Inspection·April 3, 2025

F 0677 Resident #18 Level of Harm - Minimal harm or potential for actual harm Review of Resident #18's face sheet, dated 4/3/2025, reflected a [AGE] year-old female re-admitted to the facility on [DATE] and diagnosed with Unspecified Dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities). Residents Affected - Some Record review of Resident #18's incomplete quarterly MDS dated [DATE] reflected Resident #18 had a BIMS score of 03 which indicated severe cognitive impairment. Review of Resident 18's facility care plan dated 3/7/2025 reflected: Problem: The resident has an ADL self-care deficit. Interventions: Personal Hygiene/Oral Care: The resident is totally dependent on one staff for personal hygiene and oral care. In an observation on 4/3/2025 at 8:55 AM, Resident #18 the resident had long, jagged nails. The nails varied in length from one quarter to one half inch. Resident #18 was unable to respond to questions. Resident #2 Review of Resident #2's face sheet, dated 04/2/2025, reflected a [AGE] year-old who female was admitted to the facility on [DATE] and diagnoses were Traumatic Brain Injury (injury to brain caused by an external force, that leads to impairment of cognitive, physical and psychosocial functions), and Cognitive Communication Deficit (difficulty in communication skills stemming from underlying cognitive impairments, such as attention, memory and problem solving). Record review of Resident #2's incomplete quarterly MDS dated [DATE] reflected Resident #2 had a BIMS score of 12 which indicated intact cognition. Review of Resident #2's facility care plan dated 2/19/2025 reflected: Problem: The resident has an ADL self-care deficit related to Disease Process, Hemiplegia, Limited Mobility, Musculoskeletal Impairment, Pain. Interventions: Personal Hygiene/Oral Care: The resident is on one staff for personal hygiene and oral care. In an interview and observation on 3/31/2025 at 2:37 PM, Resident #2 had chipped nail polish and jagged nails. Her nails were no longer than one half inch. Her teeth were not brushed and had a buildup of food in between her teeth. Resident #2 said her nails were horrible and she needed a manicure. She said she relied on staff to help her with all hygiene needs and did not remember the last time her teeth were brushed. In an interview and observation on 4/3/2025 at 9:00 AM, Resident #2's nails were jagged and had chipped nail polish. She said staff had not done nail care that week. During an interview on 4/3/2025 at 10:45 AM, CNA B stated the CNAs were responsible for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 2 of 24 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 04/03/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents' nail care. She said nail care included filing, clipping, cleaning underneath the nail with a wood stick, and putting lotion on their feet. She said, We tried to do it every day. During an interview on 4/3/2025 at 12:45 PM, the DON stated nail care included soaking the nails, clean underneath the nails with a wood stick, clipping and filing. She said the CNAs were responsible to provide nail care three times per week or as needed and oral care daily. She said the residents could have scratched themselves or had open scratches that introduced bacteria. During an interview on 4/3/2025 at 1:05 PM the ADM stated his expectation was that nail care was done on a regular basis or based on resident preference. He said germs could have gotten under the nails and became infected. He said nail care should have included cleaning, cleaning underneath the nails, filing, clipping, and painting. He said his expectation was that it should have been looked at, at least weekly. Review of the facility's policy titled Regency Integrated Health Services; Activities of Daily Living (ADLs) dated 5/26/2023 reflected: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 6. Documentation shall be completed at the time of service, but no later than the shift in which care service occurred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 3 of 24 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 04/03/2025 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident , encouraging both independence and interaction in the community for one of five residents (Resident #15) reviewed for activities. Residents Affected - Few The facility failed to provide Resident #15 in room activities during the months ofFebruary and March of 2025. This failure could place residents at risk for boredom, depression, and diminished quality of life. Findings included: Review of Resident #15's Face sheet , dated 04/02/2025, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnosis: vascular dementia, unspecified severity, with mood disturbance ( a type of dementia caused by conditions that damage blood vessels in the brain, resulting in reduced blood flow, and can lead to changes in mood), muscle wasting ( thinning , and weakening of muscles), age-related physical debility (an aging-related syndrome characterized by symptoms including weakness, fatigue, multiple chronic health conditions that affect different organs in the body, and reduced tolerance to medical and surgical interventions), and repeated falls ( move downward, typically rapidly and freely without control, from a higher level to a lower level). Record review of Resident #15's Annual MDS Assessment, dated 08/02/2024, reflected Resident #15's activity preference was a place to lock personal belongings, listening to music, and spending time outdoors. Record review of Resident #15's Quarterly MDS, dated [DATE], reflected Resident #15 Resident #15 was unable to complete the BIMS. Resident #15 had poor short- and long-term memory recall. Resident #15's decision making ability was severely impaired (never/rarely make decisions). Resident was assessed to have repeated falls, impaired vision, unclear speech and, minimal difficulty with hearing (difficulty with hearing in some noisy environments. She rarely or never understood others or made self-understood. Record review of Resident #15's Comprehensive Care Plan, with a