Health inspection·January 12, 2024

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some PRN any s/sx of malignant (infectious) hypertension: headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, and difficulty breathing. She was at high risk for communicable respiratory infections (influenza/pneumonia) with an intervention of monitoring facility for trends in respiratory infections. Review of Resident #1's Fall Risk Evaluation, dated [DATE], reflected a score of 9, indicating she had a low risk of falling. She was oriented x3 (time, place, person) and regularly continent. Review of Resident #1's Change of Condition Communication Form dated [DATE] at 5:20 PM, reflected the following: Signs/Symptoms Detail: post fall, AMS: unable to sit upright without leaning to a side, congested, coughing. This condition, symptom, or sign has occurred before: No . 1. Mental Status Changes: Decreased consciousness (sleepy, lethargic) 2. Functional Status Changes: Needs more assistance with ADLs and fall 3. Respiratory: Shortness of breath, abnormal lung sounds Review of Resident #1's Fall Risk Evaluation, dated [DATE], reflected a score of 11, indicating she had a high risk of falling and was disoriented x3. Review of Resident #1's progress notes, dated [DATE] at 6:29 PM and documented by LVN A, reflected the following: [Resident #1] was observed in a sitting position on the floor after staff informed (LVN A) that [Resident #1] fell. [Resident #1] verbalized that she was trying to sit on the chair before sliding down, but denied injury, or hitting her head against anything . Review of Resident #1's progress notes, dated [DATE] at 4:40 PM and documented by LVN A, reflected the following: F/u post fall day 1/3, [Resident #1] alert and oriented, able to make needs known, denied pain or injury, tolerated meals and fluids well, 75% of both meals tolerated. [Resident #1] unable to sitting upright, congested, and was coughing. NP notified gave order for CXR, CBC, and BMP, and to start DuoNeb (nebulizer treatment) QID X4 days. Review of Resident #1's progress notes, dated [DATE] at 5:39 AM and documented by LVN B, reflected the following: [Resident #1] chest x-ray result: left perihilar infiltrate, right axillary clips - notified NP gave order for Levaquin 750mg every day for 7 days. Review of Resident #1's progress notes, dated [DATE] at 8:30 AM and documented by LVN A, reflected (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 2 of 10 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 676222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 the following: Level of Harm - Immediate jeopardy to resident health or safety Found [Resident #1] leaning back on bed completely undressed to lower body. Not easily aroused. BP 144/87, HR 89, RR 20, 77% RA. Applied O2 at 2L/NC, now 95%. Abnormal CXR and initiation of Levaquin noted. Residents Affected - Some Review of Resident #1's progress notes, dated [DATE] at 1:00 PM and documented by LVN A, reflected the following: [CNA C] alerted nurse to room. Found [Resident #1] on the floor in front of bed. CNA's had attempted to transfer [Resident #1] to the bed. [Resident #1] suddenly stopped assisting staff and became dead weight. [Resident #1] fell to the floor with resting position belly down. [Resident #1] did not hit her head. Head to toe assessment completed. D/t dx of PNA and AMS, [Resident #1] unable to complete ROM but not r/t fall. A&Ox0 also r/t to dx PNA and not to fall. No injury noted. Review of Resident #1's NP progress note, dated [DATE], reflected the following: Seen for AMS, weakness, SOB. Staff reported fall, elevated temperature and hypoxia over the weekend. CXR obtained and showed infiltrates, [Resident #1] started on levofloxacin and DuoNebs TID, orders for O2 to maintain SpO2. Today, staff reports continued AMS, [Resident #1] getting out of chair without assistance, fell without apparent injury but likely related to episode of bowel incontinence as she is seen on floor covered in feces. She repeatedly removes nasal cannula. Oriented x 1. Nurse reports BG 132, and SpO2 97-98% with 2-3 L O2. Assisted staff with cleaning up [Resident #1] and returned her to bed, applied O2 mask at 2.2 L. Review of Resident #1's progress notes, dated [DATE] at 9:42 AM and documented by LVN A, reflected the following: Increased rounding by staff to assist with ADLs due to recent change of condition. Review of Resident #1's progress notes, dated [DATE] at 7:00 PM and documented by LVN A, reflected the following: At approx 5:38 PM, [CNA D] alerted this nurse and 2nd nurse to room. Upon entering room [Resident #1] was laying on her back on the bed. Bedside table was in front of the bed with meal tray ½ eaten. Upon assessment [Resident #1] was found unresponsive, no respirations nor pulse found. Started chest compressions immediately and called code blue and instructed other nurse to grab crash cart and to call 911. 