Health inspection·November 18, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm asked a question and walked away. Record review of Medication Administration: Medication Carts and Supplies for Administering Medication Policy revised 10/01/2019 revealed: Procedure: Only a Licensed Nurse or Certified Medical Aide may carry keys to the medication cart. The medication cart is locked at all times when not in use. Do not leave the medication cart unlocked or unattended in the resident care areas. Preferably, the medication cart is stored in the Medication Room when not in use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 2 of 7 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 11/18/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed make sure that drugs are stored properly and only authorized persons have access for 1 of 4 medication carts (MC #1) reviewed for drug storage and labeling. The facility failed to ensure the 300-hall medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings Included: Observation of 300-hall on 10/07/2025 at 8:25 a.m., revealed MC #1 was unattended and unlocked. MA A was at the nurses station talking to another staff member with her back turned away from the cart. The medication cart was up against the wall by the dining room entrance. The locking mechanism was protruding outward on the medication cart. The cart contained prescribed medication for residents' and over the counter medications. The state surveyor opened drawers and captured pictures. MA A did not see the surveyor open the drawers and take pictures. During an interview on 10/07/2025 at 8:30 a.m., revealed MA A had been trained on medication storage. She said the policy was to make sure the medication cart was locked when staff were away from the cart. She said the medication cart must always be locked when not giving out medication. She said she was responsible for ensuring the medication cart was locked. She said if a medication cart was left unlocked and unattended then a resident could get into the medication cart. She said she forgot to lock the cart because she got distracted. During an interview with the DON on 10/02/2025 at 11:01a.m., revealed she had only been working at the facility for four days. She said staff had been trained in medication storage. She said she did not know what the policy was for medication storage. She said she expected staff to follow the policy. When asked how she would know if staff were following the policy since she did not know she said they could ask what the policy was. She said the person on the medication cart was responsible for ensuring the medication cart was locked. She said the medication cart was to be locked when staff were not using the medication cart. She said if the medication cart was left unattended and unlocked a resident or anyone who was not authorized to pass medication could get into the cart. She said the DON and charge nurse were responsible for monitoring to ensure the medication carts were locked. She said it was monitored by observations. She said MA A did not lock the cart because a resident called her and she forgot. During an interview with the ADM on 10/07/2025 at 2:35 p.m., revealed he and staff have been trained on medication storage. He said the policy for the medication cart was that the medication cart was to be locked when the nurse or MA were not next to the cart. He said the nurse or MA using the medication cart was responsible for ensuring the cart was locked. He said if the medication cart was left unattended and unlocked, someone who is not supposed to get in the medication cart could get into the cart. He said all managers monitored to ensure the medication carts were locked. He said the managers monitored by line of sight. He said the lock would stick out and it was easy to see if the medication cart was unlocked. He said MA A left the medication cart unlocked because she was asked a question and walked away. Record review of Medication Administration: Medication Carts and Supplies for Administering Medication Policy revised 10/01/2019 revealed: Procedure: Only a Licensed Nurse or Certified Medical Aide may carry keys to the medication cart. The medication cart is locked at all times when not in use. Do not leave the medication cart unlocked or unattended in the resident care areas. Preferably, the medication cart is stored in the Medication Room when not in use. Event ID: Facility ID: 676222 If continuation sheet Page 3 of 7 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 11/18/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review facility failed to provide comfortable and safe rooms for residents for 4 of 11 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for environment. The facility failed to ensure Resident #1, Resident #2, Resident #3, and Resident #4's bedroom floor was clean from trash, food crumbs and a dried spilled substance that appeared to be coffee. Resident #4's bathroom had a brown substance around the base of the toilet, used paper towels on the resident's bathroom floor, and a half black ring in the toilet.The failure could place residents at risk of living in an uncomfortable and unsafe environment, decreased feelings of self-worth, and a diminished quality of life.Findings included: Resident #1 Record review of Resident #1's face sheet dated 10/07/2025 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included mononeuropathy of left lower limb (damage that occurs to a single nerve causing pain, loss of movement and numbness), heart disease, chronic kidney disease stage 4 (a serious condition where the kidneys are severely damaged), heart failure and absence of right leg above the knee. Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a BIMS of 11 which indicated moderate impairment. The MDS also revealed Resident #1 was partial/moderate assist with sit to stand, lower body dressing and transfers. Resident #1 was supervision/touching assist with mobility. Record review of Resident #1's care plan dated 08/24/2025, revealed Resident #1 had limited physical mobility r/t decreased physical strength, right above the knee amputation. The care plan also said Resident #1 required Supervision/touching assistance to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Resident #2 Record review of Resident #2's face sheet dated 10/07/2025 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included muscle wasting, abnormalities of gait and mobility, lack of coordination, repeated falls, ankylosis left knee (severe stiffness in the knee that can cause partial restricted movement or complete immobility), presence of artificial left knee joint, fracture of right side one rib, and hip fracture. Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 02 which indicated severe cognitive impairment. The MDS also revealed Resident #2 was substantial/ maximal assistance with sit to stand, lower body dressing and transfers. Resident #2 was partial/moderate assist with mobility. Record review of Resident #2's care plan dated 08/27/2025, revealed Resident #2 required substantial/maximal assistance to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Resident #3 Record review of Resident #3's face sheet dated 10/07/2025 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included muscle wasting, need for assistance with personal care, heart failure, depression (a persistent feeling of sadness), and absence of left leg above the knee. Record review of Resident #3's annual MDS dated [DATE] revealed Resident #3 had a BIMS of 07 which indicated severe cognitive impairment. The MDS also revealed Resident #3 was dependent on staff for lower body dressing and transfers. Resident #3 was substantial/maximal assistance with mobility. Record review of Resident #3's care plan dated 07/21/2025, revealed Resident #3's functional performance for picking up objects was marked as not applicable. Resident #4 Record review of Resident #4's face sheet dated 10/07/2025 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included right and left artificial shoulder joint, disease of musculoskeletal system and connective tissue (type of cancer that can start in your connective tissue), shortness of breath, chronic kidney disease stage 3 (a serious condition where the kidneys are severely damaged), osteoporosis (disease (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 4 of 7 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 11/18/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that weakens the bones and make them more likely to break), and atrial premature depolarization (extra heartbeats that start in the upper chamber of the heart) Record review of Resident #4's annual MDS dated [DATE] revealed Resident #4 did not have a BIMS score. The MDS also revealed Resident #4's functional abilities were not completed. Record review of Resident #4's baseline care plan dated 10/06/2025, revealed Resident #4's cognitive status was cognitively intact. The care plan also said the resident had impaired balance and unsteady gait requiring supervision. Resident was a partial/moderate assistance with transfers. Observation of Resident #1's room on 10/07/2025 at 8:31a.m., revealed the floor had brown spots that appeared to be dried spilled coffee, pieces of eggs, and sugar packet trash on the floor. Observation of Resident #3's room on 10/07/2025 at 8:36 a.m., revealed the floor had a used napkin and a used paper towel wadded up on the floor. Observation Resident #2's room on 10/07/2025 at 11:23am revealed that there were two used paper towels on the floor, and what appeared to be food crumbs on the floor. Observation of Resident #4's room on 10/07/2025 at 12:34p.m., revealed a brown substance around the base of the toilet, used paper towels on the resident's bathroom floor, a half black ring in the toilet and what appeared to be food crumbs on the floor in the bedroom. During an interview with HK B on 10/07/2025 at 10:55 a.m., revealed she had been trained on resident rights and homelike environment. She said the policy for cleaning the resident's room was to clean the room every day. She also said housekeeping staff were not to bring the cleaning cart out on the floor until after 9:00 a.m. She said staff had to put gloves on, dust everything, check the bathroom, take the trash out, spray the toilet and wait ten minutes then clean the toilet, sweep and mop. She said the residents' rooms were cleaned daily. She said that if housekeeping was not there and the CNA found a mess then the CNA was supposed to clean it up. She said if a resident's room was not clean the resident might feel dirty. She said the ES was responsible for ensuring the resident's room was clean. She said the ES monitored the residents' rooms through observation. She said the residents' rooms were not clean because housekeeping just came in to work. During an interview with CNA C on 10/07/2025 at 11:03 a.m., revealed that she had been trained on resident rights. She said that the policy for cleaning the residents' rooms was to clean the resident room and take the trash out. She said that if a resident wanted her to organize their stuff, she would help the resident. She said everyone was responsible for ensuring the residents' rooms were clean. She said if the resident's room was not clean the resident might feel bad. She said the residents' rooms were cleaned every day. She said when housekeeping was not working the CNA was responsible for cleaning the residents' rooms. She said management monitored to ensure the residents rooms were cleaned. She said management monitored through observations. She said she did not know why Resident #1, Resident #2, Resident #3, and Resident #4's rooms were dirty. During an interview with Resident #1 on 10/07/2025 11:08 a.m., revealed staff cleaned his room every day. He said that he had not had to ask staff to clean his