Inspection·June 15, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some attention. The residents said sometimes the phone calls were long, especially while feeding the residents. One resident shared that while they did not need assistance with being fed, the roommate did and when that happened all the roommate could do was scream in the dining room. Interview on 6/15/23 at 9:13 AM the Administrator said the facility had done several in-services on cell phone use. He said he would feel less than attended to if staff were on their phone while providing care which would not feel good. He was informed of the Surveyor's observations and interviews with individual residents as well as the Resident Council. He stated Resident #27 was with it enough to communicate what was going on. The Administrator stated that cell phone use was an ongoing issue in the facility. He stated that the management staff had addressed it on several occasions through in-services and would continue to do so. Interview on 6/15/23 at 11:38 AM the DON said she would be ticked off if staff were on their phone while taking care of her. Review of the facility's in-services, dated 5/24/23 and 1/2/23, revealed: Cell phones are not to be used while working, no cell phones are allowed while in hallways or resident rooms. In case of emergency let your charge nurse know and step into break room. Employee handbook F-4 - Employees are not permitted to use their personal cell phones while on work duty, including during the care of residents, except in emergency situations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 2 of 20 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 06/15/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and the facility failed to ensure the baseline care plan was developed within 48 hours of a resident's admission for 4 of 8 residents (Residents #100, #262, #265, #267) reviewed for baseline care plan. The facility failed to ensure Resident #100 had a baseline care plan that addressed his ADL status, cognitive ability, urinary incontinence, pain management, falls or breathing treatments. The facility failed to ensure Resident #262 had a baseline care plan that addressed his PEG tube (feeding tube), diabetes mellitus, pneumonitis, ADL decline, falls, and pain. The facility failed to ensure Resident #265 had a baseline care plan that addressed his wound care, osteomyelitis, and pain. The facility failed to ensure Resident #267 had a baseline care plan that addressed his end stage renal failure, intravenous antibiotic therapy, dialysis and shunt (a catheter that aids the connection from dialysis access to a major artery) care, and fluid restriction. This failure could place residents at risk of not receiving the care and services and continuity of care. Findings include: Record review of Resident #100's face sheet, dated 6/14/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), atherosclerosis (a buildup of fats, cholesterol plaque in the walls of arteries), dementia (a group of conditions that impairs memory and judgement), atrial fibrillation (irregular heart rate that causes poor blood flow), and muscle wasting (decreased muscle tissue). Review of Resident #100's MDS section of the chart, reflected her admission MDS was not completed yet. Review of Resident #100's Order Summary Report, dated 06/06/23, revealed orders: Tramadol 50 MG, give 1 tablet by mouth every 8 hours as needed for pain. Rosuvastatin Calcium 5 mg tablet, give 1 tablet by mouth at bedtime for HDL cholesterol. Ipratropium 0.5 mg inhale orally via nebulizer four times a day for shortness of breath. Lidocaine Patch 4 %, apply 1 patch transdermally one time a day for pain. Quetiapine Fumarate (used to treat schizophrenia, bipolar disorder) 25 mg, give 1 tablet by mouth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 3 of 20 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 06/15/2023 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 0655 two times a day for (no diagnosis given). Level of Harm - Minimal harm or potential for actual harm Review of Resident #100's undated care plan reflected no baseline care plan for ADL status, cognitive ability, urinary incontinence, pain management, falls, breathing treatments. Review of Resident 100's admission notes, revealed that resident was incontinent, was at risk for falls, needed assistance with pain management and ADL's. Residents Affected - Some Record review of Resident #262's face sheet, dated 6/14/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included pneumonitis (inflammation of lung tissue), cancer, gastrectomy (removal of all or part of stomach), diabetes mellitus, hypertension, severe protein calorie malnutrition, muscle wasting and difficulty walking. Review of Resident #262's MDS section of their chart reflected her admission MDS was not completed yet. Review of Resident #262's Order Summary Report, dated 06/10/23, revealed orders: Hydrocodone-Acetaminophen tablet 10-325 mg via PEG-tube, give as needed for pain. Hydromorphone Oral Tablet 2mg, give1 tablet via PEG-tube for pain. Insulin Aspart Injection ,100 UNIT/ml, Inject as per sliding scale for diabetes mellitus. Enteral Feed, one time a day Jevity 1.2 via PEG-tube. Review of Resident #262's undated care plan revealed no baseline care plan for PEG tube, diabetes mellitus, pneumonitis, ADL decline, falls, and pain. Review of Resident 262's admission notes, revealed that resident was admitted with a diagnosis of pneumonitis, diabetes mellitus, was at risk for falls, needed assistance with pain management, ADL's and a PEG tube. Record review of Resident #265's face sheet, dated 6/14/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included osteomyelitis of vertebra (bone infection