Inspection·December 4, 2022

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the physician orders for Resident #91 on 11/30/22 at 2:31 p.m. reflected no new orders entered that day. Review of the progress notes for Resident #91 reflected the following: -08/27/22 documented by LVN N Late Entry: Note Text: Resident pushed another resident causing other resident to fall into wall and sustained small laceration to top of his head. Per witness, this resident pushed the other resident (Resident #81) Neither resident is able to recall incident. This resident family member was notified and informed she would need to come sit with resident. Family member verbalized agreement. (Family member) verbalize concern that was provoked and has never had this type of behavior. Advised family member to speak with admin on Monday. Family member verbalized agreement with changing resident room to provide separation. This resident room was changed from 115B to 116A. On call notified. Safety precautions in place. -11/30/22 documented by ADON A: Note Text: 0920am-Per CNA this resident (Resident #91) and another resident (Resident #81) had an altercation in the dining room. Went to assess (Resident #91) and no apparent injuries noted. VS 118/75, 76HR, 18R, 97.9, 96%RA. Asked patient what happened and patient states That guy had my jacket on, and I hit him. Patient unable to give this nurse any other description. Per staff, (Resident #91) walked up to (Resident #92) and thy began argue over (Resident #92)'s jacket. Then (Resident #91) punched (Resident #92) three times in the face. The staff pulled them both apart and separated them. Placed (Resident #91) on 1:1 for safety precautions. Police officer did come to evaluate situation. Notified DON, Administrator, NP, and RP. Review of an incident report completed for Resident #91 dated 08/27/22 reflected the following: Resident pushed another resident, causing other resident to fall into wall and sustained small laceration to top of his head. Per witness, this resident pushed the other resident after (roommate) pushed him. Neither resident is able to recall incident. This resident wife was notified and informed she would need to come sit with resident. (Family member) verbalized agreement. Verbalized concerned that her husband was provoked and has never had this type of behavior. Advised wife to speak with admin on Monday. Wife verbalized agreement with changing resident room to provide separation. The resident room was changed from 1:15 PM to 116. On-call notified. Safety precautions in place. Review of the undated face sheet for Resident #81 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of readmission MDS for Resident #81 dated 09/01/22 reflected a BIMS score of 9, indicating a moderate cognitive impairment. Review of an incident report completed for Resident #81 dated 08/27/22 reflected the following: Aid assisted resident to nurse station. Resident has blood draining from his head down his left side of neck and back of head. Resident is unable to recall what happened. Per resident he was hit in the head and need to stop the bleeding. This nurse with assistance of other nurses cleaned blood from resident. Noted a gash 1/2 inch long, superficial, no need for further assessment. Cleansed and applied bandage. Another resident visiting family member witnessed the incident. Per witness, roommate of resident pushed this resident after he shoved him. And this resident fell into the wall hitting his head. NP notified and aware resident is on Plavix. Per NP monitor closely and continue neurochecks. Family member's notified and verbalized concerned with the incident. ADON & DON notified. Review of undated face sheet for Resident #92 reflected an [AGE] year-old male admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 2 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 0600 facility on [DATE] with a diagnosis of dementia without behavioral disturbance. Level of Harm - Immediate jeopardy to resident health or safety Review of quarterly MDS for Resident #92 dated 11/11/22 reflected a BIMS score of 3, indicating a severe cognitive impairment. Residents Affected - Few Review of the care plan for Resident #92 dated 8/15/22 reflected the following: The resident exhibits behaviors of verbally & physically aggressive with agitation towards staff during attempts of providing care/redirecting. Review of hospital records for Resident #91 dated 07/17/22 immediately prior to admission to the facility and found uploaded to the resident's chart on the facility EMR reflected the following: Patient is walking the halls with his (family member) He is currently pleasantly confused. No further aggressive behavior as of yet. Has sitter at bedside. Still waiting on placement. This patient presents with altered mental status. Patient is a [AGE] year-old male brought to the emergency department for evaluation of aggressive behavior in dementia. Patient has no medical need to be admitted and should have been placed from ED but was unable to be. Patient is awake and alert. He is not oriented to time and place. Although his vital signs are stable his labs are mostly within normal limits. He does not have any significant past medical history other than dementia. This change of behavior is relatively new in the last two weeks and after today, he tried to choke his wife, and family are concerned and brought him here. Case management has tried to admit patient directly to a safe facility unfortunately, considering his aggression and being weekend, replacement has not been established yet. Neuro exam is limited, considering patient is not oriented and does not follow commands. Continue 1 to 1 sitter. CT of his head on 7/16 neck for any acute findings. Dispo: patient is at his baseline functional status. Wife refuses to take a patient home due to his violent behavior so still just waiting on a bed at Cross Creek or oceans. Patient is cleared to discharge on ce bed available. Plan discussed with patient and wife, nurse. Addendum: seen and examined on rounds. Wife and sitter at bedside. D/W PA. Patient gets aggressive when he's told what to do, and wife not comfortable taking him home. While I was in room, he refused to say seated and got up. Not aggressive, but clearly was not planning to listen to anyone. Still awaiting a facility that will take him. Reviewed PA findings and jointly created plan as above and agree. Review of physician progress note for Resident #91 dated 07/27/22 reflected the following : Patient was seen in collaboration with the supervising physician. Discussed POC with MD. Patient was admitted as a LTC resident due to dementia with behavioral issues. Admin history reason for admission for this day: the patient is a [AGE] year-old Caucasian male with a past medical history of dementia, who was brought to the emergency department for evaluation of aggressive behavior. Over the past four years, the patient's dementia has been slowly progressing to the point where his wife had to stay home with him for 24 hour care. Over the past three days prior to admission, patient's wife stated that he had been acting very