Inspection·May 3, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/03/2023 at 2:11 p.m., the DON stated when a staff is assisting a resident with feeding the staff is supposed to sit down to help to be at the level of the resident. He also stated it has to do with dignity for the residents. The DON stated he initiated an in-service and posted in the dining hall. Review of facility's policy titled Eating Support dated 2018 reflected: Basic Responsibility-Licensed Nurse, Certified Nursing Assistant. ---never make the resident feel the meal must be hurried. Give him/her your complete attention. Sit so you are at the same level as the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 2 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 of 24 (Residents #6, #13, #15, #39, #44, and #52) reviewed for care plans. The facility failed to provide care planning for activities for Residents #6, #13, #15, #39, #44, and #52. This failure placed residents at risk of not having their recreational needs met. Findings included: Review of the undated face sheet for Resident #6 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder, schizophrenia, and cognitive communication deficit. Review of the annual MDS for Resident #6 dated 09/17/22 reflected a BIMS score of 10, indicating a mild cognitive impairment. Section F of the MDS reflected a staff assessment of Resident #6 activity preferences included participating in favorite activities. Review of the care plan for Resident #6 dated 05/30/22 reflected the following: Care Plan Description Psychosis: Hallucinations/Delusions Goal Report onset or increase in behaviors to physician. The care plan did not include any planning for activities or activity preferences. Observation on 05/01/23 at 10:06 AM revealed Resident #6 walking up and down the halls of the facility without speaking to anyone, with a fixed forward gaze. She did not stop walking or looking forward to be interviewed. Review of the undated face sheet for Resident #13 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of chronic pain, major depressive disorder, bipolar disorder, obsessive compulsive disorder, cognitive communication deficit, and anxiety disorder. Review of the annual MDS for Resident #13 dated 05/06/22 reflected a BIMS score of 3, indicating a severe cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #13: listening to music she liked, being around animals such as pets, doing things with groups of people, participating in activities she liked, and going outside to get fresh air (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 3 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 when the weather was good. Level of Harm - Minimal harm or potential for actual harm Review of the care plan for Resident #13 dated 03/29/23 reflected the following: Care Plan Description Residents Affected - Few Psychosis: Hallucinations/Delusions Goal Behaviors will not interfere with others Provide honest consistent feedback in non-threatening manner Report onset or increase in behaviors to physician Monitor and document target behaviors Teach about all tests, procedures, treatments clearly and using simple language Assess hallucinations (auditory, or factory, tactile) Do not challenge content of behaviors Administer medications as ordered. The care plan did not include any planning for activities or activity preferences. During an interview on 05/01/23 at 09:47 AM, Resident #13 stated the facility did not offer any exercise or outdoor activities except for smoking. She stated the activities program was supposed to offer a lot of activities, but all they ever did was smoking and snacks. Resident #13 stated she wanted physical activity. Review of the undated face sheet for Resident #15 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dysthymic disorder, schizoaffective disorder, generalized anxiety disorder, alcohol-induced, persisting dementia disorder, restlessness and agitation. Review of the annual MDS for Resident #15 dated 04/01/22 reflected a BIMS score of 8, indicating a moderate cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #15: participating in activities he liked, participating in group activities, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #15 dated 05/16/22 reflected the following: Goal High AIC will be below 6 Intervention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 4 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 Encourage to get daily exercise/ physical activity Level of Harm - Minimal harm or potential for actual harm The care plan included no planning for activities or activity preferences. Residents Affected - Few Observation on 05/01/23 at 07:22 AM, 09:16 AM, 10:13 AM, 12:56 PM, and 02:08 PM revealed Resident #15 was sitting on his bed with no in-room activities or other stimulation. He answered simple questions but declined to participate in an interview. Review of the undated face sheet for Resident #39 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, insomnia, anxiety disorder, Alzheimer's disease, delusional disorders, and cognitive communication deficit. Review of the annual MDS for Resident #39 dated 08/26/22 reflected a BIMS score of 14, indicating little or no cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #39: listening to music she liked, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #39 dated 03/29/23 reflected the following: Care Plan Description Resident tends to isolate herself in her room and stays in bed most of the day. Goal Participates in a daily routine that is acceptable to the resident. Participates in a daily routine that is acceptable to the resident. Encourage resident to participate in activities scheduled for the day. The care plan did not include any activity preferences specific to Resident #39. Observation on 05/01/23 at 07:20 AM, 09:20 AM, 10:14 AM, 12:57 PM, and 02:07 PM revealed Resident #39 was sitting up in her bed with no in-room activities or other stimulation. She refused to be interviewed