completion date of 02/14/2025, reflected the following care areas: *Resident #15 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits (may be present from birth or may result from environmental causes such as brain damage or mental illness) date initiated on 01/20/2022. Resident #15 activity preference appears to be nurturing her doll that she treats like an infant. Interventions: Resident #15 needed in room activities if unable to attend out of room events. *Resident #15 had a problem with communication. She spoke Korean. Resident #15's family would translate. Her family did attempt to translate, however, the family stated Resident #15 was confused and did not respond to communication or when she did speak unable to understand what she is trying to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 4 of 24 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 04/03/2025 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few say. Interventions: Anticipate and meet needs. Resident #15 required assistance from family with communication. *Resident #15 had dementia with impaired thought processes. Interventions: Engage Resident #15 in simple, structured activities that avoid overly demanding tasks. Resident #15 had depression. Intervention: Monitor and document any signs or symptoms of depression including hopelessness, anxiety, sadness, and/or insomnia. Record review of Resident #15's Activity Initial Review Form, dated 08/09/2020, reflected the form was blank. Record review of Resident #15's last Activity Progress Note documented in the electronic medical record, dated 09/22/2022 reflected Resident #15 was currently in attendance to group activities; however, she was unable to participate due to diagnosis of Dementia and Alzheimer (a type of brain disorder that causes problems with memory, thinking, and behavior) disease. She used a wheelchair for mobility, one person to assist. She was unable to understand what was being said to her due to her diagnosis. There was also a language barrier, but the staff had used the language translator on their phone in attempt to communicated with her, but she did not appear to understand. Her family member had attempted to speak to her in her native language and has reported to staff the Resident #15 speaks, her response was not making sense. Staff will continue to provide sensory stimulation as mean of socialization and comfort. Signed by the Activity Director. Record review of Resident #15's Activity Participation Record from January, February and March of 2025 reflected Resident #15 was not provided in room activities, participated in group activities and/or received any type of activities. Observation on 03/31/25 at 11:39 AM, revealed Resident #15 was lying in bed staring at the ceiling and would move her eyes toward the wall beside her. Resident #15 had television in room. There was no stimulation in her room. The privacy curtain was pulled and she was unable to look out the door into hallway. Resident #15 did not have a radio in her room. Resident #15 did not speak. Observation on 03/31/2025 at 3:20 PM, revealed Resident #15 was lying in bed and staring toward ceiling. There was no stimulation in her room. The privacy curtain was pulled, and she was unable to look out the door leading from hall into her room. She did not have a doll in her room. Resident #15 found comfort holding a doll and enjoyed music. Resident #15 did not have any electronic device to listen to music except for the television. Resident #15 did not speak. Observation on 04/01/2025 at 8:20 AM, Resident #15 was in her room lying in bed. She was staring toward ceiling and toward the television. There was no stimulation in her room. The privacy curtain was pulled where she could not look out the door leading to the hallway. Where her bed was positioned, she was unable to look out the window. There was not a doll in her room or any type of electronic device for her to listen to music. Resident #15 did not speak. Observation on 04/01/2025 at 4:30 PM Resident #15 was in her room lying in bed. She was staring toward the ceiling and then would stare toward television in front of her. Resident #15 did not have a doll or any type of electronic device to listen to music. Resident #15 did not speak. Observation on 04/02/2025 at 9:05 AM Resident #15 was in her room lying in bed. She was staring toward the wall in front of her and would stare toward the ceiling. Resident #15 did not have any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 5 of 24 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 04/03/2025 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stimulation in her room. Resident #15's privacy curtain was pulled where she could not see out the door leading into the hallway, and she was unable to see out the window. She did not have a doll in her room. Observation on 04/02/2025 at 2:30 PM Resident #15 was in her room lying in bed. She was staring toward the ceiling and toward the wall beside her. Resident #15 did not have a doll in her room and did not have any electronic device to listen to music except for her television. Observation on 04/03/2025 at 8:40 AM Resident #15 was in her room lying in bed. She did not have any stimulation in her room. Resident #15 was staring at the ceiling and would stare at the wall in front of her. She did not have a doll in her room. The privacy curtain was pulled, and she could not view the door leading to the hallway. Resident #15 could not view the outside from the window in her room due to where her bed was positioned. Interview on 03/31/2025 at 3:30 PM the Activity Director stated she did not know how to print the participation records from the computer. She stated all her documentation for in room activity and group activities was on each resident's participation record in the electronic medical record. Interview on 04/03/2025 at 9:30 AM The Activity Director stated she did not have a list of Residents that required in room activities. She stated she remembered who needed the in-room activities. The Activity Director stated Resident #15 did come out of her room and