aggressively. She stated that the morning of admission, he tried to choke her and hit their son several times when they tried to redirect him to eat, and to not wander outside . initially, we tried to place the patient into a psychiatric facility from the emergency room; however, we were unsuccessful as it was a weekend. As time progressed, the patient's wife did not want him placed in a psychiatric facility, and instead requested long-term care placement. Review of NP notes for Resident #91 dated 08/29/22 reflected the following: Patient was seen in the secure unit today. He is awake and alert, and oriented to his name only. He is ambulatory. Staff reported some behavioral issues where he had an altercation with another resident, which is unusual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 3 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few from his baseline since admission. Patient is afebrile, vital signs have been stable, will monitor closely. Assessment and plan. Dementia: dementia, aggressive behavior. Patient is awake and alert is not oriented shot time and place all the rest signs are stable. His labs are mostly within normal limits. He does not have any significant past medical history. Other than dementia. Neuro exam is limited considering patient is not oriented and does not follow commands. CT of his head on 7/16 negative for any acute findings. Patient will need a secure locked unit as he is at risk of wandering in elopement. Dementia continues to worsen and he is not oriented to place. Continue Namenda. Patient is back in the memory care unit due to exit seeking behavior. Staff reports that he had an altercation with another resident in the unit, able to redirect after the incident. Monitor closely. Interview on 11/30/22 at 11:25 a.m., the DON stated Resident #91 had punched Resident #92 in the dining room during breakfast that morning and as a result was on one-to-one supervision with a designated staff person. Observation and interview on 11/30/22 at 12:28 p.m. revealed CNA E seated in the hall adjacent to the dining area of the secure unit observing the area. She was 20 feet away from Resident #91 with three tables full of residents between them. She stated there were two CNAs assigned to the hall who were out in the main part of the facility retrieving their lunches. She stated she knew there had been an altercation between Resident #91 and #92, and she was made aware by the other CNAs. She said they told her Resident #91 was combative with another resident and to be wary of him. She stated the DON asked her to do one to one supervision of Resident #91. When asked what one to one supervision meant, she stated it meant to have him within her sight at all times. She stated there was not direction given about how close she needed to stand near the resident. She stated she had not communicated with the nurse who was currently on the hall about the incident or Resident #91's behavior. She stated LVN B told her about what happened. She stated LVN D was aware to keep eyes on everyone while on the secure unit. She stated technically, all the residents needed to be supervised, so Resident #91 did not need special supervision. She stated she was familiar with Resident #91 from when she picked up shifts, and she had never seen him exhibit any aggression. She stated she was not concerned about his behavior and that, besides some residents with high risks of falling, no one in the secure unit worried her for their safety or the safety of others. Observation and interview on 11/30/22 at 12:28 pm revealed Resident #91 seated at a table next to the back door of the secure unit dining area. Two female residents were seated at the table with him, and immediately behind him were three male residents seated at the neighboring table. There was a total of 24 residents sitting at tables in the dining area. Observation on 11/30/22 at 12:32 p.m. revealed LVN D standing at a medication cart in the nurse's station area adjacent to the dining room. The other two CNAs assigned to the hall returned with their lunch plates and went into a room off the nurse's station and closed the door. The CNAs were there for another ten minutes. Two visitors engaged CNA E in the nurse's station for a few minutes, and during this time, the residents in the dining room within, including Resident #91, were not in her line of sight. She also entered the room off the nurse's station where the other two CNAs were and closed the door behind her for a minute. Resident #91 did not have constant supervision during this period of time. Interview on 11/30/22 at 12:35 p.m., LVN D stated she had been back here about 30 minutes. She stated she had heard about an altercation, but she did not know offhand who the residents were, who were involved and had to look in her computer to determine them. She stated she was not given any instructions or guidance on what happened or what measures were in place. When asked if she knew of any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 4 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few measures, she stated her understanding was that the NP spoke to one of the ADONs, but she was not sure what the orders were. She looked in her computer and said no PRN anxiety medications were given for either resident. She said there was no one to one supervision currently needed or happening on the unit, to her knowledge. She said she had never seen Resident #91 be aggressive before, but she did not often work with him. She stated she usually found out about behaviors on a progress note or the 24-hour report. Interview on 11/30/22 at 12:48 p.m., CNA F stated she was present in the secure unit that morning (11/30/22) when Resident #91 assaulted Resident #92. She stated her back was turned helping two ladies eat, and she heard something, turned around, and saw them. She stated she worked with Resident #91 every day, and he had aggressive behaviors at times but was usually calm. When asked if she was aware of another incident of aggression by Resident #91, she first said no, but then when asked about the specific incident in August, she said she remembered. She stated it happened on the 2-10 p.m. shift, so she was not present when it occurred. She stated she believed that Resident #91 pushed Resident #81, and then Resident #91 was moved to a different room. She stated she did not think Resident #81 had any injuries after the incident. She stated she had not received any specific training or in-servicing after the incident. When asked what interventions she had been trained to use when Resident #91 exhibited aggressive behaviors toward another residents, she stated she would separate the residents. She could not think of any other interventions. When asked if she had access to view interventions in the resident care plan, she stated she did but could not remember how to access the care plans on her electronic documentation system. She stated she was updated on new incidents and resident behaviors each shift when they get a report from the outgoing CNAs or nurse. She stated she was not told that Resident #91 needed to be on one-to-one