of vertebra), stimulant drug abuse, and neuropathy (disease of peripheral nerves, causing numbness). Review of Resident #265's MDS section of their chart revealed her admission MDS was not completed yet. Review of Resident #265's Order Summary Report, dated 06/06/23, revealed orders: Oxycodone 5 mg, give 1 tablet by mouth every 4 hours as needed for pain. Nafcillin Sodium, give12 gram intravenously one time a day for osteomyelitis. Wound care: Clean area with normal saline, pat dry, apply anasept gel, apply collagen, cover with xeroform ABD, secure with Kerlix daily. Review of Resident #265's undated care plan revealed no baseline care plan for wound care, osteomyelitis, and pain. Review of Resident 265's admission notes, revealed that resident was admitted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 4 of 20 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 06/15/2023 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 0655 osteomyelitis of vertebra, needed assistance with pain management and wound care. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #267's face sheet, dated 6/14/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (kidney function has ceased), and acute respiratory failure with hypoxia (not enough oxygen in tissues). Residents Affected - Some Review of Resident #267's MDS section of their chart revealed her admission MDS was not completed yet. Review of Resident #267's Order Summary Report, dated 06/08/23, revealed orders: Tramadol 50 mg tablet, give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. Sevelamer Carbonate 800 mg, give 3 tablets by mouth with meals for end stage renal failure. Dialysis: check shunt for signs/symptoms of infection or bleeding every shift. A/V shunt restrictions: no heavy lifting, no blood pressure, and no blood draws to arm, every shift. Renal diet, regular texture, regular liquids, fluid restriction of 1500 ml's. Cefazolin Sodium, give 2 grams antibiotic intravenously in the evening every Monday and Wednesday Review of Resident #267's undated care plan revealed no baseline care plan for end stage renal failure, intravenous antibiotic therapy, dialysis and shunt care, fluid restriction. Review of Resident 267's admission notes, revealed that resident was admitted with a diagnosis of end stage renal failure. Review of Residents 267's orders revealed resident was on intravenous antibiotic therapy, required dialysis, shunt care, and fluid restriction. Interview on 6/15/23 at 12:00 PM, the DON stated that currently the process was that the admitting nurse was responsible for ensuring the baseline care plan was initiated on admission. If the admitting nurse was unable to initiate, then the MDS nurse would be next in line to initiate the baseline care plan. If neither one was able to initiate the baseline care plan, then the ADON would step in. DON stated that it was her responsibility to review new admission charts to ensure that baseline care plans were initiated. The DON stated that she failed review these charts and therefore failed to initiate the baseline care plan for these residents. Record review of the facility's, Care Plans- Baseline policy, dated 10/22/22 revealed: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. 1.The baseline care plan will: a. be developed within 48 hours of a resident admission. b. include the minimum healthcare information necessary to properly care for a resident, including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 5 of 20 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 06/15/2023 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 0655 but not limited to: Level of Harm - Minimal harm or potential for actual harm i. Initial goals based on admission orders. ii. Physician orders. Residents Affected - Some iii. Dietary orders. iv. Therapy services. v. Social services. vi. PASARR recommendations. 2. The admitting nurse, or supervising nurse on duty, shall gather information from admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. a. Once gathered, initial goals shall be established that reflect the residents stated goals and objectives. b. Interventions shall be initiated that address the residents current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. iii. Any special needs such as for IV therapy, dialysis, or wound care. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the residents medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 6 of 20 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 06/15/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a residents who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 (Residents #13 and#87) reviewed for indwelling catheters. The facility failed to ensure Resident #13 and Resident #87 indwelling urinary catheters were secured to prevent pulling or tugging. The failure could place residents at risk for discomfort, urethral trauma and urinary tract infections. Findings included: Record review of Resident #13's admission record dated 06/14/23, indicated she was admitted to the facility on [DATE] with diagnosis of retention of urine. She was [AGE] years of age. Record review of Resident #13's order summary report dated 06/13/2023 indicated in part: Check urinary catheter every shift for placement every shift for placement may use leg strap to secure foley in place. Order status active. Order date 12/09/2021. Start date 12/09/2021. Record review of Resident #13's care plan dated 04/28/2022 indicated in part: Problem: The resident has Catheter: Neurogenic bladder patient is at increased urinary infection. The resident will be/remain free from catheter-related trauma through review date. Monitor/document for pain/discomfort due to catheter. Record review of Resident #13's MDS dated [DATE] indicated in part: BIMS = 6 meaning severe impairment. Urinary incontinence = not rated, resident has a catheter. During an observation and interview on 06/13/23 at 03:02 PM Resident #13 was in bed awake and alert. Observed the resident's urinary catheter with CNA A present. The resident's catheter was not secured to the resident's leg. Resident #13 said the catheter tubing would at times pull on her and it would hurt. CNA A said she did not know why the resident's catheter tubing was not secured to the resident's leg. CNA A said the resident usually had it secured but she did not usually work on that hall. During an interview on 06/13/23 at 03:06 PM LVN B said Resident #13 usually had her urinary catheter secured. LVN B said hospice would usually bring the items to secure the catheter but that she would get one to secure it. LVN B said sometimes the resident would be showered by hospice staff and they would not place the strap back on or fail to report it to them that the resident needed another strap. Record review of Resident #87's admission record dated 06/14/23, indicated she was admitted to the facility on [DATE] with diagnosis of pressure ulcer to sacral (butt area) region. She was [AGE] years of age. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 7 of 20 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 06/15/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #87's order summary report dated 06/14/2023 indicated in part: Change catheter foley as needed. Catheter in place to progress wound healing. Order status active. Order date 12/09/2021. Start date 04/22/2023. Record review of Resident #87's MDS dated [DATE] indicated in part: Urinary incontinence = not rated, resident has a catheter. Record review of Resident #87's care plan dated 06/05/2023 indicated in part: Problem: o The resident has urinary Catheter due to stage 4 Pressure Ulcer of the sacrum-butt area. At risk for infection and other complications. Goal: o The resident will be/remain free from catheter-related trauma through review date. Monitor/document for pain/discomfort due to catheter. During an observation and interview on 06/13/23 at 09:54 AM Resident #87 was in bed in resting awake and alert. Observed urinary catheter hanging on side of the bed, the resident said she was not sure why she had a catheter, the resident pulled up her gown and the catheter tubing was not secured or anchored to her leg. The resident said she had not noticed that the catheter was tugging on her. During an observation and interview on 06/15/23 at 08:47 AM Resident #87 was in bed in resting awake and alert. Observed urinary catheter and it was secured to the resident's leg. The resident said the staff had just place the strap on her leg and that it worked well to keep the catheter tubing from tugging on her. During an interview on 06/15/2023 at 09:00 AM LVN C said Resident #87 should have a strap on her urinary catheter so that it would not pull out and help kept in place. The LVN said sometimes after the resident was showered the strap would fall off and they would forget to put another one. During an interview on 06/15/23 at 10:00 AM the DON said the residents' catheter tubing should have been secured with the leg strap. The DON said her expectations were for the nurse to check and see that the catheter is secured to the resident. The DON said if the catheter was not secured, the catheter could become dislodged and cause pain to the resident. The DON said she was not sure why that occurred and it could have been because the strap fell and no one reported it. During an interview on 06/15/23 11:54 AM the Administrator said the catheters were supposed to be secured. The Administrator said he was aware of the residents not having the catheter secured and that probably happened because the staff failed to check and see if the residents had their catheters secured. Record review of the facility's undated policy titled Indwelling urinary catheter care and removal indicated in part: Make sure the catheter is properly secured. Assess the securement device daily and change it when clinically indicated and as recommended by the manufacturer. If a new securement device is needed, connect it to the catheter before applying the device to the skin. Provide enough slack before securing the catheter to prevent tension on the tubing which could injure the urethral lumen and bladder wall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 8 of 20 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 06/15/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with bed rails were assessed for the resident for risk of entrapment from bed rails, failed to provide ongoing monitoring for the use of side rails, and failed to have an order for side rails for 1 of 5 residents (Resident #7). Resident # 7 had half side rails without medical justification and a developed care plan with measurable goals benefits and risks related to side rail use. This failure could affect residents by putting them at an increased and unnecessary risk of harm, entrapment, and injury. Findings included: Review of Resident #7's admission Record, dated 6/14/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Gastrostomy, intellectual disabilities, seizures, physical debility, and unspecified convulsions. Review of Resident #7's quarterly MDS Assessment, dated 5/23/23, revealed: She was unable to make herself understood or understand others. She had long and short-term memory impairment with severely impaired cognitive skills for decision making. She had physical behaviors directed towards other 1 - 3 days in the previous seven. She was totally dependent on two staff for ADL care Bed rail use was not indicated. Review of Resident #7's Care Plan, revised