Health inspection·July 17, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to knock before entering the resident's room. She said that there was no time that the staff should not knock before entering. She said if staff did not knock, the resident may feel like staff do not respect them. She said that all staff monitored to ensure staff were knocking on the residents' doors. She said that staff monitored by observations. She said she was not aware that CNA G was not knocking on the resident's room. During an interview with CNA G on 07/16/2025 at 1:34pm revealed that she had been trained on residents' rights. She said the policy for knocking on the resident's door was to knock, introduce themselves and tell the resident what they were there for. She said staff were supposed to knock all the time before entering the resident's room. She said that the residents may feel uncomfortable if staff did not knock. She said knocking was something that should always be done. She said there was not any time that staff did not have to knock before entering. She said the nurses were responsible for ensuring staff were knocking. She the nurses watch and listen and if the staff are not doing something correctly, the nurse will correct the staff. She said she did not realize that she did not knock on Resident #44 and Resident #68's doors. During an interview on 07/17/2025 at 2:20pm with LVN B revealed that she had been trained on residents' rights. She said that the policy for knocking on the door was staff should knock before entering. She also said that staff were to let the resident know that staff were coming into their home. She said everyone should always knock before entering the room. She said that the resident may feel like staff were not respecting their home. She said the only time staff did not have to knock was in an emergency. She said all staff should be monitoring each other through observations. She said she thought staff did not knock because they were not reminded to knock. During an interview with the DON on 07/17/2025 at 3:18pm revealed that she and staff have been trained on resident rights. She said the policy for knocking was that all staff are to knock on the resident's door before entering. She also said that staff should knock even if the resident's door was open. She said that some residents would not care if staff knocked. She also said some residents were used to the staff. She said there was not any time that staff do not have to knock. She said nurses should be monitoring the CNAs through observation. She said that she did not know why staff were not knocking on the resident's door. During an interview with the ADM on 07/17/2025 at 3:54pm revealed her and staff have been trained in resident rights. She said the policy for knocking was that all staff are to knock before entering. She said staff should give the resident time to answer. She said all staff were supposed to always knock. She said the only time staff did not have to knock unless there was an emergency. When asked how she thought the residents felt when staff did not knock, she said she could not answer the question. She said that managers were responsible for monitoring to ensure that all staff were knocking. She said managers go up and down the hall when doing rounds and check to see if staff were knocking. She said that she did not know why staff were not knocking before entering. Record review of the Leadership Policy and Procedures Resident Rights Quality of Life dated 11/01/2017 revealed Facility staff knocks on the patient/resident's door, identifies self, and requests permission to enter. Event ID: Facility ID: 676308 If continuation sheet Page 2 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 2 of 10 residents (Resident #49 and Resident #67) reviewed for environment. The facility failed to ensure Resident #49 and Resident #67's room was in good repair and free of holes in the walls. This failure could affect any resident and place them at risk for not having a sanitary homelike environment. Findings included: Resident #49 Review of Resident #49's Face Sheet dated 07/16//2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #49's diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental function), breast cancer, swimmers ear (infection in the outer ear canal), urinary tract infection, hyperlipidemia (high cholesterol), protein-calorie malnutrition (inadequate intake of both protein and calories), anxiety (feeling of uneasiness or worry), hypothyroidism (excessive production of thyroid hormones), chronic pain, dry eye, glaucoma (eye disease), and gastroesophageal reflux disease without esophagitis (reflux). Record review of Resident #49's Quarterly MDS assessment dated [DATE] revealed Resident #49 had a BIMS score of 07 indicating severe cognitive impairment. Resident #67 Review of Resident #67's Face Sheet dated 07/16//2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #67's diagnoses included glaucoma (eye disease), hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), vision loss, anemia (not enough healthy red blood cells), muscle weakness, depression, cognitive communication deficit (problems with communication), hypothyroidism (excessive production of thyroid hormones), hyperlipidemia (high cholesterol), hypertension (high blood pressure), Record review of Resident #67's Quarterly MDS assessment dated [DATE] revealed Resident #67 had a BIMS score of 12 indicating moderate impairment. Observation on Resident #67's room on 07/15/2025 at 2:19 p.m., revealed the walls in the room were a bluish gray color. On the wall behind Resident #67's head of the bed there were two parallel holes in the wall (like from moving the bed up and down). The wall across from Resident #67's bed had white paint spots. Observation of Resident #49's room on 07/16/2025 at 10:41 a.m., revealed the walls in the room were a bluish gray color. On the wall by the bathroom door appeared to have been repaired from a hole in the wall. The wall was still white and not the same color as the rest of the wall. The wall next to Resident #49's dresser had eight areas that had white paint spots on the wall. On the wall on the other side of the bathroom had five areas that had white paint spots. During an interview with Resident #67 on 7/16/2025 at 8:27 a.m., revealed that his walls had been with paint spots on them since he moved in. He said it did not feel homelike and that he wish they would fix it. During an interview with Resident #49 on 07/16/2025 at 10:41am revealed that her wall had been patched up without being repainted since she had gotten to the facility. She said that she was losing her eyesight and was not able to see the walls. During an interview with MAIN on 07/16/2025 at 4:21pm revealed he had been trained on residents' rights and homelike environment. He said he was responsible for repairing residents' rooms. He said if a resident's room needed repairs, he could move the resident into a different room. He said when the repairs were done, he could move the resident back into the room. He said the repairs usually took a day. He said that he would consider the room homelike if the room had holes in the wall or paint spots. He said he never had a complaint about the walls. He said that he may have started on the room and then the facility must have gotten a new admit. He said after seeing the way the walls were in Resident #49 and Resident #67's rooms, that he would not consider the rooms to be homelike. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 3 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said that the guardian angels (management) did rounds every day and put in a work order if rooms needed to be repaired. He said no one had put in a work order for Resident #49 and Resident #67's room. He said the residents may feel like their room was not completed. He said some residents don't want to move for the repairs to be done. He also said if a resident did not want to move it would be documented. He said he could not recall if anyone was in the room or if he told the ADM that the room was not done before the residents were moved in. He also said that he will get to Resident #49 and Resident #67's rooms one day. During an interview with CNA G on 07/17/2025 at 1:42pm revealed that she had been trained on residents' rights. She said that the policy was that residents' rooms were to feel like home and in good repair. She said everyone played a part in making a resident's room homelike. She said if something was broken or messed up in the room staff were to report it to the nurse, and DON and they would get with MAIN. She said that MAIN was responsible for making sure there were no holes in the wall and that the paint was not spotty. She said that if staff saw something broken or a hole in the wall it should be repaired immediately. She said if the resident's room was not homelike it could cause the resident to be depressed and a lot of mental issues for the resident. She said that MAIN and DON were responsible for ensuring residents rooms were homelike. She said they monitor through observations. She said she did not know why Resident #49 and Resident #67 rooms were no repaired and repainted. She said she did not consider the resident's rooms to be home like. During an interview on 07/17/2025 at 2:35pm with LVN B revealed that she had been trained on residents' rights. She said that the policy for homelike environment was that the resident's room should be comfortable and feel like home. She said all staff were responsible for ensuring that resident's rooms were homelike and in good repair. She said if something was broken or messed up in the resident's room it should be fixed immediately. She said the facility did not have a painter and that the main person had been trying to get things fixed. She said some residents may not like something in their room being messed up and some residents may not care. She said the administration team that had been assigned each room and they check to see if anything was wrong in the resident's room. She said the administration team monitors to ensure the resident's rooms are homelike. She said the rooms were monitored through inspections. She said that she did not know why there were no work