Health inspection·November 18, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of Resident #214's admission record, dated [DATE], revealed an admission of [DATE] with diagnosis of Traumatic Hemorrhage of the Cerebrum (Major Brain Bleed) and Contusion of other Part of Head (a bruise). Under Advance Directive, code status was a Full Code. Record review of document titled SW: CODE STATUS DISCUSSION, dated [DATE], revealed in person discussion with the Resident #214, stating Resident wants CPR performed if she codes. Physician was notified on [DATE]. Record review of Resident #214's orders dated [DATE], showed an order for Full code status, with a start date of [DATE], and no end date. Record review of Resident #214's care plan dated [DATE], showed the Resident was Full Code and to Ensure Residents wishes are followed as desired. 3. Record review of Resident #219's admission record, dated [DATE], revealed an admission of [DATE] with diagnosis of Acute Pancreatitis (A disease condition characterized by inflammation of the pancreas), muscle weakness, and abnormal gait (Abnormal walk). Record review of document titled SW: CODE STATUS DISCUSSION, dated [DATE], revealed in person discussion with the Resident #219, stating Resident wants CPR performed, if he codes. Physician was notified on [DATE]. Record review of Resident #219's orders, dated [DATE], showed an order for Full code status, with a start date of [DATE], and no end date. Record review of Resident #219's care plan, dated [DATE], showed the Resident was Full Code and to Ensure Residents wishes are followed as desired. 4. Record review of Resident #223's admission record, dated [DATE], revealed an admission of [DATE] with diagnosis of Fracture of Vertebra a dislocation or fracture of the vertebrae (backbone) and can occur anywhere along the spine.) and Dementia (group of symptoms that affects memory and thinking). Record review of document titled SW: CODE STATUS DISCUSSION, dated [DATE], revealed in person discussion with the Resident #223, stating Resident wants CPR performed, if she codes. Physician was notified on [DATE]. Record review of Resident #223's orders, dated [DATE], showed an order for Full code status, with a start date of [DATE], and no end date. Record review of Resident #223's care plan, dated [DATE], showed the Resident was Full Code and to Ensure Residents wishes are followed as desired. During an interview on [DATE] at 11:57 a.m. the Social Worker stated Residents #34, #214, #219, and #223 had no forms for advance directives from the hospital, or the families had not brought in any information about advance directives. He stated he had a code discussion with Resident #214, #219, and #223. He stated he did not know if they had advance directives and normally the families would bring in advance directives if they had them. He stated these Residents were on a rehab hallway and were not there for very long. He stated if they stayed longer and moved to another hallway then he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 2 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would have followed up on advance directive status. He stated he planned to touch base with Resident #34's family to see if they had a medical power of attorney. He stated he usually would ask the family towards the early part of the residents stay to bring any paperwork for advance directives. He stated Resident #34 had not specifically asked for the advance directive. He stated according to the advance directive policy he had not followed it. He stated he had not seen the policy in a while. He stated historically they would reach out to the family to see if they had an advance directive and those who did not have one, they would have asked the resident representatives about any medication changes or ER visits. The SW stated the risk for not having a residents advanced directive on file was staff not knowing what the resident had a right to decide his/her end-of-life choice. Record review of the facility's policy titled Advance Directives, dated 12/2016, stated Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation. 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical pr surgical treatment and to formulate an advance directive if he or she chooses to do so .3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 4. If the resident becomes able to receive and understand this information later, or she will be provided with the same written materials as described above, even if his or her legal representative has already been given this information .6. Prior to or planned mission of a resident, the social service director or designee will inquire of the resident, his slash her family members and slash or his or her legal representative, about the existence of any written advanced directives. 7. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she had not established advanced directives, the facility will offer assistance in establishing advanced directives. a. The resident will be giving the option to accept or decline in assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist the president's decision to accept or decline assistance . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 3 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 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 ensure each resident with a mental disorder was screened prior to admission for 1 of 3 of (#20) resident reviewed for PASRR: Residents Affected - Few The facility did not correctly identify Resident #20 on the PASRR Level 1 Screening Form as having Mental Illness and did not submit a request to correct their PASRR negative screening. This could affect resident with mental illness that was not considered to be a Positive PASRR and could result in a decrease in services. The Findings were: Record review of Resident #20's admission Record dated 11/18/2022 revealed he was admitted on [DATE] and was diagnosed with schizoaffective (condition where symptoms of both psychotic and mood disorders are present together during one episode), bipolar (8/8/22) ( causes extreme mood swings that include emotional highs (mania or hypomania) and lows). no dementia. Record review of Resident #20's Quarterly MDS section I Active Diagnoses, psychiatric/mood disorder revealed a diagnoses of schizoaffective, bipolar. Record review of Resident #20's PL1, prior to this SNF was 8/4/2022 and was positive for Mental Illness. Record review of Resident #20's PL 1 dated 8/8/2022 was negative and this was inputted into the SIMPLE (computer program to gather information on residents PASRR eligibility), program. Interview on 11/17/2022 at 3:58 PM with MDS/Care Plan coordinator revealed when asked if she knew that Resident #20 diagnosis of schizoaffective, bipolar should trigger a positive PASRR screening, she responded, not aware that she inputted the wrong PL 1 and would correct the mistake at this time. The stated she was responsible for ensuring all residents with mental Illness were indicated in the SIMPLE program as positive for PASSRR. The MDS/Care Plan coordinator stated it was a mistake. Interview on 11/18/2022 at 12:58 PM with Administrator stated the MDS and IDT were responsible for residents with positive PASRR. The Administrator stated if not completed correctly, it could affect the resident by not receiving services. Record review of the Policy PASRR (preadmission and screening resident review) rules dated 2/8/2019 revealed Guidelines: It is the intent of facility to meet the abide to the State and Federal regulations that pertain to resident PASRR rule. Purpose: The intent of this guidelines is to identify residents with Metal Illness (MI) . and to ensure they are properly placed, whether in community or in a nursing home (NF) and to ensure they review the services they require for their MI (mental illness). Procedure: The PASRR Level 1 (PL 1) the facility will receive a PL1 upon admission, if the IDT (interdisciplinary) TEAM suspects any MI . the facility prior to admission will contact the LIDDA and follow the preadmission screenings process: The referring entity (SNF)PL 1 to LIDDA 72 hour timer starts). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 4 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations for 1 of 2 (#40) residents with a positive PASRR in that: MDS/Care plan nurse did not include in care plan for Resident #40 his specialized wheelchair for a PASRR positive resident. This failure could place residents at risk for not receiving appropriate treatment and could result on a decrease in quality of care. The Findings were: Record review of Resident #40's admission record dated 11/18/2022 revealed he was admitted on [DATE] with diagnoses of paranoid schizophrenia (characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations. These debilitating symptoms blur the line between what is real and what isn't, making it difficult for the person to lead a typical life.), intellectual disabilities (a term used when there are limits to a person's ability to learn at an expected level and function in daily life), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and cognitive communications deficit. Record review of Resident #40's Annual MDS dated [DATE] revealed in section C Cognitive Patterns, 3/15 (severely impaired) section I Active diagnoses Parkinson's disease, schizophrenia, and intellectual disability. Record review of Resident #40's care plan dated 10/17/2022 revealed he met the PASARR level 1 determination for ID (intellectual disability) as per evaluation on 9/30/2022. No DME specialized wheelchair for Resident #40's was on the care plan. Each Resident's plan of shall be reviewed by an interdisciplinary team after each MDs assessments is conduced and revised necessary to reflect the resident's current care needs. Record review of Resident #40's Annual PASRR (annual assessment completed by the MDS nurse)1/2022 recommendation specialized wheelchair, resident had COVID-19, PASRR representatives was not able to come into building due to COVID-19: IDT Quarterly meeting on 4/23/2020 had DME recommendation for specialized wheelchair; DME-4/23/2020 mattress was received. Record review of Resident #40's Physician attestation for diagnosis PASARR dated 12/5/2019, included intellectual disability, ICD-10 code F79, onset 1955. Observation on 11/17/2022 at 3:50 PM in the dining room, during an activity revealed Resident #40 was sitting in his specialized wheelchair. Resident #40 was not interviewable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 5 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/17/22 at 3:39 PM with the DOR revealed she did submit proper forms for Resident #40; he does have DME for specialized wheelchair. This request was late. The specialized equipment ordered by therapy and MDS. Interview on 11/17/2022 at 3:45 PM with MDS/Care Plan nurse revealed she did not see specialized wheelchair on the care plan. MDS/Care Plan nurse stated the risk be that the resident does not receive equipment they need for their diagnoses and quality of life. Record review of Compressive Resident Care Plans (no date) revealed All items or services ordered to be provided or withheld shall be included in each resident's plan of care. The comprehensive care plan describes serviced furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. Record review of the Policy PASRR (preadmission and screening resident review) rules dated 2/8/2019 revealed Guidelines: It is the intent of facility to meet the abide to the State and Federal regulations that pertain to resident PASRR rule. Purpose: The intent of this guidelines is to identify residents with Metal Illness (MI) . and to ensure they are properly placed, whether in community or in a nursing home (NF) and to ensure they review the services they require for their MI (mental illness). Procedure: The PASRR Level 1 (PL 1) the facility will receive a PL1 upon admission, if the IDT (interdisciplinary) TEAM suspects any MI . the facility prior to admission will contact the LIDDA and follow the preadmission screenings process: The referring entity (SNF)PL 1 to LIDDA 72-hour timer starts). Post IDT meeting responsibilities: Once the ID makes is determinations about specialized care, the facility will; 1. include all specialized services and support activities in the resident comprehensive plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 6 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Residents care plans were reviewed and revised by the IDT within the required timeframe for 3 of 3 residents reviewed for care plan timing/revision, in that: 1. Resident #32's care plan conference attendees did not include the CNA, Physician, Registered Nurse, and Food and Nutrition Services. 2. Resident #49's care plan conference attendees did not include the CNA, Physician, Registered Nurse, Food and Nutrition Services. There was no documentation for September and June Care Plan Conferences. 3. A quarterly review of Resident #24's Comprehensive Care Plan was not conducted until 9 months after the review of his initial Comprehensive Care Plan. These failures could affect residents and could result in a decrease of services provided from different disciplines. The Findings were: Record review of a sample Resident Care Plan conference form include who attended the meetings; Nursing Summary, Dietary Summary; Recreations Summary; Social Work (SW) Summary; Pharmacy summary; Restorative Care/Physical /Occupational summary; Physician Summary; and Resident/Family. 1. Record review of Resident #32's admission Record dated 11/18/2022 revealed she was admitted on [DATE] with diagnoses of traumatic subdural hemorrhage without loss of consciousness (traumatic subdural hemorrhage), muscle weakness, abnormalities of gait and mobility, lack of coordination, cognitive communications deficit, diabetes II, bipolar disorder, anxiety disorder, and age-related osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D). Record review of Resident #32's Care plan dated 11/14/2022 revealed her CAA areas were BIMs of 15 (cognitively intact), cognitive loss/dementia, ADL functional/rehabilitation potential, Falls, nutritional status, pressure ulcer, and psychotropic drug use. Record review of Resident #32's Care plan Conference dated 4/20/2022 revealed the attendees were registered nurse and SW. The Care Plan Conference, B Nursing Summary included diagnoses Traumatic subdural hemorrhage, alert and oriented x3 with some difficulty with short term memory recall. Vision and hearing appear adequate for purpose. Clear speech and able to make needs known to staff; E Dietary Summary- Current Diet-Regular. Current weight 125; F Recreation Summary- up in wheelchair, watches televising, and attends some group activities, she does out on pass with family and they make regular visits; G SW summary= 13 on latest BIMS. Appears to be coping well with facility life. Resident will continue to cope well with tacitly life in next 90 days; J Physician summary-not present; K Resident/Family- spouse concerned about acid reflux, ADON informed him resident #2 was taking medications for acid reflux. Reviewed other medications. Care Level- Do not Resuscitate. The blank sections were Physician Summary with no dietary, pharmacy, activities, nursing administration, physician, family/resident or CNA attended. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 7 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of Resident #49's admission Record dated 11/18/2022 reveled she was admitted on [DATE] and re-admitted on [DATE] with diagnoses of depression, diabetes II, vitamin deviancy, heat disease with heart failure, atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), gastro -esophageal reflux disease ( a digestive disease characterized by chronic acid reflux, which occurs when stomach acid flows back into the esophagus), pain in left ankle and joints of left foot, abnormal gait and mobility, Guillain Baree Syndrome (syndrome is a rare disorder in which your body's immune system attacks your nerves) and acute kidney disease. Record review of Resident #49's care plan dated 10/24/2022 revealed she had little, or no activity involvement related to immobility, physical limitations, neurological deficits Guillain Bare she had atrial fibrillation, congestive heart failure, risk for falls. Record review of Resident #49's Care Plan Conference dated 1/12/2022 revealed the attendees were SW and Physical/Occupational therapy. Section D: Nursing Summary- Guillain Baree Syndrome; E Dietary Summary-Current diet Regular, current weight 219; F Recreation Summary- Self initiated activities between rehab sessions; G SW summary-15 on latest BIMs, struggling to take care of herself at home in the community, and family believes 24-hour caregiver or nursing home, family is working with attorney to quality for nursing home Medicaid; H Pharmacy Summary-monthly; I Physician Summary -blank, therapy department-patient doing leg exercises and will do standing frame today, Stimulate the nerve and get the circulation going. Occupational Therapy she did sliding board transfers. J Physician Summary-no note; and K Family stated she will need 24-hour care if she goes home. Care Level review-full resuscitate. The blank sections were Physician Summary with no registered nurse, dietary, pharmacy, activities, nursing administration, physician and family/resident or CNA attended. Interview on 11/18/2022 at 12:16 PM with the Social Worker (SW) stated the resident care plans were completed quarterly, and he had been working at this facility, since 2017. The SW stated he invited the family, residents and department managers to the care plan conferences. The SW stated the nurse, therapy, kitchen and Activity Director, if available come to the resident care plan conferences, but does not usually attend. The SW stated he did not document the reason why care plan conference attendees did not attend. The SW stated he was not aware of the requirements that the above disciplines attend a care plan conference. The SW stated he was not inviting physician or CNAs. Interview on 11/18/2022 at 12:58 PM the Administrator was not aware the SW was not inviting physician or CNAs to the Resident Care Plan Conferences. The Administrator stated this resulted in residents not receiving services they need. Interview on 11/16/2022 at 2:09 PM with Resident #49 stated she never went to one or was never offered to go to a care plan conference. Record review of Resident #49's chart revealed care plan conference dated-6/29/2022 was blank. Interview on 11/18/2022 at 12:34 PM the SW stated Resident #49 did not have a care plan conference September 2022 and 6/29/2022 was blank. The SW stated he was not sure why it was blank or that Resident #49 was missing September 2022 care plan conference. 3. Record review of Resident #24's admission Record printed 11/15/2022 revealed he was a [AGE] year-old male with an initial admission date of 11/19/2021 diagnosed with psychotic disturbance, mood disturbance, anxiety, and chronic diastolic (congestive) heart failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 8 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Section C Cognitive Patterns of Resident #24's Minimum Data Sheet dated 9/27/2022 revealed a Brief Interview for Mental Status score of 13, indicating intact cognitive response. Record review of Resident #24's electronic medical record revealed an explanation of an admission Multidisciplinary Care Conference (MCC) (an MCC is similar to and Interdisciplinary Care Team (IDT) meeting) signed 11/24/2021 and an explanation of a quarterly Multidisciplinary Care Conference signed 9/16/2022. During an interview on 11/15/2022 at 1:08 PM, Resident #24 stated that he was unsure about his care plan. He also stated that he did not know what medication he was taking, and that he would like to know what medication he was taking. During an interview on 11/18/2022 between 12:19 PM and 12:56 PM, the SW was unable to recall if an MCC regarding Resident #24 occurred between the months of January 2022 and August 2022. The SW stated, I can't say that the conferences occurred. Further, The SW was unable to produce a record of an MCC regarding Resident #24 occurring between the month of January 2022 and August 2022. Record Review of the 'Senior Care Centers Operational/Resident Care Policies Comprehensive Resident Care Plans [no publish date] policy on 11/18/2022 revealed instruction that Resident's care plans are reviewed at least quarterly.Record Review of the 'Senior Care Centers Operational/Resident Care Policies Comprehensive Resident Care Plans [no publish date] policy on 11/18/2022 revealed instruction that Resident's care plans are reviewed at least quarterly. Record review of the Comprehensive Resident Care Plans (no date) revealed The interdisciplinary team included, 1. The Residents Attending Physician, 2. A Registered Nurse with responsibility for the resident, 3. A nurse aide with responsibility for the resident, 4. A member of Food and Nutrition services staff, 5. Other appropriate staff in disciplines as determined by the resident needs or as requested by resident : and 6. The resident, the resident family, or the resident representative to the extent practical. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 9 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of pressure ulcers for 2 of 2 residents (Residents #24 and #51) reviewed for pressure ulcers in that: Residents Affected - Few 1. LVN G failed to perform hand hygiene practices per the facility's policy and procedure, during Resident 24's wound care on his pressure ulcers. -LVN G contaminated a clean bandage with non-sanitized scissors she used while providing Resident 24's wound care on his pressure ulcers. -LVN G failed to properly transcribe physician wound care orders for Resident 24's pressure ulcer. 