fully but stated she was bored and had nothing to do. Review of the undated face sheet for Resident #44 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type, other disorders of psychological development, schizophrenia, insomnia, dementia, restlessness and agitation, and bipolar disorder. Review of the annual MDS for Resident #44 dated 07/29/22 reflected a BIMS score of 12, indicating a mild cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #44: listening to music she liked, doing things with groups of people, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #44 dated 12/20/22 reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 5 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 Care Plan Description Level of Harm - Minimal harm or potential for actual harm I HEAR VOICES. I THINK PEOPLE ARE RAPING THE AIR OUT OF ME. I TALK ABOUT THE PARTICLES IN THE AIR, I OCCASIONALLY RESIST CARES. Residents Affected - Few Goal I WILL REMAIN SAFE IN MY ENVIRONMENT THROUGH NEXT REVIEW. The care plan did not include any activities or activity preferences specific to Resident #44. During an interview on 05/01/23 at 01:12 PM, Resident #44 stated she was bored and was looking for a deck of cards to play some cards with her friends. She stated she was bored like this often, and now that she was no longer hearing voices, she wanted more activities to keep her busy. Review of the undated face sheet for Resident #52 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of restlessness and agitation, cognitive communication deficit, schizoaffective disorder, vascular dementia, major depressive disorder, other obsessive compulsive disorder, and chronic pain. Review of the annual MDS for Resident #52 dated 04/27/23 reflected a BIMS could not be conducted. Section F of the MDS reflected the following activities were very important to Resident #52: listening to music she liked, being around animals, doing things with groups of people, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #52 dated 03/31/23 reflected the following: Care Plan Description Difficulty expressing ideas or wants Goal Expresses ideas or wants Speak in a low, clear voice Provide a quiet environment when discussing important issues. Speak directly in front of resident Ensure ears are free from impacted cerumen (wax). Use simple, direct communication Allow resident plenty of time to respond It reflected no care plan item for Resident #52's activities or activity preferences. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 6 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 05/01/23 at 07:21 AM, 09:15 AM, 10:12 AM, 12:55 PM, and 02:07 PM revealed Resident #52 was lying in bed with no in-room activities or other stimulation. She did not respond to efforts to interview her. During an interview on 05/03/23 at 12:34 PM, the ADM stated there should have been individual activities offered for each resident, and it went back to the resident's right to make their own choices. The ADM stated staff knew what each resident wanted to do. The ADM stated the majority of the residents would say they wanted to do one thing and in the next three minutes would change it. The ADM stated the residents' likes and dislikes should have been in their clinical record at least as part of their social history. The ADM stated the majority of the residents had guardians so it was not very common they could pick up the phone and call family to find out what the residents enjoyed doing. The ADM stated he thought the MDS did have an activities assessment, and it was one of the tools used to pull from. The ADM stated he was not aware of any particular activities for Residents #6, #13, #15, #39, #44, or #52. The ADM stated he wanted to be able to recognize and honor their choices to participate or not but he also wanted the offerings to be tailored to their preferences. The ADM stated RN E was responsible for completing the MDS assessments and creating the care plans, and she only worked weekends and some evenings. The ADM stated he did not think activities were required to be in care plans . An attempt was made to interview RN E on 05/03/23 at 02:10 PM by telephone with no answer received. A voicemail was left. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 7 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing 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 six of 24 (Residents #6, #13, #15, #39, #44 and #52 ) residents reviewed for activities. Residents Affected - Some 1. The facility failed to develop an activity program based on the preferences and suggestions of the resident population. 2. The facility failed to provide activities as scheduled on their activity calendar. 3. The facility failed to ensure in-room activities for Residents #15, #39, and #52, who spent most of or all their time in their rooms. These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life. Findings included: 1. Review of the undated face sheet for Resident #13 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of chronic pain, major depressive disorder, bipolar disorder, obsessive compulsive disorder, cognitive communication deficit, and anxiety disorder. Review of the annual MDS for Resident #13 dated 05/06/22 reflected a BIMS score of 3, indicating a severe cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #13: listening to music she liked, being around animals such as pets, doing things with groups of people, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #13 dated 03/29/23 reflected the following: Care Plan Description Psychosis: Hallucinations/Delusions Goal Behaviors will not interfere with others Provide honest consistent feedback in non threatening manner Report onset or increase in behaviors to physician Monitor and document target behaviors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 8 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 Teach about all tests, procedures, treatments clearly and using simple language Level of Harm - Minimal