the ADM of the facility. During an interview on 03/07/2024 at 4:12 p.m. the ADM stated the MDS coordinators were responsible for the MDS assessments and the MDS coordinators relied on the UDA (user defined assessment) in PCC. The ADM further stated when a resident was first admitted to the facility PCC will generate a UDA schedule. The ADM stated by not completing MDS assessments it could affect the billing process causing the facility to not be able to bill, and changes in care could also not be addressed which would affect the plan of care. Record review of the Centers for Medicare & Medicaid Services Long-Term Care Facility RAI (Resident Assessment Instrument) 3.0 User's Manual Version 1.18.11, dated October 2023, CH 2: Assessments for the RAI section 05, The Quarterly assessment is an OBRA non-comprehensive assessment for a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 4 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0638 that must be completed at least every 92 days following the previous OBRA assessment of any type. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 5 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 residents of 24 (Residents #43 and #63) residents reviewed for MDS assessments, in that: Residents Affected - Few 1. Facility failed to ensure Resident #43's quarterly MDS assessment with an ARD of 01/23/2024, assessment accurately reflected her bladder status. 2. Facility failed to ensure Resident #63's annual MDS assessment with an ARD of 02/20/2024, accurately reflected her oxygen therapy and her mechanical soft diet. These deficient practices could place residents at risk of inadequate care. The findings included: 1. Record review of Resident #43's electronic face sheet, dated 03/06/2024, reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: unspecified sequelae of cerebral infarction (unspecified symptoms and signs involving cognitive functions following cerebral infarction (area of necrotic tissue in brain following lack of blood supply), diabetes mellitus (inadequate control of blood levels of glucose), anemia (a condition that develops when blood produces a lower-than-normal amount of healthy blood cells), schizophrenia (a serious mental disorder in which people interpret reality abnormally) and retention of urine (not able to empty the urine from the bladder and the urine may back up into the kidneys). Record review of Resident #43's quarterly MDS assessment with an ARD of 01/23/2024 reflected she scored 5/15 on her BIMS which signified she was moderately cognitively impaired. Review of Section H Bladder and Bowel reflected Resident #43 had an indwelling urinary catheter. However, she was coded to be always incontinent of bladder when the code needed to reflect Not rated, resident had a catheter (indwelling, condom) urinary ostomy, or no urine output for the entire 7 days. Record review of Resident 43's comprehensive care plan revised date 05/25/21 reflected Focus, resident has a foley Catheter: Neurogenic bladder r/t CVA. Observation on 03/06/2024 at 2:30 pm of Resident #43 in her room in bed while CNA I performed urinary catheter care for Resident #43. During an interview on 03/07/2024 at 2:45 p.m. the MDS C stated Resident #43's quarterly MDS assessment dated [DATE], Section H Bowel and Bladder, was coded inaccurately. The MDS C stated the code needed to be not rated instead of always incontinent of bladder because Resident #43 had an indwelling urinary catheter. The MDS C stated the wrong code could lead to wrong information for the resident's care plan. During an interview on 03/07/2024 at 3:30 p.m. the DON stated the MDS accuracy was important because it provided information for the resident's care plan, and care for the resident might be missed or inaccurately communicated. During an interview on 03/07/2024 at 4:10 p.m. the ADM stated the MDS coordinators were responsible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 6 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for the MDS assessments and the MDS coordinators needed to use their resources to ensure the MDS's are accurate. She stated she was accountable for the MDS coordinators. 2. Record review of Resident #63's face sheet, dated 03/04/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: acute diastolic congestive heart failure (damage to the heart and symptoms come on suddenly, often sudden difficulty breathing and fatigue), zoster (a viral infection that occurs with reactivation of the varicella-zoster virus, usually results in a painful but self-limited dermatological rash) without complications, sepsis (severe infection) due to Methicillin Resistant Staphylococcus Aureus (staph infection that has become immune to many types of antibiotics), end state renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to dialysis or a kidney transplant) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #63's Annual MDS, with an ARD of 02/20/2024 reflected she scored 11/15 on her BIMS which signified she was moderately cognitively impaired. Review of Section KSwallowing/Nutritional Status reflected she was coded to be on a therapeutic diet, not mechanically altered. Review of Section O - Special Treatments and Programs reflected she was not coded to be on oxygen therapy while a resident. Record review of Resident #63's comprehensive care plan revised date 02/28/2024 reflected Focus, resident has oxygen therapy and Focus, diet/Interventions/Tasks, serve diet and snacks as ordered. Record review of Resident #63's Active Orders as of: 03/04/2024 reflected Regular diet, Mechanical Soft Texture, Regular consistency, Limit potatoes, tomatoes, bananas and oranges, start date 02/16/2024, May use oxygen @ 1-2 l/m via nasal cannula every shift to maintain oxygen saturation% above 92%, start date 02/16/2024. Record review of Resident #63's oxygen saturations since her readmission on [DATE] revealed she had oxygen saturations taken at least once a shift and they were within normal range and reflected she was on oxygen via nasal cannula. Observation on 03/04/2024 at 10:30 AM revealed Resident #63 lying in bed, oxygen infusing at 3 L/min via NC. During an interview on 03/04/2024 at 10:40 AM with Resident #63, she stated she was always on oxygen at the facility. Observation on 03/06/2024 at 1:00 PM of Resident #63, in her room with her lunch tray revealed she was brought a regular diet. Her tray consisted of flat chicken breast patty, mixed vegetables, and a roll. Record review on 03/06/2024 at 1:00 PM of Resident #63's meal tray card reflected Regular diet, Mechanical Soft Texture, Regular consistency, Limit potatoes, tomatoes, bananas and oranges. Interview on 03/06/2024 at 1:15 PM with CNA J, who took care of Resident #63, she stated Resident #63 was always on oxygen, and received a regular food tray which was checked by the nurse and dietary staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 7 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/07/2024 at 2:45 p.m. the MDS C stated Resident #63's annual MDS assessment with an ARD of 02/20/2024, Section K- Swallowing/Nutritional Status, was coded inaccurately. The MDS C stated the codes needed to reflect a