2. LVN D and LVN E failed to provide Resident 51's pressure ulcer treatments as prescribed by the physician. These failures could result in the Residents with pressure ulcers worsening in size and staging. The findings included: 1. Record review of Resident 24's admission record, dated 11/16/22, revealed the resident was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (affects the blood vessels), chronic heart failure, and pressure ulcer of the left heel stage 4 (A sores that extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments). Record review of Resident 24's order summary, dated 11/15/2022, revealed an order dated 10/26/22 for wound care to arterial wound (arterial ulcers are painful injuries in your skin caused by poor circulation) of the left 1st toe: paint area with betadine, apply non-stick gauze over wound, wrap area with fluff gauze roll, two times a day, no end date. A second order dated 10/26/22 for wound care clean arterial wound of the left, medial foot with normal saline, paint area with betadine, apply non-stick gauze over wound, wrap area with fluff gauze roll, two times a day continue till healed, no end date. A third order for wound care clean stage 4 pressure wound of the left heel with normal saline, paint area with betadine, apply non-stick gauze over wound, wrap area with gauze fluff roll, two times a day, continue until healed, no end date. Record review of document titled Wound evaluation and management summary, dated 11/14/22, revealed a focused wound exam for the arterial wound of the left third toe. It stated to apply betadine for 10 days, paint wound, dress with gauze roll once a day for 10 days to the left third toe. During an observation on 11/16/22 at 2:12 p.m. LVN G performed wound care on Resident 24's pressure ulcers and wounds to his left foot. LVN G used clean scissors to cut off an old bandage that had red and brown stains on it. LVN G placed the contaminated scissors on the bedside table with other clean supplies. LVN G continued wound care. At one-point LVN G removed her contaminated gloves, did not sanitizer her hands, put on new gloves with her contaminated hands, and continued wound care. LVN G also wiped around the outer edge of a wound on the medial (inner) side of the resident's left foot. LVN G used the same swab and wiped in the middle of the wound of the medial (inner) side of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 10 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left foot and contaminated the middle of the wound with the swab used to clean the outside area of the wound. LVN G was observed providing wound care to the Resident's 3rd toe. Later LVN G used the contaminated scissors to cut a clean gauze bandage. LVN G covered the residents wound on his left foot with the contaminated bandage. During an interview on 11/16/22 at 2:44 p.m. LVN G stated she cleaned the 3rd toe according to the providers orders. She stated the old treatment nurse put the order in that showed the 1st toe of the left foot should be cleaned. She stated she had only been there two weeks. She stated she never caught the order which showed the 1st toe instead of the 3rd toe. She stated Resident 24 did not have a wound on his 1st toe. She stated she should have performed hand hygiene anytime she went from a dirty to clean area. She stated she did not notice she forgot to sanitize her hands when she changed her gloves. She stated she should have cleaned the scissors after she used them. She stated she did not clean the scissor after she cut off the dirty bandage. She stated the resident's wound could be infected, contaminated from the other wounds and dressing, if she did not clean the scissors. She stated she had only received half a day of training with the previous wound care nurse. She stated she did rounds with the wound doctor on Mondays. She stated she was not sure if she had done skills check off, but she had worked at the facility since September 2022. She stated she was enrolled in a wound care certification course but had not been able to take it yet. She stated she was responsible for changes to wound care orders and she did not catch the error for the order with the wrong toe. During an interview on 11/18/22 at 9:58 a.m. RN H stated LVN G had put the incorrect order for the wound care on the resident 24's toe. She stated if the order was not for the right site someone could have treated the 1st toe and not performed wound care on the 3rd toe. She stated they could have thought the wound on the 1st toe was healed and discontinued the order and not treated the 3rd toe. RN H stated LVN G did get trained with the previous wound care nurse, with her, and with ADON C. RN H stated LVN G was a wound care nurse at a previous facility, was a floor nurse at the current facility before becoming the treatment nurse, and she also worked in a wound clinic. RN H stated LVN G shadowed the previous treatment nurse a lot. RN H stated LVN G was nervous to be observed. She stated staff should have sanitized their hands between glove changes to prevent cross contamination. During an interview on 11/18/22 at 3:38 p.m. ADON C stated staff should have performed hand hygiene anytime they performed care from clean to a dirty area. He stated they should have performed hand hygiene for a clean procedure and different items required staff to wash their hands or sanitize their hands. He stated wounds should have been cleaned from the inside outwards, so bacteria are pushed outside the wound. He stated staff should change their gloves anytime they are contaminated, and they should have sanitized between glove changes. He stated LVN G transcribed the orders from the wound care provider into the EMR. He stated LVN G was normally there Monday through Friday. He stated when LVN G was not there the RN supervisor or whoever the acting supervisor was would have done the wound care. He stated if the regular treatment nurse was off and another nurse not familiar with the resident or orders cared for the resident, hopefully they would have been a prudent nurse, and seen the 1st toe had no wound and went back to look at the order. He stated they would then have changed the order to the correct toe. 2. Record review of Resident 51's admission record, dated 11/18/22, showed an original admission date of 01/24/22 and a readmission date of 02/24/22 with diagnosis that included type 2 diabetes mellitus (high blood sugar, insulin resistance, and relative lack of insulin), heart failure, pressure ulcer of right lower back unstageable, pressure ulcer of sacral region stage 4, and blindness of right eye. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 11 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident 51's order summary, dated 11/17/22, time stamped 9:33 a.m., showed an order for wound care to coccyx (tailbone area) wound: Apply collagen powder and leptospermum honey once daily. Cover with gauze island border once daily one time a day for wound care, with a start date of 09/16/22, and no end date. A second order for wound care to right ischium (lower part of the buttocks). Cleanse with wound cleanser, pat dry. Apply leptospermum honey paste and collagen powder to wound bed and pack with calcium alginate rope. Secure with gauze island with border daily and PRN one time a day for wound care, with a start date of 10/22/22, and no end date. During an observation on 11/17/22 at 9:35 a.m. LVN D and LVN E performed wound care on Resident 51's pressure ulcers. LVN D performed the wound care and LVN E assisted in handing LVN D supplies. LVN E stated they did not have collagen powder to apply to the wounds. LVN D cleaned the coccyx area ulcer and applied leptospermum honey inside the wound bed. LVN D did not use the collagen powder and covered the coccyx pressure ulcer with a bandage. LVN D then performed