on 10/28/21, revealed: Problem: Resident #7 had an ADL self-care performance deficit related to confusion, impaired balance, limited mobility, limited range of motion due to unspecified intellectual disabilities, and poor trunk control. Goal: Resident #7 will maintain current level of function through the review date. Interventions included: Bed Mobility - the resident is totally dependent on 1 - 2 staff for repositioning and turning Review of Resident #7's Care Plan, revised 5/3/23, revealed: Problem: Resident #7 was high risk for falls related to confusion, deconditioning, gait/ balance problems, incontinence, poor communication/ comprehension, unaware of safety needs, bilateral (both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 9 of 20 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 06/15/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sides) lower extremity contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that cause the joints to shorten and become very stiff) due to intellectual disabilities, and psychosis. Goal: Resident #7 will not sustain serious injury through the review date. Interventions included: ¼ side rails for positioning (implemented 11/8/18); Bolster mattress to prevent resident from rolling out of bed secondary to uncontrolled boy movements (implemented 9/21/21) . Review of Resident #7's Order Summary Report, dated 6/14/23, revealed an order for: Bolster mattress to prevent resident rom rolling out of bed secondary to uncontrolled body movements dated 9/21/21. There was no order for the side rails. Observation on 6/13/23 at 9:59 a.m. revealed Resident #7 was in bed. She had a low bed with a bolster mattress (mattress with raised sides as part of the mattress) and half-rails on both sides at the top of the bed in place. Resident #7 was not interviewable due to her cognitive status. Observation on 6/13/23 at 3:53 PM revealed Resident #7 still in bed with a bolster mattress and half rails in place. Interview on 06/14/23 at 11:37 AM the DON described Resident #7 as total assistance with ADL care. The DON said Resident #7 was tube fed, had a history of disruptive behaviors, and had spastic abnormal body movement. The DON said Resident #7 had the scoop mattress so Resident #7 would not throw herself out of the bed. The DON explained the side rails met criteria for use by therapy. The DON confirmed Resident #7 had seizures. The DON said Resident #7 needed both the scoop mattress and the side rails at the same time so Resident #7 could reposition herself. When asked if Resident #7 was able to reposition herself the DON said no. After reviewing the Physician's Orders, she said she did not find an order for the side rails, but there was an order for the bolster mattress dated 9/21/21. Interview on 6/14/23 at 12:08 PM the DON reported that therapy did an assessment for side rails on Resident #7 and said she did not meet criteria for use. The DON stated the side rails were being removed. The DON stated it looked like Resident #7 had both the side rails and the bolster mattress since 2019. The DON said she did not know why the use of both had been missed as she only became DON 11/2022. The DON stated the facility's side rail policy was to get consent and a therapy evaluation. The DON said Resident #7 was not on therapy services which was probably why it was missed. The DON said ongoing monitoring for use was an expectation and she expected her ADONs to do assessments quarterly. The DON said she could not find where the quarterly evaluations were done. She stated that the ADON had been working the night shift due to lack of coverage recently and was not available for interview at that time. In an interview on 6/15/23 at 10:00 AM the Administrator stated that the facility did not have a written policy regarding side rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 10 of 20 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 06/15/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #100) of 5 residents reviewed for unnecessary medications. Resident #100 was prescribed an antipsychotic medication Seroquel (Quetiapine Fumarate) without a diagnosis requiring antipsychotic medication. The Facility failed to monitor Resident #100 for adverse effects of Seroquel (Quetiapine Fumarate). These failure put residents at risk of medication adverse effects as a result of being administered unnecessary antipsychotic medications. Findings include: Record review of Resident #100's face sheet, dated 6/14/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), atherosclerosis (a buildup of fats, cholesterol plaque in the walls of arteries), dementia (a group of conditions that impairs memory and judgement), atrial fibrillation (irregular heart rate that causes poor blood flow), and muscle wasting (decreased muscle tissue). Review of Resident #100's MDS section of their chart revealed her admission MDS was not completed yet. Review of Resident #100's Order Summary Report, dated 06/06/23, revealed orders: Seroquel (Quetiapine Fumarate) 25 mg, give 1 tablet by mouth two times a day for (no diagnosis given). Record review of Resident #100's MAR since admission, dated 06/15/2023 reflected he received 25 mg Seroquel (Quetiapine Fumarate) two times a day, daily from 06/06/2023 to 06/15/2023. Record review of Resident #100's pharmacy recommendation to the attending physician dated 06/12/2023 reflected a recommendation that the physician clarify the order for Seroquel (Quetiapine Fumarate) and update the diagnosis as appropriate. The recommendation reflected that dementia was not a valid diagnosis for Seroquel (Quetiapine Fumarate). There was no response from the physician to date. In an interview on 06/15/2023 at 2:15 pm with the DON and Administrator, when