mechanically altered diet, and not reflect a therapeutic. The MDS C stated the wrong code could lead to wrong information for the resident's care plan. During an interview on 03/07/2024 at 3:30 p.m. the DON stated the MDS accuracy was important because it provided information for the resident's care plan, and care for the resident might be missed or inaccurately communicated. During an interview on 03/07/2024 at 4:10 p.m. the ADM stated the MDS coordinators were responsible for the MDS assessments and the MDS coordinators needed to use their resources to ensure the MDS's are accurate. The ADM stated she was accountable for the MDS coordinators. During an interview on 03/07/2024 at 4:15 p.m. the RNC stated the facility did not have a policy for MDS accuracy but followed the RAI Manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 8 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 Residents (Residents #24, #43, and #63) of 16 residents reviewed for care plans, in that: 1.Resident #24's comprehensive care plan revised dated 01/24/2024 did not reflect she was incontinent of bowel. 2.Resident #43's comprehensive care plan revised dated 05/25/2021 did not reflect she was incontinent of bowel. 3. Resident #63's comprehensive care plan did not reflect that her diet was regular, mechanical soft texture, limit oranges, bananas, potatoes, and tomatoes which was ordered on 02/16/2024. The care plan inaccurately reflected she was on a other than regular diet. These deficient practices could place residents at risk of not receiving proper care and services. The findings included: 1. Record review of Resident #24's electronic face sheet dated 03/05/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Nondisplaced type II dens fracture of third thoracic vertebra (break in part of the cervical spine), permanent atrial fibrillation (irregular heart rhythm), chronic diastolic congestive heart failure (the lower left chamber of the heart is not able to fill properly with blood during the diastolic phase, reducing the amount of blood pumped out to the body) and trigeminal neuralgia (type of chronic pain disorder that involves sudden attacks of severe facial pain). Record review of Resident #24's admission MDS assessment dated [DATE] reflected she scored 11/15 on her BIMS which signified she was moderately cognitively impaired. She required total assistance with her ADL's. She was always incontinent of bowel and bladder. Record review of Resident #24's comprehensive person-centered care plan revised date 01/24/2024, Focus, resident has bladder incontinence. Bowel incontinence was not reflected in the care plan. Observation on 03/04/2024 at 1:00 PM of Resident #24 revealed she was lying in bed with a hospital gown on and was assisted with her lunch. Interview on 03/06/2024 at 1:15 PM with CNA J, who took care of Resident #24, she stated Resident #24 was always incontinent of bowel and bladder. During an interview on 03/07/2024 at 2:45 p.m. the MDS C and D, they both stated Resident #24's comprehensive person-centered care plan needed to reflect she was incontinent of bowel. MDS C stated the care plan needed to be accurate to provide the resident's required and preferred care and the wrong care could be provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 9 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 During an interview on 03/07/2024 at 3:30 p.m. the DON stated the care plan accuracy was important because it provided information for the resident's care and care for the resident might be missed or inaccurately communicated. 2. Record review of Resident #43's electronic face sheet, dated 03/06/2024, reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: unspecified sequelae of cerebral infarction (unspecified symptoms and signs involving cognitive functions following cerebral infarction (area of necrotic tissue in brain following lack of blood supply), diabetes mellitus (inadequate control of blood levels of glucose), anemia (a condition that develops when blood produces a lower-than-normal amount of healthy blood cells), schizophrenia (a serious mental disorder in which people interpret reality abnormally) and retention of urine (not able to empty the urine from the bladder and the urine may back up into the kidneys). Record review of Resident #43's quarterly MDS assessment with an ARD of 01/23/2024 reflected she scored 5/15 on her BIMS which signified she was moderately cognitively impaired. Review of Section H Bladder and Bowel reflected Resident #43 had an indwelling urinary catheter. She was coded to be always incontinent of bowel. Record review of Resident 43's comprehensive care plan revised date 05/25/21 reflected Focus, resident has a foley Catheter: Neurogenic bladder r/t CVA. The care plan did not address her bowel incontinence. Observation on 03/06/2024 at 2:30 pm of Resident #43 in her room in bed while CNA I performed incontinent care for a bowel movement. Interview on 03/07/2024 at 3:00 PM with C NA I, who took care of Resident #43, he stated Resident #43 was always incontinent of bowel and bladder. During an interview on 03/07/2024 at 2:45 p.m. the MDS C and D, they both stated Resident #43's comprehensive person-centered care plan needed to reflect she was incontinent of bowel. MDS C stated the care plan needed to be accurate to provide the resident's required and preferred care and the wrong care could be provided. During an interview on 03/07/2024 at 3:30 p.m. the DON stated the care plan accuracy was important because it provided information for the resident's care and care for the resident might be missed or inaccurately communicated. 3. Record review of Resident #63's face sheet, dated 03/04/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: acute diastolic congestive heart failure (damage to the heart and symptoms come on suddenly, often sudden difficulty breathing and fatigue), zoster (a viral infection that occurs with reactivation of the varicella-zoster virus, usually results in a painful but self-limited dermatological rash) without complications, sepsis (severe infection) due to Methicillin Resistant Staphylococcus Aureus (staph infection that has become immune to many types of antibiotics), end state renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to dialysis or a kidney transplant) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #63's Annual MDS, with an ARD of 02/20/2024 reflected she scored 11/15 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 10 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 her BIMS which signified she was moderately cognitively impaired. Review of Section KSwallowing/Nutritional Status reflected she was coded to be on a therapeutic diet, not mechanically altered. Record review of Resident #63's comprehensive care plan revised date 02/28/2024 reflected Focus, resident has oxygen therapy and Focus, resident has a diet order other than regular, Interventions/Tasks, the resident has a low concentrated sweets diet, resident has a no salt on tray diet. The care plan did not reflect the prescribed diet or limitations on tomatoes,' potatoes, bananas, and oranges. Record review of Resident #63's Active Orders