orders done for the Resident #49 and Resident #67's room and why they have not been taking care of. During an interview with the ADM on 07/17/2025 at 4:04pm revealed she and staff were trained on homelike environment. She said that the policy was that the residents' rooms be in good repair and feel like home. She said all managers and staff were responsible for ensuring the residents rooms were in good repair. She also said if the rooms were not in good repair staff would report issues to MAIN. She said there was no timeframe for how long the facility had to do the repairs. She said that repairs were based on priority. She said if a resident's room was not homelike the resident might feel uncomfortable, and not as happy as they could be. She said managers were responsible for ensuring the resident's rooms were homelike. She said managers monitored the rooms when they do their rounds in the mornings. She said if something happened in that room and the wall got a hole in it the facility would do the repairs. She said she did not know how long Resident #49 and Resident #67's rooms had been with the paint spots and holes. Record review of Maintenance Director Job Description dated 09/08/09 revealed Ensures the plant and equipment are properly maintained for patient/resident safety, comfort and convenience. Inspects the facility, on a regular basis, to ensure that the grounds, facility and equipment are maintained in accordance with established policies and procedures and all hazardous areas are properly identified. Is knowledgeable of patient/resident rights and promotes an atmosphere which allows for the privacy, dignity and well- being of all residents in a safe, secure environment. Record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 4 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0584 review of Maintenance Work Orders from 2/01/2025 to 07/15/2025 revealed there were no work orders put in for Resident #49, and Resident #67's rooms to be repaired. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 5 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 residents were free from any physical restraints imposed for purposes of convenience and not required to treat the resident's medical symptoms for 3 (Residents #7, Residents #12, and Resident #95) of 5 residents reviewed for restraints. The facility failed to ensure that restraints were not used on Residents #7, Residents #12, and Resident #95's bed. This failure could result in residents having physical restraints used that limited their movement without being evaluated for the medical need. Findings include: Resident #7 Record review of Resident #7's face sheet dated 07/16/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (progressive disease that destroys memory and other important mental function), metabolic encephalopathy (brain disease), dementia (memory, thinking, difficulty), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), urinary tract infection, altered mental status, cognitive communication deficit (problems with communication), repeated falls, muscle weakness, abnormalities of gait and mobility, functional quadriplegia (paralyzed not due to spine or brain injury), cerebral infraction (stroke), and breast cancer. Record review of Resident #7's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 05 indicating severe cognitive impairment. The MDS also indicated Resident #7 was dependent for bed mobility and marked as not applicable for transfers. The MDS did not have anything regarding restraints or bed rails. Record review of Resident #7's Care Plan dated 02/19/2025 revealed that Resident #7 was at risk for falls due to significant deficits in both functional ability and cognition. Approaches were encourage use of environmental devices such as hand grips, handrails, and safe transfer techniques. Bed rails were not on the care plan. Observation of Resident #7 on 07/16/2025 at 4:00 p.m., revealed Resident #7 was in her bed with her bed in the low position and the 1/2 bed rails were in use on both sides of the bed. During an interview with Resident #7 on 07/16/2025 at 4:02 p.m., revealed that she did not know why staff were using the side rails on her bed. The resident asked the surveyor why they were using the rails. She said that she could not get out of bed when the side rails were in use on her bed. She said that she might fall if she tried to get up with the rails in use. She also said she did not know how long the facility had been using the rails on her bed. When asked how she felt about the side rails being used, the resident said she wanted a peanut butter sandwich. Record review of Resident #7's Orders dated 07/10/2025 revealed that there were no orders for the 1/2 bed rails. Record review of Resident #7's Side Rail assessment dated [DATE] revealed that Resident #7 was total dependent on bed mobility and transfers. The assessment also said that the side rails posed a risk of depression, incontinence, agitation, and confusion. The box next to Resident requires/requests the use of siderails. Monitor every 30 minutes and release and reposition every two hours and PRN for toileting and/or repositing was not checked. The side rail type was marked for 1/2. The assessment also revealed that the reason for side rails was for bed mobility. Resident #12 Record review of Resident #12's face sheet dated 07/16/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including anxiety (feeling of uneasiness or worry), constipation, shortness of breath, nausea with vomiting, fever, and disturbances of salivary secretion (issue with production or flow of saliva). Record review of Resident #12's Quarterly MDS assessment dated [DATE] reflected a BIMS score was not entered. The MDS also indicated Resident #12's bed mobility and transfers were not indicated. Staff revealed that Resident #12 was unable to communicate, and bed bound. The MDS did not have anything about bed rails or restraints. Record Review of Resident #12's Care Plan dated 07/11/2025 revealed that Resident #12 was at risk for Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 6 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some falls due to significant deficits in both functional ability and cognition. Approaches were encourage use of call light, orient to room and safety devices. Bed rails were not on the care plan. Observation of Resident #12 on 07/16/2025 11:25 a.m., revealed Resident #12 was in his bed with both 1/2 side rails in use on both sides of his bed. Observation of Resident #12 on 07/16/2025 1:22 p.m., revealed Resident #12 was in his bed with both side rails in use on both sides of his bed. An interview was attempted with Resident #12 on 07/16/2025 at 1:23 p.m., but the resident was not able to communicate with the surveyor. Record review of Resident #12's Orders dated 07/16/2025 revealed that there were no orders for the 1/2 bed rails. Record review of Resident #12's Side Rail assessment dated [DATE] revealed that Resident #12 was total dependent for n bed mobility and transfers. The assessment also reflected the side rails posed a risk of incontinence, decreased mobility, constipation, and agitation. The box next to Resident requires/requests the use of siderails. Monitor every 30 minutes and release and reposition every two hours and PRN for toileting and/or repositing was not checked. The side rail type was marked for full. The assessment also revealed that the reason for side rails was not marked. Resident #93 Record review of Resident #93's face sheet dated 07/16/2025 reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition (inadequate intake of both protein and calories), breast cancer, shortness of breath, nausea with vomiting, nicotine dependency, chronic pain, disturbances of salivary secretion (issue with production or flow of saliva), and anxiety (feeling of uneasiness or worry). Record review of Resident #93's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 06 indicating severe cognitive impairment. The MDS also indicated Resident #93's bed mobility and transfers were maximum assist. The MDS did not have anything about bed rails or restraints. Record Review of Resident #93's Care Plan dated 07/11/2025 revealed that Resident #93 was at risk for falls due impaired mobility. Approaches were keep call light in reach at all times, bed in low position, keep room free of clutter and personal items in reach. Bed rails were not on the care plan. Observation of Resident #93 on 07/15/2025 at 10:30 a.m., revealed Resident #93 was in her bed with her bed in the low position and the 1/2 bed rails were in use on both sides of the bed. Observation of Resident #93 on 07/16/2025 1:25 p.m., revealed Resident #93 was in her bed with her bed in the low position and the bed rails were in use on both sides of the bed. During an interview with Resident #93 on 07/16/2025 at 1:25pm revealed the facility used the bed rails on her bed to prevent her from falling out of the bed. She said that no one went over the pros and cons of using the bed rails. She also said that as far as she knew she had not been injured due to the bed rails. She said she was not able to get out of the bed when the staff used the rails. She said the rails were in use every day while she was in the bed to prevent her from getting out of bed. She said the bed rails did not upset her. She also said she did not know how long the facility had been using the bed rails on her bed. Record review of Resident #93's Orders dated 07/16/2025 revealed that there were no orders for the any type of bed rails. Record review of Resident #93's Side Rail assessment dated [DATE] revealed that Resident #93 was independent on bed mobility and total dependent on transfers. The assessment also said that the side rails posed no risk to Resident #93. The box next to Resident requires/requests the use of siderails. Monitor every 30 minutes and release and reposition every two hours and PRN for toileting and/or repositing was not checked. The side rail type was not marked. The assessment also revealed that the reason for side rails was not marked. During an interview with CNA G on 07/16/2025 at 1:39pm revealed that she had been trained on residents' rights. She said that the facility had a no restraints policy. She also