room. He said housekeeping was the only one who cleaned his room. He said if housekeeping was not working, he had to wait until housekeeping came back the next day. He said his room was dirty because housekeeping had not gotten to his room to clean it. He said he would like his room to be cleaned even when housekeeping was gone for the day. During an interview with Resident #3 on 10/07/2025 11:13 a.m., revealed she did not know how often staff cleaned her room. She said she would like them to clean her room every other day. She said she had to ask staff to clean her room most of the time. She said if housekeeping was not working then she had to wait until they returned to work the next day to get her room cleaned. She said her room feels homelike but when her room was not clean it made her feel tired. During an interview with Resident #2 on 10/07/2025 11:25 a.m., revealed that she had been in her room for 2 months and she had not seen anyone clean her room. She said if she was not sick, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 5 of 7 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 11/18/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she would sweep and clean her room herself. She said she must ask staff to come and clean her room. She said she did not think anyone would come and clean her room after housekeeping left at 4pm every day. She said she would like them to clean her room at least every other day. She said she did not feel like her room was homelike and when her room was dirty, she felt yucky. During an interview with the FM of Resident #4 on 10/07/2025 at 11:55 a.m., revealed Resident #4 was admitted on [DATE].She said she had problems with Resident #4's room not being clean when they arrived. She said there was mold around the commode. She said that the toilet did not appear to be cleaned. She said that she could not say how Resident #4 felt because she said he was confused. During an interview with the ES on 10/07/2025 at 12:36 p.m., revealed she had been trained on resident rights and homelike environment. She said the policy for cleaning residents' rooms was that staff had fifteen minutes per room. She said staff were to dust, take out trash, clean the bathroom and sweep and mop the rooms. She said that the housekeeping staff worked from 8 a.m. to 4 p.m. She said when housekeeping staff were not working the CNAs were responsible for cleaning the residents' rooms if the room needed cleaning. She said that the residents' rooms were dirty every morning when the housekeeping staff come in to work. She said she left a housekeeping cart out so that the CNAs could use the supplies on the housekeeping cart. She said housekeeping staff cleaned all the residents' rooms every day. She said if a resident's room was not clean the resident might get upset. She said the ES monitored the housekeeping staff to ensure the residents rooms were clean. She said she did observations of the residents' rooms. She said she did not think anyone monitored after housekeeping leaves for the day. She said the Resident #1, Resident #2, Resident #3, and Resident #4's rooms were dirty because housekeeping did not bring the cleaning carts out until after the breakfast trays are picked up. During an interview with the DON on 10/07/2025 at 1:28 p.m., revealed her and staff had been trained on resident rights. She said she did not know what the policy was for cleaning resident rooms. She said all staff were responsible for ensuring the residents' rooms were clean. She said if staff saw trash on the floor they should pick up the trash. She said depending on the resident, some do not mind their room being a mess. She said other residents might want the room cleaned up. She said the residents' rooms were cleaned daily and as needed. She said that staff were to clean the residents' rooms when housekeeping was not working. She said all staff should monitor to ensure the residents' rooms are clean. She the staff should be monitoring through observation. She said she did not know why staff did not clean Resident #1, Resident #2, Resident #3, and Resident #4's room before housekeeping came in. During an interview with the ADM on 10/07/2025 at 2:38 p.m., revealed he had been trained on resident rights. He said the policy was if there was a mess staff should respond to it timely. He said staff should treat the residents' room like their home and keep it clean. He said housekeeping was responsible for ensuring the residents' rooms were clean. He also said if housekeeping was not working and there was a big mess the laundry staff had access to the cleaning supplies. He said if there was just trash on the floor any staff should be picking the trash up. He said all staff monitored to ensure the residents' rooms were clean. He said it was monitored through observation. He said if a resident's room was not clean the resident may feel dissatisfied. He said he did not know why Resident #1, Resident #2, Resident #3, and Resident #4's rooms were dirty. Record review of the Facility Manual dated 07/14/2020 revealed: Medicaid Daily Rate Services and ExclusionsHousekeeping and Maintenance Services- To promote a clean, safe, comfortable environment. Record review of General Housekeeping Policies not dated revealed: The facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. All housekeeping personnel utilize the accepted practices and procedures to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 6 of 7 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 11/18/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm keep the facility free from offensive odors, accumulations of dirt, rubbish, dust, and hazards as well as participate in ongoing education and training to maintain or increase their competency. Each occupied resident room is cleaned and put in order daily and as needed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676222 If continuation sheet Page 7 of 7