3rd nurse arrived and assisted to move [Resident #1] to the floor. Continued chest compressions. Crash cart arrived, placed AED pads, found no heart rhythm. CPR continued. EMS arrived approx. 5:50 PM and took over care. EMS called time of death at 6:20 PM. Review of Resident #1's physician orders, dated [DATE], reflected to apply O2 PRN with mask to maintain SpO2 >92%. Review of Resident #1's TAR, January of 2024, reflected she was started on Levaquin Oral Tablet 750 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 3 of 10 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 676222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some MG - one tablet by mouth one time a day related to cough for seven days, starting on [DATE]. She was administered a dose on [DATE] and [DATE]. Review of Resident #1's TAR, January of 2024, reflected she was administered Azithromycin Oral Tablet 250 MG - give two tablets by mouth one time a day for Pneumonia for one day on [DATE]. Review of Resident #1's TAR, January of 2024, reflected she was administered Ceftriaxone Sodium Injection Solution Reconstituted 1 GM intramuscularly one time for pneumonia on [DATE]. Review of Resident #1's documented vital signs in her EMR, from [DATE] - [DATE], reflected multiple occasions when her vitals were outside of her normal parameters despite the interventions being utilized: Blood Sugar: [DATE] at 11:24 AM - 174.0 mg/dL [DATE] at 8:22 AM - 242.0 mg/dL [DATE] at 11:47 AM - 163.0 mg/dL [DATE] at 4:20 PM - 216.0 mg/dL Oxygen Saturations: [DATE] at 12:12 PM - 92.0% (oxygen via mask) [DATE] at 3:13 PM - 88.0% (oxygen via mask) Pulse: [DATE] at 6:02 PM - 98 BPM [DATE] at 1:05 AM - 99 BPM [DATE] at 1:34 AM - 99 BPM [DATE] at 9:43 AM - 102 BPM [DATE] at 11:54 AM - 98 BPM During a telephone interview on [DATE] at 2:46 PM, CNA C stated she worked with Resident #1 regularly. She stated Resident #1 was very independent, was ambulatory, was continent, and could easily have a conversation with you. She stated Resident #1 had a drastic change in condition after her fall on [DATE]. She stated she was lethargic, her neck was hurting, she was very confused, and was defecating on herself. She stated she, CNA E, and LVN A repeatedly told the DON she needed to be sent to the hospital but she insisted on keeping Resident #1 in bed. She stated on [DATE] she was even worse than the day before and did not leave her room at all. She stated she was put on 1:1 care due to her extreme confusion. She stated she did not understand why the DON was so adamant about refusing to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 4 of 10 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 676222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 seek further medical care. She stated the DON dismissed her, probably because she was 'just a CNA'. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 11:13 AM, the RCRN stated if the nurse thought a resident was critically ill and they continued to decline and the interventions in place were not effective, the nurse should contact the NP or use their own judgement if they needed to. She stated she was involved with the change in condition for Resident #1 and spoke to both the NP and LVN A several times. She stated she was happy with the interventions that had been put in place and believed the NP would have sent her to the ER if she believed she needed to. Residents Affected - Some During a telephone interview on [DATE] at 11:42 AM, LVN A stated she was Resident #1's nurse on the days after her fall on [DATE]. She stated she did have a severe change in condition but was not overly concerned until she got to work on [DATE]. She stated she was told when she came onto her shift that Resident #1 had tested positive for pneumonia and had been started on Levaquin. She stated she went and assessed her and her oxygen level was 77%. She stated she requested to the NP that she be sent to the ER and the NP stated no because her vitals were stable. She stated after being administered a Rocephin shot, she was a little more alert but still not her normal self and was very confused. She stated on [DATE] in the morning, her blood pressure was low and her heart rate was elevated. She stated the DON and NP still refused to send her to the hospital because her vitals were stable, even though they were not. She stated she requested multiple times to the DON and NP to send her out on both [DATE] and [DATE] and they refused. She stated at one point on [DATE], she