supervision after the incident with Resident #92 that morning, but she was keeping an eye on him. Interview on 11/30/22 at 12:55 p.m., CNA G stated she had been involved in the incident between Resident #91 and Resident #92 that morning. She stated they were eating breakfast and were just fine, and suddenly Resident #91 stood up and walked over to Resident #92 and began punching him. She stated it happened very quickly, but she got up immediately and got in between the two residents. She stated LVN B was also there and helped to intervene. She stated LVN B took Resident #91 down the hall, and they called the ADON to come assist. She stated Resident #92 was injured, and he was sent to the hospital, but she did not know the extent of his injuries. She stated no one had in-serviced her on the incident or what to do with Resident #91, but she and her colleagues knew to keep an eye on everyone. When asked about what to do when two residents had an altercation, she stated she was to separate them and call a nurse. Interview on 11/30/22 at 1:10 p.m., the SW stated Resident #91 had been aggressive in the facility (she had no further details), but not toward his family prior to admission. The SW stated she had just learned about his assault of Resident #92 a little while ago. The SW stated she usually goes to check on residents involved in such an incident, but she had been in care plan meetings that day. The SW stated she did not have a role in any care planning for aggression and that nursing handled that. Interview on 11/30/22 at 1:26 p.m., ADON A stated she had worked at the facility since October 2018. She stated she was in her office this morning around breakfast time, and the CNA came out and said Resident #91 and #92 got into it. She stated she went onto the secure unit and saw Resident #92's eye was bleeding. She stated the charge nurse for the unit, LVN B, was on a different hall, so ADON A stated she took care of it. She said she applied gauze and notified the NP, who wanted him sent to the hospital due to him being on Plavix. She stated she then talked to Resident #91, who was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 5 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few able to tell her much. She stated staff told her that Resident #91 thought Resident #81 had his jacket on, and from there they started fighting. She stated the staff said the residents pushed each other, and Resident #91 initiated the punches. She stated they (she thought they was the DON) put him with a one-on-one staff, and she was not sure who they chose to do that job. She stated the definition of one-on-one supervision was the CNA should stay right by the resident. When asked how many feet there should be between the resident and the one-on-one supervisor, she stated the staff person should be able to see the resident at all times. She stated she did not know what the staff person assigned to provide one on one supervision was told about what that supervision should entail. She stated she told LVN B to assign someone back there to Resident #91. She stated she had heard of other times when Resident #91 was aggressive, but she had not seen him be aggressive. When asked what she knew about those events, she stated they moved him into another room after he was aggressive, and she believed it was aggression against Resident #81. She stated Resident #91 was not aggressive all the time but had his moments of aggression. She stated she was not aware of any history of aggression in Resident #91 before he came to the facility. She stated she was not sure what the interventions in place were to respond or react if Resident #91 exhibits aggression. She stated they were supposed to keep the residents safe, so separating them would be important. She stated she did conduct training and in-servicing for the staff if there was a particular problem they needed to address. She stated she had not trained staff about resident-to-resident abuse or aggressive behaviors. She stated the staff had computer-based training they were supposed to do, but she was not sure what all training had been offered to them related to aggression, behaviors, or Resident #91. Interview on 11/30/22 at 1:39 p.m., LVN B stated she was sitting in the corner of the dining room, heard a CNA yell stop and turned around and saw Resident #91 punch Resident #92 with a closed fist in the eye. She stated she and CNA G separated them. She stated she sat with Resident #91 until police showed up while ADON A assessed Resident #92. She stated once everything was calm, she was told by the DON to assign someone to one-on-one supervision, and Resident #91 had since been sitting in a chair in a dining area calm with residents. When asked what the definition of that one on one was, she stated the DON asked her to make sure the residents were safe and to keep an eye on Resident #91. She stated she assigned one on one supervision to CNA E, and her expectation was CNA E should have been right there with Resident #91. When asked if 20 feet away from the resident met the definition of one-on-one supervision, she stated, as long as Resident #91 did not appear agitated, the staff could be at a distance from him. When asked if Resident #91 was showing signs of agitation prior to assaulting Resident #92, she said he was not. She stated Resident #91 was eating his food one second and up the next. She stated the way they knew which residents had aggressive behaviors by looking at behavior notes and sometimes the 24-hour book. Interview on 11/30/22 at 1:46 pm, the DON stated a CNA came with ADON A to her that morning (11/30/22) during the breakfast hour and told her there had been an altercation. The DON said she went to the unit and saw Resident #92 with some redness around his eye, and the staff explained Resident #91 had hit him. The DON said she verified that the staff had told the ADM, who was the abuse coordinator, and she called the NP to make notification. The DON stated she stayed in the unit for 30 minutes and told LVN B to stay with Resident #91. The DON stated by the time EMS arrived, Resident #92 was walking around. The DON stated she told ADON A and LVN B to designate a third person in the secure unit so that someone could be assigned to Resident #91 to supervise one to one. The DON stated her expectation for one-to-one supervision was to have eyes on the resident the whole time. The DON said the staff should get up and follow the resident if s/he walked down that hall and stay with him or her. The DON stated one to one supervision could include being within (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 6 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few reach of the resident, but close proximity was her expectation. The DON stated the NP decided to send Resident #92 to the hospital because he was on anti-platelet medication. The DON stated she did not know yet the extent of Resident #92's injury and was waiting to hear from the hospital. The DON stated for Resident #91, the NP just advised close monitoring. The DON stated she believed there was an order for CBC, TSH, CMP labs, but