said that if the resident was a high fall risk staff used bed rails. She said that the policy was if a resident had bed rails to make sure the rails were being used on the bed, and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 7 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bed was in the low position. She said that she did not know much about Resident #12 because he had only been at the facility for maybe a week. She said with Resident #93 and Resident #7 had bed rails because they were a high-risk fall. She said that Resident #93 favored her left side, and the rails help keep her on the bed. She said the risk is getting head stuck climbing over the bed rails pros would be keeping them in the bed and preventing falls. She said that all three residents were bed bound so the rails were on 24/7. She said that Resident #93 functional ability was normal, and she can move everything. She said that Resident #12 has been declining since he got to the facility. She was not sure about Resident #7's functionality. During an interview on 07/17/2025 at 2:25pm with LVN B revealed that she had been trained on residents' rights. She said the policy for restraints were that no restraints were to be used. She said bed rails were considered a restraint. She also said that a restraint was anything preventing the resident from getting out of the bed. She said that staff should not be using the bed rails on any residents. She said for a bed rail to be used staff needed a doctor's order. She said the risk was that the resident could not get out of bed and get hurt. The benefit was that it helps a resident get up from the bed. She said that nurses were to monitor to ensure that staff were not using the bed rails. She said that she did not know why staff were using the bed rails for Resident #7, Resident #12, and Resident #93. During an interview with the DON on 07/17/2025 at 3:21pm revealed that she and staff have been trained on residents' rights and restraints. She said the facility has a no restraint policy. She said the facility does not use restraints. She said side rails can be considered a restraint because it can block a resident from getting out of bed. She said that bed rails cannot be used to prevent the resident from falling. She said that for staff to use bed rails a doctor's order was needed. She said the risk of the bed rail were that a resident could get a limb stuck in the bed rail. She said she did not know of any decline of the residents due to the bed rails. She said that she did not know the functionality of Resident #7, Resident #12 and Resident #93. She said that she did not know why staff were using the bed rails for Resident #7, Resident #12, and Resident #93. During an interview with the ADM on 07/17/2025 at :57pm revealed that she and staff have been trained on restraints. She said that the policy was that the facility does not use restraints. She said that examples of restraints were tying the resident to a chair or over medicating them. She said that bed rails were allowed if they are not being used as restraints. She said that the bed rails were not allowed to be used as a fall prevention. She said she did not know when staff started using the rails for Resident #7, Resident #12 and Resident #93or how long staff had been using them. She said she did not know the function ability of Resident #7, Resident #12 and Resident #93. She said that she did not know staff were using the bed rails for fall prevention. She said the risk of the bed rail was that it could cause harm to the resident. She said she did not know of any decline with the resident due to the bed rails being used. She said that the ADON does a monthly audit regarding bed rails. She said she did not know why bed rails were being used on Resident #7, Resident #12, and Resident #93. Record review the Nursing Policies and Procedures Restraints Policy dated 05/05/2023 revealed The use of side rails as a restraint is prohibited. Side rails are only used when necessary to treat the patient/resident's medical symptoms. Side rails can be used for physical function but only after assessment and should be considered as a last resort. The physician's order for restraints should reflect the presence of a qualifying medical symptom. Falls do not constitute self-injurious behavior or a medical condition that warrants the use of physical restraint. In the past, some types of restraints were used to prevent falls. However, the risks for serious injury related to restraints and the lack of supporting.evidence for restraint efficacy in fall prevention, have led to the eradication of that practice. Additionally, falls that occur while (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 8 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete a person is physically restrained often result in more serious injuries. Record review of Nursing Policies and Procedures Bed Rails and Side Rails, Installation and Use dated 05/05/2023 revealed: POLICY: The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. The facility will ensure the correct installation, use and maintenance of bed rails/side rails when their use is determined to be appropriate for the patient/resident. PROCEDURES:1. Acceptable alternatives will be considered prior to the installation of bed rails. Alternatives include but are not limited to roll guards, foam bumpers, lowering the bed and using concave mattresses that can help reduce rolling off the bed. https://www.fda.gov/medicaldevices/consumer-products/bed-rail-safety-updated.2. The resident will be evaluated for the risk of entrapment prior to installation.3. Qualified staff will make the determination to implement bed rails/side rails based on the criteria outlined in the facility Restraint Policy.4. The risks and benefits of bed rails/side rails will be reviewed with the resident and/or responsible party. Consent and physician order will be obtained prior to the installation of bed rails/side rails. 5. Facility will ensure the patient/resident's bed dimensions are appropriate based on the patient/resident size (height and weight) prior to installation, to minimize the potential for entrapment.6. Facility will install and maintain bed rails/side rails per the manufacturer's recommendations and specifications for the duration of use.7. Qualified staff will assess the patient/resident for continued use of bed rails/side rails at least quarterly, annually and with significant change. Requested the Bed Rail Audit from the DON on 07/17/2025 at 3:25 p.m., was not received prior to exit. Event ID: Facility ID: 676308 If continuation sheet Page 9 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide accurate PASRR screenings for individuals with a mental disorder for 1 (Resident #4) of 2 residents reviewed for PASRR. The facility failed to complete an accurate PASRR level one screening after Resident #4 was admitted with a negative PASRR Level 1 screening but had a mental illness. This failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: Record review of Resident #4's quarterly MDS assessment, dated June 05, 2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of Psychotic disorder with hallucinations due to known physiological condition (mental disorder where hallucinations are directly caused by a medical condition affecting the brain) and Depression. Her BIMS score was a 14 which indicated intact cognitive response. Record review of Resident #4's care plan dated last revised 06/19/2025 reflected the resident was on a psychotropic drug due to receiving antipsychotic medication for treatment of psychotic disorder with hallucinations. Record review of Resident #4's PASRR Level 1 screening, dated 08/31/2023 conducted by the hospital doctor, reflected Resident #4 was negative for mental illness, intellectual disability, and developmental disability. Interview on 07/17/25 at 12:45PM with the ADM revealed that she had been the ADM for the facility for 7 months. The ADM stated that a positive Level 1 PASRR could be from intellectual disability and mental illness. ADM reviewed Resident #4's diagnoses and reported that the resident should have a PASRR 2 screening completed. ADM stated that the resident could be negatively impacted by the resident not receiving the services she was eligible for. Interview on 07/17/25 at 1:00PM, with MDS Coordinator A revealed she had been the MDS coordinator for the facility for 2 years. MDSC A stated that a mental illness, intellectual disability and developmental disability would result in a positive Level 1 PASRR screening. If a resident had a positive Level 1 PASRR screening, it would lead to a screening of a Level 2 PASRR screening. MDSC A stated that Resident #4's diagnoses of behavioral issues and depression, should have resulted in a positive Level 1 PASRR. MDSC A stated that Resident #1's primary diagnosis was Vascular Dementia but had been changed due to readmittance into the facility. Interview on 07/17/2025 at 3:30PM with the DON revealed that she had been the DON at the facility for 7 years. The DON stated that positive Level 1 PASRR could be from intellectual disabilities and a diagnosis like schizophrenia. The DON stated Resident #4 having a diagnosis of psychotic disorder would result in a Positive Level 1 PASRR. The DON stated that could negatively impact the resident by the resident not receiving the services that she was eligible for. Review of the facility's PASRR policy dated last revised 11/01/2017 revealed This policy is intended as a general guide for the PASRR process. Each facility develops a process for completion of the PASRR requirements as indicated by state specific policy and procedures. This document revealed the following:1. If the Level 1 PASRR screening indicates the individual may have an ID, DD or MI diagnosis, follow the state-specific process for completion of the Level II evaluation. 2. Mental Disorder: is the equivalent to Mental illness, which states an individual is considered to have a serious mental illness if the individual meets the following requirements on diagnosis, level of impairment and duration of illness. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 10 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #53 and Resident #67) of ten residents reviewed for ADL care. The facility failed provide Resident #53 and Resident #67 with showers and brushing their teeth. This deficient practice could place residents at risk of a decline in their sense of well-being and level of satisfaction with life. Resident #53 Review of Resident #53's face sheet reflected a [AGE] year-old male re-admitted on [DATE] with initial admission date of 09/26/2024 with diagnoses of Neurocognitive disorder with Lewy bodies (is a medical condition that leads to a progressive decline in cognitive function, affecting memory, attention, and visual perception, need for assistance with personal care, acute respiratory (medical condition that can significantly impact breathing and overall health), muscle weakness (generalized), cognitive communication deficit (medical condition referring to difficulties in communication that arise from impaired cognitive functions, such as attention, memory, reasoning, and problem-solving), depressive episodes (medical condition characterized by persistent sadness, fatigue, and a loss of interest in activities), and Parkinson's disease (is a movement disorder of the nervous system that worsens over time). Review of Resident #53's MDS dated [DATE] reflected a BIMS of 09 and had an active diagnosis of hemiplegia (a medical condition that involves weakness or reduced strength on one side of the body) or hemiparesis (a medical condition characterized by complete paralysis on one side of the body) and Parkinson's disease (is a movement disorder of the nervous system that worsens over time) and requires extensive assistance with Activities of Daily Living (ADL). Review of Resident #53's Care Plan dated 05/14/2025 reflected Resident #53 has impaired functional mobility and requires assistance with ADLs. Further review reflected the goal for Resident #53 is to be clean, dressed appropriately to weather, participate to preferred activities, and stable weight for 90 days. The approach to meeting Care Plan goal was to assess Resident #53's degree of functional impairment and assist with ADLs based on the current level of mobility. Review of Resident #53's Point of Care History Report dated 6/20/2025 - 7/17/2025 reflected staff enter Showers in this system when giving showers. No documented evidence the resident received showers for the following days: 6/28/2025 Activity did not occur. 6/29/2025 Activity did not occur.6/30/2025 Activity did not occur.7/01/2025 Activity did not occur.7/08/2025 Activity did not occur.7/09/2025 Activity did not occur.7/10/2025 Activity did not occur Resident #67 Review of Resident #67's face sheet reflected a [AGE] year-old male with admission date of 03/11/2025 with diagnoses of Unspecified glaucoma (a medical eye condition that can lead to optic nerve damage, resulting in vision loss or blindness) Hypertensive heart disease with heart failure (a medical condition that arise due to chronic high blood pressure), Unqualified visual loss, both eyes, depression, unspecified, muscle weakness, age-related osteoporosis without current pathological fracture, shortness of breath, cognitive communication deficit (refers to difficulties in communication that arise from impaired cognitive functions, such as attention, memory, reasoning, and problem-solving), type 2 diabetes mellitus without complications. Review of Resident #67's MDS dated [DATE] reflected a BIMS of 12 with active diagnoses of medically complex conditions, heart failure, hypertension, rental insufficiency (poor kidney function), renal failure, or End-Stage Rental Disease (ESRD), Diabetes Mellitus (DM), and hyperlipidemia. Further review reflected Resident #67 required substantial/maximal assistance for toilet transfer and tub/shower transfer, oral hygiene, and personal hygiene. There was no documentation of oral hygiene in the Review of Resident #67's Care Plan dated 07/02/2025 reflected Resident #67 has impaired functional mobility and vision impairment Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 11 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and requires assistance with ADL's. The care plan goal was Resident #67's will be clean, dressed appropriately to weather, participate to preferred activities, and stable weight for 90 days. To approach goal facility would assess Resident #67's degree of functional impairment. There was no documentation of oral hygiene in the care plan. Review of Resident #67's Point of Care History Report dated 6/20/2025 - 7/17/ staff enter Showers in this system when giving showers reflected no documented evidence the resident received showers for the following days: 6/20/2025 Activity did not occur. 6/21/2025 Activity did not occur.6/22/2025 Activity did not occur.6/23/2025 Activity did not occur.6/24/2025 Activity did not occur.6/25/2025 Activity did not occur.6/26/2025 Activity did not occur.6/27/2025 Activity did not occur.6/28/2025 Activity did not occurDuring an interview on 07/15/2025 at 2:19 PM Resident #67 stated that he was not getting his showers. He appeared to have food on his clothing. During an interview on 07/16/2025 at 8:33 AM Resident #67 He stated that staff would not give him his shower and he wanted his showers. He also said that at times staff would only give him a bed bath and he did not want bed baths. During an interview on 07/16/2025 at 10:49 AM, Resident #53 stated he thought the facility is understaffed, 2 aides during day shift and 1 usually at night. He stated he was better off yelling for assistance then relying on the call light. He stated a female staff, CNA F told him the facility was understaffed and he could not receive a shower last week. He stated within the last 2-3 weeks he missed 2 showers in a row because of being understaffed. During an interview on 07/16/2025 at 11:40 AM, LVN A stated showers were on schedules, Monday, Wednesday, and Fridays and across the hall the schedule was Tuesday, Thursday, and Saturdays. She stated she ensures all residents on her shower schedule receive showers, and the shower sheet were completed, which were turned into the DON every morning during staff meetings. During an interview on 07/17/2025 at 2:32 PM the DON stated she conducts ADL care training for facility. She stated ADL care training usually included mechanical lift transfers, peri care, transfers, gait belts, and grooming. She stated she will check the skill set of new staff and provide additional training if necessary. She stated there was not a specific ADL care policy, nothing drawn out, knows oral care and hair brushing is needed in the AM depending on the residents' preferences. She stated showers were provided to residents 3 days a week. She stated all staff was responsible to ensure residents are cleaned and groomed. She stated they would feel crappy if not given showers. The DON said monitored ADL care was done by ADONs for each side of the facility. She stated ADONs were expected to do rounds and confirm showers were completed 3 times a week. She stated she also helps monitor that the showers were completed by reviewing the shower forms turned in for each resident for each shower given. She stated she was working with staff to ensure they are documenting the shower form with the correct residents' names. She stated she was familiar with Resident #53's care and stated she was unsure as to why there were shower forms and EMR (electronic medical records) shower entries missing for the resident and would search for them. She was unable to provide data prior to exit. The DON stated the facility was not understaffed and staff member, CNA F was recently counseled for informing residents of that information as that were spreading negativity and she was unsure why residents did not receive showers on their designated days and would look into this. During an interview on 07/17/2025 at 1:38 PM CNA C stated he is expected to provide residents with showers, dressing, brushing teeth, checking nails, brushing hair. He stated the policy for providing ADL care is to come on shift in the AM, check his assignment, check the showers roster, and give showers before a majority of residents get up. He stated ADL care should be provided in the AM when the resident wakes up. He stated he will look at the roster and time schedule, will provide showers and grooming, up until breakfast. He stated he is responsible for ensuring the resident is clean and groomed, and it is important to give ADL care because staff are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 12 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few here for the residents, to care for them, doesn't want them to be dirty, clean teeth and not have body odors. He stated if the resident does not get changed into clean clothing or groomed, they may feel neglected as everybody wants to feel clean. He stated the charge nurse is responsible for monitoring to ensure that staff are doing ADL care. He stated ADL care is monitored by the charge nurse coming to the floor and checking on the residents periodically. During an interview on 07/17/2025 at 1:56 PM CNA E stated she has been in-serviced on activities of daily living (ADL) care. She was knowledgeable of ADL care and provided examples. She stated ADL training included properly showering residents and transferring and helping them to activities. She stated the policy for providing ADL care is to do extra care if asked by the resident, she is to provide ADL care all the time, never ending, feeding, and changing. The policy for grooming is to give residents showers, get them up in the morning, some like to be wiped down, shaved, showered, brush their teeth, hair, nails, hearing aids, and dressing. She stated CNAs are responsible for ensuring the resident is clean and groomed. She stated it is important to give ADL care as everyone deserves to feel clean and needs a bath often. She stated that if the resident does not get changed into clean clothing or groomed and it can make them feel less of a person and would hurt their feelings. She stated the charge nurses, ADM, ADON, DON all help make sure to monitor staff are doing ADL care. She stated ADL care is monitored by what is put into the EMR (electronic medical record) and shower forms and by observing the resident. She stated nurses will follow up with CNAs if