Inspection·August 22, 2024

F 0558 (extreme mood swings), and dementia (memory, thinking, difficulty). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #11's Quarterly MDS dated [DATE] revealed Resident #11 had a BIMS score of 13, indicating that the resident could understand and make self-understood. The MDS also revealed that needed supervision or touching assistance with toileting. Residents Affected - Some Record Review of Resident #11's care plan dated 07/12/2024 revealed the resident needs a safe environment, a working and reachable call light. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Record review of Resident #18's admission Record dated 08/21/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (memory, thinking, difficulty), type 2 diabetes mellitus without complications (high blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol), atrial fibrillation(abnormal heart rhythm), depressive episodes, anxiety, pain, malignant neoplasm of brain (cancer of the brain), osteoarthritis (joint disease), hypermetropia (near objects are blurry in the eyes), missing organs, history of falling, muscle wasting, unsteadiness on feet, weakness, lack of coordination, adjustment disorder, insomnia (difficulty sleeping), edema (swelling), and age related physical debility. Record review of Resident #18's Quarterly MDS dated [DATE] revealed Resident #18 had a BIMS score of 1, indicating the resident rarely understood and rarely made self-understood. The MDS also revealed that Resident #18 was dependent with eating, toileting, and bed mobility. Record Review of Resident #18's care plan dated 07/26/2024 revealed encourage the resident to use bell to call for assistance. Record review of Resident #38's admission Record dated 08/22/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included heart failure, heart disease, atrial fibrillation(abnormal heart rhythm), pulmonary embolism (blood clot in the lungs), hyperlipidemia (high cholesterol), hyperthyroidism (excessive production of thyroid hormones), muscle weakness, intellectual disabilities, schizoaffective disorder depressive type (mental disorder), unsteadiness on feet, lack of coordination, muscle weakness, chronic bladder pain, dysphagia (difficulty swallowing), and cognitive communication deficit (problems with communication). Record review of Resident #38's Quarterly MDS dated [DATE] revealed Resident #38 had a BIMS score of 10, indicating the resident could understand and made self-understood. The MDS also revealed that Resident #38 was substantial/maximal assistance with toileting, bed mobility and transfers. Record Review of Resident #38's care plan dated 06/20/2024 revealed encourage the resident to use bell to call for assistance. Record review of Resident #52's admission Record dated 08/20/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia (high blood sugar), Parkinson's disease (a progressive disorder that affects the nervous system), hypertension (high blood pressure), muscle wasting, difficulty walking, unsteadiness on feet, lack of coordination, cognitive communication deficit (problems with communication), dysphagia (difficulty swallowing), long term use of insulin, and muscle wasting. (continued on next page) 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 08/22/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #52's Quarterly MDS dated [DATE] revealed Resident #52 had a BIMS score of 08, indicating the resident could understand and made self-understood. The MDS also revealed that Resident #52 was substantial/maximal assistance with toileting, bed mobility and transfers. Record Review of Resident #52's care plan dated 08/04/2024 revealed encourage the resident to use bell to call for assistance. Record review of Resident #62's admission Record dated 08/21/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (memory, thinking, difficulty), anemia (not enough healthy red blood cells), convulsions, hypertension (high blood pressure), chronic pain, hyperthyroidism (excessive production of thyroid hormones), dysphagia (difficulty swallowing), pain in right arm, history of falling, anxiety, muscle wasting, unsteadiness on feet, lack of coordination, aphasia (unable to comprehend due to damage to the brain), morbid obesity, kidney failure, adjustment disorder, reduced mobility, post-traumatic stress disorder, major depressive disorder, and malaise (feeling of general discomfort). Record review of Resident #62's Quarterly MDS dated [DATE] revealed Resident #62 had a BIMS score of 06, indicating the resident could understand and made self-understood at times. The MDS also revealed that Resident #62 was substantial/maximal assistance with toileting, bed mobility and transfers. Record Review of Resident #62's care plan dated 08/04/2024 revealed encourage the resident to use bell to call for assistance. Record review of Resident #76's admission Record dated 08/20/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system), kidney disease, ulcerative colitis (swelling in the bowels), lack of coordination, muscle wasting, repeated falls, weakness, unsteadiness on feet, cognitive communication deficit (problems with communication), dysphagia (difficulty swallowing), and dementia (memory, thinking, difficulty). Record review of Resident #76's Quarterly MDS dated [DATE] revealed Resident #76 had a BIMS score of 12, indicating the resident could understand and made self-understood. The MDS also revealed that Resident #76 was substantial/maximal assistance with toileting. Resident #76 was partial/moderate assistance for bed mobility and transfers. Record Review of Resident #76's care plan dated 06/21/2024 revealed be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. A working and reachable call light. Record review of Resident #80's admission Record dated 08/20/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral atherosclerosis (arteries in the brain become thick, hard and narrowing), heart failure, atrial fibrillation(abnormal heart rhythm), protein calorie malnutrition, cardiomegaly (enlarged heart), heart disease, muscle wasting, malaise (feeling of general discomfort), lack of coordination, dysphagia (difficulty swallowing), cognitive communication deficit (problems with communication), pain due to trauma, and oxygen. Record review of Resident #80's Quarterly MDS dated [DATE] revealed Resident #80 had a BIMS score of 3, indicating the resident could not understand and could not make self-understood. The MDS also revealed that Resident #80 was substantial/maximal assistance with toileting, transfer and bed (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 08/22/2024 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 0558 mobility. Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #80's care plan dated 07/12/2024 revealed encourage the resident to use bell to call for assistance. Residents Affected - Some An observation of Resident #76's room on 08/20/2024 at 7:41am revealed the resident's call light was hanging on the privacy curtain approx. 3 feet from the resident. An interview with Resident #76 on 08/20/2024 at 7:41am revealed that the call light was not in the reach of the resident most of the time. An observation of Resident #38's call device on 08/20/2024 at 7:54am revealed that his call light was sitting on the table approx. 3 feet from him where he could not reach the call light. A interview with Resident #38 on 08/20/2024 at 7:54am revealed that most of the time he has his call light. He stated that there are times that he must look for his call light. A observation of Resident #52's call device on 08/20/2024 at 8:36am revealed that her call light was wrapped around the bedrail that is lowered to the down position. The resident could not reach the call light. A interview with Resident #52 on 08/20/2024 at 8:36am revealed she normally does have her call light in reach but there were times that staff would not give the call light to her. An observation of Resident #80's call device on 08/20/2024 at 8:41am revealed Resident #80's call light was clipped to the privacy curtain that was against the wall. Resident #80 could not reach the call light while she was sitting in her wheelchair. A interview with Resident #80 on 08/20/2024 at 8:41am revealed she could not reach her call light. She stated that most of the time it is not in reach. An observation of Resident #11's call device on 08/20/2024 at 8:44am revealed that the resident's call light was wrapped around his bed rail that was in the down position. The resident was sitting at the end of the bed. An interview with Resident #11 on 08/20/2024 at 8:44am revealed that he did not know where his call light was. He said that he rarely used his call light. An observation of Resident #8 on 08/21/2024 at 9:07am revealed that the resident was approx. 2 feet from the call light. Resident #8 could not reach the call light to call for help. The resident was yelling for help. An observation of Resident #18's call light on 08/21/2024 at 9:51am revealed that the call light was hanging on the back of the wheelchair down to the floor. The resident could not reach the call light. An interview with LVN A on 08/22/2024 at 11:27am revealed that she had been trained on resident rights. She stated that the call light should always be within the resident's reach. She said that all staff are responsible for ensuring that the call light was in the resident's reach. She said that (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 08/22/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the call light should be in the residents always in reach because that is how they let staff know when they need help. She said that if the call light were not in the resident's reach the resident would not be able to get ahold of staff if they need something. She stated she did not know why the call lights were not in reach of the residents. An interview with the DON on 08/22/2024 at 11:32am revealed she had been trained on resident rights. She stated the call lights were to be always in the reach of the resident. She said that the call light should be next to the resident or clipped to their clothes. She said that CNAs were responsible for ensuring that the call lights were in the resident's reach. She said the call light needed to be in the reach of the resident so that the resident could get their needs met. She said if the call light were not in reach the resident could not get their needs met and the resident may fall. She stated she did not know why the call lights were not in reach of the residents. She also said that it could have been the student aides could be forgetting. An interview with CNA F on 08/22/2024 at 11:38am revealed she had been trained on resident rights. She stated the call light had to be always in the reach of the resident. She also said that if a resident is weaker on one side the call light was supposed to go on the resident's stronger side. She said CNAs were responsible for ensuring that the call lights were always in reach of the residents. She said that the call light is important because that was how residents called staff if they needed them or in case of an emergency. She also said if the call light were not in reach of the resident it could be detrimental to the resident. She said the resident could have a life threating issue and not be able to call for help. She also said she did not know why the call lights were not in reach of the resident. An interview with ADM on 08/22/2024 at 11:44am revealed staff has been trained on resident rights. He stated call lights should be placed in the resident's reach when the resident was in the room. He said all staff were responsible for answering and call light placement. He said it was important for the call light to be in the resident's reach so that the resident could get his or her needs meet. He also said if the call light was not in the reach of the resident, their needs cannot be met. He stated he did not know why the call lights were not in the reach of the residents. He also said that the facility does a lot of CNA training, and the students could just be forgetting to put them in the reach of the residents. Record Review of Call Lights: Accessibility and Timely Response Policy dated 10/13/2022 revealed staff was to ensure the call light was within reach of the resident and secured as needed. They call system will be accessible to the residents while in their bed or other sleeping accommodations within the resident's room. 