asked the indication for use of psychotropic medications, the DON stated that it would depend on the class of medication, insomnia, hallucinations, depression, and behaviors. The DON stated that the three diagnoses appropriate for antipsychotic medications were Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), schizophrenia disorder and Tourette's syndrome. The DON stated that most physicians would prefer psychoactive medications handled by the psychiatrist, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 11 of 20 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 06/15/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the psychiatrist would round in 2 weeks. When asked why Resident #100 did not have appropriate diagnosis, the DON stated that the resident was admitted from the hospital with the antipsychotic medication and she failed to catch it. When asked if the resident was being monitored for adverse effects of Seroquel (Quetiapine Fumarate), the DON stated it should be charted in the treatment administration record. Upon review of the residents treatment administration record, monitoring of adverse effects of any medications was not found. The Administrator stated that since there was not a diagnosis attached to the order for Seroquel (Quetiapine Fumarate), the usual order set was not triggered by the system, therefore no orders came up to monitor for adverse effects. He stated that it would be fixed immediately. Record review of the policy Psychotropic Medication dated 08/15/2022 reflected in part: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories : antipsychotics, antidepressants, anti-anxiety, and hypnotics. 2. The indications for initiating, withdrawing, or withholding medications, as well as the use of non-pharmacological approaches, will be determined by: a. assessing the residents underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment. b. Identification of underlying causes. 3. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and representatives, other professionals, and the interdisciplinary team. 4. The indications for use of any psychotropic drug will be documented in the medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 12 of 20 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 06/15/2023 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 0758 a. Level of Harm - Minimal harm or potential for actual harm Pre-admission screening and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility. Residents Affected - Few b. For psychotropic medications shall be initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. i.psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. ii.non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. 5. Residents shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatment. 6. The effects of the psychotropic medications on a residents physical, mental, and psychosocial well being will be evaluated on an ongoing basis. 7. The residents response to the medication, including progress towards goals and presence/absence of adverse consequences, shall be documented in the residents medical record. Record review of the website www.Drugs.com accessed on 06/15/2023 reflected that Quetiapine may cause serious side effects, including risk of death in the elderly with dementia. This medication is not for treating psychosis in the elderly with dementia. https://www.drugs.com/sfx/quetiapine-side-effects.html FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 13 of 20 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 06/15/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure that expired foods were discarded. 3. The facility failed to ensure the dishwasher dispensed the correct amount of chlorine to properly sanitize dishes. 4. The facility failed to ensure the freezer was free from leaks. 5. The facility failed to ensure the coffee machine was in good working condition. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation on 06/13/23 at 09:00 AM during the initial walkthrough of the kitchen revealed: the coffee maker spout/spigot was leaking. There was aa serving tray under the front feet of machine with towels and a metal bowl directly under the spout to catch the dripping coffee and the towels were wet from coffee. The large 2-door freezer had a 2-inch-deep baking pan sitting on top of boxes of food. The baking pan was on the top shelf with a layer, approximately 0.5 to 0.75 inch thick, of ice in it that appeared to be from a leak at the top of the freezer at a 2-inch metal bracket which also had a small amount of ice collection noted. In an interview on 06/13/23 at 09:15 AM Dietary Aid D stated the coffee pot in the kitchen had been leaking since she started working at the facility and it had been serviced several times by the contract company. She stated that the maintenance man said it was fixed but it kept leaking from the spout, so they left the bowl under it to catch the dripping coffee and emptied it when it got full. She stated the freezer was leaking a while ago, she couldn't remember how long, and the maintenance man worked on it, but they had put the pan on the top shelf to catch the leaking water and decided to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 14 of 20 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 06/15/2023 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 0812 leave it there in case it started to leak again. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 06/13/23 at 09:25 AM of small refrigerator revealed: Residents Affected - Some 1, 19.5-ounce bottle of caramel flavored dessert topping with a best by date of 3/24/23 and opened on date of 4/4/23 written on the bottle 1, 19.25-ounce bottle of raspberry flavored dessert topping with a best by date of 2/16/23 and opened on date of 4/6/23 written on the bottle 1, 10-ounce bottle of squeeze ginger with a use by date of 7/21/22 1, 19.5-ounce bottle of vanilla flavored dessert topping with a best by date of 3/31/23 and opened date of 12/12/22 written on the bottle The items were shown to Dietary Aid D, and she stated that those were the last of the flavored dessert topping bottles the facility had and immediately disposed of them in the trash can. She stated she had never seen the squeeze ginger before and did not know what it was used for. Dietary Aid D then disposed of the bottle of squeeze ginger in the trash can. She was unable to give an explanation as to why the expired bottles were in the refrigerator and still in use by kitchen staff. She stated that is not good. Observation on 06/13/23 at 09:35 AM revealed that after Dietary Aid E had run a cycle on the dishwasher, the water was tested with a chlorine strip and the strip reflected 10 ppm chlorine. The reading was verified with Dietary Aid E and [NAME] F. Review of the June 2023 Daily Dish Machine Temperature and Sanitizer Log hanging on the wall opposite the dishwasher revealed that all chlorine levels were 50 ppm, and were checked at breakfast, lunch, and dinner. Observation and interview on 06/13/23 at 09:40 AM with Dietary Aid E and [NAME] F, revealed Dietary Aid E ran the dishwasher again with no dishes and used test strips on the outside water where sanitizer mixed into the machine and inside the dishwasher and both strips reflected 10 ppm chlorine. Verified the strip reading with Dietary Aid E and [NAME] F. Dietary Aid E stated when she ran the test that morning the strip reflected at 50 ppm but she agreed that the current strip did not look the same. [NAME] F stated they thought there was an issue with the pipe or hose that connected the sanitizers to the machine coming loose or not being secured and the machine had been serviced recently. [NAME] F stated they had not had any issues with the readings in the past that she was aware of. Dietary Aid E stated before she logged the reading every morning, she had to run two cycles to let the sanitizer get to the right mixture, but after that she never had a problem with the readings. Dietary Aid E went to the sanitizer hose connection and attempted to push the hose back into place more securely. Another cycle was ran without dishes in the machine and the test strip was dipped in the water inside the dishwasher and continued to reflect 10 ppm. The strips were then shown to the Food Service Manager and the situation was explained to her. The Food Service Manager stated she would look into when the last time the machine was serviced was and find out exactly what was done to the machine at that time. The Food Service Manager also confirmed the strips were showing 10 ppm chlorine and that was below the acceptable level for sanitizing dishes. Observation on 06/13/23 at 09:50 AM of the kitchen's dry storage revealed: 6, 36-ounce boxes of rice pilaf with a receive date of 4/26/23 and no expiration date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 15 of 20 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 06/15/2023 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 0812 2, 36-ounce boxes of Spanish rice with a receive date of 6/9/23 and no expiration date Level of Harm - Minimal harm or potential for actual harm 1, 85-ounce bag of white corn tortillas with a receive date of 4/23 and no expiration date 2, 5-pound bags of devil's food cake mix with a receive date of 12/17/22 and no expiration date Residents Affected - Some 1, 5-pound bag of yellow cake mix with a receive date of 5/12/23 and no expiration date 6, 5-pound bags of brownie mix with a receive date of 6/6/23 and no expiration date 3, 4-pound bags of cheesecake mix with a received date of 1/10/23 and no expiration date 1, 4-pound open bag (approximately 2 pounds remaining) of cheesecake mix with a receive date of 1/10/23 and no expiration date 20 boxes of individually wrapped oatmeal cream pies with no expiration date 7, 11.3-ounce bags pork roast gravy mix with a receive date of 6/5/23 and no expiration date 2, 14-ounce bags of chicken gravy mix with no receive date and no expiration date 3, 11.3-ounce bags of turkey gravy mix with a receive date of 12/20/22 and no expiration date 4, 24-ounce bags of peppered biscuit gravy mix with a receive date of 6/6/23 and no expiration date 18, 4-ounce containers of nectar thickened orange juice with an expiration date of 4/2023 48, 4-ounce containers of nectar thickened orange juice with an expiration date of 6/10/23 In an interview on 06/13/23 at 09:55 AM with the Food Service Supervisor, she stated she was not aware that food companies were not legally required to put expiration or use by/best by dates on food items, so she did not look for them on all foods. She stated that most of the food items she had in the kitchen she believed had best by dates on the packaging, so she was surprised to see how many did not. She stated that was alarming, especially with items such as cake mixes that contained eggs, because if the items were to expire it could cause the residents to get sick. She stated that knowing that not all foods would come with expiration dates would make her more aware and change her process for storage and labeling. She stated she did use stickers from the facility's supplier that had receive on and use by dates for some food items, so the staff knew when to throw things out. She stated she had only been at the facility for a little over a month and she was still working on getting everything in working order for herself, but she had a lot of new staff, and she was still short a cook, so she had not had