Inspection·October 1, 2024

F 0609 discomfort, scalp bruise on the right side of her head. No other skin issues at this time. WCTM. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's CT scan (is an imaging test that uses x-rays and a computer to create detailed images of your bones and soft tissues of the head dated 09/23/2024 reflected, Right parietal scalp contusion (it occurs when there is bleeding under the scalp, but the skin is not broken. The affected area may have swelling) without fracture. Residents Affected - Few Review of facility's investigation folder regarding the incident reflected the following statements: On 09/24/2024 at 10am administrator and myself went to talk to (Resident #1). I help him translate. We asked what happen. stated she had fallen backwards in the van, on her way to her dialysis and she wasn't strap properly. She said only was strap with one strap. She hit her head. She told dialysis nurses about it. MD at the clinic told them to send out since she told her head was hurting. She then was sent to the local hospital. Resident #1, was interviewed by the Administrator regarding the incident that occurred during transporting to Dialysis. The resident stated her chair tilted backward during transport. She stated that as the Van driver accelerated from tile stoplight, the wheelchair tilted backwards, and she bumped her head. I asked if she was properly secured in the van. She (Resident #1) stated she could not see the straps but [NAME] as though the chair could not have been secured correctly, however she was not sure. Signed by the administrator, undated. Review of facility's Van Driver personnel file reflected staff was taken off the van and suspended as of 09/26/2024 due to failure to report an incident and failing to meet job expectation. The following was also reflected and signed by the administrator and van driver, Official written reprimand for failure to perform the required functions of your job duties per instruction and training. On 9/23/24 there was an incident that took place on the van during resident transport to a recurring appointment. This incident of carelessness had the potential to cause harm. Review of Resident #1's skin assessment dated [DATE] reflected: Top of scalp knot to top of head from transfer related incident. Review of facility's in-services reflected the following: Post fall procedures dated 09/26/2024. Abuse and Neglect dated 09/26/2024 . Review of facility's record in TULIP reflected the incident was not reported to the State Agency. During an interview on 10/01/2024 at 11:01 am, the Van Driver stated she had been driving the facility's van for 2 years. She stated she was trained on how to operate the van prior to driving the van and was trained routinely. The Van Driver stated on 09/23/2024 at about 10:25 am while taking Resident #1 and 2 to dialysis, she had stopped at the red light, when the light changed green, the moment she put her foot on the gas she heard Resident #1 yelling saying she was moving back, and that she hit her head. The Van driver stated she looked over her shoulder and saw that Resident #1's wheelchair tilted back, she couldn't pull over right away because they were in the middle of the road, so she drove a little for safety and to pull to the side. The Van driver stated she parked the van, went (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 2 of 9 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 10/01/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to the back where both Residents were and positioned Resident #1 properly in the wheelchair. The Van Driver stated she observed a bump on Resident #1's head, she immediately called the facility, spoke with the Administrator, and 2 other nurses, and was told to take Resident #1 to dialysis. The Van Driver said she called the dialysis center, staff at the center spoke with Resident #1, and the dialysis center staff said to take Resident #1 to dialysis. The Van Driver stated when she got to the dialysis center, the staff were waiting outside for Resident #1, she was assessed before and after taking her in and she was told it was ok to leave. The Van Driver stated she strapped Resident #1 in but was not sure what happened. The Van Driver stated she hadn't driven the van since the incident, she was interviewed by the Administrator and suspended. During an observation and interview on 10/01/2024 at about 11:23 am of the facility's van with the Van Driver, the Van Driver demonstrated how to properly strap a resident in the van. It was observed that there were 4 straps, 1 for each wheel on the wheelchair, 2 seat belts to secure the resident. It was also observed that when a wheelchair was strapped properly, there was no way for the wheelchair observed to tilt or move. The Van Driver was then asked what did she see when she stopped the van and went to check the Resident? The Van Driver touching the right wheel of the wheelchair and stated it was not on proper and saying the wheelchair was strapped. The Van Driver stated she lifted Resident #1's wheelchair but her feet were not in the air. The Van Driver again stated she noted a bump on Resident #1's head that was when she called everyone. The Van driver stated it all happened so fast, she stated Resident #1 was still connected to straps and she didn't know what happened. During an interview on 10/01/2024 at 11:42 am Maintenance Director stated he checked the van monthly and asked the Van Driver to report if the tires