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 08/22/2024 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy including leaving electronic medical records out for public view for 1 (Resident #4) of 4 residents reviewed for privacy and protected HIPPA information. Residents Affected - Some 1) The facility failed to ensure nursing staff locked the computer screen when it was unattended, which had displayed Resident #4's personal medical information during medication administration while RN C was away from the computer administering medication to Resident #4 at 07:56 AM on 8/16/2024. 2) On 08/20/24 at 08:13 AM RN C once again left Medication Cart A unattended and Resident #4's personal medical information open on computer screen. These failures could allow residents' protected HIPPA information to be shared with individuals who do not have a need or right to know, resulting in facility staff not honoring the resident's privacy, including during visits, treatment, or leaving medical records out for public view. The findings include: Record review of Resident #4's undated admission record revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to Cerebral infarction (Stroke), Flaccid hemiplegia affecting right dominant side (weakness or paralysis on one side of the body), Need for assistance with personal care, Hypertension, Lack of coordination, Vascular dementia, Pain in joints right hand, Major depressive disorder, Epileptic seizures, Chronic pain syndrome, and Cognitive communication deficit. Record review of Resident #4's Annual MDS dated [DATE] and a Discharge MDS dated [DATE] revealed her BIMS assessment was not completed. Record review of Resident #4's Care Plan dated 08/14/24 reflected the resident had impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision making, long-term memory loss, short-term memory loss and CVA (Stroke), and the relevant interventions were: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. 2. Ask yes/no questions in order to determine resident's needs. 3. Communication - use the resident's preferred name. Identify yourself at each interaction. Face the (continued on next page) 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 08/22/2024 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 0583 resident when speaking and make eye contact. Level of Harm - Minimal harm or potential for actual harm 4. Cue, reorient and supervise as needed. Residents Affected - Some 5. Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. 6. The resident needs assistance with all decision making. Observation on 08/20/24 at 07:56 AM revealed RN C walked away from medication cart and went into Resident #4's room. RN C left Resident #4's medical information up on screen. RN C then returned to the medication cart and retrieved a sanitizing wipe and sanitized the blood pressure cuff. RN C then walked back into the Resident #4's room to check her oxygenation level with a pulse oximeter and left Resident #4's information visible on the screen. Observation on 08/20/24 08:13 AM revealed RN C had again left Resident #4's medical information visible on the screen. Interview on 08/20/24 at 08:11 AM with RN C revealed he had worked at the facility for 2 months in PRN status. RN C stated he should have turned Resident #4's privacy screen off when he stepped away from the medication cart to administer Resident #4's medications. RN C further stated leaving a resident's medical information visible to other residents and visitors was a HIPPA violation. During an observation and interview on 08/20/24 at 08:21 AM revealed Resident #4 was sitting in her bed and was awake and alert. She was sharing her room with another resident. Resident #4 resided to the left side of the room when facing her from the entrance door. Her roommate who resided at the right side of the room, was not in the room during medication administration. RN C was the designated nurse providing medications to Resident #4 on this day. During an attempted interaction by the investigator, Resident #4 was not able to answer questions about her right to have privacy. Interview on 08/22/24 at 02:26 PM with the DON who revealed protecting resident information was very important, as someone could steal their information. The DON stated this was the first and last time RN A would work as a medication aide and probably would no longer be utilized. The DON also stated her expectation was for all nurses and medication aides to keep the screen secured at all times. The DON stated she had started in-servicing her staff on locking the resident's privacy screen on 08/20/24. Interview on 08/22/24 at 03:30 PM with the ADM revealed the privacy screen not on Resident #4's electronic health record and keys left on top of the cart should not have happened and was a HIPPA violation. Record review of the facility's undated policy titled Resident Rights reflected: (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 08/22/2024 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 0583 Level of Harm - Minimal harm or potential for actual harm The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States . . The resident has a right to be treated with respect and dignity . Residents Affected - Some 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 (X3) DATE SURVEY COMPLETED A. Building 08/22/2024 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 - Few 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 observation, interview, and record review, the facility failed to ensure residents who entered the facility with indwelling catheters received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #203) reviewed for catheter. The facility failed to ensure orders were entered related to Resident #203's Foley catheter at his admission on [DATE]. This failure placed residents at risk of UTI and other catheter-related complications. Findings included: Review of the undated face sheet for Resident #203 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included urinary tract infection (UTI) and sepsis ( a serious condition in which the body responds improperly to an infection). Review of of the MDS assessments for Resident #203 reflected none had been completed for Resident #203. Review of the baseline care plan for Resident #203 dated 08/15/24 and completed by LVN D reflected he had an indwelling catheter. It reflected the following care planning options related to his indwelling catheter, each with buttons next to them that indicated they could be checked/triggered, but none of them were checked: Problem: The resident has (SPECIFY: Condom/Intermittent/Indwelling Suprapubic) Catheter: Goal: The resident will be/remain free from catheter-related trauma through review date. Goal: The resident will show no s/sx of Urinary infection through review date. Intervention: CATHETER: last changed: (SPECIFY Date). Change catheter (FREQ). (SPECIFY Size) (SPECIFY Type) Intervention: CATHETER: The resident has (SPECIFY Size) (SPECIFY Type of Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. Intervention: Check tubing for kinks [# TIMES] each shift. Intervention: Monitor and document intake and output as ordered Intervention: Monitor for s/sx of discomfort on urination and frequency. (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 08/22/2024 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 Intervention: Monitor/document for pain/discomfort due to catheter. Level of Harm - Minimal harm or potential for actual harm Intervention: Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, Residents Affected - Few deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Problem: The resident has (SPECIFY: Condom/Intermittent/Indwelling Suprapubic) Catheter. Review of the physician's order summary for Resident #203 pulled from the EMR on 08/22/24 at 12:55 PM reflected no orders related to an indwelling catheter. Observation on 08/22/24 at 10:02 AM revealed Resident #203 had a foley catheter tube emerging from his penis and connected to a plastic bag partially filled with yellow liquid. He did not respond to any efforts to converse with him. During an interview on 08/22/24 at 01:05 PM, LVN D stated she had been the nurse on duty when Resident #203 was admitted to the facility and had entered his orders and processed his admission paperwork on 08/15/24. She stated she knew Resident #203 had a catheter, and if he did not have orders for the catheter entered into the MAR, it was probably because she had made a mistake. She stated, as the admitting nurse, entering the orders for Resident #203 had been her responsibility. LVN D stated it was important to have orders related to catheters because a lack of orders in the system could cause new staff not to know he had a catheter. She stated if the catheter was not monitored for placement, patency, and quality of the urine. During an interview on 08/22/24 at 02:34 PM, the DON stated when a new resident admitted , the admitting nurse should have entered orders right then and there. She stated the orders should have been entered immediately, and if they were not, the team looked at the admission the next day in morning meeting and caught the omission. The DON stated she did not know why the missing catheter orders for Resident #203 were not caught in the morning meeting. She stated there had been no negative impact, because she had assessed him when they learned the orders had not been entered, and his urine was clear and yellow, not cloudy or tinged, and placement of the catheter was good. The DON stated the admitting nurse was responsible for entering the orders, and she and her ADONs were responsible for following up to ensure it was done. During an interview on 08/22/24 at 03:15 PM, the ADM stated there needed to be orders related to a resident's catheter. He stated it was the responsibility of the charge nurse for the resident and nurse management to ensure those orders were in place. He stated a resident could have negative outcomes without catheter orders, but he did not elaborate. A policy on catheters was requested from the ADM on 08/22/24 at 03:34 PM but not provided by the time of exit. 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 08/22/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide routine and emergency drugs to its residents for 1 of 8 residents (Resident #206) reviewed for administration of medication. The facility failed to ensure Resident #206's medication orders were entered immediately upon his admission, and he did not receive his temazepam for insomnia his first night in the facility, 08/19/24. This failure placed residents at risk of insomnia and discomfort. Findings included: Review of the undated face sheet for Resident #206 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included muscle wasting and atrophy, hypertension (high blood pressure), hyperlipidemia (high cholesterol), type two diabetes mellitus(high blood sugar), obstructive sleep apnea (sleep-related breathing disorder), atrial fibrillation (irregular and often very rapid heartbeat), and insomnia. Review of the MDS assessments for Resident #206 reflected he did not have any complete assessments. Review of the physician's order summary for