Health inspection·July 10, 2025

F 0644 a PASSAR policy and would follow the STATE regulations. 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 2 of 6 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 07/10/2025 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observations, interviews, and record review the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater for 1 of 1 facility in that:The facility failed to post the Nursing Staff posting and have retention for 18 months. This failure could affect all residents and could result in resident not being aware of which staff were working for the day or not being aware of the census for the day.The Finding: Observation on 7/8/2025 at 10:00 AM while walking halls, there was no observation of the nurse staff posting posted. Observation on 7/9/2025 at 10:50 AM while walking halls, there was no observation of the nurse staff posting posted. Observation on 7/9/2025 at 5:00pm while walking halls, there was no observation of the nurse staff posting posted. Observation on 7/9/2025 at 5:01 PM revealed the Direct Care Daily Staffing, dated March 14, 2025, was sitting under the Receptionist counter. Interview on 7/9/2025 at 5:00pm with the ADM and Receptionist, responsible for posting the Nurse staffing information were not aware that it needed to be posted and was not sure they needed to keep 18 months. The Receptionist stated it was her responsibility to post the Direct Care Staffing sheet and had stopped. The Receptionist stated the last Direct Care Staffing posted was March 14,2025.Record review of Posting Direct Care Daily, Staffing Numbers, dated August 2022, was documented Our facility will post on a daily basis for each nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. 1 Within 2 hours of beginning of each shift, the number of licensed nurses and the number of unlicensed nursing personnel directly responsible for resident care is posted in a prominent location and in a clear and readable format. Shift staffing information is recorded on a form for each shift. 6. Records of staffing information for each shift are kept for a minimum of 18 months or as required by state law. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 3 of 6 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 07/10/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a process which provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 2 of 6 residents (resident #1 and Resident #2) reviewed for procedures for accurate acquiring, receiving, dispensing, and administering of all drugs, in that: 1. The facility had Resident #1's controlled medications unsecured, 3 loose, 0.25mg pills of clonazepam stored in the ADON's desk drawer separated from the narcotic count sheet. 2. The facility had Resident #2's controlled medications unsecured, a bottle of liquid Dilauded, loose in a narcotic drawer separated from the narcotic count sheet. These failures could place residents at risk for safety from medication errors. The findings included: 1 a record review of Resident #1's admission record dated 7/8/2025, revealed an admission date of 8/17/2024 with a discharge date of 10/15/2024 with a diagnosis which included anxiety disorder. A record review of Resident #1's discharge MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for long term palliative care and discharged to the hospital via emergency services. A record review of Resident #1's physicians orders dated 8/18/2024, revealed the physician had prescribed Resident #1 to receive clonazepam 0.25mg, daily, 1 pill by mouth at bedtime for anxiety. A record review of Resident #1's narcotic count sheet dated 9/18/2024 revealed the pharmacy delivered 14 pills of clonazepam 0.25mg. further review revealed facility nurses documented Resident #1 had received 11 administrations of the drug and had received her last dose on the evening of 10/15/2024 and had 3 remaining pills left. A record review of the facility's CMS form 3613A provider investigation form dated 3/10/2025 revealed a search of the previous DON and ADON's offices evidenced many controlled narcotic drugs which were not returned to the pharmacy for destruction after residents had discharged . The facility coordinated with the pharmacy to process the drugs for destruction; after the process the pharmacy and the DON discovered 3 loose pills identified as clonazepam 0.25mg. further search of the offices of the previous DON and ADON revealed a narcotic count sheet for clonazepam 0.25mg for Resident #1 without the card of narcotics attached. The conclusion was plausible the 3 loose pills may have been Resident #1's. further review revealed, . Drug Diversion . numerous narcotic medications were found in the ADON desk drawer. There were narcotics in there from June 2024. 3 tablets of clonazepam 0.25mg were found loose in the drawer . 2 A record review of Resident #2's admission record dated 7/10/2025 revealed an admission date of 3/3/2024 and a discharge date of 10/20/2024 with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), senile (related to dementia) degeneration of brain, and encounter for palliative care (a focus on the comfort, care, and quality of life for individuals with a serious illness). A record review of Resident #2's discharge MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted for palliative long-term care related to his diagnosis of dementia. A record review of Resident #2's physicians orders dated 10/19/2025 revealed the physician prescribed for Resident #2 to receive hydromorphone 1mg sub lingual, under his tongue, every 3 hours for pain. A record review of Resident #2's October 2024 electronic medication administration record revealed nurses documented on 10/19/2024 that Resident #2 received 3 doses of hydromorphone 1mg/1ml for effective pain relief. A record review of Resident #2's narcotic count sheet dated 10/19/2024 revealed the pharmacy delivered to the facility a bottle of liquid hydromorphone which contained 30ml at a concentration of 1mg per ml, 1mg/ml. further review revealed the document was void of any documentation for any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 4 of 6 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 07/10/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administrations. A record review of the facility's CMS form 3613A provider investigation form dated 3/10/2025 revealed a search of the previous DON and ADON's offices evidenced many controlled narcotic drugs which were not returned to the pharmacy for destruction after residents had discharged . The facility coordinated with the pharmacy to process the drugs for destruction; after the process the pharmacy and the DON discovered a narcotic count sheet for Resident #2's bottle of liquid hydromorphone 30ml at 1mg/ml. The document revealed the pharmacy delivered the drug on 10/19/2024. The DON and the ADON reviewed the document and revealed there was no documentation for any drug administrations. A record review of Resident #2's narcotic count sheet for hydromorphone dated 10/19/2024 revealed the pharmacy delivered a bottle of liquid hydromorphone which contained 30ml of hydromorphone at a concentration of 1mg/ml. further review revealed no documentation for any administrations. During an observation on 7/10/2025 at 3:50 PM revealed the facility's discontinued narcotic storage cabinet in the ADON's office secured behind a locked closet door. Further observation revealed a bottle of liquid hydromorphone for Resident #2 dated 10/19/2024 and contained 27lm of liquid medication. The bottle was not stored with the narcotic count sheet. During an interview on 7/10/2025 at 1:33 PM ADON B stated she was the ADON during the period from 2/1/2024 to 3/1/2025. ADON B stated during the period of 2/1/2025 through 2/12/2025 DON A was the DON. ADON B stated during the DON's tenure she had not processed the narcotics to be returned to the pharmacy for discharged residents and kept the sole key to the to the cabinet in which the drugs were stored. ADON B stated DON A had no more room in the cabinet for discontinued narcotics and began to store the drugs in the ADON desk. The ADON stated she protested and had reported the incident to the leadership to include the regional nurse and the administrator. ADON B stated she worked with DON C during the last week in February 2025 and began to coordinate with DON C to process narcotics for destruction and resigned prior to the completion of the process. During an interview on 7/11/2025 at 11:50 AM DON C stated she was the DON for the end of February 2025 and then on through March, and April 2025 and at the end of February 2025 she had learned that ADON B and DON A had not processed discontinued narcotics for return and destruction to the pharmacy since June of 2024. DON C stated, it was a mess . they had narcotics everywhere in the closet, which was not locked, and in ADON B's desk. DON C stated she coordinated with the pharmacy and eventually settled all the narcotic drugs with the pharmacy prior to her resignation as the DON in April 2025. DON C stated she discovered 3 loose pills identified as 0.25mg clonazepam in the drawer of ADON B's desk and in DON A desk a narcotic count sheet for Resident #2's liquid hydromorphone but no bottle of the hydromorphone was located. During an interview on 7/10/2025 at 11:00 AM the current ADON stated she was the ADON as of 3/1/2025 and had learned from DON C that DON A and ADON B had not processed discontinued narcotics to be returned to the pharmacy for destruction for the months of June 2024 through early February 2025. The ADON stated she reviewed the discontinued narcotic storage cabinet today (7/10/2025) and discovered a bottle of liquid hydromorphone, 1mg/1ml, which contained 27ml of medication. The ADON stated the bottle was labeled for Resident #2. The ADON stated Resident #2's October 2024 MAR revealed he was administered 3 doses prior to his discharge and thus the bottle she discovered more than likely was the bottle for the narcotic count sheet which was found without the bottle. The ADON stated the policy, and procedure was for the nurse who administered a narcotic to a Resident was to immediately after the administration document the administration in the residents electronic MAR and then immediately document the administration on the residents' paper narcotic count sheet. The ADON stated the policy and procedure for the residents who had narcotics after they were discharged was for the nurses to alert the DON who would then remove the narcotics from the medication carts and then coordinate with the pharmacy monthly to destroy the medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455941 If continuation sheet Page 5 of 6 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 07/10/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The ADON stated the narcotics should be accompanied by the paper narcotic count sheet, the narcotic count sheet should accurately document the remaining doses of medication remaining. During an interview on 7/10/2025 at 12:10 PM the current DON stated he was the DON for the last 3 paychecks (since the end of May 2025) and had learned from DON C that DON A and ADON B had not processed discontinued narcotics to be returned to the pharmacy for destruction for the months of June 2024 through early February 2025. The DON stated he had learned from DON C that 3 loose pills of 0.25mg clonazepam were discovered in the desk drawer for ADON B and the bottle of Resident #2's dilauded was missing. The DON stated the expectation was for all narcotics to be controlled in a manner where the drugs are secured and accounted accurately with the narcotic count sheet. The DON stated the process was for the nurse who administered a narcotic to a Resident was to immediately after the administration document the administration in the residents electronic MAR and then immediately document the administration on the residents' paper narcotic count sheet. The DON stated the policy and procedure for the residents who had narcotics after they were discharged was for the nurses to alert the DON who would then remove the narcotics from the medication carts and then coordinate with the pharmacy monthly to destroy the medications. The DON stated the narcotics should be accompanied by the paper narcotic count sheet; the narcotic count sheet should accurately document the remaining doses of medication remaining. The DON stated the risk to residents was a loss of security control for their narcotics and could expose residents for a risk of overdosing and or under dosing. A record review of the facility's Controlled Substances policy dated November 2022, revealed, Policy StatementThe facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. 13. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed. 14. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation. 15. The consultant pharmacist or designee routinely monitors controlled substance storage records. A record review of the United States of America's Drug Enforcement Administration's website titled Drug scheduling https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdfAccessed 7/14/2025, revealed clonazepam was a controlled narcotic on the schedule IV and hydromorphone a controlled narcotic on the schedule II. Further review revealed, Drug SchedulesDrugs, substances, and certain chemicals used to make drugs are classified into five (5) distinct categories or schedules depending upon the drug's acceptable medical use and the drug's abuse or dependency potential. The abuse rate is a determinate factor in the scheduling of the drug; for example, Schedule I drugs have a high potential for abuse and the potential to create severe psychological and/or physical dependence. As the drug schedule changes-Schedule II, Schedule III, etc., so does the abuse potential-- Schedule V drugs represent the least potential for abuse. Event ID: Facility ID: 455941 If continuation sheet Page 6 of 6