received stimulation by watching other residents. She stated Resident #15 was not capable of participating in group activities. The Activity Director stated she was to follow the care plan on all the residents. She stated Resident #15 did enjoy holding a doll. She stated the doll brought comfort to Resident #15. She stated a doll was not left in Resident #15's room for her to hold all the time due to the dolls was very expensive. The Activity Director stated the doll would be difficult to replace if it was missing. She stated a family member of Resident #15 would probably bring her a doll if she contacted a family member. She stated she did not think about getting her another type of doll for her to hold that was not a life-like doll. The Activity Director stated if Resident #15's participation record was blank in the computer system she missed documenting on Resident #15. She stated she was expected to document on every resident of the type of activity they did during the day. She stated Resident #15 did enjoy music and she did not ask a family member if they knew Resident #15's favorite music. The Activity Director verified after looking on the electronic medical record there was no documentation on Resident #15's participation record. She stated if a resident was not receiving any type of activities there was a possibility a resident may become bored, depressed or have a decline in their mental status. She stated not receiving activities would affect their overall quality of life. The Activity Director stated she did not know how she forgot to not document on Resident #15. She stated she completed section F on the MDS. The Activity Director stated she did not know what section E was and she did not complete section E ( Mood and Behavior) of the MDS. Interview on 04/03/2025 at 12:25 PM the Administrator stated if Resident #15 was not receiving any type of activities there was a possibility Resident #15 may have some repercussions. He stated I am not sure of what type of repurcussions. The Administrator stated the activity care plan was expected to be followed. He stated if there was a doll intervention on Resident #15's care plan, the doll was expected to be provided and left in Resident #15's room. The Administrator stated the Activity Director was responsible to ensure all residents received the type of activities related to their cognition and culture. He stated he was the Activity Director's supervisor. The Administrator stated he did give an in-service with the Activity Director this week on in room activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 6 of 24 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 04/03/2025 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 0679 Level of Harm - Minimal harm or potential for actual harm Record review of The Activity Director Job Description (this is considered the facilities policy for the Activity Department), dated 08/03/2022, reflected the following: The Activity Director will be responsible for planning, coordinating, and directing the resident's activity program and the maintenance of necessary documentation. Residents Affected - Few 1. Organize both individual and group activities on the needs to the residents. 2. Ensure that multiple activities are occurring for both high and low functioning residents. 3. Develop the activities component of the Comprehensive Care Plan from the completed activity assessment. 4. Complete an annual assessment for each resident on the activity's component of the Resident Assessment. 5. Provide activities for residents that are bedfast and/or unable to participate in group activities (one to one) and documents in the appropriate record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 7 of 24 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 04/03/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure medications and biological's were stored in locked compartments for one of seven (Hall 300 medication cart) medication carts reviewed for medication storage. The facility failed to ensure Hall 300 medication cart was locked and medications were secure and not accessible to other staff, resident, or visitors. This failure could place residents at risk of having unauthorized access to medications, biological's, and needles. Findings included: Observation on 03/31/2025 at 3:30 PM revealed a unlocked medication cart on Hall 300; located near the entrance of the hallway, closest to the nurse's station. The back of the cart was against the wall with the drawers facing the hallway. The state surveyor observed the medication cart with the locking mechanism protruding outward. The state surveyor opened the drawers and captured photos. During an interview on 3/31/2025 at 3:40 PM, the RN said she thought she had locked the medication cart on Hall 300 before she walked away. She said she could not believe the cart was unlocked, as she had the only set of keys for that cart. She said if residents had accessed the medication cart they could have overdosed, taken the wrong medication, had an allergic reaction, could require hospital admission. She said she had previously been in-serviced on locking the medication carts and could not recall the specific date. She said she was aware the medication cart should have been locked. During an interview on 4/3/2025 at 12:45 PM, the DON said her expectation was the medication cart should have been locked. She said she had in-serviced staff multiple times and had reminded staff this morning to ensure the medication carts were locked. Review of the facility's undated policy titled, Medication Administration, Medication Carts and Supplies for Administering Meds reflected: Policy: The facility maintains equipment and supplies necessary for the preparation and administrations of medications to residents. The mobile medication cart will be used to facilitate administration of medications to residents. The purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. Med Carts: . 2. The medication cart is locked at all times when not in use. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 8 of 24 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 04/03/2025 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 0761 Do not leave the medication cart unlocked or unattended in the resident care areas. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 9 of 24 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 04/03/2025 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to employ staff with the appropriate competencies and skill Residents Affected - Few sets to conduct the functions of the food and nutrition services for one of three kitchen staff (Dietary Aide E) reviewed for qualified dietary staff. Dietary Aide E had not received onboarding training with the appropriate competencies and skills to conduct the functions of the food and nutrition services department and his food handler certificate was expired. This failure placed residents at risk of not having their nutritional needs met and placed them at risk of food borne illness. Findings included: Interview and observation on 04/02/2025 at 5:35 AM Dietary Aide E introduced himself as the [NAME] for the day (he did not mention he was in training to be a cook). He stated he did not know when the Dietary Manager was coming in for the day. Dietary Aide E stated the Dietary Manager usually came to work between 7:30 AM and 8:00 AM. He was observed placing pots on the stove. Observation on 04/02/2025 at 6:12 AM Dietary Aide E in training placed twenty-eight sausage patties into the puree blender. He had a pitcher of water and began pouring water without measuring or reviewing the recipe. Interview on 04/02/2025 at 6: 14 AM Dietary Aide E stated he had never pureed food before and he was guessing how much water needed to be in the container with the sausage before he pureed the sausage. He did not know if he was to view the recipe prior to pureeing the sausage. He stated he had cooked by himself before, and he usually did puree at 6:25 AM or 6:30 AM without anyone assisting him. When the Dietary Manager entered the kitchen, he stated he had never pureed food before and today would be his first time. Interview on 04/02/2025 at 6:18 AM the Dietary Manager stated Dietary Aide E was in training to be a cook. He had not finished his training and she was expected to be in the kitchen with him on 04/02/2025, however, she overslept. She stated he was not to cook by himself he had not been trained to be a cook. The Dietary Manager stated he was not to puree food by himself or do any cooking by himself. Observation and interview on 04/02/2025 at 6:45 AM the Dietary Aide E were by himself in the kitchen finishing cooking and preparing for breakfast. The Dietary Manager was in the dishwashing room washing dishes and was not with the Dietary [NAME] in Training. The Dietary Aide E placed eggs on the steam table and they were not fully cooked. He stated he was in training to be a cook. He stated when he introduced himself around 5: 30 AM he said he was the cook for the day and did not explain he was in training to be a cook. The Dietary Aide E stated he only had one day of training, and it was observing another cook. Interview /Observation on 04/02/20225 at 6:48 AM The Dietary Manager stated she was needing to wash (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 10 of 24 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 04/03/2025 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few some dishes before breakfast. She stated she would stop and obtain the temperature of the food on the steam table. She entered the kitchen area where the steam table was located and began taking temperature of the oatmeal and then she pulled back the aluminum foil covering the uncooked eggs and she stated these eggs are not cooked and we cannot serve raw eggs. The Dietary Aide E came to the steam table and carried the eggs to the stove to re cook the eggs. The Dietary Aide E stated he thought they were cooked. Record review on 04/02/2025 and 04/03/2025 of Dietary Aide E personnel file reflected Dietary Aide E had a new position of [NAME] on 03/24/2025 with effective date on 04/06/2025. There was not any documentation in his personnel file of him being trained as a Cook. He did have his food handler license, however, it expired on 05/16/2024. Reviewed his training and he was not trained on being a cook. Record review of the dietary staff training and Dietary Aide E only had one training related to the kitchen and it was on infection and hand hygiene. Interview on 04/03/2025 at 8:30 Am the Dietary Manager stated she thought he had his food handler license and she stated she did not believe his license had expired. She stated his most current food handler license would be in his personnel file. She stated she did not have any thing documented on Dietary Aide E training. The Dietary Manager stated Dietary Aide E was expected to receive 4 straight days of training from her on how to be a cook. She stated he only got one day of training about 2 weeks ago and she did not document the training she provided to him. She stated she did not recall the training he received on that one day. The Dietary Manager stated the Dietary Aide E was not qualified to cook alone. She stated he needed to be with her when Dietary Aide E cooked. The Dietary Manager stated she should have called him and told him not to cook until she got to the facility. She stated the eggs Dietary Aide E placed on the food prep table was not cooked properly and it was a possibility if a resident had eaten raw eggs the residents would have developed some type of food borne illness. The Dietary Manager stated she did not have a recipe for that type of sausage the Dietary Aide E was pureeing. Record Review of Dietary Manager job description reflected she was responsible for daily operations of the dietary department, according to the facility policy and procedures and federal/state regulations. The Certified Dietary Manager provides leadership and guidance to ensure that food quality, safety standards, and client expectations are satisfactory met. 3. Interview, train, coach, and evaluate dietary staff. 