Inspection·December 9, 2022

F 0656 Somewhat important to you to keep up with the news. Level of Harm - Minimal harm or potential for actual harm Somewhat important to you to do things with groups of people. Somewhat important to you to do your favorite activities. Residents Affected - Some Somewhat important to you to go outside to get fresh air when the weather is good. Very important to you to participate in religious services or practices. Review of the care plan for Resident #99 dated 11/08/22 reflected no care planning for activities or activity preferences. During an interview on 12/08/22 at 10:11 a.m., Resident #99 stated she liked to color and do crossword puzzles and she liked bingo. She stated she liked to be invited to group activities. Review of the undated face sheet for Resident #101 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of right femur (a specific type of hip fracture), fracture of the lower end of right radius (lower arm fracture), acute posthemorrhagic anemia (condition in which a person quickly loses a large volume of circulating blood cells), acute kidney failure, hypoosmolality and hyponatremia (diluted blood and low blood sodium content), major depressive disorder, obstructive and reflux neuropathy (a condition in which the flow of urine is blocked), hypertensive heart disease (heart problems that occur because of high blood pressure), gastroenteritis and colitis (infectious disease that affects the intestines), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), ulcerative colitis (an inflammatory bowel disease that causes inflammation and sores in your digestive tract), muscle wasting and atrophy, abnormalities of gait and mobility, need for assistance with personal care, muscle weakness, and lack of coordination. Review of the admission MDS for Resident #101 dated 11/23/22 reflected a BIMS score of 12, indicating a moderate cognitive impairment. Review of Section F Preferences for Customary Routine and Activities reflected the following answers: Somewhat important to you to have books, newspapers, and magazines to read. Somewhat important to you to listen to music you like. Somewhat important to you to be around animals such as pets. Somewhat important to you to keep up with the news. Somewhat important to you to do things with groups of people. Somewhat important to you to do your favorite activities. Somewhat important to you to go outside to get fresh air when the weather is good. Very important to you to participate in religious services or practices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the care plan for Resident #101 dated 12/06/22 reflected no care planning for activities or activity preferences. During an interview on 12/07/22 at 1:35 p.m., Resident #101 stated she liked to read and to go outside, but she was trying to focus on healing. She stated she would be interested in participating in activities in the facility when she was feeling better. Review of the undated face sheet for Resident #46 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of displaced trimalleolar fracture of right lower leg (ankle fracture), cellulitis of right lower limb (skin infection on the leg), long-standing persistent atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles), hypertensive heart disease (heart problems that occur because of high blood pressure), vitamin D deficiency, overactive bladder, major depressive disorder, hyperlipidemia (high cholesterol), hypertension (high blood pressure), osteoarthritis (the protective cartilage that cushions the ends of the bones wears down over time), benign prostatic, hyperplasia (A condition in which the flow of urine is blocked due to the enlargement of prostate gland), dysphagia (A condition with difficulty in swallowing food or liquid), muscle wasting and atrophy, abnormalities of gait and mobility, need for assistance with personal care, and muscle weakness. Review of the admission MDS for Resident #46 dated 10/26/22 reflected a BIMS score of 13, indicating mild cognitive impairment. Review of Section F Preferences for Customary Routine and Activities reflected the following answers: Somewhat important to you to have books, newspapers, and magazines to read. Somewhat important to you to listen to music you like. Not very important to you to be around animals such as pets. Very important to you to keep up with the news. Somewhat important to you to do things with groups of people. Somewhat important to you to do your favorite activities. Somewhat important to you to go outside to get fresh air when the weather is good. Very important to you to participate in religious services or practices. Review of the care plan for Resident #46 dated 11/08/22 reflected no care planning for activities or activity preferences. During an interview on 12/08/22 at 11:21 a.m., Resident #46 stated he enjoyed activities at the facility and often participated in bingo and exercise. He stated he felt there could be more activities for men. He stated he was not sure if anyone had talked to him about what activities he would like, but he did not have complaints. Review of the undated face sheet for Resident #76 reflected a [AGE] year-old male admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE] with diagnoses of melena (black colored stool), permanent atrial fibrillation (uneven heart rate), atherosclerotic heart disease (hardening and narrowing of your arteries), gastrointestinal hemorrhage (bleeding in