harm or potential for actual harm Assess hallucinations (auditory, or factory, tactile) Do not challenge content of behaviors Residents Affected - Some Administer medications as ordered. The care plan did not include any planning for activities or activity preferences. During an interview on 05/01/23 at 09:47 AM, Resident #13 stated the facility did not offer any exercise or outdoor activities except for smoking. She stated the activities program was supposed to offer a lot of activities, but all they ever did was smoking and snacks. Resident #13 stated she wanted physical activity. Review of the undated face sheet for Resident #6 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder, schizophrenia, and cognitive communication deficit. Review of the annual MDS for Resident #6 dated 09/17/22 reflected a BIMS score of 10, indicating a mild cognitive impairment. Section F of the MDS reflected a staff assessment of Resident #6 activity preferences included participating in favorite activities. Review of the care plan for Resident #6 dated 05/30/22 reflected the following: Care Plan Description Psychosis: Hallucinations/Delusions Goal Report onset or increase in behaviors to physician. Observation on 05/01/23 at 10:46 AM revealed Resident #6 walking up and down the East wing of the facility quickly and not responding to efforts to speak with her. The care plan for Resident #6 did not address activities or activity preferences. Observation on 05/01/23 at 10:06 AM revealed Resident #6 walking up and down the halls of the facility without speaking to anyone, with a fixed forward gaze. She did not stop walking or looking forward to be interviewed. During an interview on 05/02/23 at 12:53 PM, a FM of Resident #6 stated the one thing that would have helped Resident #6 was for the AD to engage Resident #6 in activities she would have liked. The FM stated the facility did not have a lot of activities, which was a shame. The FM stated Resident #6 had been involved in the greenhouse at the state hospital where she lived for many years before she came to the facility, and when they asked for gardening activities, for her, the facility staff said it could not happen. The FM stated Resident #6 paced the halls and had a lower quality of life as a result. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 9 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 - Some Review of the undated face sheet for Resident #44 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type, other disorders of psychological development, schizophrenia, insomnia, dementia, restlessness and agitation, and bipolar disorder. Review of the annual MDS for Resident #44 dated 07/29/22 reflected a BIMS score of 12, indicating a mild cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #44: listening to music she liked, doing things with groups of people, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #44 dated 12/20/22 reflected the following: Care Plan Description I HEAR VOICES. I THINK PEOPLE ARE RAPING THE AIR OUT OF ME. I TALK ABOUT THE PARTICLES IN THE AIR, I OCCASIONALLY RESIST CARES. Goal I WILL REMAIN SAFE IN MY ENVIRONMENT THROUGH NEXT REVIEW. The care plan did not include any activities or activity preferences specific to Resident #44. During an interview on 05/01/23 at 01:12 PM, Resident #44 stated she was bored and was looking for a deck of cards to play some cards with her friends. She stated she was bored like this often, and now that she was no longer hearing voices, she wanted more activities to keep her busy. During an interview on 05/03/23 at 01:46 PM, the Psych for Residents #6, #13, #15, and #44 stated the facility needed to have more activities. The Psych stated diverting and meaningful activities for residents with psychiatric issues prevented behaviors. The Psych stated she had discussed this with the facility administration, but she did not have much say in the matter. During an interview on 05/03/23 at 02:16 PM, the SW said it was common knowledge at the facility that the residents needed more engagement, as defined by activities and recreational therapies. The SW stated they had a lot of residents who preferred isolation or were not interested in activities, but there were others who needed more options. The SW stated, in her perspective, she felt as though the people in charge of activities had gotten to the point where they were frustrated that every time they put something together, no residents showed up. When asked for examples, the SW stated there were arts and crafts activities and puzzles that no one attended. The SW stated as long as one resident showed up, that was all that mattered to make the activity worth it. The SW stated the new ADM was putting more focus on activities, and he had only been at the facility for two months. 2. Review of the posted activity calendar for May 2023 reflected the following activities on the calendar: 05/01/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 10 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 10:00 AM Enjoy a Snack Level of Harm - Minimal harm or potential for actual harm 11:00 AM Current Events 02:00 PM Spa Day Residents Affected - Some 5/02/23 10:00 AM Enjoy a Snack 11:00 AM Current Events 02:00 PM [NAME] Dancing and Snacks 05/03/23 10:00 AM Enjoy a Snack 11:00 AM Current Events 02:00 PM Bingo Observation on 05/01/23 from 11:00 AM to 12:00 AM revealed no activity occurring in the dining area or any other area of the facility. Observation on 05/01/23 from 02:00 PM to 03:00 PM revealed no activity occurring in the dining area or any other area of the facility. Observation on 05/02/23 from 11:00 AM to 12:00 AM revealed no activity occurring in the dining area or any other area of the facility. Observation on 05/02/23 from 02:00 PM to 03:00 PM revealed no activity occurring in the dining area or any other area of the facility. Observation on 05/03/23 from 11:00 AM to 12:00 AM revealed no activity occurring in the dining area or any other area of