as of: 03/04/2024 reflected Regular diet, Mechanical Soft Texture, Regular consistency, Limit potatoes, tomatoes, bananas and oranges, start date 02/16/2024. Observation on 03/06/2024 at 1:00 PM of Resident #63, in her room with her lunch tray revealed she was brought a regular diet, regular texture. Her tray consisted of flat chicken breast patty, mixed vegetables, and a roll. Record review on 03/06/2024 at 1:00 PM of Resident #63's meal tray card reflected Regular diet, Mechanical Soft Texture, Regular consistency, Limit potatoes, tomatoes, bananas and oranges. During an interview on 03/06/2024 at 1:05 PM with Resident #63, she stated she was on a regular diet. She stated the staff brought her regular food. 03/06/2024 at 1:10 PM, meal ticket was shown to the DON who was outside of Resident #63's room. The DON stated, Resident #63 was brought a regular diet tray instead of mechanical soft, and he would investigate the matter. Interview on 03/06/2024 at 1:15 PM with CNA J, who took care of Resident #63, she stated Resident #63 received a regular food tray which was checked by the nurse and dietary staff. During an interview on 03/07/2024 at 2:45 p.m. the MDS C and D, they both stated Resident #63's comprehensive person-centered care plan needed to reflect her correct diet and any special limitations or restriction. MDS C stated the care plan needed to be accurate to provide the resident's required and preferred care and the wrong food and nutrition could be provided which could result in too much potassium for a resident with kidney problems. During an interview on 03/07/2024 at 3:30 p.m. the DON stated the care plan accuracy was important because it provided information for the resident's care and care for the resident might be missed or inaccurately communicated. Record review of the facility policy and procedure titled Comprehensive Care Planning (undated) reflected 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 that are identified in the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 11 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 - Few 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 observations, interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 residents (Residents #45 and #57) of 24 residents reviewed for comprehensive care plans, in that: 1.Resident #45's comprehensive care plan revised date 02/11/2024 was not updated to reflect he no longer had an indwelling urinary catheter which was removed on October of 2023. 2. Resident #57's comprehensive care plan revised date 04/05/2023 was not updated to reflect his MASD which was noted in his quarterly MDS assessment with an ARD of 12/24/2023. These deficient practices place residents at risk of missed or miscommunicated care. The findings included: 1. Record review of Resident #45's electronic face sheet dated 03/05/2024 reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: cellulitis of the right upper limb (a common bacterial skin infection causing inflammation), acute kidney failure (a sudden episode of kidney failure or damage that happens within a few hours or days), type 2 diabetes mellitus (cells in muscle, fat and the liver become resistant to insulin and do not take in enough sugar), dysphasia (difficulty or discomfort in swallowing) and spastic hemiplegia affecting right dominant side (tightness and involuntary contractions in the limbs and extremities of one side of the body). Record review of Resident #45's quarterly MDS assessment dated [DATE] reflected he scored 5/15 on his BIMS which signified he was moderately cognitively impaired. Review of Section H-Bladder and Bowel reflected he did not have an indwelling catheter and he was always incontinent of bladder. Record review of Resident #45's comprehensive person-centered care plan revised 02/11/2024 reflected Focus, resident has an indwelling catheter. Observation on 03/04/2024 at 11:30 AM revealed Resident #45 lying on his bed. He did not have an indwelling urinary catheter. Observation on 03/07/2024 at 12:01 PM of Resident #45 revealed he was lying on his bed. He did not have an indwelling urinary catheter. During an interview on 03/07/2024 at 12:05 PM, Resident #45 stated he had the urinary catheter removed in October of 2023. Interview on 03/07/2024 at 3:00 PM with CNA I, who took care of Resident #45, he stated Resident #45 was always incontinent of bladder and he could not remember the resident having an indwelling urinary catheter. During an interview on 03/07/2024 at 2:45 p.m. the MDS C and D, they both stated Resident #45's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 12 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 - Few comprehensive person-centered care plan needed to be updated to reflect he no longer had an indwelling urinary catheter. MDS C stated the care plan needed to be accurate to provide the resident's required and preferred care and the wrong care could be provided. During an interview on 03/07/2024 at 3:30 p.m. the DON stated the care plan update was important because it provided information for the resident's care and care for the resident might be missed or inaccurately communicated. 2. Record review of Resident #57's electronic face sheet dated 03/05/2024 reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: unspecified protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), periprosthetic fracture around internal prosthetic left hip joint (fracture that occurs around an artificial body part), and atherosclerosis heart disease (a common condition that develops when plaque builds up inside the arteries). Record review of Resident #57's quarterly MDS assessment with an ARD of 12/24/2023 reflected he scored 10/15 on his BIMS which signified he was moderately cognitively impaired. He required a moderate amount of assistance for ADL's. He had MASD and received ointment to his skin for the affected area. Record review of Resident #57's comprehensive person-centered care plan revised date 04/05/2023 reflected Focus, resident has a potential for pressure ulcer development. Record review of Resident #57's Active Orders as of: 03/06/2024 reflected Wound Care: MASD to the bilateral R buttocks, peri. area: Clean with wound cleanser, pat dry with 4x4 gauze, apply Zinc Oxide, LOTA. every 12 hours as needed for MASD Active 12/28/2023. Record review of Resident #57's TAR dated 03/01/2024 - 03/31/2024 reflected he received wound are to his MASD bilateral right buttocks, peri area: Clean with wound cleanser, pat dry with 4X4 gauze, apply Zinc Oxide, LOTA, twice a day. During an interview on 03/04/2024 at 10:30 AM, Resident #57 stated he had ointment applied to a sore area on his bottom. Interview on 03/05/2024 at 1:55 PM with the Treatment Nurse, she stated Resident #57 had MASD on his right buttock. Interview on 03/06/2024 at 1:15 PM with C NA J, who took care of Resident #57, she stated Resident #57 had skin issues on his right buttock. During an interview on 03/07/2024 at 2:45 p.m. the MDS C and D, they both stated Resident #57's comprehensive person-centered care plan needed to be updated to reflect his MASD. MDS C stated the care plan needed to be accurate to provide the resident's required and preferred care. During an interview on 03/07/2024 at 3:30 p.m. the DON stated the care plan updated for accuracy was important because it provided information for the resident's care and care for the resident might be missed or inaccurately communicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 13 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 Record review of the facility policy and procedure titled Comprehensive Care Planning (undated) reflected 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, preferences and needs of the resident and in response to current interventions. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 14 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 - Few 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 observation, interviews and record reviews, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 resident (#78) of 1 reviewed for enteral care. LVN K failed to check the placement of Resident #78's placement of the tube by aspiration of contents, did not flush with 5-10 ml of water between the two medications he administered and did not stop the continuous feeding for 30 minutes prior to medications being administered on 03/05/2024 These deficient practices could place residents at risk for aspiration pneumonia, bloating discomfort and malabsorption of medications administered. The findings included: Record review of Resident #78's electronic face sheet dated 03/06/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Encounter for attention to gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach) (used for appointments where the primary purpose is the care and management of the gastrostomy), atrial fibrillation (an irregular and often very rapid heart rhythm), aphasia (a disorder that affects how you communicate), and unspecified severe protein-calorie malnutrition (a disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food). Record review of Resident #78's admission MDS assessment dated [DATE] reflected she scored 8 out of 15 on her BIMS which signified she was moderately cognitively impaired. She was dependent for assistance with ADLs and she received tube feedings. Record review of Resident #78's comprehensive person-centered care plan revised date 02/26/2024 reflected Focus, Isosource (a calorie dense nutrition feeding) 1.5 per pump at 60ml/hr.down at 11:00 AM. Up at 1:00 PM. Observation on 03/05/2024 at 04:36 PM of LVN K as he administered Resident #78's, Midodrine HCL (used to treat low blood pressure) 10mg via PEG tube and 1 Tylenol (relieves mild to moderate pain) tablets 325mg via PEG tube revealed he did not shut the feeding pump off for 30 minutes prior to the medication administration. He paused the pump and took a piston syringe and with his stethoscope injected air and listened for air in the stomach for placement. LVN K did not aspirate for stomach contents. He administered the Tylenol diluted with water, and then administered the Midodrine HCL diluted with water. He did not use 5-10 ml of water to flush between the medications . During an interview on 03/07/2024 at 2:30 PM, LVN K stated he was not aware of the facility policy and procedure on enteral medication administration. He stated he was trained on it but had forgotten. He stated it was important to shut down the pump for 30 mins, and then administer the medications in case the medications were incompatible with the feeding, it could make the resident nauseated or cause pain. He stated he needed to aspirate for stomach contents instead of listening for air because more evidence has shown it was more accurate for tube placement. He stated he forgot to flush (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 15 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 between the medications, and that could cause stomach upset for the resident. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/07/2024 at 3:37 PM, the DON stated the facility policy and procedure reflected LVN K needed to aspirate for stomach contents for tube placement, stop the feeding pump a half hour prior to administering the medications and he needed to flush between the medications. He stated the resident could experience untoward effects such as nausea or bloating. Residents Affected - Few Record review of the facility Nurse Proficiency Audit dated 01/18/2024 reflected LVN K had training and was checked off as satisfactory for G-tube (Gastrostomy Tube) administration of medication. Record review of the facility policy and procedure titled Enteral Medication Administration revised 01/25/2013 reflected Check the placement of the tube by aspiration of contents .administer one medication at a time with a flush of 5-10 ml water between each medication .continuous tube feeing must be stopped 30 minutes prior to medications being administered. Consult the pharmacy or drug reference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 16 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 who need respiratory care were provided such care, consistent with professional standards of practice for 2 of residents (Resident #63 and #190) reviewed for respiratory care. Residents Affected - Few 1. Facility failed to ensure Resident #63's oxygen was administered at the prescribed rate on 03/04/2024 and 03/05/2024. 2. Facility failed to ensure Resident #190 who used oxygen had physician orders for oxygen administration. This facility failure could result in residents receiving inadequate treatment. Findings included: 1. Record review of Resident #63's face sheet dated 03/04/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: acute diastolic congestive heart failure (damage to the heart and symptoms come on suddenly, often sudden difficulty breathing and fatigue), zoster (a viral infection that occurs with reactivation of the varicella-zoster virus, usually results in a painful but self-limited dermatological rash) without complications, sepsis (severe infection) due to Methicillin Resistant Staphylococcus Aureus (staph infection that has become immune to many types of antibiotics), end state renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to dialysis or a kidney transplant) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #63's Annual MDS, with an ARD of 02/20/2024 reflected she scored 11/15 on her BIMS which signified she was moderately cognitively impaired. Review of Section O - Special Treatments and Programs reflected she was not coded to be on oxygen therapy while a resident which was inaccurate. Record review of Resident #63's comprehensive care plan revised date 02/28/2024 reflected Focus, resident has oxygen therapy. Record review of Resident #63's Active Orders as of: 03/04/2024 reflected, May use oxygen @ 1-2 l/m via nasal cannula every shift to maintain oxygen saturation% above 92%, start date 02/16/2024. Record review of Resident #63's oxygen saturations since her readmission on [DATE] revealed she had oxygen saturations taken at least once a shift and they were within normal range and reflected she was on oxygen via nasal cannula. Observation on 03/04/2024 at 10:30 AM revealed Resident #63 lying in bed, oxygen infusing at 3 L/min via NC. During an interview on 03/04/2024 at 10:40 AM with Resident #63, she stated she was always on oxygen at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 17 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 03/06/2024 at 07:40 AM of Resident #63, in her room revealed Resident #63 lying in bed, oxygen infusing at 3L/min. During an observation and interview on 03/06/2024 at 07:45 AM, RN L stated she was the charge nurse on 03/04/2024 and she did not check Resident #63's oxygen rate. She stated it was important to check the rate to insure it infused at the prescribed dose to prevent respiratory distress. During an interview on 03/07/2024 at 3:37 PM, the DON stated the nurses needed to check the oxygen rates on the concentrators. He stated too much oxygen or too little oxygen could cause respiratory problems. Record review of RN L's Nurse Proficiency Audit dated 01-18-2024 reflected she was checked off satisfactory for oxygen administration/maintenance. 