and engine lights were on. The Maintenance Director stated they have not had problems with the van. He also stated trainings were done every 6 months on how to secure the wheelchair in the van. The Maintenance Director said he couldn't tell if Resident #1's wheelchair was properly strapped because he was not in the van at the time of the incident . During an interview on 10/01/2024 at about 11:50 am, Resident #2 stated he was in the facility's van on 09/23/2024 when the incident happened with Resident #1. Resident #2 stated he was put in the van first by the Van Driver, strapped and then Resident #1. Resident #2 stated they were at the light, when the Van Driver accelerated, he heard Resident #1 saying she was going back in her chair and that she had hit her head. Resident #2 stated when he turned, he saw Resident #1's feet in the air, her wheelchair was tilted over but he couldn't see Resident #1's head. Resident #2 stated he could help Resident #1 because he was strapped but the front 2 wheels of Resident #1's wheelchair was not strapped. Resident #2 stated the Van Driver couldn't park immediately because they were in the middle lane, other cars were coming on both ends. Resident #1 stated when they parked after the traffic had cleared, the Van Driver got down, had to pick Resident #1 up because her feet were in the air. Resident #2 stated that was the first time such an incident had happened. During an interview on 10/01/2024 at 12:24 pm, Resident #1 was sitting in her room, eating lunch. Resident #1 understood English and spoke a little with demonstration. When asked about the incident on the van, Resident #1 started to yell, saying she fell and hit her head. Resident #1 then started to demonstrate that her feet were in the air while saying it, touching the 2 front wheels of her wheelchair saying it was not hooked. Resident #1 then demonstrated while saying she had the belt strapped around her, her wheelchair went back, and she hit her head while pointing to where she hit her head. The State Surveyor observed a raised bruise area on right parietal head about the size of a nickel. Resident #1 also stated she was scared and that she went to the hospital when she went to dialysis. Resident stated she was not hurting and said, thank you Jesus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 3 of 9 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 10/01/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/01/2024 at about 3:48 pm, the Administrator stated he was the abuse and neglect coordinator, and it was his expectation that staff reported any suspicion of abuse and neglect to him immediately. He also stated if there were allegations of abuse or neglect, he in-serviced the staff, investigated, and determined if it had to be reported to the state. He stated he was made aware of the incident with Resident #1, and he initiated an investigation. The Administrator stated according to what he was told, the Van Driver was taking Resident #1 to her routine dialysis, when she accelerated at the light, Resident #1 bumped the top rear of her head. The Administrator stated from the way it was explained to him, it appeared to be a very light bruise. The Administrator stated he took the Van Driver off the van pending investigation, the Resident was sent to the ER and the findings were negative, neurological assessments (exam consist of physical examination to identify signs of disorders affecting the brain, spinal cord, and nerves) were completed accordingly, family and MD/NP notified, safe survey with other residents who rode the van, abuse and neglect in-service with staff, and the Resident would be transported by commercial transport until the van was check out. He stated he asked the Van Driver to explain and show him what had happened. The Administrator stated, My finding is, there was no way possible, this would have happened if the resident was strapped properly, based on expectations and training. Staff were in-serviced on abuse and neglect. The Administrator stated, from the way the incident was explained to him, he did not think it was reportable. The Administrator stated the Van Driver was suspended because he didn't think the Van Driver was saying the truth. The Administrator stated he spoke with Resident #1 and Resident #2, but the Residents were not sure if the wheelchair was strapped properly. The Administrator stated suspicion of abuse and neglect with injury was reportable . Review of facility's policy titled Abuse, Neglect, and Exploitation dated 08/15/2022 reflected: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse neglect, exploitation, and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reporting/Response A The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation} involve abuse or result in serious bodily injury, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 4 of 9 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 10/01/2024 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 0609 b. Level of Harm - Minimal harm or potential for actual harm Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Residents Affected - Few The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 5 of 9 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 10/01/2024 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 observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 (Resident #2) of 2 residents reviewed for blood glucose monitoring. Residents Affected - Few RN A failed