Resident #206 reflected an order dated 08/19/24 for Temazepam Oral Capsule 15 MG (Temazepam) Give 1 capsule by mouth at bedtime for INSOMNIA with a start date of 08/20/24. Observation and interview on 08/20/24 at 09:00 AM, revealed Resident #206 was seated in a chair next to his bed, awake and alert. He stated he was alright except that his medications did not come in the night before, and he had gone without the medicine he took to help him sleep. He stated it was not a very welcoming experience. He stated he had asked the nurse, whose name he did not know, for his temazepam, but she told him the pharmacy had not delivered it. He stated he had arrived at the facility at 06:00 PM the night before, on 08/19/24, and he did not understand why there was not communication between the hospital and the nursing facility to ensure he got his night medications. He stated the sleep medication was the only medication he took at night. He stated he did not sleep well after not receiving his medication, but he was not in very much distress about it. During an interview on 08/22/24 at 12:04 PM, LVN E stated she had admitted Resident #206 on the night of 08/19/24. She stated when she had an admission in the evening, she first did everything on her hall for her residents before she sat down and did the admission in the computer. She stated she finished all her work the night of Resident #206's admission and then sat down and began entering his information into the computer, including orders. She stated when she finished the admission, she went to visit him and offered him a temazepam from the emergency kit. She stated she did that because she saw he had a nighttime medication and the aides said he had been asking the aides for it. She stated he declined the medication from the emergency kit and said he would start the medication the following day. She stated it was 01:00 AM or 02:00 AM at that point. LVN E stated she had not documented anywhere that it was that late in the night, but she agreed it might be too late for someone to feel comfortable taking a sleeping medication. She stated it might have affected his night of sleep (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 08/22/2024 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 0755 and might have made his first night in the facility unpleasant. Level of Harm - Minimal harm or potential for actual harm During an interview on 08/22/24 at 02:46 PM, the DON stated the procedure should have been the admitting charge nurse for a new resident placed medication orders immediately in the EMR as soon as they were obtained by the referral and the resident arrived. She stated if the admission was after 05:00 PM, they would not have been able to receive the medications by their 08:00 PM pharmacy delivery, but if the orders were entered, the resident could have received the medication form the emergency kit. The DON stated her expectation was the nurse who admitted a resident entered medication orders immediately and not after completing all the work on their hall. The DON stated LVN E should have prioritized putting the medication orders in for Resident #206. She stated Resident #206 should have received his medication for sleep the night of his admission on [DATE]. She stated she thought his experience was not very favorable if he did not receive his sleeping medication. She stated it was the admitting nurse's responsibility to ensure medication orders were entered immediately upon resident admission, and it was nurse management's Residents Affected - Few During an interview on 08/22/24 at 03:15 PM, the ADM stated medication orders should have been entered at admission to avoid residents missing medications. The ADM stated it was primarily the admitting nurse's responsibility to ensure the medication orders were entered, but nurse management oversaw the system for compliance. He stated a potential negative impact of not receiving his nighttime medications for Resident #206 was poor sleep. A policy on Entering/Following Physician Orders was requested from the ADM on 08/22/24 at 03:34 PM but was not provided by the time of exit. 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 08/22/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assure that medications were secured and inaccessible to unauthorized staff and residents for 1 of 8 medication carts (Medication Cart A), and that supplies in the medication room were not expired for medication storage and labeling. 1) Facility staff failed to ensure Medication Cart A was locked while administering medications to Resident #4 at 8:13 AM on 8/16/2024. 2) On 08/20/24 at 08:13 AM staff left Medication Cart A unlocked again and left a set of keys on top of the cart. 3) Observation on 08/21/24 at 01:45 PM in the medication room revealed 12 IV Start Kits with an expiration date of 05/19/24. 4) A resident (Resident #151) had prescription medications in his room sitting on the windowsill. These failures could lead to others accessing and ingesting medications that could cause clinically significant adverse consequences necessitating hospitalization to stabilize the resident and/or drug diversion. The findings included: Record review of Resident #4's undated admission record revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to Cerebral infarction (Stroke), Flaccid hemiplegia affecting right dominant side (weakness or paralysis on one side of the body), Need for assistance with personal care, Hypertension, Lack of coordination, Vascular dementia, Pain in joints right hand, Major depressive disorder, Epileptic seizures, Chronic pain syndrome, and Cognitive communication deficit. Record review of Resident #4's Annual MDS dated [DATE] and a Discharge MDS dated [DATE] revealed her BIMS assessment was not completed. Record review of Resident #4's Care Plan dated 08/14/24 reflected the resident had impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision making, long-term memory loss, short-term memory loss and CVA (Stroke), and the relevant interventions were: 1. (continued on next page) 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 08/22/2024 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 0761 Administer medications as ordered. Monitor/document for side effects and effectiveness. Level of Harm - Minimal harm or potential for actual harm 2. Ask yes/no questions in order to determine resident's needs. Residents Affected - Some 3. Communication - use the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. 