2. Record review of Resident #190's face sheet, dated 03/05/2024, revealed Resident #190 was admitted on [DATE] with diagnoses which included: chronic obstructive pulmonary disease, acute respiratory failure, unspecified whether with hypoxia or hypercapnia, and unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Record review of Resident #190's Medicare Part A 5-day MDS assessment, dated 02/21/2024, revealed Resident #190's BIMS score was 12 for moderate cognitive impairment with section O Special Treatments, Procedures and Programs of the MDS noting Resident #190 received oxygen therapy while a resident. Record review of Resident #190's care plan with an initiated date of 02/20/2024 and a targeted date 05/20/2024, revealed Resident #190 had a Focus: The resident has Oxygen Therapy and Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. Record review of Resident #190's physician order summary report, dated, 03/05/2024, revealed no orders for Resident #190's oxygen administration. Observation and interview on 03/04/2024 at 11:26 a.m. revealed Resident #190 in his room with oxygen concentrator running and Resident #190 placing his nasal canula in his nose while sitting in the wheelchair. Resident #190 stating staff change his tubing for his oxygen regularly and he wears it daily. Observation on 03/05/2024 at 3:30 p.m. revealed Resident #190 wheeling in the hallway with portable oxygen to back of wheelchair and wearing his nasal canula. Further observation revealed the portable oxygen tank set to 2 liters. During an interview on 03/06/2024 at 11:23 a.m. LVN B stated Resident #190 used the oxygen for SOB and believed he had a diagnosis of COPD. LVN B after reviewing physician's orders in PCC stated Resident #190 did not have an order for his oxygen. LVN B stated orders purpose was to tell the staff to take oxygen saturations and what the oxygen administration should have been. LVN B further stated typically it was the standard order of 2 to 4 liters and the order would inform the staff of the range his oxygen should be set to. LVN B stated Resident #190 wears his oxygen all the time except for when he was in his room doing little things. LVN B stated Resident #190 did need help at times putting the nasal canula on and would tell staff when he was short of breath stating he was usually set at 2 liters. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 18 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 03/07/2024 at 3:40 p.m. the DON stated the nurses are responsible getting the physician orders for oxygen and the ADON was to ensure the orders were accurate. The DON further stated the facility couldn't just give oxygen with an order and depending on the resident's diagnosis giving oxygen could cause respiratory issues. Record review of the facility's policy titled Oxygen Administration, revised February 13, 2007, revealed Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or l/min and method of administration is ordered by the physician ., Goals #1 The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen., Procedure #1. Become familiar with the type of oxygen administration, medical diagnosis and reason for oxygen, intermittent or continuous use of oxygen, amount to be delivered. Event ID: Facility ID: 676121 If continuation sheet Page 19 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 - Few 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, interviews, and record reviews the facility failed to ensure the safe and secure storage of drugs and biologicals for 1 of 8 medication carts observed for mediation storage in that: On 03/06/2024 a medication cart was left unlocked and unattended beside the nurse's station at the end of 800 hall. This deficient practice could affect residents with medications and could result in missing or misuse of drugs by unauthorized personnel. Findings include: Observation on 03/06/2024 at 5:50 PM revealed a medication cart by the nurse's station at the end of 800 hall was unattended and unlocked for approximately 5 minutes. There were no staff observed at the nurse's station or the surrounding area, only residents. Interview with MA H on 03/06/2024 at 5:56 PM revealed she went into the dinning room to give medications to a resident and forgot to lock the medication cart. MA H stated that the policy was that all medications are put away and the medication cart and computer are to be locked before leaving the medication cart unattended. MA H stated it was important to lock the medications up prior to leaving the cart to ensure the medications are secure and out of reach of the residents. MA H stated if a resident was to get into the medication cart, they could take medications that did not belong to them causing bad things including medication interactions and overdosing. Interview with DON on 03/07/2024 at 2:17 PM revealed his expectations are that medication staff are locking the medication carts. DON stated that the facility has a policy that states medication carts are to be locked when not in use. DON stated it was important to lock the medication cart to ensure no one other than the medication staff has access to the medications, also ensuring residents don't get ahold of medications not prescribed to them. Review of the facility policy titled Medication Carts dated 2003 revealed 2. The carts are to be locked when not in use or under the direct supervision of the designated nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 20 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to prepare food in a form to meet individual needs for 1 of 24 residents (Resident #63) observed for dietary needs. Facility failed to serve Resident #63 on 03/06/2024 the prescribed diet of regular, mechanical soft texture and served her regular with regular texture. This deficient practice places residents at risk for choking or malnutrition. The findings included: Record review of Resident #63's face sheet dated 03/04/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: acute diastolic congestive heart failure (damage to the heart and symptoms come on suddenly, often sudden difficulty breathing and fatigue), zoster (a viral infection that occurs with reactivation of the varicella-zoster virus, usually