the digestive tracts), stage four chronic kidney disease, congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles), acute posthemorrhagic anemia (a condition in which a person quickly loses a large volume of circulating blood cells), hypothyroidism (a condition in which your thyroid gland doesn't produce enough of certain crucial hormones), gastroesophageal reflux disease (a condition affecting the food pipe), muscle weakness, muscle wasting and atrophy, abnormalities of gait and mobility, need for assistance with personal care, dysphagia (A condition with difficulty in swallowing food or liquid), and cognitive communication deficit (deficits resulting in difficulty with thinking and how someone uses language). Review of the admission MDS for Resident #76 dated 11/24/22 reflected a BIMS score of 13, indicating mild cognitive impairment. Review of Section F Preferences for Customary Routine and Activities reflected the following answers: Somewhat important to you to have books, newspapers, and magazines to read. Somewhat important to you to listen to music you like. Not very important to you to be around animals such as pets. Very important to you to keep up with the news. Somewhat important to you to do things with groups of people. Somewhat important to you to do your favorite activities. Somewhat important to you to go outside to get fresh air when the weather is good. Very important to you to participate in religious services or practices. Review of the care plan for Resident #76 dated 12/08/22 reflected no care planning for activities or activity preferences. During an interview on 12/07/22 at 8:40 a.m., Resident #76 stated he had not been interested in group activities but did not think anyone had asked him what activities he might want. Review of the undated face sheet for Resident #37 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction (related conditions that cause weakness on one side of the body after a stroke), lobar pneumonia (a form of pneumonia that affects a large and continuous area of the lobe of a lung), pericardial effusion (condition with the accumulation of too much fluid in the sac surrounding the heart), dysphasia (a partial or complete impairment of the ability to communicate resulting from brain injury), paroxysmal atrial fibrillation (a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), hypertensive heart disease (disease of the heart caused by high blood pressure), candida stomatitis (yeast infection of the mouth), constipation, hyperlipidemia (high cholesterol), muscle weakness, adjustment disorder, major depressive disorder, muscle wasting and atrophy, abnormalities of gait and mobility, need for assistance with personal care, cognitive communication deficit (deficits (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resulting in difficulty with thinking and how someone uses language), aphasia (a comprehension and communication disorder resulting from damage or injury to the specific area in the brain), hypertension (high blood pressure), and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). Review of the admission MDS for Resident #37 dated 11/14/22 reflected a BIMS score of 13, indicating mild cognitive impairment. Review of Section F Preferences for Customary Routine and Activities reflected the following answers: Somewhat important to you to have books, newspapers, and magazines to read. Somewhat important to you to listen to music you like. Not very important to you to be around animals such as pets. Not very important to you to keep up with the news. Not very important to you to do things with groups of people. Somewhat important to you to do your favorite activities. Somewhat important to you to go outside to get fresh air when the weather is good. Very important to you to participate in religious services or practices. Review of the care plan for Resident #37 dated 11/21/22 reflected no care planning for activities or activity preferences. During an interview on 12/07/22 at 8:59 a.m., Resident #37 stated she had been involved in some exercises but had not participated in anything else. She stated she did not know if she would want to be involved in anything else, because she is focusing on her recovery. During an interview on 12/09/22 at 1:36 p.m., the AD stated she was responsible for completing the activity portion of the MDS assessment, and she gathered that information by interviewing residents when they first admitted to the facility. She stated she entered her initial assessment straight into the activities section of the MDS. She stated the MDS did not capture much about what they enjoyed doing, and the questions were very basic, so she asked them additional questions about religion and past activities, where are they planned to discharge to, and what their goals were. She stated all those items went into the care plan, and she did not use the MDS exclusively to form her care plan goals. She stated she was responsible for creating those care plan items herself and added the goal and interventions were based on all the sources of information she received from residents upon admission. She stated she did not have a specific time she created the care plan and was not aware of any rules regarding care plan timeframes. When asked about Resident #76, she stated she had not created a care plan for him. She stated he liked aerobics classes, drum fitness, and music activities. She stated he had also mentioned recently he