Health inspection·April 29, 2022

F 0656 diabetes were not reflected in her comprehensive care plans. Level of Harm - Minimal harm or potential for actual harm Observation of Resident #63 on 04/26/22 at 2:11 pm revealed resident in her bed with eyes closed. Residents Affected - Few Observation and interview with Resident #63 on 04/27/22 at 8:57 am revealed she was in her wheelchair in her room. Resident #63 said she had just had breakfast and liked to attend activities. During interview, Resident #63 was noted to be very hard of hearing and was not wearing a hearing aid. Interview on 04/27/22 at 9:24 am with MDS B revealed she was the MDS Coordinator for Resident #63. She said she had missed developing a care plan for focus areas of cognitive communication deficit, advance directives and diagnosis of diabetes. Interview on 04/28/22 at 1:20 pm with MDS B revealed the comprehensive care plan for Resident #63 should have been developed and completed seven days after the MDS assessment dated [DATE]. Resident #63's care plan should have been completed by 04/01/22. MDS B said the baseline care plan had been completed. MDS B said she missed developing the care plan for Resident #63. The care plans gave instructions to staff for care to be provided to residents. MDS B said the comprehensive care plan was based on the MDS assessment and was a combination of resident's goals, timelines to achieve those goals and interventions to help meet those goals. Interview on 04/28/22 at 2:16 pm with Social Worker revealed she was responsible for developing the comprehensive care plan for advance directives for Resident #63. The Social Worker said she had missed developing the care plan for advance directives. The care plans gave staff instructions on providing care according to interventions. If this care plan is not developed, staff had the potential to not provide the proper care regarding advance directives. Observation on 04/28/22 2:39 pm of Resident #63 revealed resident in her wheelchair at nurse's station, alert and in good spirits. Interview on 04/28/22 2:48 pm with LVN E revealed she referred to the physician orders and the MARS to verify what care the resident required. MDS B said she met with the IDT in their morning meetings and did not remember reviewing Resident #63's care plans. During morning meetings with CNAs, she would verbally explain to CNAs precautions (interventions) to provide care to residents. All direct care staff would look in their ADLs instructions in computer. MDS B said she didn't think CNAs had access to care plan. If there is no care plan developed, it would be her duty to let Administration that there is no care plan or to clarify. MDS B said she had not noticed Resident #63's care plans were not complete. Interview on 04/28/22 at 3:28 pm with CNA H revealed Resident #63 was sometimes confused and voiced some situations that were not facts. CNA H said she did not know if Resident #63 was diabetic. CNA H said she would get communication from her charge nurse on care required for residents on daily meetings. CNA H said she knew that a care plan described care was needed. CNA H said she did not have access to care plans on the computer. Interview on 04/29/22 at 9:15 am with the DON revealed Resident #63's comprehensive care plans were not developed by MDS staff as required. The DON said MDS B was responsible to develop the comprehensive care plans for Resident #63. The DON said the comprehensive care plan provided information for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 2 of 11 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 676299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpark Meadows Nursing and Rehabilitation Cente 9801 S 1st Street Austin, TX 78748 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 staff for continuous care. If a comprehensive care plan is not developed, it places this resident at risk of not receiving appropriate care for her specific care areas. Record review of the facility policy titled Care Planning; updated December 2017 indicated: A comprehensive, person centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial and functional needs. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 3 of 11 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 676299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpark Meadows Nursing and Rehabilitation Cente 9801 S 1st Street Austin, TX 78748 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to review and revise by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2(Resident #30 and #60) of 12 residents reviewed for care plan revisions in that: 1. Resident #30's bowel status was not revised to reflect on her comprehensive person-centered care plan that she was always incontinent of bowel. 