4. Cue, reorient and supervise as needed. 5. Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. 6. The resident needs assistance with all decision making. Record review of Resident #151's undated admission record revealed an [AGE] year-old male was recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to Anxiety disorder, depression, Hypertension, Hypokalemia (low serum potassium), Urinary tract infection, and Benign prostatic hypertrophy with urinary tract symptoms ( enlarged prostate gland with urinary tract symptoms). Record review of Resident #151's Comprehensive MDS dated [DATE] revealed his BIMS assessment had not been completed. Record review of Resident #151's Care Plan dated 08/14/24 reflected the resident was a smoker. Goal - the resident will not smoke without supervision through the review date and the resident will not suffer injury from unsafe smoking practices through the review date. Instruct the resident about smoking risks and hazards and about smoking cessation aids that are available and observe clothing and skin for signs of cigarette burns. Observation on 08/20/24 at 07:56 AM revealed RN A walked away from Medication Cart A and went into Resident #4's room. RN A left Medication Cart A unlocked . RN A did not press the lock button on Medication Cart A when he went into Resident #4's room. RN A then returned to Medication Cart A and retrieved a sanitizing wipe and sanitized the blood pressure cuff. RN A then walked back into the Resident #4's room to check her oxygenation level and Medication Cart A was still left unlocked, and a set of keys were sitting on top of Medication Cart A. (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 08/22/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 08/20/24 08:13 AM revealed RN A had again left Medication Cart A unlocked, and a set of keys were left on top of the cart. Interview on 08/20/24 at 08:11 AM with RN A revealed he had worked at the facility for 2 months in PRN status. RN A stated he should have locked Medication Cart A when he walked away from Medication Cart A to administer Resident #4's medications. RN A further stated leaving Medication Cart A unlocked put residents at risk of someone taking their medications. Observation of the medication room on 08/21/24 at 01:45 PM revealed 12 IV Start Kits with PVP Prep Pad with an expiration date of 05/19/24 in the bottom drawer of a 3-drawer plastic bin. Observation on 08/21/24 at 03:28 PM revealed there were 3 prescription medications sitting on Resident #151's windowsill. Resident #151 was not in the room at the time. The medications had Resident #151's name on them, and the label on each bottle reflected a prescription for Escitalopram 10mg, Chlordiazepoxide 5mg, and Fluticasone Propionate nasal spray 50mcg. Resident #151's roommate was bedbound and required a mechanical lift transfer to get up to his wheelchair. Interview on 08/21/24 at 4:26 PM with LVN A revealed she had not noticed Resident #151 had medications sitting on his windowsill, and she had worked the past weekend. LVN A further stated had she seen the medications she would have confiscated them and ensured they were locked up. Interview on 08/22/24 at 9:28 AM with Resident #151 revealed he had asked his friend to bring the medications that were on his windowsill and some clothing to him so he could talk to the NP at the facility about them. Resident #151 further stated he did not intend any harm and had not thought about the possibility of another resident getting his medications and wanted to cooperate with the facility rules. Resident #151 stated the facility had taken the medications and locked them up. Interview on 08/22/24 at 02:26 PM with the DON revealed she was responsible for overlooking the expired IV start kits when she checked the medication room. The DON stated she was responsible for rotating the items in medication room and removing expired medications and supplies. The DON stated the medication carts should always be locked when staff step away, to prevent anyone from going into the medication cart and grabbing things from it. The DON stated her expectation was to keep medication carts locked at all times when unattended. The DON further stated she did go around and check the carts, at least twice per week, and when a medication cart was found unlocked, she would lock the cart in her office. The DON stated Resident #151 had a visitor who he had asked to bring clothing and the medications to review with the NP. The DON stated she would expect the charge nurse to notice the medications. The DON further stated the charge nurse had been a nervous wreck during state observation of g-tube care for Resident #151's roommate and had not seen the meds in the window. The DON stated the medications on the windowsill should have been confiscated by the charge nurse and locked up. Interview on 08/22/24 at 03:30 PM with the ADM revealed he had gone to look in Resident #151's room in the afternoon of 08/21/24 and found medications on his windowsill. The ADM further stated they had confiscated the medications after Resident #151 was present and communicated to Resident #151 the medications had to be locked up. The ADM stated Resident #151 had felt badly about the medication incident, and he had wanted to talk with the NP about them. The ADM stated the potential impact of a resident