wound care on the ischium pressure ulcer. LVN D applied leptospermum honey inside the wound bed, applied calcium alginate rope inside the wound. LVN D did not use the collagen powder and covered the ischium pressure ulcer with a bandage. During an in interview on 11/18/22 at 9:40 am RN H stated hospice was responsible for providing wound care supplies for Resident 51. RN H stated there was a shortage of collagen powder. She stated the first she heard of them being out of the collagen powder was on 11/17/22. RN H stated you can treat a wound with out an order. She stated the point of wound care is to promote healing. She stated they needed to call the doctor and tell him what was going on. She stated they called the doctor and the doctor told them when the collagen powder comes in to start using it again. She stated they changed the order to a triad cream and calcium alginate rope only. She stated staff should not wait until they run out of supplies before they let someone know. She stated when you have about 7 days' worth left then you should order more. She stated the nurse who performed the wound care yesterday documented they were out of the powder. She stated hospice was called but she did not know when, and hospice stated they did not have any powder. She stated they did receive more supplies or powder the day before, but the order was changed, and they were no longer using the collagen powder. Record review of Resident 51's MAR, dated 11/18/22, revealed an order to reorder all medications through hospice every shift, start date 08/27/22. The order had been marked administered for the 6 a.m. shift and 6 p.m. shift from November 1st through November 17th, 2022. Record review of Resident 51's order summary, dated 11/18/22, revealed an order for wound care to right ischium. Cleanse with wound cleanser, pat dry. Apply leptospermum paste to wound bed and pack with calcium alginate rope. Secure with gauze island with border. Due to collagen powder delayed arrival. D/C once supplies available. one time a day until 11/24/2022 5:59 a.m., Start Date-11/18/2022 6:00 a.m. During an interview on 11/18/22 at 3:44 p.m. ADON C stated when staff are out of supplies the needed to call the doctor ahead of time and tell them what supplies they had available. He stated if you get the order ahead of time it was okay to put the current order on hold. Record review of facility's document titled Inservice Nurse wound care, dated 09/09/22, stated before you do wound care, make sure you have an order and clearly know what the order is. If you do not have an order slash it dropped off, disappeared and you know according to the wound notes there is an order. Clarify this with the doctor add the order. Do you not just carry out the treatment according to the physicians wound no dash enter the order in the EMR, or you also have to sign out the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 12 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few order once it is done. Many orders are good for so many days. It is everyone's job to know when orders need to be updated etc. Maybe you know a resident get a certain treatment everyday dash question why is it no longer showing in the EMR and let someone in administrative help you with this concern. The document contained signature for LVN G's signature and LVN E's signature. Record review of the facility's policy titled Drug Orders, no date, stated All drugs must be prescribed by the resident's physician or consulting physician, dentist, podiatrist, or other individual allowed by law to prescribe. If drugs are verbal, they must be taken by a licensed nurse, pharmacist, physician assistant, or a physician, and immediately recorded and signed by the person receiving the order. All drug orders will be counter-signed by the prescriber and returned to the chart in a timely manner. Verbal drug orders for Schedule II drugs are permitted in an emergency. Medications will be ordered and reordered on a timely basis so as to ensure residents do not miss doses. Record review of the facility's policy titled Pressure Ulcers, no date, stated The facility will provide care based on each resident's comprehensive assessment to ensure that a resident who enter the facility without pressure ulcers does not develop pressure ulcers unless pressure ulcers are unavoidable due to the predictable patterns of the resident's clinical condition or the resident or his/her representative's refusal of care and treatment to prevent pressure ulcers .services are provided to prevent the formation of pressure ulcers. Resident having pressure ulcers receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing . Record review of the facility's policy titled Handwashing/Hand Hygiene, dated 08/2015, stated policy statement. This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation. Number one all personnel shall be trained and regularly in serviced on the importance of hand hygiene and preventing the transmission of healthcare associated infections 2. all personnel shall follow the hand washing slash hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors . 6. wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situation a. when hands are visibly soiled .7. News and alcohol based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .d. Before preparing any non-surgical invasive procedures .h. Before moving from a contaminated body site to a clean body site during resident care i. after contact with the resident's intact skin .k. after handling used dressings, contaminated equipment, etc. l. After contact with objects in the immediate vicinity of the resident m. after removing gloves . applying and removing gloves 1. perform hand hygiene before applying nonsterile go up FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 13 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 residents (#213 and #216) of 8 residents reviewed for accidents, hazards, and supervision, in that: 1. Resident #213 had a razor in his room. 2. Resident #216 had a razor in his room and a prescription cream on his bedside table. These failures could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: 1. Record review of Resident #213's admission record, dated 11/17/22, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of aftercare following joint replacement surgery, muscle weakness, bipolar disorder, depression, anxiety, and post traumatic stress disorder. Record review of Resident #213's care plan, dated 11/11/22, revealed the resident dresses independently and needed set up assistance only for bathing. During on observation on 11/15/22 at 11:25 a.m. Resident #213 was observed laying in his bed. On the counter by the sink in his room was a disposable razor. 