4. Specify standards and procedures for preparing food. 5. Food safety- Assure safe receiving, storage, preparation, and service of food. Signed by the Dietary Manager on 01/26/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 11 of 24 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 04/03/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve nutritive value for 1 of 1 kitchen observed. Residents Affected - Few The facility failed to provide a recipe for pureeing sausage which resulted in Dietary Aide E adding an unmeasured amount of water to the puree. This failure could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings included: Observation on 04/02/2025 at 6:12 AM Dietary Aide E placed 28 sausage patties into the puree blender. He had a pitcher of water and began pouring water without measuring. Interview on 04/02/2025 at 6:14 AM Dietary Aide E stated he had never puree food before and he was guessing how much water needed to be in the container with the sausage before he pureed the sausage. He did not know if he was to view the recipe prior to pureeing the sausage. He stated he had cooked by himself before, and he usually did puree at 6:25 AM or 6:30 AM without anyone assisting him. The Dietary Manager entered the kitchen, he stated Dietary Aide E had never puree food before and today would be his first time. Interview on 04/03/2025 at 8:30 Am the Dietary Manager stated the Dietary Aide E was expected to receive 4 straight days of training from her on how to be a cook. She stated the dietary aide/cook in training had not been trained on how to puree food. The Dietary Manager stated she did not have a recipe for the sausage patty the Dietary Aide E was pureeing. She stated her expectations was for him to receive the proper training on how to be a cook prior to him cooking without any supervision. The Dietary Manager stated, I knew he was at the facility to cook but I overslept and did not come in to supervise him until after 6:00 and he was almost finished with preparing breakfast when I arrived at the facility on 04/02/2025. She stated Dietary Aide E was required to follow the recipe for pureeing the sausage and the recipe was not available in the recipe book. She stated what was used the puree sausage was what was on the recipe to use. Record Review of Dietary Manager job description reflected she was responsible for daily operations of the dietary department, according to the facility policy and procedures and federal/state regulations. The Certified Dietary Manager provides leadership and guidance to ensure that food quality, safety standards, and client expectations are satisfactory met. 1. Interview, train, coach, and evaluate dietary staff. 2. Specify standards and procedures for preparing food. Food safety- Assure safe receiving, storage, preparation, and service of food. Signed by the Dietary Manager on 01/26/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 12 of 24 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 04/03/2025 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 0804 The policy /protocol for pureeing food and the recipe for pureeing sausage was not provided at the time of exit. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 13 of 24 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 04/03/2025 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 - Some 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 food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary [NAME] C, Dietary [NAME] D and Dietary Aide E used proper hand hygiene during food preparation. 2. The facility failed to ensure Dietary Aide E wear a hair net and Dietary Aide F wear a beard guard when standing over the oven and the food prep table. These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 03/31/2025 at 9: 20 AM Dietary [NAME] C was wearing gloves in the kitchen. She was standing by the stove preparing lunch. Dietary [NAME] touched the right side of her shirt when she moved her right hand from her right side to the handle of the utility cart. She placed her right hand on the shredded cabbage located in a large plastic bag on the utility cart. Dietary [NAME] C touched the outside of the bag with her right hand prior to opening the plastic bag wider for her right hand to pick up purple shredded cabbage located in a small clear plastic bag inside the large plastic bag. Dietary [NAME] C did not change gloves prior to touching the shredded cabbage. Interview on 03/31/2025 at 9:25 AM Dietary [NAME] C stated the outside of the plastic bags was not contaminated and she was not required to change her gloves when she touched the utility cart or the outside of plastic bag of cabbage. She stated she did not recall if she touched her shirt. She stated it was a possibility, but she did not recall touching her shirt. Dietary [NAME] C stated the utility cart was not considered contaminated. She stated the only time she was required to change her gloves if she touched anything contaminated. She stated the dietary staff sprays disinfectant on all the clear plastic bags when the food is delivered and before they place the food in the refrigerator or freezer. She stated they did not sanitize the bags every time someone touched the bag. Dietary [NAME] C stated she did not document when she cleaned the plastic bags. She stated there should not be any holes in the plastic bags when asked if she checked the bags for any holes before she sprayed each plastic bag. She stated she had been in serviced on hand hygiene and she did not recall the date of the in-service. Interview on 03/31/2025 at 9:35 AM The Dietary Manager stated the dietary staff cleans and sanitizes all plastic bags with sanitizer before they place the clear plastic bags in the refrigerator or freezer. She stated all staff was expected to change their gloves if they touched anything contaminated. The Dietary Manager stated outside of a plastic bag came from outside source was not considered contaminated. She also stated the utility cart, and the cooks top was not considered to be contaminated. The Dietary Manager stated she did not document they sanitized the clear plastic bags of food or when the