got extremely upset and got in the NP's face and stated, What is going on? She is so sick and would be in the ICU right now. She stated in hindsight, she should have gone around the NP and just let herself get in trouble (by sending her to the hospital). She stated Resident #1 was on 1:1 because she was so sick and kept taking her oxygen off. She stated she had 1:1 care on [DATE] and up until 2:00 PM on [DATE]. She stated she immediately went to the ADON and asked why she no longer had 1:1 care and the ADON told her she no longer got to have one (sitter). She stated that evening, [DATE], the aides must have brought her dinner tray and left her alone. When asked how a resident was supposed to eat while utilizing an oxygen mask to keep their oxygen saturations up, LVN A sighed and stated, Exactly. She stated Resident #1 clearly took off the mask to eat and her oxygen saturations dropped. She stated she should have been monitored, and quite honestly, should have been sent to the hospital long before then. LVN A was extremely tearful and felt like it was her fault because she had Resident #1's life in her hands. She stated she could not even face returning to the facility after that day and was so upset the NP and DON did not value her nursing expertise and/or opinion. During an interview on [DATE] at 12:14 PM, the DON stated she was informed of Resident #1's change in condition after her second fall on [DATE]. She stated they did not attribute the fall to her change in condition. She stated she had 1:1 care to help keep her oxygen on and to prevent her from getting up. She stated if she took off her oxygen it would only cause more confusion. She stated she was not informed as to why the 1:1 care stopped on [DATE]. She stated if a resident was utilizing a face mask for oxygen, she would expect for someone to sit with them during meals to ensure their saturations did not drop or to utilize a nasal canula during the meal. She stated she was not sure if anyone monitored Resident #1 during dinner on [DATE]. She stated she was not notified by any staff members in particular that they believed Resident #1 did need to go to the hospital, but was aware there were numerous occasions when the NP was told by staff they believed she needed to be sent out. She stated she was not a doctor or the facility NP, but her gut told her that maybe they could keep an eye on her a little longer before she required hospitalization. When asked if she believed Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 5 of 10 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 676222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some had been improving after reading her chart, she stated her vitals seemed ok, so who knows. She stated she could not answer if the NP was right or not for not sending her out. During an interview on [DATE] at 12:27 PM, the ADM stated the NP was working very closely with Resident #1. He stated he was worried about her but did not know if she should have been sent to the hospital as he was not a nurse. He stated he made sure nurses knew to notify the NP of any changes in her condition. He stated the NP saw her early on [DATE] and Resident #1 was able to recognize her and thought she was responding well to the treatment. He stated Resident #1 was never on 1:1 because they do not provide 1:1, but the staff was closely monitoring her. He stated he did not know the answer to what should be done during a meal when a resident was utilizing an oxygen mask but would imagine she would have been monitored. He stated he did not think any staff members had voiced their concerns to the NP about Resident #1 needed hospitalization because she would have listened to them. During a telephone interview on [DATE] at 1:10 PM, CNA E stated she worked with Resident #1 on [DATE] from 6:00 AM - 10:00 PM and she was absolutely not herself. She stated she was on 1:1 the whole day. She stated she personally notified LVN A, NP, and DON that she believed she needed to be sent to the ER and the DON told her that as long as her vitals were stable and her oxygen mask was on, there was no need for the ER. During a telephone interview on [DATE] at 1:15 PM, CNA F stated she worked closely with Resident #1 and worked with her on [DATE]. She stated she was on 1:1 in the morning but not on the 2:00 PM - 10:00 PM shift. She stated Resident #1 was not herself and she was very worried about her. She stated she was not instructed on what to do during mealtime (dinner) for Resident #1. She stated she and another aide (CNA G) were passing trays and assisting with feeding residents in the dining room. She stated there was no one in Resident #1's room when she was eating dinner. During