showers not done on the scheduled day. During an interview on 07/17/2025 at 2:08 PM CNA F stated she had been in-serviced on activities of daily living (ADL). She stated ADL care training included encouraging residents to do as much for themselves. She stated during new hire orientation and continuing education she was to help clean residents, provide grooming, bathing, make sure they keep up with hygiene and grooming. The policy for providing ADL care was to make sure to go through rooms, make sure residents are safe, take time, do not rush, look at them and see if there was a need. She stated staff should provide ADL care every 2 hours and as needed, as some will need it more than others. She stated the grooming policy was to see how much the resident can do, do what were needed, some days they can, learn their people. She stated everybody, specifically CNAs are responsible for ensuring the resident is clean and groomed. She stated it was important to give ADL care to help residents keep their dignity. She stated when ADL care was not provided it makes the resident feel less human, and quality of care is down. She stated the nursing staff were responsible for monitoring to ensure staff are doing ADL care. She stated nursing staff monitor ADL care were being completed by going behind CNAs and asking residents questions in passing to make sure they observe he/she is washed, glasses are on, pay attention to details, groomed well, identify if glasses, sweaters, hats are on. She stated showers were conducted 3 times a week on a schedule of every other day for hallways. She stated the shower policy was to stay in the restroom with them, those that can do alone keep an eye on them, make sure within line of vision, but allow them privacy if they ask. She stated the EMR was documented with shower completed and any skin details. She stated she only completes the shower form if there were skin concerns identified. She stated she was familiar with Resident #53's care. She stated he gets showers on his scheduled days; she has never given him a bed bath as she knows he prefers showers. She stated a few weeks back he was not getting his showers as the facility was understaffed. During an interview on 07/16/2025 at 11:40 AM, LVN A stated showers were on schedules, Monday, Wednesday, and Fridays and across the hall the schedule was Tuesday, Thursday, and Saturdays. She stated she ensures all residents on her shower schedule receive showers, and shower sheet were completed, which were turned into the DON every morning during staff meetings During an interview on 07/17/2025 at 1:56 PM CNA E stated she was familiar with Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 13 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #67's care. She stated he receives showers 3 times a week and she was not aware if there have been missed showers. She stated she will offer him assistance with teeth brushing, showering, and changing clothes. She was unsure as to why there are missing shower sheets for the resident, but any showers have been entered into the EMR. She stated she was unable to provide information as to why there was a 7-day span with no showers for the month of June2025. Record review of Nursing Policies and Procedures Activities of Daily Living Optimal Function Policy dated 05/05/2025 revealed the facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. Event ID: Facility ID: 676308 If continuation sheet Page 14 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 4 (Residents #28, #33, #68, and #93) of 4 residents reviewed for sufficient staffing.The facility failed to ensure that the facility had sufficient staffing to meet the needs of Residents #28, #33, #68, and #93. This failure could affect and diminish the resident's quality of life by potentially placing the residents at risk of not receiving timely care or receiving nursing interventions to meet the resident's needs, risk of injury, risk of safety, and or it can make the resident feel neglected affecting their mental health and overall psychosocial well-being not being met by facility staff.Findings include: Record review of Resident #28's Face Sheet dated 07/17/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses that included fracture of right lower leg (break in the continuity of a bone to left leg), Depression (a common mental disorder that involves a depressed mood or loss of interest in activities for long periods of time), Chest pain (discomfort or pain that you feel anywhere along the front of your body between your neck and upper abdomen), Muscle weakness (lack of muscle strength), Diabetes Mellitus with Diabetic Polyneuropathy (multiple peripheral nerves malfunction throughout the body) Hypertensive Chronic Kidney Disease with stage 1 through stage 4 (persistent kidney disease that reduces the rate at which kidneys filter waste and fluids), and Atherosclerotic Heart Disease (condition that causes arteries to narrow, restricting healthy blood flow to organs and other parts of the body).Record review of Resident #28's quarterly Minimum Data Set, dated [DATE] reflected a Brief Interview for Mental Status Score of 15, which indicated to be cognitively intact.Record review of Resident #28's Care Plan dated 05/30/2025 reflected Resident #28 required assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs while encouraging independence. The goals were for Resident #28 to maintain current level of function with assistance in his daily living care needs.Record review of Resident #33's Face Sheet dated 07/17/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses that included Chronic Atrial Fibrillation (type of heart arrhythmia that causes the top chambers of your heart, the atria, to quiver and beat irregularly), Glaucoma (eye condition that damages the optic nerve), Heart Failure (chronic progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs), and Chronic KidneyDisease (gradual loss of kidney function).Record review of Resident #33's quarterly Minimum Data Set, dated [DATE] reflected a Brief Interview for Mental Status Score of 15, which indicated to be cognitively intact.Record review of Resident #33's Care Plan dated 07/11/2025 reflected Resident #33 required assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #33 to maintain current level of function with assistance in his daily living care needs.Record review of Resident #68's Face Sheet dated 07/17/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included Iron Deficiency Anemia (include decreased iron intake, increased iron loss, and increased iron requirements), Polyneuropathy (type of neuropathy, or nerve disease, that affects many nerves), Dysuria (pain or a burning sensation during urination), Shortness of Breath (unable to get enough air to lungs), Anxiety Disorder (mental health condition characterized by excessive fear that interferes with daily activities), Hypertensive Heart Disease with Heart Failure (group of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 15 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disorders that includes heart failure, ischemic heart disease, and left ventricular hypertrophy), Muscle weakness (lack of muscle strength), Respiratory Disorder (disease or condition that affects the lungs and the ability to breathe), Depression (a common mental disorder that involves a depressed mood or loss of interest in activities for long periods of time), and Dementia (group of symptoms affecting memory, thinking and social abilities).Record review of Resident #68's quarterly Minimum Data Set, dated [DATE] reflected a Brief Interview for Mental Status Score of 12, which indicated to be cognitively intact.Record review of Resident #68's Care Plan dated 04/28/2025 reflected Resident #68 required assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #68 to maintain current level of function with assistance in her daily living care needs.Record review of Resident #93's Face Sheet dated 07/17/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included Chronic Kidney Disease (gradual loss of kidney function), Pulmonary Hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart), Type 2 Diabetes Mellitus with Hyperglycemia (has high blood sugar levels), and Atherosclerotic Heart Disease (buildup of plaque in the arteries).Record review of Resident #93's quarterly Minimum Data Set, dated [DATE] reflected a Brief Interview for Mental Status Score of 15, which indicated to be cognitively intact.Record review of Resident #93's Care Plan dated 04/28/2025 reflected Resident #93 required assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #93 to maintain current level of function with assistance in her daily living care needs.During an interview on 07/15/2025 at 10:19 AM with Resident #68, she stated there was concerns and she was afraid to say anything. She said sometimes she had to wait a long time for facility staff to get her ice water. Resident #68 stated during the night shift, she presses the call button, and it was at least two hours for a response by staff. Resident #68 stated the facility got rid of staff during shifts 2:00 PM to 10:00 PM and 6:00 PM to 2:00 AM because of the census. Resident #68 stated she had been stuck in the bathroom before because she could not get the help she needed from staff.In an interview on 07/15/2025 at 10:44 AM with Resident #28, he stated he had concerns with waiting 2 to 3 hours for assistance with going to the bathroom when he pushed his call light button. Resident #28 stated it depended on what staff was on shift, but the majority of time he waited a long period of time for any resident care by staff.In an interview on 07/15/2025 at 11:34 AM with Resident #93, she stated the average wait response time for facility staff to check on call lights is 30 to 45 minutes, and it has always been like that since residing at the facility.In an interview on 07/15/2025 at 11:40 AM with Responsible Party A, she stated to be the Responsible Party for Resident #93. Responsible Party A stated in terms of the facility staff response time to call light assistance, the facility staff take a long time to provide assistance for Resident #93 due to being understaffed. In an interview on 07/15/2025 at 11:44 AM with Resident #33, he stated the