she did not know why the order had not been entered. The DON stated Resident #91 did not have any PRN medication for agitation, because he did not get agitated. She stated Resident #91 would be sitting and smiling one minute and then, all of a sudden, he was aggressive. The DON stated she learned the jacket Resident #92 was wearing looked similarly to one of Resident #91's favorite jacket, and she thought that triggered him. When asked if Resident #91 had ever assaulted anyone, DON stated she did not think he had but remembered the incident on 08/27/22 after checking the EMR. The DON stated she did not know that he had a history of aggression before being admitted to the facility. The DON looked at the hospital progress note and the MD's progress note after admission and stated she did not remember seeing that information . When asked how they ensure the admission referral was thoroughly read, DON stated she tried to read all the referrals. She stated the IDT was responsible for reading the entire admission packet, but she was not sure specifically who should be primarily responsible. The DON did not describe any formal process in place for reviewing admitting information. The DON stated Resident #91 was placed on the secure unit on admission, and that was because they assumed he would have some behaviors, but what they were aware of was wandering and exit seeking. The DON stated the secure unit has more staff supervising residents, and they have a lot of activities. The DON stated someone from activities was usually with them. The DON stated the first incident of aggression by Resident #91 was triggered when his roommate pushed him, and Resident #91 pushed back. The DON stated the roommate was injured. The DON stated in the immediate aftermath of this event, Resident #91's family member came to the facility and sat with him all day. She stated they did not put anything in place after the first incident except general closer monitoring. The DON stated they updated his care plan at that point, and she read the following interventions from his care plan, communication, cues, assisting verbalization, psych consult as indicated, when he becomes agitated intervene, engage calmly in conversation. The DON stated she thought they did not intervene more, because his roommate initiated the event. The DON stated he should have had a psych consult and did not know why that had not occurred. The DON stated it was the ADON's responsibility to oversee processes like that, but it was always also her responsibility. The DON stated there was no formal direction after the incident of that morning given by her to the staff. Interview on 11/30/22 at 2:05 p.m., the ADM stated he was aware of the incident of Resident #91 punching Resident #92. The ADM stated his understanding was that Resident #91 assumed the jacket Resident #92 was wearing was his own jacket. The ADM stated a CNA came to him and told him the incident had occurred. The ADM stated he went back there and saw that there was a bruise around Resident #92's eye. The ADM stated the NP sent Resident #92 out to the hospital to be assessed, and they put Resident #91 on one-on-one monitoring. The ADM stated the DON assigned the one-on-one supervision. The ADM stated at that point in the situation, there were four staff designated to the secure unit, and the one-on-one supervisor was a fifth. The ADM stated the one-on-one supervision was going to last until they deemed Resident #91 was not a danger to others. The ADM stated he could not presently say when that would be. The ADM stated they could deem him safe after constant supervision to see what his actions were. The ADM stated they could request the SW to speak with him to determine if he was safe, and they could get psychology involved. When asked what defines one on one supervision, ADM stated it depended on the situation. The ADM stated it would mean the one-on-one supervisor would stay in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 7 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few general area of the resident. The ADM stated that on the secure unit, there was not a lot of room to maneuver, and they just had to have a straight line of sight of the resident being supervised. The ADM stated he did not know about Resident #91's history of aggressive behaviors. He was asked to read the hospital paperwork for Resident #91 in order to verify that the document included mention of recent aggressive behaviors, but he did not do so during the interview and did not remark on the content of this document or the facility physician progress note. The ADM stated he thought the incident on 08/27/22 to be an isolated incident. The ADM stated the facility procedure was to review the clinical information, and it was the job of the IDT to do so. The ADM stated they normally did not admit aggressive people or they had a plan to manage the behaviors. When asked what kind of plan they would enact, ADM stated they normally just would not admit anyone with a recent history of aggression. When asked if he would have admitted Resident #91 had they read the hospital referral paperwork, he stated it would depend and did not elaborate. Interview on 11/30/22 at 2:45 p.m., LVN N stated she vaguely remembered an incident when Resident #91 and Resident #81 had an altercation. LVN N stated Resident #81 was going through Resident #91's things and would not stay on his own side of the room. LVN N stated the witness who explained what happened was the family member of another resident, but she could not remember who was the aggressor in the situation. LVN N stated she did not recall what happened. She stated she did recall that Resident #91's family member came to the facility, and he changed rooms. LVN N stated she did not remember any in-servicing, directions from management, or new orders from that event. When asked what she should do if residents in her care had an altercation, LVN N stated she would split them up and get them each assessed. Review of facility policy dated September 2018 and titled Protection of Residents During Abuse Investigations reflected the following: Our facility will protect residents from harm during investigations of alleged abuse. During investigations of alleged abuse, residence will be protected from armed by the following measures: a. C. If the alleged abuse involves another resident, the accused residence representative and attending physician will be informed of the alleged abuse incident, and that there may be restrictions on the accused resident's ability to visit other residence, rooms, unattended. If necessary, the accused resident's family members may be required to help meet this requirement. This was determined to be an Immediate Jeopardy (IJ) on 11/30/22 at 5:30 p.m. The ADM was notified. The ADM was provided with the IJ template on 11/30/22 at 5:33 p.m. The following Plan of Removal submitted by the facility was accepted on 11/30/22 at 12:45 p.m.: Plan of Removal Issue: The facility failed to prevent Resident #91 from abuse, and neglect. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: On 11/30/22 there were 26 Residents with the potential to be affected by Resident #91. On 11/30/22, the Director of Nursing placed Resident #91 on 1:1 monitoring with a facility staff member remaining within 6 feet of the member while outside of the resident's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 8 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Beginning 11/30/22 and on-going, the DON / designee will assign a staff member to do 1:1 continuous observation on all shifts and provide training requirements to the staff for the resident at the time of assignment. Upon assignment, The DON / designee will in-service the assigned staff member(s), they must be between the resident and the entryway into the resident's room while in resident's room alone. Staff providing the 1:1 monitoring will sign in on the schedule binder to show the coverage day and hours. Resident #91 will remain on 1:1 monitoring until he is sent to a psychiatric facility to be evaluated. The DON / designee will be responsible for ensuring this is carried out. On 11/30/22, Resident's Primary care Physician gave an order for (psychology provider) Psychology to evaluate and treat. (Psychology provider) will follow Resident #91 while resident in this facility. The DON will be responsible to ensure Resident #91 continues to be treated by (Psychology provider). Beginning 12/1/22, The Regional Nurse Consultant will monitor that Resident #91 remains on services per physician's orders by verifying that visits are taking place, one time per week for four weeks, then two times per month for two months. The Director of Nursing re-educated the licensed nurses that were on shift at that time, on the indications of usage of PRN Antianxiety medication. The remainder of facility Nurses that were not working at that time, were re-educated prior to working their next shift and / or via telephone. All Licensed Nurses were re-educated by 12/2/22 by the DON / designee. Beginning 12/2/22 and on-going, The DON / designee will monitor all facili[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 9 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 - Few 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, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 8 residents (Resident #78) reviewed for care plans. The facility failed to address Resident #78's knee pain in the care plan. The facility failed to revise Resident #78s care plan to reflect her medical diagnosis. These failures could place residents at risk of not having their needs identified, addressed, or met to achieve their highest quality of life. Findings include: Review of Resident #78's face sheet dated 12/03/2022 documented that he was [AGE] years old and who was admitted to the facility on [DATE]. Resident #1's diagnoses included right knee pain, muscle wasting and atrophy (shrinking and weakening of the muscles), and other abnormalities of gait and mobility). Review of Resident #78 care plan dated 11/10/22 revealed no mention of knee pain. Observation and interview on 11/28/2022 at 7:08 PM, Resident #78 was in bed resting. Resident #78 stated his knees hurt and that his family member (FM) had been worried about him. Resident #78 stated staff was not checking up on him regarding his knee. Resident #78 stated days ago I complained to nursing that my knee hurt, and they gave me an ointment. Resident #78 showed no signs of distress. Interview on 11/29/22 at 10:47 AM with FM reported that Resident #78 had knee pain for quite a while. FM stated that facility said Resident#78 had problems with his gait. FM continued that the facility never contacted her about Resident #78's knee pain, and that the facility was supposed to communicate to FM before resident #78 was to receive any new treatment since FM is part of the care plan team. Observation on 11/29/22 at 10:59 AM revealed Resident #78 walked slowly with a limp as moved to the bed, moving in a routine like motion, sighing when lifting each leg with no signs of pain or distress. Interview on 11/29/22 at 11:02 AM, Resident #78 reported he was admitted to the facility due issues with his knees and mobility issues. Interview on 11/30/22 at 11:25 AM with CNA G reported she did not know what was going on with Resident #78. CNA G was unaware Resident #78 had issues with pain in knees. CNA G continued that Resident #78 used a walker and that whenever CNA G went inside the room he would only mention wanting snacks and did not note any knee pain to facility staff. CNA G stated that when a resident was noted to be in pain, staff were expected to immediately notify a nurse and the nurse would go assess the resident. CNA G stated that Resident #78 had a walker even though she was unclear of the specific reason why. CNA G continued that therapy was helping Resident #78 with walking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 10 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 - Few Interview on 11/30/22 at 11:25 AM with CNA F reported Resident #78 seldom let staff know if he was experiencing pain. CNA F stated Resident #78 will sometime express to her that he is experiencing issues with his knee but will not express these concerns to physical therapy. Interview on 11/30/22 at 12:50 PM with LVN B stated Resident #78 did not usually complain about pain or issues with his knee. LVN B also stated, nursing staff assed Resident #78's pain at least three times a day, when providing direct care and if he expressed he was in pain, they would give him with Tylenol. LVN B stated that the DON, MDS coordinator, and charge nurse on duty were the staff responsible for updating the care plan. Observation on 11/30/22 at 12:53 PM, LVN B looked at the EMR. The EMR showed a medical diagnosis of right knee pain and no mention of the diagnosis in the care plan. Interview on 11/30/22 at 12:54 PM, revealed, when asked LVN B stated she was unaware why Resident #78's right kneee was not reflected in his care plan. LVN B stated she would get this addressed, and talk to Resident #78 and his FM to see what was going on. Interview on 11/30/22 12:55 PM LVN C stated that she was in charge of documenting and updating care plans. LVN C claimed, when I do my MDS assessments, I go to residents to ask questions, to see if they are in pain, I look at the records, progress notes, talk to nurses. LVN C reported I see how often the pain is? I will do this for my quarterly, and upon residents' admission to the facility. I am unaware how we did not catch that with Resident #78, but I will go see what is going on. Record review of Resident #78 medical orders dated 11/30/22 at 04:57 PM listed an order for Tylenol 325 mg for pain FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 11 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for one meal (breakfast on 11/28/22), directly affecting one (Resident#49) out of five residents reviewed for mealtime, and the facility failed to serve a suitable, nourishing alternative meals and snacks to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care for all residents residing in the facility. The facility failed to ensure meals were consistently served at the posted mealtimes and