2. Resident #60 put on and took off her own oxygen nasal cannula and changed the rate of her oxygen on the concentrator and her comprehensive person-centered care plan was not revised to reflect these behaviors. This deficient practice could affect residents who have changes in care and result in lack of or inaccurate care. The findings were: 1. Review of Resident #30's electronic face sheet dated 4/27/22 revealed she was admitted to the facility on [DATE] with diagnoses of unspecified atrial fibrillation (heart dysrhythmia), tachycardia (fast heart rate), anemia (low iron in blood), cognitive communication deficit (lapse in memory) and dysphagia (difficulty swallowing). Review of Resident #30's quarterly MDS assessment with an ARD of 2/19/22 revealed under section HBowel and Bladder that she was coded a 3 which indicated she was always incontinent of bowel and bladder. She scored an 11/15 on her BIMS which indicated she was moderately cognitively impaired. Review of Resident #30's comprehensive person-centered care plan initiated on 2/19/22 and revised on 4/13/22 revealed has MIXED bladder incontinence but did not reflect she was always incontinent of bowel. Observation on 4/29/22 at 08:20 a.m. revealed Resident #30 had her brief changed after an episode of incontinence. Interview on 4/29/22 at 08:30 a.m. with Resident #30 revealed she was incontinent of bowel and bladder and hadn't used the toilet for quite a while. Interview on 4/29/22 at 09:30 a.m. with MDS C revealed that Resident #30's comprehensive person-centered care plan should have been revised after her quarterly review to reflect her bowel status. She stated that it was important for staff to be aware of the type of care Resident #30 required. She stated it was her mistake and she missed it somehow. Interview on 4/27/22 at 3:00 p.m. with the DON revealed that Resident #30's comprehensive person-centered care plan needed to reflect her incontinence of bowel because it was important for staff to know what type of care the resident required. 2. Review of Resident #60's electronic face sheet dated 4/26/22 revealed she was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 4 of 11 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 676299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpark Meadows Nursing and Rehabilitation Cente 9801 S 1st Street Austin, TX 78748 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (lung disorder that affects breathing), diabetes mellitus (blood sugar disorder), hypertension (high blood pressure) and dependence on oxygen (required supplemental oxygen). Review of Resident #60's quarterly MDS assessment with an ARD of 3/24/22 revealed under Section O -Special Treatments and Programs, she had oxygen therapy checked off while a resident. She scored an 11/15 on her BIMS which indicated she was moderately cognitively impaired. She was able to understand and to be understood. She required supervision and oversight with her ADL's. Review of Resident #60's comprehensive care-plan initiated on 7/6/21 and revised on 7/26/21 revealed .has COPD-OXYGEN DEPENDENT r/t h/o smoking. Her orders are for 2L/NC continuous. Review of Resident #60's Order Summary Report dated 4/26/22 revealed Oxygen at 2 LPM via NC every shift for COPD Prescriber Written Active 06/25/2021 06/25/2021. Review of Resident #60's nurse MAR dated April 2022 revealed Oxygen at 2 LPM via NC every shift for COPD-Start Date-06/25/2021. Observation on 4/26/22 at 10:45 a.m. of Resident #60 revealed she was sitting on the side of her bed; oxygen was set at 3 Liters on her concentrator. She had her nasal cannula on the floor. Observation on 4/27/22 at 08:30 a.m. of Resident #60 revealed she was sitting in her room on her bed eating breakfast. Her oxygen cannister was set to deliver 3 L/min. Interview on 4/27/22 at 08:40 a.m. with Resident #60, when asked if she took her nasal cannula off and put it on herself, she stated yes and when asked if she changed the rate of her oxygen on the concentrator, she stated no that the nurses did that. Observation on 4/27/22 at 09:00 a.m. with the DON of Resident #60's oxygen setting on her concentrator revealed it was set at 3 Liters. The DON stated that Resident #60 changed the settings on her oxygen. Interview on 4/27/22 at 09:30 a.m. with LVN A, the charge nurse she stated she did not check the oxygen rate on the cannister and knew that she should have. She stated it was important to make sure the resident was on the correct oxygen rate because of their ability to breath and have enough saturation of oxygen in the blood. She stated that Resident #60 took off and put on her nasal cannula and sometimes it was on the floor. Interview on 4/28/22 at 1:20 p.m. with MDS B revealed that Resident #60's comprehensive person-centered care plan should have been revised after her quarterly MDS assessment to reflect that she took off and put on her nasal cannula and adjusted her rate of oxygen on the concentrator to make staff aware of her behaviors and to monitor for changes. She stated she missed the update to reflect Resident #60's