the facility. During a confidential interview on 05/02/23 at 10:12 AM, four anonymous residents stated they wanted more exercise, and it had been discussed with the AD and administration before. The residents stated no additional activities had been added to the calendar, and all they did was smoking, snacks, and Bingo once per week. 3. Review of the undated face sheet for Resident #15 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dysthymic disorder, schizoaffective disorder, generalized anxiety disorder, alcohol-induced, persisting dementia disorder, restlessness and agitation. Review of the annual MDS for Resident #15 dated 04/01/22 reflected a BIMS score of 8, indicating a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 11 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 moderate cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #15: participating in activities he liked, participating in group activities, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #15 dated 05/16/22 reflected the following: Residents Affected - Some Goal High AIC will be below 6 Intervention Encourage to get daily exercise/ physical activity The care plan included no planning for activities or activity preferences. Observation on 05/01/23 at 07:22 AM, 09:16 AM, 10:13 AM, 12:56 PM, and 02:08 PM revealed Resident #15 was sitting on his bed with no in-room activities or other stimulation. He answered simple questions but declined to participate in an interview. Observation on 05/02/23 at 09:53 AM, 12:54 PM, and 02:12 PM revealed Resident #15 was sitting on his bed with no in-room activities or other stimulation. Observation on 05/03/23 at 09:22 AM, 11:10 AM, and 02:14 PM revealed Resident #15 was sitting on his bed with no in-room activities or other stimulation. Review of the undated face sheet for Resident #39 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, insomnia, anxiety disorder, Alzheimer's disease, delusional disorders, and cognitive communication deficit. Review of the annual MDS for Resident #39 dated 08/26/22 reflected a BIMS score of 14, indicating little or no cognitive impairment. Section F of the MDS reflected the following activities were very important to Resident #39: listening to music she liked, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #39 dated 03/29/23 reflected the following: Care Plan Description Resident tends to isolate herself in her room and stays in bed most of the day. Goal Participates in a daily routine that is acceptable to the resident. Participates in a daily routine that is acceptable to the resident. Encourage resident to participate in activities scheduled for the day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 12 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 The care plan did not include any activity preferences specific to Resident #39. Level of Harm - Minimal harm or potential for actual harm Review of the undated face sheet for Resident #52 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of restlessness and agitation, cognitive communication deficit, schizoaffective disorder, vascular dementia, major depressive disorder, other obsessive compulsive disorder, and chronic pain. Residents Affected - Some Observation on 05/01/23 at 07:20 AM, 09:20 AM, 10:14 AM, 12:57 PM, and 02:07 PM revealed Resident #39 was sitting up in her bed with no in-room activities or other stimulation. She refused to be interviewed fully but stated she was bored and had nothing to do. Observation on 05/02/23 at 09:50 AM, 12:53 PM, and 02:16 PM revealed Resident #39 was sitting up in her bed with no in-room activities or other stimulation. Observation on 05/03/23 at 09:21 AM, 11:09 AM, and 02:13 PM revealed Resident #39 was sitting up in her bed with no in-room activities or other stimulation. Review of the annual MDS for Resident #52 dated 04 /27/23 reflected a BIMS could not be conducted. Section F of the MDS reflected the following activities were very important to Resident #52: listening to music she liked, being around animals, doing things with groups of people, participating in activities she liked, and going outside to get fresh air when the weather was good. Review of the care plan for Resident #52 dated 03/31/23 reflected the following: Care Plan Description Difficulty expressing ideas or wants Goal Expresses ideas or wants Speak in a low, clear voice Provide a quiet environment when discussing important issues. Speak directly in front of resident Ensure ears are free from impacted cerumen (wax). Use simple, direct communication Allow resident plenty of time to respond It reflected no care plan item for Resident #52's activities or activity preferences. Observation on 05/01/23 at 07:21 AM, 09:15 AM, 10:12 AM, 12:55 PM, and 02:07 PM revealed Resident #52 was laying in bed with no in-room activities or other stimulation. She did not respond to efforts to interview her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 13 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 Observation on 05/02/23 at 09:55 AM, 11:02 AM, 11:47 AM, 02:30 PM revealed Resident #52 was laying in bed with no in-room activities or other stimulation. Observation on 05/03/23 at 08:35 AM, 10:17 AM, 11:08 AM and 02:25 PM revealed Resident #52 was laying in bed with no in-room activities or other stimulation. Residents Affected - Some During an interview on 05/03/23 at 12:34 PM, the ADM stated there should have been individual activities offered for each resident, and it went back to the resident's right to make their own choices. The ADM stated staff knew what each resident wanted to do. The ADM stated the majority of the residents would say they wanted to do one thing and in the next three minutes would change it. The ADM stated the residents' likes and dislikes should have been in their clinical record at least as part of their social history. The ADM stated the majority of the residents had guardians so it was not very common they could pick up the phone and call family