2. Record review of Resident #216's admission record, dated 11/16/22, revealed an admission date of 08/29/22 and readmission date of 11/4/22 with diagnosis of acute respiratory failure with hypoxia (low oxygen levels), muscle weakness, and unspecified lack of coordination. Record review of Resident #216's care plan, dated 08/31/22, revealed, the resident required x1 assistance with bathing, dressing, and used a shower chair. During an observation on 11/15/22 at 11:28 a.m. a tube of prescription cream, cotton swabs, and food seasoning was noted on a bedside table in Resident #216's room. During an observation and interview on 11/16/22 at 9:02 a.m. Resident #216 was noted to have a razor on the counter by the sink in his room. Resident #216 stated he shaved on his own every morning. He stated he had a tube of prescription mupirocin ointment which he applied to the inside of his nose every day. He stated the skin doctor gave it to him because he almost burned a hole through his nose. He stated at the hospital they gave him a prescription for the mupirocin ointment which he applies with a cotton swab to his nostrils daily. He stated he guessed the facility did not know he had the ointment. During an interview on 11/17/22 at 3:19 p.m. LVN J stated resident on the 100 hallway, where Resident #213 and #216 reside, needed set up help with bathing because they had not been released from therapy yet. She stated 6 residents had showers in their rooms on the 100 hallway and they all had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 14 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sinks to brush their teeth in their rooms. She stated she would have to ask the aides to see who was able to shave on their own. She stated the aides helped with shaving. She did not think any of the residents had an electric razor. She stated the aides would allow the residents to use the razors to shave then they put them away in the carts or discard of them in a sharps container. She stated residents are allowed to use an electric razor on their own, but she did not know if any residents had one. She stated she thought Resident #216 was approved to use a muscle rub ointment on his own. She stated she thought there was a sheet they fill out to self-administer medications and it could be located under miscellaneous documents in the EMR. She stated if he was able to self-administer medications it could be under orders or in his care plan. Observation at 3:33 p.m. this surveyor and LVN J went to Resident #216's room where the razor and prescription tube of ointment was shown to LVN J. She stated the prescription mupirocin ointment could now be purchased over the counter. This surveyor pointed out the label on the prescription showed Rx only. When asked if Residents were allowed to keep over the counter medications in their rooms LVN J said they were not allowed. She stated there was supposed to be staff who do quality of life rounds daily where they look for prohibited items in the residents' rooms and ask them questions about their likes. LVN J and this surveyor went to Resident #213's room where a razor was observed on the counter next to the sink. She stated she did not know if he was allowed to have the razor. LVN J stated if the residents were allowed to have a medication in their room it needed to be care planned. During an interview on 11/17/22 at 3:33 p.m. LVN K stated residents should not have razors in their rooms. During an interview on 11/18/22 at 10:12 a.m. RN H stated there are items residents should not have in their rooms. She stated she planned to have an in-service on this topic that day. She stated while doing rounds she located a razor and nebulizer is Resident #216's room and removed them. She stated Resident #216 should not have had the razor or medicated cream in his room. She stated it was an option to see if he was able to have either, but the resident has good days and bad days. She was not sure if Resident #213 was allowed to have a razor. She stated a beside assessment would need to be done to determine if a resident was able to keep a medicated cream at bedside. She stated if a resident brings in a medication after they are admitted they would not know because they can not dig around in drawers. This surveyor informed RN H the medicated cream was visible on the bedside table since 11/15/22. She stated they have been able to provide a lock box to keep items but they preferred to encourage residents to allow them to keep items for them, because if they are having an issue the staff may not know. During an interview on 11/18/22 at 3:19 p.m. ADON C stated no residents should have razors in their rooms. He stated they are only allowed electric razors. He stated if a resident was allowed to have a razor they would have needed to be check off, reassessed regularly, and properly stored. He stated the razors need to be stored where no one else can get to them and it needed to be care planned. He stated when a resident is admitted the aides will help put their items away. He stated they try not to have the residents feel like they are being searched for prohibited items. He stated they tried to educate residents and the families on why they need to know about all medications they have. He stated they need to know what the residents are always taking in case it needs to be communicated to the doctor or the ER. He stated the razors in the residents' rooms should have been found already and razors are bad period. He stated when a razor is found in the room the expectation is to fix it, educate, and train. Record review of facility's policy titled Self-administration of Drugs, no date, stated the medication nurse will bring the drugs to the resident within one hour of the time scheduled for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 15 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administration. The medication nurse will flag with red flags the medications left with the resident. The medication nurse will return within one hour and retrieve the medication left with the resident. The medication nurse will confirm self-administration of the drugs left with the resident and document drugs administered in the medical record. If the interdisciplinary team, including the attending physician, determines that the resident may not self-administer drugs safely, the decision will be discussed with the resident, the resident's family or legal representative and the assessment will be documented by the interdisciplinary team in the residence medical record. Record review of facility's policy titled Accidents, no date, stated the facility shall remain as free from accident hazards as possible. Each resident receives adequate supervision and assistive devices, based on the comprehensive assessment, to prevent accidents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 16 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that are accurately documented for 1 of 20 residents (#22 and #51) reviewed for resident records, in that: 1. Resident #22's care plan and MDS showed the resident had an indwelling catheter. The catheter had been previously discontinued. These deficient practices could affect residents that reside in the facility and could result in errors in care and treatment. The findings were: 1. Record review of Resident #22's admission record, dated 11/17/22, with an admission date of 06/21/18 and a readmission date of 03/24/21 revealed diagnoses of atrial fibrillation (irregular often rapid heart rhythm) and repeated falls. Record review of Resident #22's MDS, dated [DATE], revealed under section H for Bladder and Bowel the resident had an indwelling catheter. Record review of Resident #22's care plan dated 08/19/22, revealed the resident had indwelling catheter with interventions to check the tubing, monitor for pain or discomfort from the catheter, change and care for as ordered. Record review of Resident #22's order summary, dated 11/18/22, revealed orders for foley catheter care every shift and as need as, with a start date of 06/30/22 and 09/14/22, and no end dates. All orders for a foley catheter were