as much time to do the administrative things she wanted to do in the kitchen. Observation on 06/13/23 at 10:00 AM the Food Service Manager ran the dishwasher without dishes and dipped a test strip in the water inside the machine and the strip reflected 10 ppm chlorine. Observation and interview on 06/13/23 at 10:40 AM the Food Service Manager ran the dishwasher without dishes and tested the water inside machine and outside the machine where sanitizer mixed and the strip reflected 10 ppm chlorine. The Food Service Manager stated she had already contacted the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 16 of 20 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 06/15/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some company that serviced the dishwasher to come check it out and they would be there that day. She stated that the chlorine content in the dishwasher was a sanitization issue and if the dishes, pots, pans and utensils were not sanitized correctly residents could get sick, so the machine needed to be fixed immediately. In an interview on 06/13/23 05:50 PM with the Administrator, he stated the company who serviced the dishwasher had been notified of the sanitizer not mixing correctly and they would send a technician to check on it that day if they had not already done so. When he was informed of the leak in the coffee machine and leak in the freezer, he stated the coffee pot had been fixed in the past due to what sounded like the same issue. He was unaware there had been a leak in the freezer, but he stated that he would have the Maintenance Supervisor investigate it that day. He was not aware that food items were not required by law to have expiration dates, but he stated he did not like the idea of not knowing when food was no longer okay to eat. He stated there was too much risk of residents contracting a food-borne illness from expired food if the staff was not aware of the expiration date. He stated he would work with the Food Service Supervisor to come up with a solution to the lack of expiration or use by dates on food items. In an interview on 06/15/23 at 09:37 AM with the Maintenance Supervisor, he stated the leak in the freezer was from the condenser hose that ran from the inside of the unit to a drain pan in the back of the unit. He stated the leak started 8 months to a year ago when the hose separated from the drain connection inside the freezer. He stated when the leak started, he reattached the hose and the leak had stopped. The Maintenance Supervisor stated that as far as he was aware it had been working without any leaks. He was made aware of the leak by the Administrator the previous day (6/14/23). He stated he was able to secure the hose with a bracket and it should not leak again. He stated the coffee maker in the kitchen had also been repaired previously. He stated that in March 2022 the handle on the spout broke and began leaking due to the spring wearing out from use. He stated it was a very simple thing to fix if he was made aware of it. He stated the part had already been ordered and it would be fixed by the end of the week. He stated the facility used a computer program to put in work orders for him to know when something is broken so he could order parts or call someone to do work. He stated he never received a work order about the coffee pot or the freezer, but the Food Service Manager was new, so she did not know how to put the work order in the system. He stated he did not do any work on the dishwasher and that it was all done by the contract company. The Maintenance Supervisor was able to provide invoices from the contract company for the dishwasher to show it had been serviced 1/25/23, 4/19/23 and 6/14/23. Review of the facility policy Food Storage revised June 1, 2019, revealed, in part: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies so that the older items are used first. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 17 of 20 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 06/15/2023 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of kitchen reviewed for essential equipment. Residents Affected - Many 1. The facility failed to ensure that the dishwasher dispensed the correct amount of chlorine to properly sanitize dishes. 2. The facility failed to ensure the freezer was free from leaks. 3. The facility failed to ensure the coffee machine was in good working condition. This failure could place residents at risk of being exposed to food-borne illnesses from equipment that does not function properly. The findings included: Observation on 06/13/23 at 09:00 AM during initial walkthrough of the kitchen revealed: Coffee maker spout/spigot leaking - had serving tray under front feet of machine with towels and a metal bowl directly under the spout to catch the dripping coffee and the towels were wet with coffee. The large 2-door freezer had a 2-inch-deep baking pan sitting on top of boxes of food. The baking pan was on the top shelf with a layer, approximately 0.5 to 0.75 inch thick, of ice in it that appeared to be from a leak at the top of the freezer at a 2-inch metal bracket which also had a small amount of ice collection noted. In an interview on 06/13/23 at 09:15 AM Dietary Aid D stated that the coffee pot in the kitchen had been leaking since she started working here and it had been serviced several times by the contract company. She stated that the maintenance man said it was fixed but it kept leaking from the spout, so they left the bowl under it to catch the dripping coffee and emptied it when it got full. She stated that the freezer was leaking a while ago, she couldn't remember how long, and the maintenance man worked on it, but they had put the pan on the top shelf to catch the leaking