to find out what the residents enjoyed doing. The ADM stated he thought the MDS did have an activities assessment, and it was one of the tools used to pull from. The ADM stated he was not aware of any particular activities for Residents #6, #13, #15, #39, #44, or #52. The ADM stated he wanted to be able to recognize and honor their choices to participate or not but he also wanted the offerings to be tailored to their preferences. The ADM stated he had not received complaints about activities. The ADM stated the facility usually had music playing all the time, and for some reason there had not been any during the state survey. The ADM stated staff and residents were usually dancing and singing and having fun, but he had noticed how quiet it had been while HHSC staff had been in the building. During an interview on 05/03/23 at 03:46 PM, the AD stated she had worked there 27 years. The AD stated she came up with the activities on the calendar. The AD stated she came up with things that were not too hard to do. The AD stated some of the residents understood and some did not. Some of the activities she had may have been kind of childish, but the resident liked them. The AD stated the residents could ask for games any time they wanted, and she would put them on the table. The AD stated she had never consulted an outside source for what kinds of activities would be helpful or enjoyable to residents with psychiatric issues or cognitive decline. The AD stated someone had suggested she do that, and that many years ago, there was a corporate level woman who would take her to different kinds of workshops, but after COVID, everybody backed off of those kinds of opportunities. The AD stated Resident #13 liked to go outside but had never said she would like to have more exercise. The AD stated Resident #6 liked to crochet and do the crossword. The AD stated she made sure Resident #6 had the crossword puzzle books. The AD stated Resident #44 liked to walk around and sit outside and would sometimes play cards. The AD said she placed care plan meetings on the calendar. The AD stated when they had the care plan meetings, she was supposed to attend. The AD stated the main thing residents constantly told her was they wanted more smoking breaks. The AD stated they had four smoke breaks, and that was as many as they could handle. The AD stated she did in-room activities with the residents who never liked to come out of their rooms. The AD stated she did in-room activities with Resident #15, #39, and #52. The AD stated she had written documentation of her in-room visits. Observation on 05/03/23 at 04:02 PM revealed the AD seated in the ADON's office writing a log of in-room visits on a mostly blank piece of white printer paper. At 04:22 PM she provided a stack of in-room visit logs on sheets of white printer paper. Review of in-room visit logs provided by the AD reflected no in-room visits for Residents #15, #39, or #52 . Review of undated facility policy titled Activity Program reflected the following: Purpose: provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 14 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete a wide range of activities to enhance the lives of residence. Provide opportunities for residents and staff to interact on a social basis. 1. Activities will be scheduled on a regular basis to enrich the lives of residents. Activities will include, but are not limited to: social events, indoor and outdoor activities, activities, outside of the facility, religious programs, creative activities, intellectual and educational activities, exercise, activities, individualized, activities, and room, activities, and community activities. 3. Scheduled activities are posted on the facility bulletin board. 4. Individualized and group activities are provided that: reflect the schedules, choices and rights of the residents; are offered at ours convenient to a preferred by the residents, including holidays and weekends; reflect the cultural and religious interests of the residents; appeal to both men and women, as well as all age groups of residents, residing in the facility. Event ID: Facility ID: 676291 If continuation sheet Page 15 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for one of two wings (West) reviewed and three of five posted evacuation routes reviewed. 1. The facility failed to updated floor plans with evacuation route when they closed two of the facility's seven fire exits due to construction. 2. The facility failed to ensure that boards nailed over a non-functioning exit door were free of broken, splintered ends accessible to residents on the [NAME] wing. These failures placed residents at risk of injury. Findings included: 1. Observation on 05/01/23 at 07:33 AM, revealed a set of double doors in the facility lobby blocked with an upright piano. The Exit sign over the doors was covered, and the area outside the doors was filled with construction materials. Observation on 05/01/23 at 07:41 AM, revealed a door at one end of the [NAME] wing of the facility near rooms 29-32. Several wooden boards were nailed across the door making egress impossible. The Exit sign over the door was covered. Observation on 05/01/23 at 07:42 AM, revealed the floor plan with evacuation route posted across from the lobby and outside the dining room listed the evacuation routes from that location as through the lobby or through a door on one end of the East wing. A second floor plan with evacuation route posted at the [NAME] wing nurse's station listed the evacuation routes from that location as through the lobby doors and the door at one end of the [NAME] wing of the facility near rooms 29-32. The floor plan posted on the [NAME] wing hall listed the evacuation routes from that location as through the door at one end of the [NAME] wing of the facility near rooms 29-32 and the door at the other end of the [NAME] wing. During interviews on 05/01/23 between 08:00 AM and 08:45 AM, LVN A, CNA B, NA C, and MA D each described