marked as discontinued under order status. There was not discharge date . Observation on 11/18/22 at 12:57 p.m. Resident #22 revealed she did not have a indwelling catheter. During an interview on 11/18/22 at 12:58 p.m. Resident #22 stated she used to have a catheter but not anymore. She was unsure of how long ago but thought it had been a few months ago that she had it. During an interview on 11/18/22 at 1:00 p.m. the MDS nurse stated she was responsible for updating care plans and the MDS' for residents. The MDS nurse stated she had been required to complete the acute care sections for residents and there are many other duties for her to do. She stated MDS' are updated quarterly or with a significant change. She stated a foley catheter that was discontinued did not constitute a significant change for the MDS and should have been updated in the care plan when the order was discontinued. During an interview on 11/18/22 at 3:26 p.m. ADON C stated he does not do the MDS or care plan changes. He stated the MDS coordinator was responsible for those. He stated he hoped the resident #22 did not still have a catheter and if it still showed in the care plan it would not affect the care the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 17 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 resident received. He stated the resident is cared for 100 percent of the time. He stated every day they reviewed new orders, discontinued orders, on hold orders, and completed orders at morning meetings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 18 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 2 of 10 residents (Residents #19 and #24) reviewed for infection control, in that: Residents Affected - Few 1. LVN I contaminated her gloves by touching a privacy curtain and immediately administering an injection to Resident 19. 2. LVN G failed to perform hand hygiene practices per the facility's policy and procedure, during Resident #24's wound care on his pressure ulcers. -LVN G contaminated a clean bandage with non-sanitized scissors she used while providing Resident #24's wound care on his pressure ulcers. These deficient practices could place residents in the facility at risk for infections. The findings were: 1. Record review of Resident #19's MDS, dated [DATE], showed an admission date of 4/14/22, with diagnosis that included coronary artery disease (major blood vessels supplying the heart are narrowed) and diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar). Under section N- medication indicated the resident receives injection for insulin. During an observation on 11/17/22 at 11:28 a.m. LVN I stated she planned to check Resident #19's blood glucose. LVN I performed hand hygiene, put on clean gloves, then pulled the privacy curtain closed, contaminating her gloves. LVN I then touched Resident #19's finger with the contaminated gloves, cleansed the resident's finger with an alcohol, grabbed the glucose monitor with her contaminated gloves, grabbed a glucose monitor strip with her contaminated gloves, stuck the contaminated strip into the meter, lanced the resident's finger with a lancet, and placed the contaminated glucose meter strip up to the open cut with blood on the resident's finger. During an interview on 11/17/22 at 11:45 a.m. LVN I stated she touched the privacy curtain with her gloved hands because she was not sure if she needed to provide more privacy for the resident when there was no roommate. She stated once she touched the privacy curtain, she should have changed her gloves because they were contaminated. During an interview on 11/18/22 at 3:39 p.m. ADON C stated LVN I should have changed her glove after touching the privacy curtain if she was using the hand to care for the resident. He stated staff should perform hand hygiene for a clean procedure. 2. Record review of Resident #24's admission record, dated 11/16/22, revealed the resident was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (affects the blood vessels), chronic heart failure, and pressure ulcer of the left heel stage 4. Record review of Resident #24's order summary, dated 11/15/2022, revealed an order dated 10/26/22 for wound care to arterial wound of the left 1st toe: paint area with betadine, apply non-stick gauze (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 19 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 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 over wound, wrap area with fluff gauze roll, two times a day, no end date. A second order dated 10/26/22 for wound care clean arterial wound of the left, medial foot with normal saline, paint area with betadine, apply non-stick gauze over wound, wrap area with fluff gauze roll, two times a day continue until healed, no end date. A third order for wound care clean stage 4 pressure wound of the left heel with normal saline, paint area with betadine, apply non-stick gauze over wound, wrap area with gauze fluff roll, two times a day, continue until healed, no end date. Record review of document titled Wound evaluation and management summary, dated 11/14/22, revealed a focused wound exam for the arterial wound of the left third toe. It stated to apply betadine or 10 days, paint wound, dress with gauze roll one a day for 10 days to the left third toe. During an observation on 11/16/22 at 2:12 p.m. LVN G performed wound care on Resident #24's pressure ulcers and wounds to his left foot. LVN G used clean scissors to cut off an old bandage that had red and brown stains on it. LVN G placed the contaminated scissors on the bedside table with other clean supplies. LVN G continued wound care. At one-point LVN G removed her contaminated gloves, did not sanitizer her hands, donned new gloves with her contaminated hands, and continued wound care. LVN G also wiped around the outer edge of a wound on the medial (inner) side of the resident's left foot. LVN G used the same swab and wiped in the middle of the wound of the medial (inner) side of the left foot and contaminated the middle of the wound with the swab used to clean the outside area of the wound. Later LVN G used the contaminated scissors to cut a clean gauze bandage. LVN G covered the residents wound on his foot with the contaminated bandage. During an interview on 11/16/22 at 2:44 p.m. LVN G stated she cleaned the 3rd toe according to the providers orders. She stated the old treatment nurse put the order in that showed the 1st toe of the left foot should be cleaned. She stated she had only been there two weeks. She stated she never caught the order which showed the 1st toe instead of the 3rd toe. She stated Resident #24 did not have a wound on his 1st toe. She stated she should have performed hand hygiene anytime she went from a dirty to clean area. She stated she did not notice she forgot to sanitize her hands when she changed her gloves. She stated she should have cleaned the scissors after she used them. She stated she did not clean the scissor after she cut off the dirty bandage. She stated the resident's wound could be infected, contaminated from the other wounds and dressing, if she did not clean the scissors. She stated she had only received half a day of training with the previous wound care nurse. She stated she did rounds with the wound doctor on Mondays. She stated she was not sure if she had done skills check off, but she had worked at the facility since September 2022. She stated she was enrolled in a