having access to medications the facility was not aware of could cause an undesirable interaction for the resident, and also the possibility of another resident taking the medications. The ADM stated the expired IV start kits found in the medication room and medication cart left unattended, and keys left on top of the cart should not have happened. The ADM stated the nurse and nurse (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 08/22/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete management were responsible for ensuring resident medications were secured, and that all medications and IV tubing in the medication room were removed if expired. The ADM further stated no medications should be at bedside unless approved by a physician and the resident was self-administering their medications. Review of facility Policy and Procedure titled, Expiration Dating and Expired Medications: dated 10/01/19 reflected, The facility is to strictly adhere to the expiration dating and It is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. Expired medications will not be administered in the facility. All expired medications will be disposed of per Facility policy. 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 08/22/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 4 of 32 residents (Residents #8, #81, #206, and #217) reviewed for clinical records. 1. The facility failed to ensure a legal MPOA was in the clinical record for Resident #8. 2. The facility failed to ensure a legal OOH-DNR was in the clinical record for Resident #81. 3. The facility failed to ensure the code status for Resident #206 was evident in the clinical record. 4. he facility failed to ensure medical documents for Resident #217 were filed in the correct clinical record. This failure placed residents at risk of having their confidentiality and their rights violated. Findings included: 1. Review of the undated face sheet for Resident #8 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included frontotemporal neurocognitive disorder (type of memory), severe protein calorie malnutrition, thalassemia (inherited blood disorder), dementia (memory, thinking, difficulty), dysphagia (difficulty swallowing), type 2 diabetes mellitus without complications (high blood sugar), hyperlipidemia (high cholesterol), constipation, hypertension (high blood pressure), muscle wasting, unsteadiness on feet, lack of coordination, anxiety order, and adjustment disorder. Review of Resident #8's quarterly MDS assessment dated [DATE] reflected the resident was rarely/never understood. Resident #8 did not have a BIMS score due to not being able to complete assessment. Review of the miscellaneous documents section for Resident #8 reflected the MPOA that had been uploaded had no date, signature, or notary seal. 2. Review of the undated face sheet for Resident #81 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture of neck of right femur (broken thigh bone), anemia (low blood iron), hypertension (high blood pressure), weakness, arthritis, history of breast cancer, urinary tract infection, muscle wasting and atrophy, unsteadiness on feet, lack of coordination, cognitive communication deficit (difficulty communication due to cognitive impairment), and cerebral aneurysm (bulge or ballooning in a blood vessel in the brain that can rupture and cause a brain bleed). Review of Resident #8's admission MDS assessment dated [DATE] reflected a BIMS score of 02, (continued on next page) 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 08/22/2024 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 0842 indicating severely impaired cognition. Level of Harm - Minimal harm or potential for actual harm Review of the profile information for Resident #81, which included the date of admission, code status, and primary diagnosis and appeared at the top of every section of the EMR, reflected a code status of DNR. Residents Affected - Some Review of the physician's order summary for Resident #81 reflected the following order dated 07/23/24: DNR (Do Not Resuscitate). Review of the miscellaneous documents section for Resident #81 reflected no OOO-DNR form present. During an interview on 08/22/24 at 01:17 PM, the SW stated she thought Resident #8's family member sent the wrong MPOA form, and somebody uploaded the form by accident. She stated the BOM was the person who uploaded the MPOA for Resident #8 into the clinical record, and she was out on leave. She stated she did not know if she was responsible for uploading the OOH-DNR for Resident #81, but usually it was tied to the code status order being placed in the order list at admission. The SW stated she could not enter orders, as she was not a nurse or a nurse practitioner. She stated a potential negative impact of the failures related to the MPOA and the OOH-DNR was residents might not receive the care they wanted. An attempt was made on 08/22/24 at 03:04 PM to interview the BOM but she did not answer her phone or return contact. 3. Review of the undated face sheet for Resident #206 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included muscle wasting and atrophy, hypertension (high blood pressure), hyperlipidemia (high cholesterol), type two diabetes mellitus(high blood sugar), obstructive sleep apnea (sleep-related breathing disorder), atrial fibrillation (irregular and often very rapid heartbeat), and insomnia. Review of the MDS assessments for Resident #206 reflected he did not have any complete assessments. Review of the physician's order summary for Resident #206 reflected an order dated 08/19/24 for code status to be full code. Review of the profile information for Resident #206 reflected his code status was not present in the heading at the top of the page. This profile information included the date of admission and primary diagnosis and appeared at the top of every section of the EMR, but the area reserved for code status did not