knowledge of an evacuation plan that took into account the closed fire exits in the lobby and routed evacuating residents through the existing five fire exits. During an interview on 05/01/23 at 08:30 AM, the ADM stated a Life Safety Code surveyor had been to the building and determined the closed exits were compliant as long as the Exit signs were covered. The ADM stated the facility had a problem with the sewer system and contractors had to tunnel under the building in order to repair the problems. The ADM stated that there were deep trenches outside and construction equipment, and it would not have been safe for residents to go out of those doors. The ADM stated the evacuation plans should have been updated and posted to reflect the new evacuation pattern. The ADM stated posting the correct plans on the walls should have been the responsibility of the MAINT. When asked what a potential negative impact to the residents could have been, the Adm stated there was no potential negative impact, because the staff knew what to do in the event of an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 16 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 0689 evacuation. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/03/23 at 12:18 PM, the MAINT stated the facility had to replace drains and sewer plumbing, and they had completed most of the work. The MAINT stated the exits in the lobby and at one end of the [NAME] wing had been blocked off for close to nine months. The MAINT stated she conducted an in-service with staff when she blocked off the exits in May 2022 and taught them about the new evacuation routes. The MAINT stated she showed them copies of the revised floor plan with evacuation routes. When asked whose responsibility it was to post the new floor plans, she stated she was not sure because the administrator who was there before the current ADM would reprimand the staff if they placed anything on the walls without her permission, and the previous administrator handled all the postings in the facility. The MAINT stated she had not noticed the ones on the walls in the building were not current. The MAINT stated it was not clear after the current ADM arrived who should have updated them. Residents Affected - Some Review of an in-service in the disaster preparedness binder dated 05/19/22 and titled May Fire Drill reflected the following: explained the staff on new evacuation plan for area that closed off for construction and included revised floor plans with alternate evacuation routes. 2. Observation on 05/01/23 at 12:57 PM revealed the door at one end of the [NAME] wing of the facility near rooms 29-32 was blocked by three sets of wooden boards: a two by four nailed diagonally across the door, a fence picket nailed vertically across the door, and two fence pickets stacked together and nailed horizontally over the panic rim exit device (surface-mounted bar on the door, with the door latch projecting from the panic device rather than the door edge). These two boards were broken at the right end and projected a sharp, splintered surface accessible to anyone passing by. The broken edge of the board was sharp to the touch and deposited a splinter into the surveyor's finger. During an interview on 05/03/23 at 12:04 PM, the MAINT stated she had boarded up the door on the [NAME] wing herself. When asked if she knew how the boards became broken, she stated one of the residents had broken it while trying to go outside that door. She stated the resident was very strong, and the board was not very strong, and the facility staff had been right behind the resident, but the MAINT had not replaced the board. The MAINT stated this had happened a week prior. When asked why she had not replaced the board yet, the MAINT stated she had just gotten the two by four boards in that she needed to replace it. The MAINT stated residents and staff could be injured if they were to come into contact with the board. During an interview on 05/03/23 on 12:34 PM, the ADM stated he had not noticed the broken boards on the door by the [NAME] wing nurse's station and ensuring the safe condition of any construction areas accessible to the residents was the responsibility of the MAINT. The ADM stated a potential negative impact of the broken boards was that someone could grab it and splinter themselves. Review of undated facility policy titled Safety Policy reflected the following: Provide a safe environment for staff, residents, and visitors to work, live and visit. Procedure: 1. This facility provides a safe environment for all the staff to work, residents to live in and guests to visit. 2. Safety is the responsibility of everyone and any safety concern should be reported to management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 17 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to post nurse staffing data on a daily basis at the beginning of each shift in a clear and readable format and in a prominent place readily accessible to residents and visitors for two of three days of the recertification survey. Residents Affected - Many The facility failed to post nurse staffing information on 05/02/23 and 05/01/23. This failure placed residents and visitors at risk of being unaware of the facility daily staffing requirements. Findings included: Observation on 05/01/23 at 07:10 AM and 01:23 PM revealed no posted nurse staffing in any public, visible place in the facility. Observation on 05/02/23 at 09:02 AM and 02:40 PM revealed no posted nurse staffing in any public, visible place in the facility. During observation and an interview on 05/02/23 at 02:42 PM, the DON stated he did not know where the nurse staffing information was posted. He went to the nurse's station on the east wing and asked LVN A if she knew, and she went through some papers in a wire tiered filing [NAME] and pulled out a clip board with several blank nurse staffing information pages which included spaces for the date, census, and a grid of shifts