failed to provide a diabetic friendly snack at bedtime. These failures could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, unplanned weight loss, side effects from medication give without timely food, diminished quality of life, decreased blood sugars and complication of diabetes. Findings included: Review of Resident #49's undated face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (chronic lung disease), morbid obesity, peripheral vascular disease (disease affecting the blood vessels), major depressive disorder (depression), epilepsy, hypertension (high blood pressure), and osteoarthritis (inflammation of joints). Review of Resident #49's MDS assessment dated [DATE] reflected a BIMS score of 12, which indicated moderate cognitive impairment. Review of Resident #49's care plan last revised on 7/30/2022 reflected she was a smoker, at risk for impaired skin integrity, and had limited physical mobility. Observation and interview on 11/28/2022 at 9:43 a.m., revealed Resident #49 was sitting in her room when a staff member delivered her breakfast tray. Resident #49 stated there had been times when she did not receive her breakfast until after 10 a.m. Resident #49 stated she was supposed to receive her breakfast earlier. Resident #49 did not state the reason why breakfast was late other than that the kitchen was so slow there. In a Resident Council Meeting group interview on 11/29/22 at 10:05AM, three out of seven residents stated facility does not provide bedtime snacks. Resident #83 stated the residents don't receive snacks at night and when residents ask for snacks the staff states that kitchen has been closed. Resident #54 stated the staff always told the residents that the kitchen was closed, and they were not able to get snacks from the kitchen. Resident #55 stated staff also told her the kitchen was closed when asked for snacks. Interview on 11/29/22 at 8:37 PM, Resident #56 stated she did not get bedtime snack and would like to have one. Observation and interview on 11/29/22 at 8:40 PM, CNA S was observed to be sitting in the 300 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 12 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hallway using her cellphone. CNA S stated she did not pass snacks today. CNA S stated it depended on when kitchen made the snack, usually between 7:30pm to 8pm was when the snacks were ready. CNA S stated the kitchen will let them know when the snack were ready. Observation and interview on 11/29/22 at 8:45 PM, ADON W, stated the snacks were kept inside the nourishment room. ADON W, pulled out a tray with nine and a half sandwiches made of ham and cheese that were dated 11/28, cranberry juice, apple juice, milk, apple sauce and orange juice. ADON W stated these snacks were from yesterday. ADON W went to the kitchen and the kitchen was closed and locked. ADON W walked to the memory care unit and checked with CNA R to inquire if snacks were received from the kitchen. CNA R reported to ADON W that there were no snacks provided to the memory care unit. ADON W stated, I guess there were no snacks provided to the residents tonight. ADON W stated this same incident of not having snacks had happened once or twice before and she had informed management. ADON W stated, in this situation, if residents want a snack the staff has a key to the kitchen that was kept at the nurse's station which could be used to obtain dry snacks from the kitchen. ADON W stated kitchen was responsible for putting out the snacks for the nursing staff and the CNAs were responsible for passing out the snacks to the residents. ADON W stated, it was important the residents who were diabetic to get bedtime snacks, so it did not affect their blood sugar level and for the non-diabetic residents not to get hungry between their actual mealtimes. Interview on 11/29/22 at 9:20 PM, Resident #37 stated she did not get bedtime snacks tonight and would like to have one. Resident #37 stated, I ask staff, but they told me they do not have any snacks. Interview on 11/29/22 at 9:22 PM, Resident #10 stated she did not receive bedtime snack tonight and would like to have one. Interview on 11/29/22 at 9:23 PM, Resident # 29 stated he did not receive bedtime snack tonight and would like to get a snack. Resident #29 stated he did not ask them for snack because they told him they got nothing. Interview on 11/29/22 at 9:26 PM, LVN J stated the residents should have gotten the snacks and that she did not know if they had their snacks. LVN J stated the CNAs were responsible to pass out the snacks. LVN J did not know that her residents did not get their bedtime snacks until surveyor informed her. LVN J responded, out of all these days, they did not get their snack today, and nodded her head. LVN J stated the adverse effect of residents not receiving the snacks could lower the blood sugar level if residents were diabetics. Interview on 11/30/22 at 10:07 AM, the ADM stated bedtime snacks were to be provided between 6:30PM and 7PM every day. The ADM stated aids from the kitchen were responsible to bring out the snacks and nursing staff, mainly the CNAs were responsible for passing out the snacks to their residents. The ADM stated, he was told by DM that bedtime snacks were provided on 11/29/22. The ADM stated the adverse effect of residents not receiving bedtime snacks could affect their blood sugar level if residents were diabetics and could go hungry till their next mealtime. The ADM stated he was never informed of residents not receiving snacks. Interview on 11/30/22 at 10:25 AM, the DA Sstated bedtime snacks were made by 7:30PM every day. The DA S stated nursing staff would go and pick up the bedtime snacks from the kitchen. The DA S stated he never [NAME] the snacks out to the nursing staff or to the nurse's station. The DA S stated he was new to the facility, so he did not know all the staff name, so he would let the nursing staff go (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 13 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and pick up the snacks from the kitchen. The DA S stated DM usually made the bedtime snacks and, stated DM made the bedtime snacks on 11/29/22. The DA S stated he did not know if anyone went to pick up the snacks the previous day. Interview on 11/30/22 at 10:30AM, the DM stated she had been working with the facility for three weeks. The DM stated everyone was responsible, but the dietary aids usually made the snacks. The DM stated one of the aids made the bedtime snacks on 11/29/22. The DM stated the bedtime snacks were put out inside the kitchen around 7PM on 11/29/22. The DM stated he saw one of the nursing staff come around 6:30PM and picked up the snacks from the kitchen on 11/29/22. A record review of the facility's meal times reflected breakfast was to be served at 7:30 a.m. Review of facility's policy titled Nutritious Lifestyle, Inc. dated 10/13/17, revealed that snacks would be served to residents as ordered and at HS. 4) All residents are to be offered an HS snack. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 14 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 one of one kitchen reviewed for sanitation and food storage. The facility failed to ensure all food items were properly stored, labeled, dated, and discarded prior to their use-by or best-by dates and that all kitchen staff wore effective hair restraints while in the kitchen. These failures could place the residents at risk of foodborne illness. Findings included: Observation and interview on 11/28/2022 at 6:50 a.m. revealed CK J was in the kitchen without a hair restraint. CK J was observed placing a steam pan in the service line. CK J stated hairnets were required in the kitchen. Observation on 11/28/2022 at 6:52 a.m. revealed DA H was walking through the kitchen without a hair restraint. Observations of the kitchen's reach-in refrigerators on 11/28/2022 from 6:58 a.m. -7:10 a.m., revealed the following: At 6:58 a.m., the reach-in refrigerator contained four trays of portioned out water and tea, unlabeled and undated. One tray had 12 cups of beverages which were uncovered. The second tray had four covered beverages, the third had 13 covered beverages, and the fourth had five covered beverages. At 7:01 a.m., the reach-in refrigerator contained chocolate cake covered with aluminum foil, labeled but undated. At 7:04 a.m., the reach-in refrigerator contained a container of sliced cheddar cheese labeled 11/21/2022 with a lid that did not completely cover the container. At 7:05 a.m., the reach-in refrigerator contained four bowls of salad, uncovered, on a plastic tray dated 11/27/2022. At 7:06 a.m., the reach-in refrigerator contained six bowls of cottage cheese, labeled but undated. At 7:10 a.m., the reach-in refrigerator contained a container of salsa, labeled 7/07/2022, without an opened date. Interview on 11/28/2022 at 7:10 a.m., DA H stated everything in the reach-in refrigerator should have an opened date, and it would be written as an IN date. DA H stated all food times should be tightly covered. When asked if all food times should be labeled and dated, DA H stated yes. DA H stated she had organized the refrigerator before she left and that she had just returned to work after being off. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 15 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 Observation of the reach-in freezer on 11/28/2022 at 7:15 a.m. revealed frozen waffles dated 11/14/2022 in a plastic sealable bag which was opened and not sealed. Observation of the reach-in refrigerator on 11/28/2022 at 7:18 a.m. revealed a bag of coleslaw mix with a use-by date of 11/20/2022. The coleslaw mix appeared soggy and brown. Residents Affected - Many Observation of the reach-in refrigerator on 11/28/2022 at 7:20 a.m. revealed a box of 14 bell peppers dated 11/10/2022. All bell peppers contained a black substance. Interview on 11/28/2022 at 7:21 a.m., DA H stated leftovers were kept for three days. DA H stated the black substance on the bell peppers looked like mold in her opinion, stating I hope it is not mold. DA H stated the bag of coleslaw should have been discarded as well as the bell peppers. DA H stated the other dietary aides had not been trained on throwing away leftovers, stating if she were not there, it did not get done. Interview on 11/28/2022 at 7:26 a.m., CK J stated she had received some in-service training on labeling and dating. CK J stated she was responsible for training the new dietary aide. Observations of the dry storage area on 11/29/2022 from 11:19-11:32 a.m., the following were noted: At 11:19 a.m., the dry storage area contained a six-quart plastic container of cornflakes dated 11/27/2022 with a jar that did not completely cover or fit the container. At 11:21 a.m., the dry storage area contained seven packages of hamburger buns with best-by dates of 11/24/2022. At 11:32 a.m., the dry storage contained a container of teriyaki sauce, opened, and with a package that reflected refrigerate after opening. Interviews on 11/29/2022 from 11:21 a.m. - 11:32 a.m., the LD stated the following: At 11:21 a.m., the LD stated she was not sure whether the facility adhered to best-by dates, but that she would check. At 11:32 a.m., when asked if the opened teriyaki sauce should be refrigerated, the LD stated yes, I would recommend refrigerating it. Interview on 11/29/2022 at 11:45 a.m., the LD stated the kitchen's policies on food storage included discarding leftovers after three days and ensuring foods were covered, labeled, dated, and visually inspected to ensure quality. The LD stated yes that all items should be discarded prior to their use-by date. The LD stated she thought staff should look at it to see if it were rotten, and if the item were soft and mushy, the cook should throw it away. The LD stated yes that she thought bell peppers with black spots should be thrown away. When asked how items such as condiments should be labeled after opened, LD stated they should have an opened date. LD stated the kitchen's sanitation policy included restraining hair via a hair net. LD stated all staff should wear a hair net and cover their hair. The LD stated she had noticed some issues with staff restraining their hair. The LD stated she had noticed staff had not been completely covering all of their hair while in the kitchen. LD stated the DM monitored the kitchen, but she was not sure how the DM monitored. LD stated she monitored the kitchen herself by completing a monthly sanitation audit. LD stated she completed the last (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 16 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sanitation audit about two weeks ago. LD stated she had noticed some issues with staff not labeling and dating food items and had completed an in-service training. The LD stated all kitchen staff had a food handlers license. LD stated either herself or the DM trained staff by completing in-services. When asked what a potential negative resident outcome could be if the kitchen's policies on food storage and sanitation were not followed, LD stated residents could get sick because they were at higher risk. LD stated older populations could become sick more easily. Observation and interview on 11/29/2022 at 1:34 p.m., DA I was observed walking through the kitchen towards the exit door without a hair net on. DA I stated her shift started at 1:30 p.m. DA I was observed to grab a hair restraint located near the kitchen exit and put it on. Interview on 11/29/2022 at 1:35 p.m., the LD clarified that the facility did adhere to best-by dates, stating they had thrown away the hamburger buns with the best-by dates of 11/24/2022. Interview on 11/29/2022 at 2:24 p.m., the DM stated she used checklists to monitor the kitchen for food storage and sanitation. LD stated she completed a walk-through of the kitchen every morning. LD stated cooks completed walk-throughs of the kitchen upon starting their shift. Interview on 11/30/2022 at 4:45 p.m., the ADM stated food should be stored according to how long it was good to be stored. The ADM stated items should be stored first in, first out when storing new food items. The ADM stated things should be checked on a regular basis and discarded when it was out of date. The ADM stated food should