wound care certification course but had not been able to take it yet. She stated she was responsible for changes to wound care orders and she did not catch the error for the order with the wrong toe. During an interview on 11/18/22 at 9:58 a.m. RN H stated LVN G had put the incorrect order for the wound care on the resident's toe. She stated if the order was not the right site someone could have treated the 1st toe and not performed wound care on the 3rd toe. She stated they could have thought the wound on the 1st toe was healed and discontinued the order and not treated the 3rd toe. RN H stated LVN G did get trained with the previous wound care nurse, with her, and with ADON C. RN H stated LVN G was a wound care nurse at a previous facility, was a floor nurse at the current facility before becoming the treatment nurse, and she also worked in a wound clinic. RN H stated LVN G shadowed the previous treatment nurse a lot. RN H stated LVN G was nervous to be observed. She stated staff should have sanitized their hands between glove changes to prevent cross contamination. During an interview on 11/18/22 at 3:38 p.m. ADON C stated staff should have performed hand hygiene anytime they performed care from clean to a dirty area. He stated they should have performed hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 20 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 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 hygiene for a clean procedure and different items required staff to wash their hands or sanitize their hands. He stated wounds should have been cleaned from the inside outwards, so bacteria are pushed outside the wound. He stated staff should change their gloves anytime they are contaminated, and they should have sanitized between glove changes. Record review of the facility's policy titled Infection Control Policy, no date, stated infection prevention and control program. The facility has established and maintains an infection control program that has a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, visitors, volunteers, and other individuals providing contractual services to the facility . all employees are required to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice . Record review of the facility's policy titled Handwashing/Hand Hygiene, dated 08/2015, stated policy statement. This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation. Number one all personnel shall be trained and regularly in serviced on the importance of hand hygiene and preventing the transmission of healthcare associated infections 2. all personnel shall follow the hand washing slash hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors . 6. wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situation a. when hands are visibly soiled .7. News and alcohol based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .d. Before preparing any non-surgical invasive procedures .h. Before moving from a contaminated body site to a clean body site during resident care i. after contact with the resident's intact skin .k. after handling used dressings, contaminated equipment, etc. l. After contact with objects in the immediate vicinity of the resident m. after removing gloves . applying and removing gloves 1. perform hand hygiene before applying nonsterile go up FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 21 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 24 residents (Resident #24) for sanitary conditions in that: The facility failed to repair a leak in the bathroom of 1 of 15 rooms for the duration of 13 months. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unsanitary. The Findings were: Record review of admission Record printed 11/15/2022 revealed Resident #24 was a [AGE] year-old male with an initial admission date of 11/19/2021 diagnosed with anxiety, and chronic diastolic (congestive) heart failure. Record review of Care Plan printed on 11/15/2022 revealed a problem with Bathing/Dressing and interventions with include 1 Person Assist Bathing and the use of a shower chair initiated on 12/03/21. During an interview on 11/15/2022 at 1:08 PM, Resident #24 stated that there was water leaking in his bathroom. Observation of the bathroom floor in room [ROOM NUMBER] on 11/15/2022 at 1:08 PM revealed a puddle of clear liquid measuring approximately one foot wide and half an inch deep standing between the toilet and shower. During an interview on 11/16/2022 at 08:47 AM, the Maintenance Director stated that when staff notices an issue, they alert me. I advise staff to list the issue in the maintenance log. Then I go and fix it [the issue]. The Maintenance Director added, All issues to this date [11/16/2022] have been resolved, but I've been too busy to record that I fixed them Observation of the facility maintenance log on 11/16/2022 at 8:50 AM revealed an issue reading shower head is leaking and flooding the bathroom in room [ROOM NUMBER] noted by on 10/6/2021. There was no listed resolution date. During an interview on 11/16/2022 at 8:57 AM, the Maintenance Director stated that he fixed things in room [ROOM NUMBER] all the time. He also stated that he had not been notified of the leak in the bathroom of room [ROOM NUMBER] until last Wednesday [11/9/2022]. During an interview on 11/16/2022 at 10:46 AM, CNA A stated that he reported a leak in the bathroom of room [ROOM NUMBER] to maintenance at 10:40 AM today [11/16/2022] but had not noticed a leak prior to today. CNA A stated that he thought the water was leaking from the toilet in the bathroom of room [ROOM NUMBER]. During an interview on 11/16/2022 at 10:50 AM HA B stated that she cleaned water off the floor in the bathroom of room [ROOM NUMBER] yesterday [morning of 11/15/2022] and did not inform maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 22 of 23 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm of a possible leak. HA B also stated that she did not recall seeing a leak in the bathroom of room [ROOM NUMBER] prior to 11/15/2022. Observation of the bathroom in room [ROOM NUMBER] on 11/17/2022 between 3:00 PM and 4:00 PM revealed a puddle of clear liquid on the bathroom floor between the shower and toilet Residents Affected - Some During an interview on 11/17/2022 at 4:09 PM, the RMD stated that the facility does not have an internal policy for identifying or addressing possible hazards, but we adhere to the Life Safety Code regulation. The RMD added the facility uses TELS [TELS Building Services software] and the maintenance logbook for identifying hazards and address major issues during the monthly maintenance meeting. During an interview on 11/18/2022 at 3:50 PM, ADON C stated that he noticed a puddle in the bathroom of room [ROOM NUMBER] during wound care of Resident #24 but he does not recall the date. He stated that he called housekeeping and verbally reported the issue to the Maintenance Director. ADON C added that the puddle could increase the risk of injury for the staff and would serve as a detriment to the resident's home-like environment. Record Review of the 'Senior Care Centers Operational/Resident Care Policies - Environment [no publish date] policy on 11/18/2022 revealed that The facility provides a safe, clean, comfortable, and homelike environment and provide for safety in treatment and support for daily living in an environment that maximizes resident independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 23 of 23