facility staff response time to call light's is long for any needed resident care assistance. Resident #33 stated he had to wait 2 hours the other day. Resident #33 stated the long waits for call light response time by the facility staff interferes with his quality of life.In an interview on 07/16/2025 at 12:43 PM with Responsible Party B, she stated to be the Responsible Party for Resident #28. Responsible Party B stated staff have advised that it's written in policy that in terms of call response time it reflected staff are to respond to residents as soon as they can respond. Responsibly Party B stated Resident #28 was getting a disservice and it was undignified. Responsible Party B stated she visits three times a week and has observed during each visit when the call light was pushed for resident care assistance, the facility staff response time was on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 16 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some average one hour and other times she has to go to the nursing station to get Resident #28 assistance.In an interview on 07/16/2025 at 1:33 PM with Registered Nurse K at the nursing station, she stated to be trained in neglect. Registered Nurse K stated neglect goes over call light response times as it would fall under neglect if residents were having to wait for a long period of time. Registered Nurse K stated call light response time realistically should be responded in 5 minutes and in her professional opinion in terms of neglect, it would be neglectful of staff if they were responding in 15 to 20 minutes to call lights. Registered Nurse K stated when the call lights got pushed, the residents room light outside the door illuminates and they get notified at the nursing station. Registered Nurse K stated she had been trained in call lights. Registered Nurse K stated the staff wouldn't know if the triggered call light was an emergency until getting there or if they hear someone yelling for help. Registered Nurse K stated if a staff member wasn't responding in an appropriate timely manner and busy with another resident, she would step in to assist. Registered Nurse K stated it's herself and a certified nurse aide assigned to the hall. Registered Nurse K stated she felt that it was challenging to meet all the residents needs and call light response times as well as each hall would benefit from more staffing assistance to respond to call light. Registered Nurse K stated if not responding to call lights in an appropriate manner, it can affect the resident's quality of life and care if they need assistance such as, medication, the restroom, and personal care. In an interview on 07/16/2025 at 1:54 PM with Certified Nurse Aide C, he stated he had been trained in neglect. Certified Nurse Aide C stated neglect would be if staff were not responding to call lights. Certified Nurse Aide C stated he had been trained in call light response time in which the response time would be depending on what staff were in the middle of with another resident and nurses were to assist certified nurse aides if they are busy. Certified Nurse Aide C stated he hasn't seen a call light go unchecked no longer than one minute. Certified Nurse Aide C stated if there was a call light pushed the staff won't be able to know if it's for a resident requesting for ice or an emergency situation until staff respond to the resident. Certified Nurse Aide C stated if staff aren't able to respond to call lights in a timely manner, it will have an effect on the resident's quality of life. In an observation on 07/16/2025 at 8:25 PM Revealed Resident #68 pressed the call light to ask for assistance with peri care. At 8:37 PM staff responded to call light, shut it off, and asked Resident #68 if she needed assistance. Resident #68 informed her that she needed to be changed. Staff stated she would get the supplies and return. At 8:58 PM another staff entered the resident's room and stated she was searching for another staff, and she checked on the roommate and fixed her blanket and walked out without asking the resident if she required assistance. At 9:02 PM, 25 minutes after the call light was originally pressed, staff returned with peri care supplies and stated she was back to change Resident #68. The Investigator exited Resident #68's room to allow for privacy. At 9:02 PM, the Administrator and Director of Nursing were standing directly outside of Resident #68's room and waiting for Investigator. The Investigator asked the Administrator what a reasonable call light response is, in which the Administrator stated as soon as possible with no exact time. In an interview on 07/16/2025 at 9:02 PM the Administrator stated the reasonable response time for a call light is as soon as possible and would not provide a specific amount of time. She stated she was unsure what Certified Nurse Aide G was doing to have delayed 25 minutes to provide Resident #68 with peri care. The Administrator stated Certified Nurse Aide G's delayed response time may be due to other priority tasks being performed but she was not sure. In an interview on 07/17/2025 at 1:38 PM Certified Nurse Aide C, he stated the policy on call light response is that there are 2 types of call lights, red emergency; will prioritize discomfort over needing ice; works on the urgent one; stated orientation is informed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 17 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some call light is very important and to answer within 1 minute. Certified Nurse Aide C stated a reasonable call light response was no wait time is reasonable, always check them immediately, believes anything after 5 minutes isn't reasonable. Certified Nurse Aide C stated more than 15 minutes plus to wait for peri care is considered neglect; stated the housekeeper and charge nurse will ask residents if they need assistance when the light is on; stated he does not work the night shifts. Certified Nurse Aide C stated everywhere there is a shortage of certified nurse aides and needs people. Certified Nurse Aide C stated since being at the facility, he has not seen a shortage of staff and residents get the care they need. In an interview on 07/17/2025 at 1:56 PM Certified Nurse Aide E, she stated the policy to answer call lights is no longer than 5 minutes. Certified Nurse Aide E stated the reasonable call light response time is within 15 minutes, and it is realistic to provide peri care within 5 minutes. Certified Nurse Aide E stated aid can answer the call light, change the resident and be done. Certified Nurse Aide E wants to make sure they got their care, don't want to rush them; will answer call light within 5 minutes and notify the resident and return within 5-10 minutes if unable to perform care at that time. Certified Nurse Aide E stated she would prioritize a resident; all residents' needs are valid; wanting water; within 5-10 minutes to return; nobody wants to sit in their own feces or urine for a long period of time; we have the option to return, doesn't want to rush the individual; less than 15 minutes to return for peri care is reasonable and any more time than that could be considered neglectful, wants to devote time to the resident. In an interview on 07/17/2025 at 2:08 PM Certified Nurse Aide F, she stated the reasonable amount of time to answer call lights: only sees it, minutes, matter; observed the red call light go off, the sound system is low, but light goes red, she knew resident was in the restroom; under 5 minutes to respond is reasonable; catch the lights, within 5-10 minutes; acknowledge them and their light; will return, will finish with other resident; believes anything after 15 minutes and up for peri care would be considered neglectful; will ask other staff for help; 2 staff on hallway and nurse at times will not really be helpful. In an interview on 07/17/2025 at 2:20 PM with, Licensed Vocational Nurse B stated to be trained in neglect. Licensed Vocational Nurse B stated the training for neglect went over call light response and any staff member can respond to check on residents. Licensed Vocational Nurse B stated in her professional opinion, she wishes it could be better in terms of having a sufficient amount and enough staff to meet all the residents needs in a timely manner, but it's better than most facilities. Licensed Vocational Nurse B stated the acceptable response time to call lights for resident care is within two to three minutes. Licensed Vocational Nurse Stated an unreasonable amount of time to respond to call lights would be anything over five minutes. Licensed Vocational Nurse B stated 30 minutes to 2 hours would be unreasonable amount of time to respond to call lights. Licensed Vocational Nurse B stated those unreasonable amounts of times to respond to call lights is considered neglectful and would mean staff aren't paying attention to residents. Licensed Vocational Nurse B stated her expectations for staff response times to residents call lights is to check on the residents right away and if another light goes on in the middle of something then they can check on that resident to advise they will come back to check on them once the staff member is complete with assisting another resident. Licensed Vocational Nurse B stated the staff do the best they can in terms of meeting all residents needs with the ratio of staff the facility has as there is nothing set in place of how many individuals are needed to a facility. Licensed Vocational Nurse B stated during the night shift, the staff level is lower, and they tend to the residents needs as best as possible. Licensed Vocational Nurse B stated a resident's quality of life can be affected if residents are waiting for long periods of time because the residents can be in pain, and staff wouldn't know what the residents need until the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 18 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff member checks on them. In an interview on 07/17/2025 at 2:32 PM with the Director of Nursing, she stated a reasonable timeframe for call light response will depend on what was going on in the hallway and tasks being performed by staff. Director of Nursing stated she was unable to give a specific timeframe. Director