with nursing positions. The DON stated he thought they filled out the information each day and left it in the filing [NAME] but did not know they needed to post it. The DON stated the charge nurse for the wing was responsible for filling out that information. He stated he had never been told what he should do with the nurse staffing information. The DON stated he could see how it would be important to residents and visitors to know how many staff to expect to be working. During an interview on 05/02/23 at 02:47 PM, LVN A stated she usually filled out the nurse staffing information and left it on the desk where anyone could see it if they walked by, but she did not know why she had not filled out the information or posted it that day. LVN A stated she did not get any particular training or direction from management about what to do with the nurse staffing information. Review of undated facility policy titled Policy and procedure on daily direct care staff posting reflected the following: Policy: it is the policy of the facility to maintain the daily direct care staff to provide the best quality of care for all resident with sufficient staffing ratio on all shift. Procedure: daily, direct care staff posting must be posted prior to the beginning of all shift. 1. Per federal regulations the posting of the daily direct care stuff is required for all shift. 3. The posting will contain RN hours, LVN hours for all shift, number of non-licensed staff hours, which include the certified nurse, aides, certified medication, aids, and/or restorative. 4. The daily direct care posting must be posted in a prominent place and readily accessible to all residents and visitors. 6. This posting must have the census, information, facility, name, and date on the form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 18 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 diseases and infections for one of one (Resident #17) resident and 1 of 1 nurse (LVN A) observed for G-Tube medication administration. Residents Affected - Few LVN A failed to maintain the G-tube tubing tip and syringe plunger clean while administering G-Tube medication. This failure could place residents with G-tubes at risk of decline in health due to inappropriate G-tube care and infection. Findings include: Review of Resident #17's face sheet revealed a 75-years-old female DOB [DATE] with admission date of 07/06/2011 and readmission date of 07/28/2022. Diagnoses include Esophageal reflux, Dysphagia (Dysphagia is difficulty swallowing - taking more time and effort to move food or liquid from your mouth to your stomach) Review of Resident #17's MDS assessment dated [DATE] revealed a BIMS score of 00, staff assessment was conducted indicating memory problems. Review of Resident #17's Care Plan dated 04/07/2022 revealed Resident #17 is being fed by alternative means, being fed by GTUBE (gastrostomy tube (also called a G-tube) is a tube inserted through the belly that brings nutrition directly to the stomach.) During an observation on 05/02/23 at 10:38 a.m., while LVN A was administering medication to Resident #17, LVN A was observed disconnecting the G-Tube tubing from Resident #17, covering the tip of the tubing with a cap which inner portion was on the G-Tube pole, making the inner of the cap contaminated. LVN A then used the contaminated cap to cover the tip of Resident #17's G-Tube. LVN A was also observed putting the inner portion of the plunger of the syringe used to administer medication to Resident #17 on the medication cart. The medication cart was not disinfected, thereby making the plunger contaminated. LVN A did not take a towel with her when administering medication to Resident #17, while administering water to Resident #17 via G-Tube, LVN A spilled water on Resident #17 abdomen and did not acknowledge it. During an interview on 05/02/23 at 10:46 a.m., LVN A stated the cap for the tip of the G-Tube was kept on the top of the G-Tube pole. LVN A also stated the cap is not clean because the inner portion is exposed to the pole which is not disinfected. LVN A stated the plunger for the syringe should have been put on something, not on the cart. LVN A stated, I should have taken a towel, pat dry Resident #17 and apologized. During an interview on 05/03/2023 at 2:11 p.m., the DON stated LVN A should have taken a towel with her as equipment. He also stated the plunger is considered contaminated because there was nothing on the cart to keep it clean. He stated LVN A told him about the cap for the tip of the G-Tube tubing, and it was not clean. The DON stated that was an infection control issue. The DON stated LVN A had completed competency check on G-tube medication administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 19 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 LVN A's training records reflected LVN A completed G-Tube medication administration check off on 01/20/2023. Level of Harm - Minimal harm or potential for actual harm Review of facility's policy titled Enteral Nutrition Therapy (Tube Feeding) dated 2006 reflected: Residents Affected - Few Basic Responsibility-Licensed Nurse. Purpose: to provide liquid nourishment through a tube, inserted into the stomach. To provide hydration through a tube inserted into the stomach. Equipment: feeding syringe, towel, waterproof pad if FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 20 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one of two wings (West) reviewed and three of five posted evacuation routes reviewed. 1. The facility failed to updated floor plans with evacuation route when they closed two of the facility's seven fire exits due to construction. 