water and decided to leave it there in case it started to leak again. Observation on 06/13/23 at 09:35 AM revealed that after Dietary Aid E had run a cycle on the dishwasher, the water was tested with a chlorine strip and the strip read 10 ppm chlorine. The reading was verified with Dietary Aid E and [NAME] F. Review of the June 2023 Daily Dish Machine Temperature and Sanitizer Log hanging on the wall opposite the dishwasher revealed that all chlorine levels were 50 ppm, and were checked at breakfast, lunch, and dinner. Observation and interview on 06/13/23 at 09:40 AM with Dietary Aid E and [NAME] F, Dietary Aid E ran the dishwasher again with no dishes and used test strips on outside water where sanitizer mixes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 18 of 20 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 06/15/2023 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many into machine and inside the dishwasher and both strips read at 10 ppm chlorine. Verified the strip reading with Dietary Aid E and [NAME] F. Dietary Aid E stated that when she ran that test that morning the strip read at 50 ppm but she agreed that the current strip did not look the same. [NAME] F stated that they thought there was an issue with the pipe or hose that connected the sanitizers to the machine coming loose or not being secure and that the machine had been serviced recently. [NAME] F stated they had not had any issues with the reading in the past that she was aware of. Dietary Aid E stated that before she logged the reading every morning, she had to run two cycles to let the sanitizer get to the right mixture, but after that she never had a problem with the readings. Dietary Aid E went to the connection and attempted to push it back into place more securely. Another cycle was run without dishes in the machine and the test strip was dipped in the water inside the dishwasher and continued to read at 10 ppm. The strips were then shown to the Food Service Manager and the situation was explained to her. The Food Service Manager stated that she would look into when that last time the machine was serviced was and find out exactly what was done to the machine at that time. The Food Service Manager also confirmed that the strips were showing 10 ppm chlorine and that was below that acceptable level for sanitizing dishes. Observation on 06/13/23 at 10:00 AM the Food Service Manager ran the dishwasher without dishes and dipped a test strip in the water inside the machine and the strip read at 10 ppm chlorine. Observation and interview on 06/13/23 at 10:40 AM the Food Service Manager and surveyor ran dishwasher without dishes and tested water inside machine and outside machine where sanitizer mixes and strip read at 10 ppm chlorine. The Food Service Manager stated that she had already contacted the company that services the dishwasher to come check it out and they would be there that day. She stated that the chlorine content in the dishwasher was a sanitization issue and if the dishes, pots, pans and utensils were not sanitized correctly residents could get sick, so the machine needed to be fixed immediately. In an interview on 06/13/23 05:50 PM with the Administrator, he stated that company who serviced the dishwasher had been notified of sanitizer not mixing correctly and they would send a technician to check on it that day if they had not already done so. When he was informed of the leaking coffee machine and leaking freezer, he stated that the coffee pot had been fixed in the past due to what sounded like the same issue. He was unaware that there had been a leak in the freezer, but he would have the maintenance supervisor investigate it that day. In an interview on 06/15/23 at 09:37 AM with the Maintenance Supervisor, he stated the leak in the freezer was from the condenser hose that ran from the inside of the unit to a drain pan in the back of the unit. He stated the leak started 8 months to a year ago when the hose separated from the drain connection inside the freezer. He stated when the leak started, he reattached the hose and the leak had stopped. The Maintenance Supervisor stated that as far as he was aware it had been working without any leaks. He was made aware of the leak by the Administrator the previous day (6/14/23). He stated he was able to secure the hose with a bracket and it should not leak again. He stated the coffee maker in the kitchen had also been repaired previously. He stated that in March 2022 the handle on the spout broke and began leaking due to the spring wearing out from use. He stated it was a very simple thing to fix if he was made aware of it. He stated the part had already been ordered and it would be fixed by the end of the week. He stated the facility used a computer program to put in work orders for him to know when something is broken so he could order parts or call someone to do work. He stated he never received a work order about the coffee pot or the freezer, but the Food Service Manager was new, so she did not know how to put the work order in the system. He stated he did not do any work on the dishwasher and that it was all done by the contract company. The Maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 19 of 20 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 06/15/2023 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 0908 Level of Harm - Minimal harm or potential for actual harm Supervisor was able to provide invoices from the contract company for the dishwasher to show it had been serviced 1/25/23, 4/19/23 and 6/14/23. In an interview on 06/15/23 at 10:00 AM the Administrator stated that the facility did not have a written policy on essential equipment. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 20 of 20