clarify a code status. During an interview on 08/22/24 at 12:04 PM, LVN E stated she had admitted Resident #206 and should have entered his code status so that it could be seen at the top of the page in his clinical record in the EMR. She stated she was very busy that night and must have forgotten. She stated it was her responsibility. She stated she did not think it would have a negative impact, because he had a full code status, and they would always treat a resident as a full code if there was a question about their code status. (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 08/22/2024 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 0842 4. Level of Harm - Minimal harm or potential for actual harm Review of the undated face sheet for Resident #217 reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged on 08/08/24. His diagnoses included urinary tract infection, cellulitis of right, lower limb, methicillin susceptible staphylococcus aureus infection (infection caused by bacteria commonly found on the skin), emphysema (destructive disease of the lung), obstructive and reflux uropathy (when urine can't flow through the ureter, bladder, or urethra due to some type of obstruction), anemia, anxiety disorder, acute kidney failure, chronic kidney disease stage four, and hyperkalemia (high blood potassium). Residents Affected - Some Review on 08/21/24 of the miscellaneous documents section of the clinical record for Anonymous Resident #1 reflected Resident #217's hospital records from 07/29/24 had been uploaded to Anonymous Resident #1's clinical record. Review on 08/22/24 of the miscellaneous documents section of the clinical record for Anonymous Resident #2 reflected Resident #217's hospital records from 07/13/24 had been uploaded to Anonymous Resident #2's clinical record. Both Anonymous Residents #1 and #2 were currently residing in the facility during the time Resident #217's records were found in their charts. During an interview on 08/22/24 at 12:54 PM, the MR stated she was responsible for uploading documents to the EMR and had uploaded the two hospital documents for Resident #417 into the wrong clinical records. She stated she was not sure why the documents were filed incorrectly, but it might have been because they were sent to other departments to view, sent back to her, and were stacked with a different resident. She stated a potential impact of the document being uploaded in the wrong record was a provider who was looking might also have missed the name and thought they were looking at clinical information about the patient they were treating and give them the wrong care, or it could have been a violation of HIPAA. During an interview on 08/22/24 03:15 PM, the ADM stated he had determined there were three aspects of the same clinical records issue. He stated with Resident #8, the BOM had been assisting the family with getting him on Medicaid, and the MPOA document that was provided by the MPOA was the one that was uploaded and sent to Medicaid. The ADM stated Medicaid was approved, so the person who reviewed the Medicaid application obviously did not check closely the MPOA, either. He stated in that situation, the BOM was responsible for uploading the correct, legal document in the chart. The ADM stated the issue with Resident #217's documents being placed in the wrong clinical records was because of the high number of admissions they had at the facility, as they admitted and discharged many short-term skilled residents each week. He stated the stacks of information coming from all the disciplines were so many documents, that the MR simply misfiled a couple. Related to the issue of Resident #206 not having his code status clearly printed in his chart at the top of his profile information, he stated that was because there was a drop-down menu nurses had to use to enter a code status after they entered orders, and the admitting nurse must have forgotten. He stated the oversight could have resulted in Resident #206 not receiving emergency treatment as quickly as possible as the staff would have to dig into the record to find the information. He stated the records being filed under the wrong resident chart could have had the impact of violating HIPAA or of clinicians not getting the correct clinical information about the patient they were looking up. He stated a potential impact of a resident not having a legal MPOA was that it could have been a rights violation if the person claiming MPOA did not have a full and legal designation. He stated a potential impact of not having a legal OOH-DNR in the clinical record was the resident might not have had her wishes observed. He stated the SW should have been responsible for checking the legal documents and ensuring they were available, and the MR was responsible for ensuring they went into the correct chart. He stated the nurses and nurse management were responsible for ensuring the code status was entered into the EMR profile. (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 08/22/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Review of a document provided by the ADM on 08/21/24 reflected a legal MPOA dated 01/24/24 for Resident #8 delegating his FM as his MPOA. Review of a document provided by the ADM on 08/21/24 reflected a legal OOH-DNR for Resident #81 dated 07/23/24. Residents Affected - Some Review of the facility policy dated 10/24/22 and titled Documentation in the Clinical Record reflected the following: Each resident's medical record should contain accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of facility policy dated 10/24/22 and titled Residents' Rights Regarding Treatment and Advance Directives reflected the following: It is our policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and formulate an advanced directive. 3. Upon admission, should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676299 If continuation sheet Page 20 of 20