2. The facility failed to ensure that boards nailed over a non-functioning exit door were free of broken, splintered ends accessible to residents on the [NAME] wing. These failures placed residents at risk of injury. Findings included: 1. Observation on 05/01/23 at 07:33 AM, revealed a set of double doors in the facility lobby blocked with an upright piano. The Exit sign over the doors was covered, and the area outside the doors was filled with construction materials. Observation on 05/01/23 at 07:41 AM, revealed a door at one end of the [NAME] wing of the facility near rooms 29-32. Several wooden boards were nailed across the door making egress impossible. The Exit sign over the door was covered. Observation on 05/01/23 at 07:42 AM, revealed the floor plan with evacuation route posted across from the lobby and outside the dining room listed the evacuation routes from that location as through the lobby or through a door on one end of the East wing. A second floor plan with evacuation route posted at the [NAME] wing nurse's station listed the evacuation routes from that location as through the lobby doors and the door at one end of the [NAME] wing of the facility near rooms 29-32. The floor plan posted on the [NAME] wing hall listed the evacuation routes from that location as through the door at one end of the [NAME] wing of the facility near rooms 29-32 and the door at the other end of the [NAME] wing. During interviews on 05/01/23 between 08:00 AM and 08:45 AM, LVN A, CNA B, NA C, and MA D each described knowledge of an evacuation plan that took into account the closed fire exits in the lobby and routed evacuating residents through the existing five fire exits. During an interview on 05/01/23 at 08:30 AM, the ADM stated a Life Safety Code surveyor had been to the building and determined the closed exits were compliant as long as the Exit signs were covered. The ADM stated the facility had a problem with the sewer system and contractors had to tunnel under the building in order to repair the problems. The ADM stated that there were deep trenches outside and construction equipment, and it would not have been safe for residents to go out of those doors. The ADM stated the evacuation plans should have been updated and posted to reflect the new evacuation pattern. The ADM stated posting the correct plans on the walls should have been the responsibility of the MAINT. When asked what a potential negative impact to the residents could have been, the Adm stated there was no potential negative impact, because the staff knew what to do in the event of an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 21 of 22 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 evacuation. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/03/23 at 12:18 PM, the MAINT stated the facility had to replace drains and sewer plumbing, and they had completed most of the work. The MAINT stated the exits in the lobby and at one end of the [NAME] wing had been blocked off for close to nine months. The MAINT stated she conducted an in-service with staff when she blocked off the exits in May 2022 and taught them about the new evacuation routes. The MAINT stated she showed them copies of the revised floor plan with evacuation routes. When asked whose responsibility it was to post the new floor plans, she stated she was not sure because the administrator who was there before the current ADM would reprimand the staff if they placed anything on the walls without her permission, and the previous administrator handled all the postings in the facility. The MAINT stated she had not noticed the ones on the walls in the building were not current. The MAINT stated it was not clear after the current ADM arrived who should have updated them. Residents Affected - Some Review of an in-service in the disaster preparedness binder dated 05/19/22 and titled May Fire Drill reflected the following: explained the staff on new evacuation plan for area that closed off for construction and included revised floor plans with alternate evacuation routes. 2. Observation on 05/01/23 at 12:57 PM revealed the door at one end of the [NAME] wing of the facility near rooms 29-32 was blocked by three sets of wooden boards: a two by four nailed diagonally across the door, a fence picket nailed vertically across the door, and two fence pickets stacked together and nailed horizontally over the panic rim exit device (surface-mounted bar on the door, with the door latch projecting from the panic device rather than the door edge). These two boards were broken at the right end and projected a sharp, splintered surface accessible to anyone passing by. The broken edge of the board was sharp to the touch and deposited a splinter into the surveyor's finger. During an interview on 05/03/23 at 12:04 PM, the MAINT stated she had boarded up the door on the [NAME] wing herself. When asked if she knew how the boards became broken, she stated one of the residents had broken it while trying to go outside that door. She stated the resident was very strong, and the board was not very strong, and the facility staff had been right behind the resident, but the MAINT had not replaced the board. The MAINT stated this had happened a week prior. When asked why she had not replaced the board yet, the MAINT stated she had just gotten the two by four boards in that she needed to replace it. The MAINT stated residents and staff could be injured if they were to come into contact with the board. During an interview on 05/03/23 on 12:34 PM, the ADM stated he had not noticed the broken boards on the door by the [NAME] wing nurse's station and ensuring the safe condition of any construction areas accessible to the residents was the responsibility of the MAINT. The ADM stated a potential negative impact of the broken boards was that someone could grab it and splinter themselves. Review of undated facility policy titled Safety Policy reflected the following: Provide a safe environment for staff, residents, and visitors to work, live and visit. Procedure: 1. This facility provides a safe environment for all the staff to work, residents to live in and guests to visit. 2. Safety is the responsibility of everyone and any safety concern should be reported to management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 22 of 22