sanitized the utility cart. She stated it was not possible to document everything they did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 14 of 24 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 04/03/2025 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 - Some due to needing to cook and do other things to prepare for meals. She did not answer the question when asked what if there were holes in the plastic bags and when spraying it with disinfectant was there a possibility the disinfectant may be on the food. Observation on 04/01/2025 at 1:45 PM Dietary [NAME] D was preparing puree bread. She was not wearing gloves. She placed the puree bread in the oven and exited where the oven was located and enter the area of the kitchen near entrance into the dishwashing room. She picked up the mop and placed it in the mop water container. Dietary [NAME] D entered the area of the kitchen where the stove was located and she checked the food in the oven and opened the silver container with the pureed bread and her ring finger and middle finger from the knuckle to the edge of her fingers touched the pureed bread inside the silver container. She did not wash her hands after she touched the mop. Interviewed on 04/01/2025 at 2:00 PM Dietary [NAME] D was unable to understand English. Dietary [NAME] D stated she did not wash her hands and she did touch the mop and touched the pureed bread by accident. Dietary [NAME] D stated she was expected to wash her hands when she touched anything that was dirty. She stated the germs on her hands possible transfer to the food. She stated she had been in-service on hand hygiene. She did not recall the date or time. Observation on 04/02/2025 at 5:35 AM to 6:15 AM revealed the following: * Dietary Aide E was in the only dietary staff working at that time. He was wearing gloves. Dietary [NAME] E touched his cell phone, touched his shirt, and began to cook oatmeal on the stove. He picked up the large mixing spoon and touched the inside of the rounded part of the spoon and placed it in the oatmeal to stir. * Dietary Aide F did not have on a hair net. He was cooking eggs, oatmeal, and sausage without wearing a hair net. He also pureed sausage without wearing a hair net. Interview on 04/02/2025 at 6:00 AM, Dietary Aide E stated he did not change his gloves until now (6:00 AM). He stated he did touch his cell phone; his shirt and he touched inside the spoon before he placed it into the oatmeal cooking on the stove. He stated he was to change gloves after he touched his phone and shirt. He stated germs may transfer to the food from his hands. Dietary Aide E stated if a resident ate food with germs on it there was a possibility a resident may become ill with stomach problems such as vomiting. He stated he had been in-service on hand hygiene but did not remember the date of the in-service. Interview on 04/02/2025 at 6:10 AM Dietary Aide E stated his hair was short and he did not think he needed a hair net with his hair being short. He stated all dietary staff was expected to wear hair net when in the kitchen. Dietary Aide E stated it was a possibility hair may fall in the food while he was cooking. He stated hair was considered to have germs on it and the germs may get on the resident's food. He stated if a resident ate food with germs on it there was a possibility a resident may become ill with stomach issues such as vomiting. Dietary Aide E stated he had been in-service on wearing hair nets. He did not recall the date of the in-service. Observation on 04/02/2025 at 5:55 AM Dietary Aide entered the area where the food prep tables were located, and he had six to eight inches of growth on his face (around his chin and side of face). He was not wearing a beard guard when he was standing over the food prep table. Interview on 04/02/2025 at 6:12 AM Dietary Aide F stated he was required to wear a beard net when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 15 of 24 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 04/03/2025 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 he entered any area of the kitchen. He stated there was a possibility hair may fall onto food or table where food is prepared. He stated hair may touch residents' food and contaminate the food. He stated he did not know if a resident may become ill if they ate any food with hair on it or where hair had been on the food. Dietary Aide F stated he had been in-service on wearing beard guards. He stated he did not recall the date of the in-service. Residents Affected - Some Interview on 04/03/2025 at 8:30 Am the Dietary Manager stated the Dietary Aide E was expected to receive four straight days of training from her on how to be a cook. The Dietary Manager stated the Dietary Aide E did not know how to puree food. She stated the dietary aide E had not been trained on how to puree food. The Dietary Manager stated she did not have a recipe for the sausage patty the Dietary Aide E was pureeing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 16 of 24 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 04/03/2025 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for one of one kitchen Residents Affected - Some 1. The facility failed to keep overflowing garbage away from an area where food was being prepared for resident meals. 