results in a painful but self-limited dermatological rash) without complications, sepsis (severe infection) due to Methicillin Resistant Staphylococcus Aureus (staph infection that has become immune to many types of antibiotics), end state renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to dialysis or a kidney transplant) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #63's Annual MDS, with an ARD of 02/20/2024 reflected she scored 11 out of 15 on her BIMS which signified she was moderately cognitively impaired. Review of Section KSwallowing/Nutritional Status reflected she was coded to be on a therapeutic diet, not mechanically altered. Record review of Resident #63's comprehensive care plan revised date 02/28/2024 reflected Focus, diet/Interventions/Tasks, serve diet and snacks as ordered. Record review of Resident #63's Active Orders as of: 03/04/2024 reflected Regular diet, Mechanical Soft Texture, Regular consistency, Limit potatoes, tomatoes, bananas and oranges, start date 02/16/2024 . Observation on 03/06/2024 at 1:00 PM of Resident #63, in her room with her lunch tray revealed she was brought a regular diet. Her tray consisted of flat chicken breast patty, mixed vegetables, and a roll. Record review on 03/06/2024 at 1:00 PM of Resident #63's meal tray card reflected Regular diet, Mechanical Soft Texture, Regular consistency, Limit potatoes, tomatoes, bananas and oranges. During an interview on 03/06/2024 at 1:05 PM with Resident #63, she stated she was on a regular diet. Resident #63 stated the staff always brought her regular food. 03/06/2024 at 1:10 PM, meal ticket was shown to the DON who was outside of Resident #63's room. The DON stated, Resident #63 was brought a regular diet tray instead of mechanical soft, and he would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 21 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0805 investigate the matter. Level of Harm - Minimal harm or potential for actual harm Interview on 03/06/2024 at 1:15 PM with CNA J, who took care of Resident #63, she stated Resident #69 received a regular food tray which was checked by the nurse and dietary staff, she just delivered the tray. Residents Affected - Few During an interview on 03/07/2024 at 3:30 p.m. the DON stated the nurses checked the ticket and told him Resident #63 would refuse the soft texture, so they just give her a regular diet. He stated that should not have happened, and they would get a nutritional and dietary evaluation of the resident to see what diet she should be on. He stated the staff should follow the physician orders and deliver the prescribed diet or a resident might choke or not get their nutritional needs met. Record review of the facility document titled Recommended Diets dated 2019 reflected The regular diet provides a well-balanced diet without restrictions or texture modifications. The mechanical soft was a modified texture diet for people who have issues with chewing such as missing teeth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 22 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Residents Affected - Many The facility failed to ensure dietary staff were wearing beard restraints who had facial hair. The facility failed to ensure dietary staff used proper hand hygiene during meal service. The facility failed to ensure dietary staff properly handled soup bowls while serving soup. These failures could place resident who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 03/04/2024 at 10:07 a.m. revealed [NAME] E with a thin mustache and beard to his chin with hair approximately ½ inch to an inch long not wearing beard guard or beard restraint. When asked about his beard [NAME] E stated Oh and went to go find the beard guards placing a hair restraint on his face. [NAME] E further stated the reason for wearing a beard guard was so hair wouldn't go into the food. [NAME] E stated it could cause bacteria in the food or if was to fall into the food and residents could get sick. [NAME] E stated he was supposed to always wear a beard restraint when in the kitchen. During an interview on 03/04/2024 at 10: 14 a.m. the FSS stated by not wearing a beard guard/restraint with facial hair could cause physical harm to the food. The FSS further stated if facial hair got in the food, it could cause cross contamination to the food. The FSS stated staff with facial hair should be always wearing the beard restraints or guards when in the kitchen. Observation on 03/06/2024 at 1:00 p.m. revealed through the kitchen door window [NAME] E near the serving line and stirring a stock pot on stove with his beard guard/restraint under his chin on neck of which once he noticed surveyor [NAME] E pulled his beard guard/restraint up over his chin and mouth covering his beard and mustache. Observation of dinner meal service on 03/06/2024 from 5:35 p.m. to 5:45 p.m. revealed [NAME] F preparing residents plates while wearing gloves, touching the tray rack, moving it around, removing trays from the rack placing on the serving line, placing cut sandwiches on the plates and arranging them, leaving the dining room to get a box of plastic wrap, leaving the serving line to go get tray of sandwiches from the refrigerator, touching his apron and sides of his clothing all of which without washing hands or changing gloves [NAME] F continued to serve the sandwich quarters with his hands. Observations further revealed DA G while she prepared bowls of soup and placed them on trays she would pick up a bowl with her right hand with thumb gripping the inside of the bowl then transfer to the left hand and placed soup in the bowl. DA G was further observed touching her face and pushing up her glasses, leaving the service area getting a box of plastic wrap and returned to serving soup, wrapping bowls of soup with plastic wrap all of which without washing hands or changing gloves. During an interview on 03/06/2024 at 5:43 p.m. DA G stated she should not have done that (referring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 23 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 to placing thumb in soup bowls when serving) with the bowls, it could cause cross contamination. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/06/2024 at 5:45 p.m. [NAME] F stated by touching everything and then touching the sandwiches it could have caused the risk of food borne illness and cross contamination. [NAME] F stated, But I put multiple gloves on so I can remove them. [NAME] F acknowledged however, he had not removed the gloves. The FSS instructed [NAME] F to go remove his gloves and wash his hands. Residents Affected - Many During an interview on 03/07/2024 at 12:13 p.m. the FSS stated [NAME] F could have caused cross contamination and food poisoning by not having washed his hands and changed gloves. The FSS further stated they should have started with using tongs from the beginning for the sandwiches during the dinner meal service on 03/06/2024. Review of facility policy Dietary Food Services Personnel Policy and Procedures, policy number HR 00-2.0, no date, from the Dietary services Policies & Procedures Manual 2012 read Sanitation and Food Handling. 