behaviors related to her oxygen therapy. Interview on 4/27/22 at 3:00 p.m. with the DON revealed that the nurses needed to follow the physician's orders and check the oxygen rate on the concentrators because too much or too little oxygen could be detrimental for the resident. She stated that Resident #60 changed her oxygen rate however the nurses needed to check it each shift. She stated she was accountable and checked on the nurses as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 5 of 11 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 676299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpark Meadows Nursing and Rehabilitation Cente 9801 S 1st Street Austin, TX 78748 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete needed. She stated Resident #60's comprehensive person-centered care plan needed to reflect her behaviors related to her oxygen therapy because then staff would check more often to ensure she had the right oxygen rate being delivered. Review of CMS's RAI Version 3.0 Manual CH 4: CAA Process and Care Planning October 2017 Page 4-10 assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents . A well developed and executed assessment and care plan: o Looks at each resident as a whole human being with unique characteristics and strengths; o Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); o Gives the IDT a common understanding of the resident; o Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); o Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); o Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow up; o Reflects the resident's/resident representative's input, goals, and desired outcomes; o Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of wellbeing (care planning); o Re-evaluates the resident's status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. Following the decision to address a triggered condition on the care plan, key staff or the IDT should subsequently: o Review and revise the current care plan, as needed. Event ID: Facility ID: 676299 If continuation sheet Page 6 of 11 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 676299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpark Meadows Nursing and Rehabilitation Cente 9801 S 1st Street Austin, TX 78748 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care and tracheal suctioning, is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 (Residents #37 and #60) of 3 residents observed for oxygen management in that: Residents Affected - Few 1. Resident #37's oxygen concentrator was set on 3 L/min and he did not have a physician's order for his oxygen. 2. Resident #60's oxygen concentrator was set on 3 L/min and her physician orders were for 2L/min via NC. This deficient practice could affect residents on oxygen therapy and could result in too much or too little oxygen administered and result in respiratory distress. The findings were: 1. Review of Resident #37's electronic face sheet dated 4/27/22 revealed he was admitted to the facility on [DATE] with diagnoses of dementia (cognitive dysfunction related to brain), schizophrenia (psychiatric mood disorder), hypotension (low blood pressure), COPD (lung disease) with exacerbation, and contracture of muscle, multiple sites (permanent tightening of muscles, tendon and skin). Review of Resident #37's quarterly MDS assessment with an ARD of 3/1/22 revealed he was not on oxygen therapy. He scored a 10/15 on his BIMS which indicated he was moderately cognitively impaired. He required extensive assistance with his ADL's. Review of Resident #37's comprehensive person-centered care plan initiated 4/22/22 revealed The resident has altered respiratory status/difficulty breathing AEB worsening dyspnea on exertion, 02 sats <85%, mild productive cough/rales and respiratory wheezing. NON-COMPLIANT WITH OXYGEN. No rate was specified. Review of Resident #37's Order Summary Report dated April 2022 did not reflect an order for oxygen, he was ordered breathing treatments every 6 hours for 14 days on 4/14/22. Review of Resident #37's progress notes dated 4/16/22 revealed Resident #37 was on oxygen at 2L/NC and on 4/22/22 he had a change in condition and his oxygen saturation dropped into the 80's and he was placed on oxygen. Review of Resident #37's progress notes from 4/23/22 revealed on 4 L/M via NC. Observation on 4/27/22 at 2:29 p.m. while observing a breathing treatment, Resident #37's oxygen rate on his concentrator was set at 3 L/min. Interview on 4/27/22 at 2:30 p.m. with LVN A revealed Resident #37's oxygen rate is 3 L/min. Interview on 4/27/22 at 2:40 p.m. with LVN A, the charge nurse she stated she did not check the orders for Resident #37 and knew she should have. She stated it was important to make sure the resident was on the correct oxygen rate because of their ability to breath and have enough saturation of oxygen in the blood, and that Resident #37 had just had a change in