a telephone interview on [DATE] at 1:19 PM, CNA G stated she was not instructed on what to do during dinner with Resident #1. She stated it her first day was on [DATE] and she arrived around mealtime and jumped in to help feeding residents. She stated when she went to pick up her tray after dinner around 6:40 PM, she found Resident #1 without her oxygen mask on and she was unresponsive. During a telephone interview on [DATE] at 1:24 PM, Resident #1's NP stated it was her understanding that she had a change in condition with congestion on [DATE]. She stated a chest x-ray had determined she had Pneumonia and she started her on Levaquin. She stated when she saw her on [DATE] she was confused and had bowel incontinence which were both definitely unusual for her. She stated she added another antibiotic at this time. She stated her vitals remained stable, she had an order for a breathing treatment every hour, and she had a sitter with her. She stated she was not made aware that 1:1 care had stopped on [DATE]. She stated it would be her expectation that someone was in the room monitoring her during dinner and would reapply the mask after she was done eating. She stated staff members would have different opinions but in her clinical opinion, she was stable and the hospital was a place that was not without risk either. She stated she made her clinical judgement. A copy of the facility's Change in Condition Policy was requested but was only given a Notification of Changes Policy, dated [DATE]. This policy does not reflect when to seek further medical treatment after a resident has a change in condition. The ADM, DON, and RCRN were notified on [DATE] at 4:05 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 6 of 10 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 676222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 The following POR was accepted on [DATE] at 1:46 PM: Level of Harm - Immediate jeopardy to resident health or safety On [DATE], the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. Residents Affected - Some The immediate jeopardy allegations are as follows: Issue:

F684 Quality of Care Resident #1 is no longer in the facility. On [DATE] with completion date by [DATE], the Director of Nursing/designee will evaluate all residents (#90) in the facility to ensure there were no unidentified changes in condition. Evaluation will be documented in the resident progress notes in (electronic records). On [DATE], the Director of Nursing / designee initiated reeducated with Licensed Nurses on the following topics: Abuse and Neglect Notification of Changes in Condition Quality of Care Respiratory Care Oxygen Use Vital Sign parameters Contacting Attending and Medical Director as secondary contacts for interventions up to and including hospital transfer as necessary One-on-one supervision On [DATE], the Director of Nursing / designee initiated reeducated with Certified Nurse Aides, Nurse Aides, and Medication Aides on the following topics: Abuse and Neglect Notification of Changes in Condition Quality of Care Respiratory Care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 7 of 10 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 676222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Oxygen Use Level of Harm - Immediate jeopardy to resident health or safety One on one supervision Residents Affected - Some Re-education of 100% of nursing staff will be completed by [DATE]. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Vital Sign parameters · Beginning [DATE] and going forward, the Director of Nursing / designee will review the 24- hour report in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative. · Beginning [DATE] and on-going, the Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. · Beginning [DATE] and on-going, the Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition. An AdHoc QAPI was conducted on [DATE], by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning ensuring that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The Survey Team monitored the POR on [DATE] as followed: During a telephone interview on [DATE] at 1:54 PM, Resident #1's MD stated he attended the QAPI meeting the day before by telephone. He stated a resident should be sent to the hospital when the facility could not provide the level of care needed, such as abnormal lab results, not being able to sustain adequate oxygen levels, or if there was anything the facility could not sustain that was out of threshold. He stated usually the DON would need to get involved at that point. He stated if the DON and the clinical team thought the resident met valid clinical criteria requiring hospitalization, then the resident