of Nursing stated reasonable response time of 15 is appropriate but may not be able to provide service at that time. Director of Nursing stated peri care is high on the priority level and hallways are worked with 2 certified nurse's aides and 1 nurse. Director of Nursing stated due to emergencies on the hallway staff cannot guarantee quick response to call lights. Director of Nursing stated a resident waiting more than 25 minutes is not neglectful and there are many factors to consider when providing peri care, such as requiring 2 staff, mechanical lift transfers, and timeframe. Director of Nursing stated she cannot speak to reason why Certified Nurse Aide G did not provide peri care after responding to the call light and would need to ask her. In an interview on 07/17/2025 at 3:17 PM with the Director of Nursing, she stated to be trained in resident neglect. The Director of nursing stated in her professional opinion, there was sufficient and enough staff to meet all the residents needs in a timely manner on all shifts. The Director of nursing stated the acceptable response time to call lights for resident care was, she can't give a specific time, and it depends on the duties staff are performing when working with residents and Nurses should assist. The Director of nursing stated it was the nursing staff and leadership's responsibility to monitor call light response times and maintaining sufficient staff during each shift. The Director of nursing stated an unreasonable amount of time to respond to call lights would be, and she cannot provide a time. The Director of nursing stated 30 minutes to 2 hours was an unreasonable amount of time. The Director of nursing stated the unreasonable amount of time to respond to call lights can be considered neglectful depending on what the resident was needing and the situation. The Director of nursing stated her expectations for maintaining sufficient staffing and call light response time is to prioritize the residents that may need more assistance while reaching out to additional staff or leadership for assistance if it is needed. The Director of nursing stated she doesn't want to provide an answer to the question, but the resident's quality of life can be affected if resident's needs aren't being met in terms of sufficient staffing and not responding to call lights. In an interview on0 7/17/2025 at 3:55 PM with the Administrator, she stated to be trained in neglect towards residents. The Administrator stated in her professional opinion, there is sufficient and enough staff to meet all the residents needs in a timely manner on all shifts. The Administrator stated there are days that the facility struggles when there is staff call outs, but for the most part the facility has sufficient staff. The Administrator stated there isn't a set amount of time for what the acceptable response time to call lights is for resident care as long as the residents are being cared for and there is no negative affect. The Administrator stated there isn't a set amount of time she could provide for an unreasonable amount of time to respond to call lights would be. Administrator stated residents waiting 2 hours is an unreasonable amount of time, but she would question the resident's accuracy on response time. The Administrator stated 2 hours would be unreasonable amount of time to wait and won't be appropriate. The Administrator stated her expectations for sufficient staffing is making sure to have enough staff to meet all the residents needs without a negative impact or delay to answering call lights. The Administrator stated there is upper management that can assist staff if there is support needed for residents needs to be met. The Administrator stated she hasn't read the policy on call light response time in a while and there isn't a specific time written besides responding as soon as possible. The Administrator stated resident's quality of life can be affected if not having sufficient staff and responding to call lights in a timely manner. Record review of in-service training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 19 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete reflected call lights/ hand bells were completed on 05/29/2025, and call light response in a timely manner was completed on 02/14/2025 as well as reflecting staff attendance. Record review of facility staff schedule reflected days in which there were three Certified Nurse Aides working 10:00 PM to 6:00 AM with shifts assigned to one Certified Nurse Aide to 100 hall, one Certified Nurse Aide to 200 hall, and one Certified Nurse Aide to 300/ 400 hall in which the Certified Nurse Aides were splitting the facility census of 93 residents. Record review of Call Lights, responding to Policy dated 05/05/2023 reflected: the staff will respond to call lights or other requests for assistance to meet the patient's/resident's needs. 1. Respond to call lights and requests for assistance as quickly as practicable.2. Staff respond to emergency lights immediately.3. Staff knock on the patient or resident room door before entering to promote privacy and dignity.4. Staff will cancel the call light to notify others that the resident is being assisted.5. If unable to complete the requested task, inform the patient/resident/family and notify the appropriate discipline. Call lights should not be canceled until the resident's need has been addressed.6. When leaving the patient or resident room, ensure the call light is placed within the patient's/resident's reach. Record review of Staffing Policy revised on 11/01/2027 reflected: the Facility's Leadership will provide a sufficient number of staff to successfully implement patient/resident-focused functions. To provide a sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related service to assure resident safety and attain or maintain the highest practical physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnosis of the facility's resident population.1. Provides qualified personnel based on the organization's mission, scope of services provided, the populations served, and federal and state certification and licensure requirements.2. The adequacy and competency of staff is determined by a facility assessment of the resident population. The facility assessment includes residents care needs in accordance with their care plans and considering the number, acuity, and diagnosis of the facility's resident population. Event ID: Facility ID: 676308 If continuation sheet Page 20 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates for 1 of 4 medication carts reviewed. During observation of MC A, Resident #28's box of Novolin 70/30 had been opened on 05/29/25 and according to the manufacturing instructions should be disposed after 42 days of opening which would be on or before 07/10/25. This failure could lead to medication not being effective, and therefore impacting residents' health. Findings included: Record review of Resident #28's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #28 had diagnosis which included diabetes mellitus type 2. Record review of Resident #28's Active Physician's Orders, dated 07/17/25, reflected he had been prescribed Humulin 70/30 U-100 Kwik Pen 100 unit/mL and to receive 28 units subcutaneous once daily. An observation on 7/17/25 at 9:40 AM of a medication cart revealed an expired medication Novolin (Humulin same and both names can be used interchangeably) 70/30. The box of Novolin 70/30 had been opened on 05/29/25. An interview on 7/17/25 at 9:40 AM with RN L who administered the medications stored on the medication cart stated that the medication was prescribed for Resident #28 and the medication should have been removed before the expiration date 07/10/25., or 42 days. RN L was aware of the policy for monitoring medications on the med cart for expiration dates and prompt removal the expired medications. She stated that the resident had non-expired medication already available for administration on the cart. An interview on 07/17/25 at 2:40 PM with the DON, who stated the charge nurse should be checking the medication carts for expiration dates before administering medications, and the Pharmacist checked all medications and carts monthly. The DON further stated that she and the Pharmacist were responsible for ensuring there were no expired medications on the medication carts. The DON further stated an expired medication might not be therapeutic to a resident if the medication was past the expiration date. Review of Novolin 70/30: Package Insert/Prescribing Info dated 08/24/23 reflected:Table 2: Storage Conditions and Expiration Dates for NOVOLIN 70/30 for the 10 mL multiple-dose vial reflected once in use/opened the medication was to be kept at room temperature for up to 42 days and up to 77 degrees Fahrenheit, and not to refrigerate.Review of an undated Policy and Procedure for Medication Labeling and Storage reflected, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.4. For over the counter (OTC) medications in bulk containers the label contains:a. the medication name.b. strength.c. quantity.d. accessory instructions.e. lot number; andf. expiration date (if applicable). Event ID: Facility ID: 676308 If continuation sheet Page 21 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Resident #2, Resident #63 and Resident #57) reviewed for infection control. 1. CNA H, CNA C, and CNA K did not sanitize their hands between glove changes during peri-care for Resident #2 and Resident #57. 