condition and was on nebulizer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 7 of 11 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 676299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpark Meadows Nursing and Rehabilitation Cente 9801 S 1st Street Austin, TX 78748 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few treatment for one more day. LVN A stated she was not aware that Resident #37 did not have an oxygen order and she stated that oxygen was considered a medication and needed to have an order. Interview on 4/27/22 at 3:00 p.m. with the DON revealed that the nurses needed to follow the physician's orders and check the oxygen rate on the concentrators because too much or too little oxygen could be detrimental for the resident. She stated that Resident #37 was placed on oxygen when he was short of breath and his oxygen saturations dropped, however, if he remained on oxygen which he did, he needed an order and the nursing staff know that. She stated she did not know why one had not been obtained. 2. Review of Resident #60's electronic face sheet dated 4/26/22 revealed she was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (lung disorder that affects breathing), diabetes mellitus (blood sugar disorder), hypertension (high blood pressure) and dependence on oxygen (required supplemental oxygen). Review of Resident #60's quarterly MDS assessment with an ARD of 3/24/22 revealed under Section O -Special Treatments and Programs, she had oxygen therapy checked off while a resident. She scored an 11/15 on her BIMS which indicated she was moderately cognitively impaired. She was able to understand and to be understood. She required supervision and oversight with her ADL's. Review of Resident #60's comprehensive care-plan initiated on 7/6/21 and revised on 7/26/21 revealed .has COPD-OXYGEN DEPENDENT r/t h/o smoking. Her orders are for 2L/NC continuous. Review of Resident #60's Order Summary Report dated 4/26/22 revealed Oxygen at 2 LPM via NC every shift for COPD Prescriber Written Active 06/25/2021 06/25/2021. Review of Resident #60's nurse MAR dated April 2022 revealed Oxygen at 2 LPM via NC every shift for COPD-Start Date-06/25/2021. Observation on 4/26/22 at 10:45 a.m. of Resident #60 revealed she was sitting on the side of her bed; oxygen was set at 3 Liters on her concentrator. Observation on 4/27/22 at 08:30 a.m. of Resident #60 revealed she was sitting in her room on her bed eating breakfast. Her oxygen concentrator was set at 3 L/min. Interview on 4/27/22 at 08:40 a.m. with Resident #60, when asked if she took her nasal cannula off and put it on herself, she stated yes and when asked if she changed the rate of her oxygen on the concentrator, she stated no that the nurses did that. Observation on 4/27/22 at 09:00 a.m. with the DON of Resident #60's oxygen setting on her concentrator revealed it was set at 3 Liters. Interview on 4/27/22 at 09:30 a.m. with LVN A, the charge nurse she stated she did not check the oxygen rate on the cannister and knew that she should have. She stated it was important to make sure the resident was on the correct oxygen rate because of their ability to breath and have enough saturation of oxygen in the blood. She stated that Resident #60 sometimes took off and put on her nasal cannula. She admitted that nothing was done to address this. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 8 of 11 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 676299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpark Meadows Nursing and Rehabilitation Cente 9801 S 1st Street Austin, TX 78748 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 0695 Level of Harm - Minimal harm or potential for actual harm Interview on 4/27/22 at 3:00 p.m. with the DON revealed that the nurses needed to follow the physician's orders and check the oxygen rate on the concentrators because too much or too little oxygen could be detrimental for the resident. She stated that Resident #60 changed her oxygen rate however the nurses needed to check it each shift. When asked if the facility had a policy or procedure for oxygen management, she stated it did not. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 9 of 11 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 676299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpark Meadows Nursing and Rehabilitation Cente 9801 S 1st Street Austin, TX 78748 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 - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 (Resident #3) of eight residents in the facility that were observed. Resident #3's room refrigerator was dirty with grime, food containers undated and leaking melted water from the freezer compartment in the upper section of fridge. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant and non-homelike. Findings Included: Record review of Resident #3's admission Record dated 04/28/22 indicated Resident #3 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was re-admitted on [DATE] and her diagnoses included vascular dementia (problems with reasoning, memory, and other thought processes), hemiplegia and hemiparesis (spinal cord injury), chronic kidney disease stage 3 (loss of kidney function), diabetes and lack of coordination. Record review of Resident #3's quarterly MDS dated [DATE] indicated Resident #3: -cognitive status was independent. -required extensive assistance with two persons for bed mobility, dressing, and bathing. -required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs), and personal hygiene. -had impairment on both sides of lower extremity (hip, knee, ankle, foot). Record review of Resident #3's care plans dated 10/29/20 indicated. -had diabetes, at risk for hyper/hypoglycemia. Interventions included to take all medications as ordered by doctor and educate resident regarding medications, revised 02/09/21. -had altered chronic endocrine status adrenal insufficiency due to chronic kidney disease stage 3, revised 02/09/21. swallowing difficulty as related to dementia and dysphagia, revised on 08/13/19. Interventions included administer meds as ordered, fasting serum blood sugar as ordered by doctor, revised on 02/09/21. Observation and interview on 04/26/22 at 11:27 am with Resident #3 revealed she was in her wheelchair in her room, waiting for her meal. Resident #3 said she kept foods in her refrigerator that were brought from home. The refrigerator contained leftovers in containers, bottles of dressing for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 10 of 11 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 676299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southpark Meadows Nursing and Rehabilitation Cente 9801 S 1st Street Austin, TX 78748 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 salads, flavored syrups, tomato catsup, mustard, supplemental drinks, etc. Resident #3 said she had to clean her own refrigerator and it needed cleaning today. Resident #3 said she would ask staff to help her clean it out, but no one came to help her clean the refrigerator. The thermostat inside the refrigerator read 45 degrees while the door was been opened for inspection by surveyor and staff. The refrigerator had dirt and dark stains in the walls and shelves of refrigerator. Residents Affected - Few Interview on 04/28/22 at 10:30 am with CNA D revealed she thought Resident #3's refrigerator looked disgusting and dirty. CNA D said she did not know who should be cleaning the resident's refrigerator, but it did need cleaning because it was dirty and had the risk to cause food illnesses for the resident. CNA D said the refrigerator had dirty, dark stains in the walls, shelves of refrigerator. Interview on 04/28/22 at 10:35 am with the DON revealed housekeeping staff should be cleaning the refrigerators in resident's rooms. The DON said there had been a lot of housekeeping staff turnover and staff had not been cleaning the refrigerator as required. The DON said she was not aware the refrigerator for Resident #3 was not been cleaned out and the freezer section was leaking melted water. Interview on 04/28/22 at 11:08 am with LVN E revealed she did not know who was supposed to clean out the refrigerators. LVN E said the refrigerator looked very dirty with grime and dark stains. LVN E said Resident #3 was very alert and she family bringing her food items that resident kept in her refrigerator. LVN E said the thermostat in refrigerator was reading 45 degrees and melted water was leaking from freezer compartment. Interview on 04/28/22 at 10:37 am with Housekeeping F revealed it was housekeeping staff's duty to maintain the refrigerators in resident rooms' clean. There was no schedule, but when housekeeping was done in each room daily, staff were supposed to be checking the refrigerator to see if they needed cleaning. Housekeeping F said she had never cleaned Resident #3's refrigerator and it was very dirty with dark stains. Interview on 04/28/22 at 10:50 am with Housekeeping G revealed she had not been instructed to clean resident's refrigerators in their rooms. Interview on 04/28/22 at 3:30 pm with the facility Administrator revealed she did not have a policy or schedule to clean out personal items in resident rooms such refrigerators. Housekeeping staff was responsible to clean out refrigerators in the resident's rooms. No one had been assigned to oversee this task. On 04/29/22 at 9:52 am the DON said there were staff who are designated as angels to do rounds for each resident. That designated staff should be checking the areas of concern like the cleaning of refrigerators in resident's rooms. The DON said if the refrigerator is not maintained clean or sanitary, there was the potential for bacteria to grow and storing foods that were expired and not keeping foods at proper temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 11 of 11