would then be sent out. He stated normally a resident would not be sent out unless there was a dramatic difference from their baseline. He stated according to the NP, Resident #1's vitals had remained within normal parameters, she did not have a fever, and her respiratory rate was not elevated. During an interview on [DATE] at 3:35 PM, the ADM stated the DON and ADON were responsible for ensuring all staff were in-serviced before working the floor and they had already in-serviced approximately 50% of all staff. During interviews on [DATE] from 2:17 PM - 3:02 PM, revealed one MA, two CNAs, and three LVNs all stated they were in-serviced on several topics before the start of their shift. They were all able to state who their Abuse and Neglect Coordinator was as well as give several types of abuse such as mental, physical, and sexual. They all were able to state when a resident should be on 1:1 and what that would entail. They were all able to describe changes of conditions such as confusion, elevated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 8 of 10 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 676222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety blood pressure, fever, or being lethargic. They all relayed they are to notify the charge nurse immediately if they notice any changes of condition in a resident. They all stated no resident should be left alone to eat if they utilized an oxygen mask. Review of the facility's Ad Hoc QAPI Meeting Attendance sheet, dated [DATE], reflected the ADM, DON, MD, and RCRN were in attendance. Residents Affected - Some Review of an in-service entitled Oxygen Devices, dated [DATE] and conducted by the RT and DON, reflected nurses were reeducated on oxygen orders, devices (nasal cannula, high flow cannula, oxygen masks, venti mask, non-breather) bubble humidifier, pop-off refillable humidifier, vital monitoring, and monitoring between device changes. Review of an in-service entitled Oxygen Masks, dated [DATE] and conducted by the DON, reflected all clinical staff were reeducated on oxygen masks. Review of an in-service entitled Quality of Care, dated [DATE] and conducted by the RCRN, reflected the following: This goal of this facility is to provide the best care to each and every resident. This includes but is not limited to: monitoring and assessing/evaluating for changes in condition, providing prompt notification to the medical provider and responsible party, intervention and treatment for issues when they arise, appropriate reevaluation of the interventions, and thorough and accurate documenting in the medical record. If the residents' condition does not improve, notify the provider and RP and follow orders as applicable. Review of an in-service, dated [DATE] and conducted by the ADM, reflected the nursing department was reeducated on the following: If a nurse wants one on one supervision for a patient, they must consult with the DON or Administrator prior to placing the patient on one-to-one supervision. If a nurse wants to remove a patient from one-on-one supervision, they must consult with the DON or Administrator first. One on one means within arm's reach, can't leave until relieved. Review of an in-service entitled Abuse and Neglect, dated [DATE] and conducted by the ADM, reflected all staff were reeducated on the following: Residents have the right to be free from neglect regarding their care. If a resident has orders for oxygen and we are concerned about their condition, we need to make sure that we monitor them more closely during their meals. If they are not stable, their meal should wait until they are feeling better and sats/vitals are WNL and they feel like eating. Review of an in-service entitled Vital Signs, dated [DATE] and conducted by the DON, reflected clinical staff were reeducated on the following: If you check vitals on a resident and they are out of range for that particular resident, notify the charge nurse and have them recheck them. If there continues to be a change from baseline, notify the NP/MD as indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 9 of 10 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 676222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of an in-service entitled Changes in Condition, dated [DATE] and conducted by the DON, reflected CNAs were reeducated on the following: If you are taking care of a resident and you see a change in condition, notify the charge nurse. If you feel that not enough is being done for the resident, please promptly notify the DON and express your concerns. While the IJ was removed on [DATE] at 4:45 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 676222 If continuation sheet Page 10 of 10