2. The facility failed to keep garbage away from an area where clean cook ware was stored. These failures could place residents at risk for exposure of germs and diseases carried by vermin and rodents. Findings Included: Observation on 04/01/2025 at 2:30 PM revealed there was a garbage barrel with the lid off on half of the barrel. There was overflowing garbage with cans and boxes with food residue inside and outside of the cans, containers and, boxes located in the garbage barrel. The garbage barrel was located approximately three feet from the stove-oven, and less than two feet away from clean pans in the food prep area. Observation on 04/02/20255 at 6:05 AM revealed there was a garbage barrel with the lid not completely covering the top of the barrel. There were boxes, food, and a large can inside the garbage barrel. There was a roach moved from underneath the garbage barrel when barrel was moved. In an interview on 04/02/2025 at 6:10 AM the Dietary Aide/Cook in Training stated the garbage barrel was expected to be located next to the door that leads to outside. He stated he had been in-service not to leave garbage barrel in the kitchen area and to always keep the lid on it. He stated there was a possibility garbage in the kitchen area may cause bugs to come into the kitchen where food is prepped. The Dietary Aide/ [NAME] in training stated he knew the pests was not clean and may have some type of germs. He stated he did not like to talk about pests. In an interview on 04/02/2025 with the Dietary Manager at 6:35 AM she stated the garbage barrels was expected to be stored in the area near the back door to the outside area. She stated the garbage barrel was to be covered completely and not overflowing with garbage. She stated on 04/01/2025 the garbage barrel was overflowing with garbage and there was a possibility someone could accidentally touch the garbage and not change gloves and prep food when it was near the stove. She stated the garbage may attract roaches or any type of pest. She stated she did not recall at this time if she in-serviced staff on removing garbage. Facility Policy on Garbage Receptacles, revised on 06/01/2019, reflected the facility will maintain receptacles in a clean and sanitary manner to minimize the risk of food hazards. Indoor receptacles: 1. Trash cans will be kept with lid in place when not in use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 17 of 24 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 04/03/2025 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 0814 2. Level of Harm - Minimal harm or potential for actual harm Refuse shall be removed from the premises when trash can is full or at a frequency that will minimize the development of objectional odors and attract insects and rodents. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 18 of 24 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 04/03/2025 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 4 residents (Resident #35 and, Resident #68) reviewed for infection control: Residents Affected - Few 1. The facility failed to ensure MA B sanitized the nasal spray before it was used in Resident #68's nostril and before storing it in the med cart after her use. 2. The facility failed to ensure CNA A was not using soiled gloves while handling clean items during peri care on Resident #35. These failures could place residents at-risk for infection due to improper care practices. Findings included: Review of Resident #35's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #35 had diagnoses of Alzheimer's disease, Anxiety disorder, Major depressive disorder, Age-related physical debility, Lack of coordination, Pain, Vitamin B12 deficiency and need for assistance with personal care. Review of Resident #35's annual MDS dated [DATE] reflected a BIMS score of 0 which indicated her cognition was severely impaired. Review of Resident #35's Care Plan dated 03/25/25 reflected she had bowel incontinence related to Dementia and relevant intervention was providing peri care after each incontinent episode. During an observation on 03/31/25 at 4:33pm CNA A was doing peri care on Resident #35. CNA A washed her hands, put on gloves, and performed the peri care on Resident #35. CNA A removed the brief soiled with urine and feces and cleaned the front, back and the perineal area (the area between the anus and the genitals) of the resident. CNA A then without changing the soiled gloves put on the new brief on the resident. After the completion of the procedure, using the same gloves, pulled up the blanket and adjusted the bed for Resident #35. During an interview on 03/31/25 at 4:50pm CNA A stated she thought she was doing it correctly. When the surveyor walked through the process, she was able to identify the mistake she made. CNA A stated she should have changed the gloves before handling the clean items like the new brief, bedlinen, and blanket. CNA A stated she was aware that handling materials with contaminated gloves could spread diseases. CNA A stated she received in services on peri care however did not remember exactly when it was. Review of Resident #68's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #68 had diagnoses of Hypertension, Age-related physical debility, Need for assistance with personal care, Type 2 diabetes, Dementia, Psychotic disturbance, Mood disturbance, Anxiety Chronic pain, Tobacco use, Unspecified asthma, Rhinitis (inflammation of the nasal lining) and COPD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 19 of 24 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 04/03/2025 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 Review of Resident #68 annual MDS dated [DATE] reflected a BIMS score of 05 which indicated her cognition was severely impaired. Level of Harm - Minimal harm or potential for actual harm Review of Resident #68's Care Plan dated 03/14/25 had not reflected the management of rhinitis. Residents Affected - Few Record review of Resident #68's March 2025 MAR reflected: Fluticasone Propionate Nasal Suspension 50 MCG (Fluticasone Propionate (Nasal)) 2 sprays in each nostril one time a day for Rhinitis. During an observation on 03/31/25 at 9:30 am MA B was administering medication in Hall 400. She had provided Resident #68's Fluticasone Propionate to her for self-administration, under her supervision. Resident #68 inserted the nozzle of the bottle into her nostrils and squeezed two times in each nostril. After the administration she returned the bottle to MA B. MA B then put the bottle back in the drawer of the med cart. MA B did not sanitize the Fluticasone Propionate bottle before and after the resident inserted it into her nostrils. During an interview on 03/31/25 at 9:55 am MA B stated she forgot to sanitize the nozzle of the bottle before and after the use. She stated this was necessary to minimize spreading germs of various diseases from residents. MA B stated she received