be discarded after three days depending on what it was. The ADM stated yes that the kitchen adhered to best-by dates. The ADM stated dry storage food items were labeled when they came in. The ADM stated leftovers were labeled as they were placed in the fridge and dated as the day it was first used. The ADM stated food should be covered with a lid that fit the container, with saran wrap, or with a different type of covering. ADM stated staff ensured hair did not get into food by using hair nets. The ADM stated the DM and the LD, who came out twice a month or so, were responsible for monitoring the kitchen to ensure compliance of food storage and sanitation. The ADM stated the kitchen was monitored by the DM and the LD who came in and checked that things were labeled and dated. The ADM stated the DM checked that sanitation was good daily and the LD checked sanitation whenever she came in. The ADM stated kitchen staff were required to have a ServSafe certification which gave them the majority of their training. The ADM stated as far as he knew, kitchen staff had all been trained on food storage and sanitation. The ADM stated the ServSafe training was web-based and additional training was provided by the DM as needed such as demonstrating how things should be done. The ADM stated if food were spoiled or molded, it could affect the residents in that way. The ADM stated if food were expired or molded and served to residents, it could have foodborne pathogens., The ADM stated if hair restraints were not worn, hair could get into food. Review of the LD's most recent sanitation audit dated 11/17/2022 reflected the following: Section 4: Staff Sanitation reflected no that hair nets and beard guards (if necessary) were in use. Section 5: Food Storage reflected no that all refrigerated and frozen foods not covered, labeled, dated, labeled with an open date, free of spoilage, and not expired. General comments reflected Continue working on dating and labeling, and record temperature logs. Discussed findings with DM and Admin. RD in-service this month on labeling, and temperature logs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 17 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An in-service dated 11/17/2022 labeled Dating & Labeling reflected all kitchen staff were trained on labeling and dating. Review of the facility's policy titled Food Storage dated October 1 2018 reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will e stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 3. Freezers e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. A record review of the facility's policy titled Employee Sanitation dated 12/01/2011 reflected the following: Policy: The consultant dietitian will monitor each facility to ensure that the facility uses good sanitation practices in accordance with the state and Federal Food Codes. The following guidelines should be used to ensure adequate sanitation practices are in place. 3. Employee Cleanliness Requirements b. Hair restraints, such as hats, hair coverings or nets, caps and beard/moustache restraints (snoods) or other effective hair restraints are worn to keep hair from contacting food and food-contact surface. A record review of the FDA's 2017 Food Code reflected the following: Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 18 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Pf FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 19 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent development and transmission of communicable disease and infections for 1 of 1 resident (Resident #44) reviewed for infection control Residents Affected - Few CNA G failed to change gloves and perform hand hygiene between cleaning the resident and before applying new brief. This deficient practice could place all residents who were occasionally or frequently incontinent of bladder and/or bowel at risk for cross-contamination and the spread of infection. Finding included: Review of face sheet of Resident #44 reflected [AGE] year-old female admitted to the facility on [DATE] with diagnosis of muscle wasting and atrophy, hypertension (high blood pressure), dementia, age-related physical debility. Review of Resident #44's quarterly MDS dated [DATE] revealed BIMS score of 8, which indicates significant cognitive deficit, Review of Resident #44's undated care plan revealed, resident had bowel and bladder incontinence related to dementia. Observation on 11/30/22 at 10:48AM revealed that CNA G did not change gloves and did not perform hand hygiene after cleaning resident's bowel movement and proceeded to place new brief under the resident followed by applying barrier cream onto the skin of the resident's sacrum area with the use of the same gloves. Interview on 11/30/22 at 12:03PM, CNA G stated she forgot to change the gloves and perform hand hygiene after cleaning the resident and stated it was important to perform hand hygiene to prevent cross contamination and spread of infection which possible can get resident from getting infected. Interview on 11/30/22 at 4:40PM, ADM stated the adverse effect of not changing gloves from going from dirty to clean and not performing hand hygiene was an infection control and it was to prevent cross contamination. ADM stated his expectation for this staff are to follow the policy and to follow sanitation process. Interview on 11/30/22 at 5:24PM, DON stated her expectation for her staff was to change gloves when going from dirty to clean while providing care and to perform and hygiene between gloves changing. DON stated it was important so that it reduced the infections, and the adverse effect could possibly be resident's having urinary tract infection or some kind of infections. DON stated the bedtime snacks were dietary's responsibility to make it and to place it at the nurse's station. DON stated CNAs passed out the snacks to the residents and both the nurses and CNAs were responsible for making sure the residents received the snacks. DON stated the adverse effect of residents not receiving the bedtimes snacks could be blood sugar dropping down for those who were diabetics but stated the staff had keys to the kitchen if they needed to go grab anything for the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 20 of 21 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 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 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 Review of facility's policy titled, Incontinence Care dated 04/15 revealed, the purpose of this procedure was to provide guidelines that should aid in preventing the resident's exposure and spread of infections. For urinary incontinence: - Residents Affected - Few e. Turn resident on side. Appropriately and gently wash, rinse, and dry the remaining area including the rectum and buttocks without returning to the urethral area. f. Finish with a clean, moist cloth to remove soap or other incontinent product that may require rinsing. g. Remove gloves, sanitize hands, and apply clean gloves. h. apply barrier cream or lotion as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 21 of 21