liked bingo. She stated she did not know if she had completed a care plan item for Resident #46, but she knew he had his computer and had come to some of the church services and exercise classes. She stated she could not recall who Residents #99, 101, and 37 were by name, as it was harder for her to remember the newly admitted short term residents. After checking her records, she stated Resident #101 liked reading but was upset she could not see, and they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had talked about audiobooks. She stated Resident #101 loved big band music and was proud of being from California. She stated Resident #37 loved music and attended the fitness classes. She stated Resident #99 also participated in drum fitness, chair aerobics, cranium crunches, was very close to all the therapists and would attend any activity if they invited her. She stated she should have completed the care plans if the residents had been in the facility for a few weeks. She stated she could not recall whether she had received training about when and how to complete care plans. During an interview on 12/09/22 at 2:59 p.m. the DON stated activities care plans were important, and all the managers used them to learn more about residents. She stated she had only been in the position for a little over a month, and she had not transitioned into overseeing compliance with care plans, so she did not know if there was already a system in place to ensure it was completed, but that would be a question for the chief compliance officer. She stated she thought it was the MDS nurse's responsibility to ensure they were done in a timely manner. She stated she could not think of anything harmful to the resident that would come out of a care plan item for activities not being done, but the staff did rely on them to know resident preferences. During an interview on 12/09/22 at 3:10 p.m., the MDSN stated the AD was responsible for creating the activities care plan items. She stated there should have been care plans on activities for residents who had been in the building more than three weeks. She stated she frequently checked care plans, but there was not a formal process in place to ensure that everything that should be care planned was there. She stated nurses, aides, and anyone in the IDT used the care plans. She stated a potential negative outcome of not having activities care planned was that resident preferences might not be recognized, especially their hobbies and things they like to do or, perhaps more importantly, did not like. She stated she did not think she had received any training about care plans, but any new guidance or direction came from the CCO. During an interview on 12/09/22 at 3:26 p.m., the CCO stated the person/people responsible for creating care plans was multidisciplinary. She stated, for example, the MDSN entered code status, allergies, and medications; the dietitian entered nutrition care plans; and activities would come in and do their part. She stated once the plan was completed, they personalized it further during the care plan meeting. She stated there was not one person responsible for ensuring it was done. She stated she would expect activities be in the care plan. She stated the AD was responsible for that portion of the care plan. During an interview on 12/09/22 at 4:03 p.m., the ADM stated she knew activities should be in the care plans for long term residents, but for shorter term residents, it depended on the situation. She stated if a resident had been in the building for more than ten days, there should have been a care plan for activities. She stated she was not aware of a formal process to ensure compliance. She stated she did not think the residents would experience any negative impact as a result of not having activities care plans, because they were still getting the activities. Review of undated facility policy titled Comprehensive Care Plans reflected the following: The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 1. The comprehensive care plan will describe the following: the services that are to be furnished to attain the resident's highest practicable, physical, mental, and psychosocial well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676280 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgetown Nursing and Transitional Care 4011 Williams Dr Georgetown, TX 78628 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Any services that would otherwise be required but are not provided due to a resident exercising the right to refuse treatment and services. -The comprehensive care plan will be developed within seven days after completion of the comprehensive assessment unless the comprehensive care plan will be used as the baseline care plan which requires completion within 48 hours of admission to the facility. -Prepared by an interdisciplinary team IDT that includes but is not limited to: 1. Attending physician. 2. Assigned nurse with responsibility for the resident. 3. Food and nutrition services staff member. 4. Activity Director staff member. 5. The resident and their representative, where practicable and/or requested, and documentation in the medical record, explaining why their participation isn't practicable for the development of the residence care plan. 6. Other appropriate staff, or disciplines, as determined by need or requested by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676280 If continuation sheet Page 7 of 7