training's and in services on infection control and aware of the importance of following infection control protocol however was nervous and forgot to implement it during administering the nasal spray. During an interview on 04/03/25 at 12:35pm the DON stated MA B expected to sanitize the nasal spray every time when it was used. She stated this was essential to limit the spread of various diseases at the facility. The DON stated the infection control in services were conducted frequently. She stated she had not remembered the exact days however the documentation of in services were available in the in-service folder. During an interview on 04/03/25 at 12:55pm the IP stated she was responsible for the supervision of the infection control management at the facility. She stated the expectation was, all staff at the facility would follow the facility's infection control policy. She stated she routinely observed if the staff followed the correct infection control procedures. IP stated staff were provided in service sessions and one to one in service if necessary. IP stated she observed wound care and peri care time to time, to make sure the staff followed the correct procedure as recommended in the infection control policy. Record review of facility policy Infection Prevention and Control Program dated 05/13/23 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 . . 2. All staff are responsible for following all policies and procedures related to the program. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 20 of 24 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 04/03/2025 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 . 4. Level of Harm - Minimal harm or potential for actual harm Standard Precautions: a. Residents Affected - Few 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 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 21 of 24 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 04/03/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interviews, the facility failed to maintain an effective pest control program so that the facility was free of pests for one of one kitchen reviewed for pests. Residents Affected - Some Cockroaches were seen in the kitchen near the garbage can located beside clean pots and pans and one located in the dining room near the large wall of cabinets. This failure could place residents at risk of infection, discomfort, and diminished quality of life. Findings included: Observation on 04/02/2025 at 6:05 AM revealed a cock roach was beside a garbage can located by shelves full of pots and pans. Observation on 04/02/2025 at 6:08 AM, a cock roach was moving from underneath the garbage can located by the shelves of pots and pans into the dishwasher area. Observation on 04/02/2025 at 7:10 AM a cock roach was near the large cabinets against the wall in the dining room. Interview on 04/02/2025 at 6:35 AM The Dietary Manager stated anytime roaches, or any type of pest was observed in the kitchen she would report it to the Maintenance Supervisor. She stated the pest control company comes to the facility once a month and it was time for him to come this month (April). She stated there is a maintenance log where the staff documents any maintenance issues including pests. She stated if roaches were in the kitchen there was a possibility roaches may have contact with dishes or other food contact surfaces. The Dietary Manager stated she was not certain of what the roaches could spread to areas in the kitchen. Interview on 04/03/2025 at 12:25 The Administrator stated the pest control company came to the facility this week and sprayed in the kitchen. He stated the pest control company does come to the facility monthly. He stated if there were roaches in the kitchen there was a possibility it may make residents sick or uncomfortable with the pests. The Administrator stated if there were any pests in the facility, if they pest control need to make more than one visit per month to the facility, he would call the pest company and they will come out that day or the next day. Interview on 04/03/2025 at 1:05 PM the Maintenance Supervisor stated there was a book where the staff wrote any type of issues for maintenance to take care of and pest was one of those issues. He stated the pest control comes once a month and as needed. He stated whenever they call the pest company, they will come either that day or the next day. Record review of Program Specifications of pest control contract reflected the facility would receive service from pest control company once a month. All interior and exterior areas will be serviced during each service visit to ensure that a completed and total service was provided. The following programs will be implemented such as: interior crawling insect, interior rodent, interior large fly, exterior crawling insect, exterior rodent, exterior large fly bait (dumpster) and, fire ants. The following are the areas of service: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 22 of 24 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 04/03/2025 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 0925 1. Level of Harm - Minimal harm or potential for actual harm Dietary / dining 2. Residents Affected - Some Central Nurse Station 3. Activities 4. Rehabilitation Services/ Physical therapy 5. Laundry / Housekeeping 6. Maintenance / Central stores 7. Clean/ Soiled Utility 8. Health and Beauty 9. Resident Halls/ Common Areas 10. Office/ Administrative 11. Employee Breakroom 12. Exterior Perimeter. Follow-up services, even low levels of pest activity are not tolerated. Therefore, the initial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 23 of 24 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 04/03/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm services is followed up with additional services performed at a frequency necessary to eliminate all pest infestation. Follow up services also provide a communication opportunity to ensure we are meeting the client's expectation. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676245 If continuation sheet Page 24 of 24