2. Hair nets or hats covering the hairline are worn at all times. [NAME] guards are required for facial hair. 5. Do not handle food with bare hands. Use proper utensil or wear disposable gloves. Remember to change gloves after touching anything that should not contact food, including clothing, hair, doorknobs, etc. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 24 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews , the facility failed to maintain medical records on each resident that were accurately documented for 2 of 24 residents (Residents #63 and #71) reviewed for accurate medical records in that: 1. RN L initialed off that Resident #63's oxygen was infused at 1-2 l/min, when it was at 3L/min , and she had not checked the rate on 03/04/2024 and 03/05/2024. 2. LVN M did not initial off for treatments for Resident #71 on his TAR for wound care on 03/01/2024, 03/02/2024 and for both treatments on 03/04/2024. This deficient practice could affect residents who have medical records and could result in misinformation about professional care provided. The findings included: 1. Record review of Resident #63's face sheet dated 03/04/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: acute diastolic congestive heart failure (damage to the heart and symptoms come on suddenly, often sudden difficulty breathing and fatigue), zoster (a viral infection that occurs with reactivation of the varicella-zoster virus, usually results in a painful but self-limited dermatological rash) without complications, sepsis (severe infection) due to Methicillin Resistant Staphylococcus Aureus (staph infection that has become immune to many types of antibiotics), end state renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to dialysis or a kidney transplant) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #63's Annual MDS, with an ARD of 02/20/2024 reflected she scored 11out of/ 15 on her BIMS which signified she was moderately cognitively impaired. Review of Section O - Special Treatments and Programs reflected she was not coded to be on oxygen therapy while a resident which was inaccurate. Record review of Resident #63's comprehensive care plan revised date 02/28/2024 reflected Focus, resident has oxygen therapy. Record review of Resident #63's Active Orders as of: 03/04/2024 reflected, May use oxygen @ 1-2 l/m via nasal cannula every shift to maintain oxygen saturation% above 92%, start date 02/16/2024. Record review of Resident #63's oxygen saturations since her readmission on [DATE] revealed she had oxygen saturations taken at least once a shift and they were within normal range and reflected she was on oxygen via nasal cannula. Record review of Resident #63's TAR dated 03/01/2024 - 03/31/2024 reflected May use oxygen @ 1-2 l/min via nasal cannula every shift. This was initialed off (as done) on 03/04/2024 by RN L for Day shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 25 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0842 Level of Harm - Minimal harm or potential for actual harm Observation on 03/04/2024 at 10:30 AM revealed Resident #63 lying in bed, oxygen infusing at 3 L/min via NC. During an interview on 03/04/2024 at 10:40 AM with Resident #63, she stated she was always on oxygen at the facility. Residents Affected - Few Observation on 03/06/2024 at 07:40 AM of Resident #63, in her room revealed Resident #63 lying in bed, oxygen infusing at 3L/min. During an observation and interview on 03/06/2024 at 07:45 AM, RN L stated she was the charge nurse on 03/04/2024 and she did not check Resident #63's oxygen rate. She stated she did sign off on Resident #63's TAR that the oxygen was at the right rate of 1-2 L/min, and she should not have done that because she did not check the oxygen. She stated that documentation in a resident record must be accurate, or it was considered falsifying records and could result in problems related to resident condition if they had a physical reaction to the higher dose of oxygen. During an interview on 03/07/2024 at 3:37 PM, the DON stated the nurses needed to check the oxygen rates on the concentrators. He stated too much oxygen or too little oxygen could cause respiratory problems. He stated a nurse must accurately document in the resident's record to show the resident's care and condition. Record review of RN L's Nurse Proficiency Audit dated 01-18-2024 reflected she was checked off satisfactory for oxygen administration/maintenance and documentation. 2. Record review of Resident #71's electronic face sheet dated 03/04/2024 reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: encounter for orthopedic aftercare following surgical amputation (care following the loss of a limb or body part to include rehabilitation), type 2 diabetes mellitus (a condition caused by a problem the way the body regulates the use of sugar), acute osteomyelitis (a serious infection of the bone that can either be short term or long term), left ankle and foot, and peripheral vascular disease (a slow and progressive circulation disorder affecting body parts other than the brain or heart). Record review of Resident #71's quarterly MDS assessment with an ARD of 11/26/2023 reflected he scored a 15/15 on his BIMS which signified he was cognitively intact. He required moderate assistance with his ADL's. Record review of Section M - Skin Conditions, surgical wound care was checked. Record review of Resident #71's comprehensive person-centered care plan revised dated 01/27/2024 reflected Focus, resident has venous ulcer to RLE, bottom of right great toe and 2nd toe. Further review reflected, sometimes refused medications and treatments. Record review of Resident #71's Active Orders as of: 03/04/2024 reflected Wound Care: RLE- Clean with wound cleanser, pat dry with 4x4 gauze, Apply Triamcinolone (used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) ointment 0.1%, and cover with compression stocking in the morning and remove compression stocking at HS. Two times a day for wound care Active 02/08/2024. Record review of the Resident #71's TAR, dated from 3-1-24 to 3-31-24, revealed there was no nurse initials for PM on 03/01/2024 and 03/02/2024 and no nurse initials for AM and PM on 03/04/2024 . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 26 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Resident #71's nursing progress note for March 2024 revealed there were no nursing progress notes on 03-01-24, 03-02-24 and 03/04/2023 to address the lack of documentation for the treatment . Observation on 03/05/2024 at 2:00 PM of the Treatment Nurse perform wound care for Resident #71 revealed he had venous ulcer areas on his right lower leg, to which she cleaned, patted dry with gauze, and then applied Triamcinolone ointment and his compression stocking. During an interview on 03/05/2024 at 2:30 PM, Resident #71 stated he did not always get his leg treatment twice a day. During an interview on 03/06/2024 at 4:20 PM with the Treatment Nurse, she stated she was not at the facility on 03/04/2024, she stated it was LVN M that worked, so LVN M would have completed her treatments for Resident #71. She stated when the resident refused, we coded it with a number 9 and do a note. She stated he refused his treatments at times, but the refusal needed to be documented and a progress note written. She referred to an internal treatment log, and she stated it appeared the treatments for Resident #71 for 03/01/2024 and 03/01/2024 were done, but no other documentation could be found. She referenced the log and stated the treatments for Resident #71's RLE for 03/04/2024 were not done. Record review of Resident #71's TAR dated 03/01/2024 to 03/31/2024 reflected a legend at the end of the TAR where the # 9 code referred to Other/See Nurses Notes. During an interview on 03/07/2024 at 10:00 AM, LVN M stated she worked on 03/04/2024 and there were staff who called in, so ADON N and her were tag teaming and trying to get everything finished. She stated she thought ADON N had done Resident #71's treatment and ADON N thought she had done Resident #71's treatment. She stated it did not get done, and they notified the NP. She stated she did not initial off on the TAR, code it or write a progress note as was required for clinical documentation. During an interview on 03/07/2024 at 10:00 AM, ADON N stated it was a mix up on 03/04/2024 and Resident #71's treatments were not done, and the NP was notified, however, she did not document anything, and that was wrong, because the resident record could be considered a legal document. During an interview on 03/07/2024 at 3:37 PM, the DON stated the nurses must accurately document in the resident's record to show the resident's care and condition. Review of the facility policy and procedure titled Documentation 2003 reflected Documentation is the recording of all information both objective and subjective, in the clinical record of the individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets. Documentation also occurs in the clinical software PCC .The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 27 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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, interviews, and record reviews, 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 Resident (#43) of 5 residents reviewed for infection control in that: Residents Affected - Few CNA I failed to sanitize his hands after he changed gloves when he emptied Resident #1's urine container, wiped with the same wipe, same area several times, placed a clean brief onto Resident #1's bed with soiled gloves on and did not sanitize his hands or change gloves throughout the whole procedure of incontinent care to include after wiping feces from the residents anal area on 03/06/2024. This facility failure affects residents who need assistance with ADL's and could result in cross contamination and spread of infections. The findings included: 1.Record review of Resident #43's electronic face sheet, dated 03/06/2024, reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: unspecified sequelae of cerebral infarction (unspecified symptoms and signs involving cognitive functions following cerebral infarction (area of necrotic tissue in brain following lack of blood supply), diabetes mellitus (inadequate control of blood levels of glucose), anemia (a condition that develops when blood produces a lower-than-normal amount of healthy blood cells), schizophrenia (a serious mental disorder in which people interpret reality abnormally) and retention of urine (not able to empty the urine from the bladder and the urine may back up into the kidneys). Record review of Resident #43's quarterly MDS assessment with an ARD of 01/23/2024 reflected she scored 5/15 on her BIMS which signified she was moderately cognitively impaired. She sometimes could understand. Review of Section H - Bladder and Bowel reflected Resident #43 had an indwelling urinary catheter. She was always incontinent of bowel. She was dependent on assistance to complete her ADL's. Record review of Resident 43's comprehensive care plan revised date 05/25/21 reflected Focus, resident has a foley Catheter: Neurogenic bladder r/t CVA. Her care plan did not reflect she was always incontinent of bowel. Observation on 03/06/2024 at 2:30 pm of Resident #43 in her room in bed while CNA I performed urinary catheter care and incontinent care for Resident #43. CNA I put on gloves and emptied Resident #43's urinary catheter drainage bag into a plastic graduated (marked with units of measurement) intake and output container. He emptied the urine into the toilet in the restroom, and then changed gloves without washing or sanitizing his hands. CNA I then picked up a clean incontinent brief, opened it, and laid it onto Resident #43's bed. He then changed gloves without sanitizing his hands. CNA I took a clean wipe and performed catheter care, took another clean wipe, and wiped 6 times (with the same area of the wipe) over Resident #43's labia. CNA I then took another clean wipe, turned Resident #43 and wiped feces from her anal area, discarded the wipes into a trash bin near the bed, and then placed Resident #43's clean brief onto her with the same soiled gloves. CNA I then covered the resident with her bedding. CNA I did not change gloves after he placed Resident #43's clean brief on the bed or sanitize hands when he performed catheter care and incontinent care for Resident #43. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 28 of 29 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 676121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Tree Nursing and Rehabilitation Center 930 Roy Richard Dr Schertz, TX 78154 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 During an interview on 03/06/2024 at 2:45 PM, CNA I stated he thought if he did not leave Resident #71's room he did not need to change gloves. He stated he was trained on hand washing and infection control and understood that cross contamination of bacteria could happen and cause infection. During an interview on 03/06/2024 at 2:50 PM, the RNC stated staff were trained and she did not understand the confusion CNA I had, but would investigate, and provide more training. During an interview on 03/06/2024 at 2:55 PM, the ADM stated that clean needed to stay clean, and dirty needed to stay dirty during incontinent care for residents. Record review of CNA I's Proficiency Audit dated 02/20/2024, reflected he was signed off Satisfactory for hand washing. Record review of CNA I's Nurse Aide Incontinence Care Proficiency Assessment dated 02/20/2024 reflected he Failed one part of the assessment for puts on gloves which was corrected. Record review of the facility policy and procedure titled Perineal Care Female dated revised December 8, 2009, reflected. DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE OF THE PRE-MOISTENED CLEANSING WIPES .change gloves .change gloves .change gloves .Closing steps: If gloved, remove and discard gloves, wash hands. Record review of a facility In-service Training Attendance Roster Topic, Peri-Care Female dated 02/11/2024 reflected CNA I attended the training. Record review of the facility policy and procedure titled Fundamentals of Infection Control Precautions dated 2019 reflected Hand Hygiene .after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676121 If continuation sheet Page 29 of 29