to perform hand hygiene and wear gloves while checking Resident #2's blood glucose. This failure place residents at risk of infections. Findings included: Review of Resident #2's face sheet dated 10/01/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmission date of 04/02/2024 with diagnoses that included end stage renal disease, type 2 diabetes mellitus, peripheral vascular disease, and dependence on renal dialysis. Review of Resident #2's care plan initiated 02/13//2024 reflected Resident #2 had an ADL self-care performance deficit related to right below the knee amputation, independent with all ADL's and driving. It was also reflected Resident #1 was at risk for fluid volume overload or potential fluid volume overload related to end stage kidney disease. Review of Resident #2's Nursing Home Quarterly MDS assessment dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident #2's physician orders reflected: Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale subcutaneously before meals and at bedtime for DM dated 04/02/2024. During an observation on 10/01/2024 at about 12:02 pm, RN A walked into Resident #2's room to check his blood glucose for lunch, ungloved hands with a glucometer machine, test strip, a lancet, an alcohol pad, and a 2x2 gauze. RN A did not perform hand hygiene after entering the room, did not wear gloves, she took Resident #2's finger, and disinfected it with the alcohol pad. RN A then used her ungloved hands and dried Resident #2's finger, thereby disinfecting the finger. RN A then stuck Resident #2's finger with the lancet and put a blood sample on the test strip that was inserted in the glucometer. RN A then used the 2x2 gauze to wipe the blood off Resident #2's finger with her ungloved hands. RN A walked out Resident #2's room without hand hygiene, touching the doorknob. During an interview on 10/01/2024 at 12:10 pm Resident #2 stated the staff always checked his blood glucose without wearing gloves. Resident #2 also stated you don't know what the staff have touched, and they were touching you with ungloved hands. During an interview on 10/01/2024 at about 12:39 pm RN A stated, I didn't wear gloves, I was supposed to allow the alcohol to air dry. We wear gloves to protect the residents and the staff from infection. I do not want to transmit infection from the resident to me or from me to the resident. I do not know what to say, I know that was not right, he was my last resident to do accu check and I was hurrying to go to the dining hall. During an interview on 10/01/2024 at about 2:57 pm, the DON stated there was no excuse for what RNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 6 of 9 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 10/01/2024 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 Residents Affected - Few did when checking Resident #2's blood glucose. The DON stated RN A should have knocked on the Resident #2's door, wash her hands, wore gloves, cleaned Resident #2's finger, allowed it to air dry, and took the blood sample. The DON stated gloves should be worn when coming in contact with Resident's bodily fluids, for infection control, protecting the resident, and the staff. The DON stated she expected the staff to follow the checkoff steps for checking blood glucose. The DON stated RN A told her what had happened, and she went ahead and in-serviced RN A on infection control and hand hygiene with return demonstration. Review of in-service dated 10/01/2024 titled Infection Control and hand hygiene presented by the DON, signed by RN A. Review of the facility's Glucometer/Fingerstick check off undated reflected: Procedure -- Did the nurse set up equipment prior to starting the procedure? --Clean the Glucometer before use? -- Did the nurse wash hands prior to putting on gloves? -- Identify Resident, ensure privacy, and explained the procedure to the resident? -- Place barrier down for equipment? -- Clean the finger of the patient with alcohol pad and allow the area to dry? -- Place test strip and lancet in sharps container after the procedure was performed. -- Disposed of gloves and washed hands before touching anything else and exiting the room. -- Re-glove and disinfect glucometer with germicidal (must remain wet for 2 minutes) ·and allowing it to air dry for the appropriate amount of time? -- After cleaning glucometer if placed on top of cart was the area cleaned with a POI wipe or was a barrier provided? --Disposed of gloves and rewashed hands? Review of the facility's policy titled Hand Hygiene dated 10/24/2022 reflected: (Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 7 of 9 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 10/01/2024 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 Residents Affected - Few Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility's policy titled Infection Prevention and Control Program dated 05/13/2023 reflected: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. Staff Education: a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 8 of 9 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 (X3) DATE SURVEY COMPLETED A. Building 10/01/2024 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 All staff shall demonstrate competence in relevant infection control practices. Level of Harm - Minimal harm or potential for actual harm c. Direct care staff shall demonstrate competence in resident care procedures established by our facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 9 of 9