2. CNA H did not sanitize their hands between glove changes during Foley catheter care for Resident #63. These failures could place the residents at risk of infection transmission, sepsis (a systemic infection), and hospitalization. Findings included: An observation on 7/16/25 at 11:32 AM revealed CNA H did not sanitize her hands between changing gloves during peri-care for Resident #2. More specifically, CNA H did not sanitize hands when changing gloves when going from the peri-area to the bottom. Record review of Resident #2's face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia, cerebral infarction (stroke), pressure ulcer sacral region (the sacral bone can endure a lot of pressure and motion. Along with the coccyx (tailbone), the sacrum provides a stable platform to help you sit upright.), dysphagia (difficulty swallowing), and muscle weakness. Record review of Resident #2's Quarterly MDS assessment, dated 06/07/25 did not reveal a BIMS score. Further review of the MDS revealed Resident #2 had a Stage 4 pressure injury, and had a pressure reducing device for the bed, nutrition or hydration interventions to manage skin problems, and was receiving pressure ulcer/injury care Record review of Resident #2's Care Plan dated 06/11/25 reflected: [Resident #2] had Enhanced Barrier Precautions in place related to wounds. The goal was for prevention of transferring infection within the next 90 days. Approach included staff to wear gloves and a gown for high-contact resident care/activities. [Resident #2] had a pressure ulcer to sacrum with a wound vac in place. The goal was for [Resident #2's] ulcer to heal without complications. The approach was to limit sitting up in wheelchair to 2 hours, use therapeutic air cushion for pressure reduction when resident is in chair, apply dressings per physician order. Review of Active Orders dated 07/17/25 for Resident #2 reflected to cleanse the sacral wound with Dakin's solution, apply skin prep and ostomy (artificial surgical opening created by a surgeon) border. Place black foam cut to fit wound, cover with draping, attach to suction at 125mm/hg once daily on Monday, Wednesday and Friday. An observation on 7/16/25 at 11:32 AM revealed CNA H did not sanitize her hands between changing gloves during peri-care for Resident #2. More specifically, CNA H did not sanitize hands when changing gloves when going from the peri-area to the bottom. Record review of Resident #63's face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included sepsis (systemic infection), nontraumatic acute subdural hemorrhage (bleeding in the brain), urinary tract infection, chronic kidney disease, hypertension, dysphagia (difficulty swallowing), muscle weakness, benign neoplasm of prostate (cancer of the prostate gland), and chronic pain. Record review of Resident #63's Comprehensive MDS assessment dated [DATE] revealed a BIMS Score of 2, which reflected severe cognitive impairment. Further review of Resident #63's assessment revealed he had an indwelling catheter device for a diagnosis of neurogenic bladder (injury or disease interrupts the electrical signals between nervous system and bladder function). Record review of Resident #63's Care Plan dated 06/11/25 reflected: [Resident #63] had Enhanced Barrier Precautions in place related to a Foley catheter. The goal was for prevention of transferring infection within the next 90 days. Approach included staff to wear gloves and a gown for high-contact resident care/activities. Review of Active Orders dated 07/17/25 for Resident #63 reflected Foley catheter care may be completed by nursing assistant every shift. An observation on 07/17/25 at 09:58 AM of peri-care for Resident #63 revealed CNA Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 22 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few H cleansed his peri-area and changed gloves without conducting hand hygiene. CNA H then did not change gloves before cleansing the Foley catheter tubing. CNA H changed gloves but did not conduct hand hygiene before applying the new brief. Interview on 07/17/25 at 10:21 AM with CNA H revealed they were provided with Foley catheter care training, which was provided every 6 months. CNA H stated nurses changed Foley and tubing once a week and the CNAs cleaned only 5 inches of the tubing from meatus (the opening of the urethra to the exterior of the body). CNA H stated they needed to sanitize their hands every time they changed gloves. Record review of Resident #57's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), urinary tract infection, dysuria (difficulty with urination), hypertension, diabetes mellitus type 2, chronic pain, muscle weakness, and need for assistance with personal care. Record review of Resident #57's Quarterly MDS assessment dated [DATE] revealed a BIMS Score of 14, which reflected mild cognitive impairment. Further review of Resident #57's assessment revealed she was frequently incontinent of bladder and bowel and required substantial/maximal assistance for her activities of daily living. Record review of Resident #57's Care Plan dated 06/11/25 reflected: [Resident #57] experiences bowel and bladder incontinence related to impaired mobility. She uses a Pure wick(Female External Catheter uses suction and a soft, flexible wick to draw voided urine away from the body and into a collection canister) at night for bladder incontinence. [Resident #57] tends to refuse care during rounds and prefers to get changed at end of shifts despite education. The goal was for [Resident #57] to maintain current level of bowel and bladder continence within the next 90 days. The approach included assistance and incontinent care after each incontinent episode and every shift. An observation on 07/17/2025 at 1:21 PM of peri-care for Resident #57 revealed CNA C did not change gloves when going [NAME] the peri area to the bottom. Interview on 07/17/25 at 1:36 PM regarding hand hygiene practice, CNA C stated that they were trained on hand hygiene, and they were supposed to wash their hands between glove changes. The CNA further stated they were supposed to change gloves and conduct hand hygiene between front and back peri-care areas and if gloves become soiled. CNA C stated she must have been nervous and had forgotten to do hand hygiene between glove changes. (Female External Catheter uses suction and a soft, flexible wick to draw voided urine away from the body and into a collection canister.)An interview on 07/17/25 at 2:21 PM with LVN B revealed charge nurses should monitor how staff were conducting hand hygiene and following infection control measures, and the DON conducted oversight. LVN B further stated the policy on hand hygiene and providing peri-care, wound care, and Foley catheter care was to conduct handwashing before and when they come out of the room with wound care, aides were to conduct handwashing when they come in and out. She stated when going in and coming back out, they were supposed to gel their hands. She further stated there was an order in how you do things from the cleanest to the dirtiest, depending on the male and female, who should be cleansed from front to back. She stated for wound care staff were to cleanse the wound, remove gloves, wash hands or gel, put on clean gloves and apply the wound treatment. LVN B further stated she had been trained on infection control and hand hygiene many times, and the potential negative outcome for the residents when not practicing good hand hygiene was cross-contamination. An interview on 07/17/25 at 2:40 PM with the DON, who stated she had worked here for 7 years. The DON stated that she and the infection preventionist were responsible for ensuring staff were conducting proper hand hygiene/following infection control measures when providing care for the residents. She stated the infection preventionist conducted weekly routine checks and audits. She stated the policy on hand hygiene, providing peri-care, wound care, and foley catheter care was to conduct hand hygiene before going in the room, and when coming out of the room. The DON stated training on infection control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676308 If continuation sheet Page 23 of 24 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 676308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and hand hygiene was taught during boot [NAME] (title for the facility's annual skills trainings), weekly audits, and was talked about it in huddles. The DON stated a potential negative outcome for the residents would be transmission of bacteria. Review of Policy and Procedure for Infection Prevention and Control Program and Plan dated 05/15/23 reflected, The purpose was to establish a facility wide program that incorporates a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. The program covers all residents, staff, consultants, students in the facility's nurse aide training program, and other individuals providing services under a contractual agreement and is based on the individual facility assessment following accepted national standards. Policy5. Infection Prevention and Control Programs are required by state and federal regulation and recommended by the Centers of Disease Control and Prevention (CDC). Staff DevelopmentA. Staff education on important infection prevention and control topics is coordinated through the Infection Preventionist and staff development personnel.B. Infection prevention and control training is provided at the time of new-hire orientation and at least every 12 months to meet state and federal requirements.E. Staff is provided with information and training on:3.) Hand hygiene, including handwashing and alcohol-based hand rub (ABHR).4.) Universal/Standard and Transmission Based Precautions.9.) Care of invasive devices, such as vascular access, urinary catheter, and tracheostomies. Follow-up competency evaluations identify staff compliance. Review of Hand Hygiene/Handwashing Policy and Procedure dated 05/15/23 reflected, Hand hygiene/handwashing is the most important component for preventing the spread of infection. Maintaining clean hands is important for patients/residents/visitors as well as staff.After:c. After contact with a contaminated object or source where there is a concentration of microorganisms, such as mucous membranes, non-intact skin, body fluids, blood or wounds.h. After removal of medical/surgical or utility gloves. Review of an undated Indwelling Urinary Catheter Care and Removal Policy reflected, The Centers for Medicare and Medicaid Services considers Catheter-Associated Urinary Tract Infection (CAUTI) a hospital -acquired condition because various best practices can reasonably prevent it. To reduce the risk of CAUTI when caring for a patient with an indwelling urinary catheter, be sure to follow evidence-based CAUTI prevention practices, such as performing hand hygiene before and after any catheter manipulation; maintaining a sterile, continuously closed drainage system. Event ID: Facility ID: 676308 If continuation sheet Page 24 of 24