Health inspection·June 20, 2025

F 0552 given on 06/02/25 at 07:10PM by LVN B. Level of Harm - Minimal harm or potential for actual harm Interview on 06/20/25 at 10:59 AM, Resident #29's RP (and guardian) revealed he gave written permission and verbal permission to give Resident #29 medication prescribed by the psychiatric NP. The RP revealed the facility always communicated with him about giving her these medications and he always gave them permission because it helped the resident. Residents Affected - Few Attempted interview with Resident #29 on 06/20/25 at 12:36PM was unsuccessful, the resident refused the interview. Interview on 06/20/25 at 04:20PM, the DON revealed Resident #29 did not have form 3713 completed for the antipsychotic Haldol. She revealed she did not realize it was not signed. She revealed it was important because it went back to resident safety and resident rights. Record review of facility's policy, revised April 2019, reflected 22. The individual administering the medication initials the resident's MAR and the appropriate line after giving each medication and before administering the next ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 2 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and that were not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #29) reviewed for freedom from physical and chemical restraints. Residents Affected - Some The facility failed to ensure Resident #29 was free from physical restraint when nursing staff physically restrained her for medication administration on 06/02/25, 06/04/25, and 06/17/25. These deficient practices could place residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control). The findings include: Record review of Resident #29's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, which indicated severe cognitive impairment. Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). Resident #29 rejected care daily. Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences. It further reflected a focus of Behavior Management, initiated on 06/10/25, with interventions to include educated resident/representative on necessity of care attempted to provide .ensure the safety of resident and others. Resident #29's care plan further reflected a focus of risk for harm: self-directed or other-directed, initiated 06/16/25, to include interventions administer medications as prescribed, encourage resident to verbalize cause for aggression, if resident poses a potential threat to injure self or others notify provider. It further reflected a focus of The resident has a behavior problem (schizoaffective disorder (mental health condition)) r/t (refusal to comply with medication regimen, refusing to comply with standard tasks, becoming verbally aggressive with staff), initiated 06/09/25, with intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. dated 06/09/25. Record review of Resident #29's care plan did not reflect anything about Resident #29 needing a therapeutic hold for medication administration. Record review of Resident #29's June MAR reflected Haldol Injection Solution 5 MG/ML. Inject 5 mg intramuscularly one time only related to Disorganized Schizophrenia, with start date 06/02/25, was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 3 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0604 given on 06/02/25 at 07:10 PM by LVN B. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly at bedtime every 14 day(s) related to Disorganized Schizophrenia, with start date 06/04/25 and D/C date 06/09/25, was blank on 06/04/25 at 08:00 PM. Residents Affected - Some Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG. Inject 50 mg intramuscularly every day shift every 14 day(s) related to Disorganized Schizophrenia, with start date 06/17/25, was blank on 06/17/25 Day. Record review of Order Granting Leave to Resign and Appointing Succesor Guardian of the Person, dated 06/18/20, reflected [Resident #29's RP] is appointed as the successor guardian of the person of [Resident #29], an Incapacitated Person. [Resident #29] is found to be incapacitation and lacks the necessary capacity to care for herself as a reasonable prudent person would do, and a full guardianship of the person is hereby granted with all the rights, duties, and powers granted to a successor guardian by law. [Resident #29] is declared fully incapacitated without the authority to exercise any rights or powers over herself. Record review of nurse's note, dated 06/17/25 at 10:30 PM and authored by LVN C, reflected [Resident #29] informed of ordered IM Risperidone 50mg injection, increased agitation noted, resident quickly stated, no you will not! Get out of my room! Several attempts to educate the resident regarding the medication were unsuccessful, four employees assisted to ensure safety and protect the resident from hurting herself or others. Safety techniques effectively applied by staff, IM Risperidone 50mg administered to the right upper outer gluteal quadrant without incident. Resident voiced frustration and yelled, I said get out of my room, staff exited room, visual safety checks applied and continued monitoring throughout the night to ensure safety and monitor for any possible side effects Interview on 06/20/25 at 10:45 AM, the DON revealed she was present on June 2nd when Resident #29 was throwing things and being verbally aggressive to staff when they needed to give Resident #29 a medication, so they called the psychiatric NP, who ordered Haldol on 06/02/25. The DON revealed Resident #29 was not allowing staff to administer Haldol. The DON revealed she tried to explain to Resident #29 the RP and NP wanted them to give her the injection and gave Resident #29 options to sit in bed or in a chair to receive the injection. The DON revealed they tried to give the medication when Resident #29 was in the chair, but the resident physically swung. The DON revealed the psychiatric NP and attending physician said the nursing staff could hold the resident for medication administration. The RP gave verbal permission to hold Resident #29 for medication administration. The DON revealed they had 4 staff members hold Resident #29, 1 staff member for each limb, while LVN C gave the injection. She further revealed no nursing staff were trained or practiced doing a therapeutic hold for a resident. She revealed it was important for resident safety and Resident #29 sustained no injuries. Interview on 06/20/25 at 10:59 AM, Resident #29's RP (and guardian) revealed he gave written permission and verbal permission to give Resident #29 medication prescribed by the psychiatric NP. He revealed when the shot was wearing off for Resident #29, Resident #29 did not have reason and was combative. The RP revealed the facility always communicated with him about giving her these medications and he always gave them permission because it helped the resident. He further revealed he had been in contact with her psychiatrist, and they were all in agreeance that this helped the resident. He was okay the facility had to physically restrain her because it was for her benefit, health wise. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 4 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 06/20/25 at 12:18 PM, the DON revealed Resident #29's use of restraints was not care planned and there was no assessment to show the need for physical restraints for the resident. She revealed the use of restraints was a verbal order from the doctor, but it needed to be signed and entered into the resident's medical record. She revealed when they entered the doctor's order, they would add what health condition it was used for in the additional comments. She revealed it was important for resident safety because restraints could lead to injury. Attempted interview with Resident #29 on 06/20/25 at 12:36PM was unsuccessful, the resident refused the interview. Interview on 06/20/25 at 12:57 PM, the DON revealed there was not an assessment available to complete for using restraints on Resident #29 for medication administration. She revealed the facility had created an assessment so they could complete this assessment before doing a therapeutic hold on Resident #29 for medication administration. She revealed when they used a therapeutic hold on Resident #29 on 06/17/25 and monitored Resident #29 every 5 to 15 minutes. The DON revealed she sat with Resident #29 for about 2 hours to ensure resident safety. She revealed after each therapeutic hold for medication administration, Resident #29 had no injuries and did not appear to be affected by the therapeutic hold. Interview on 06/20/25 at 02:01 PM, the MD revealed he was called before the nursing staff held Resident #29 down for medication administration. He revealed Resident #29 was on a special psychiatric medication and she has had, on more than one occasion, been held because she was yelling and throwing items. He revealed the facility called and asked him if this was appropriate to hold Resident #29 for medication administrator. He revealed for resident's comfort and well-being, medication was vital because there could be an emergency room trip if she had not received these medications. He revealed Resident #29 was not harmed in anyway, because the medication was administered in a respectful and non-violent manner. He revealed his orders were done verbally because the medication administration needed to be done quickly. He revealed there should be a doctor's order afterward. He revealed his order would have read: With familial consent and doctor approval, okay to hold patient for medication administration to improve uncontrolled symptoms of aggression and allow time for new medication to take effect. He revealed he may revise this order and have it read more eloquently. He revealed this should be a one-time thing and if the facility wanted to do it again, he would be contacted. He revealed this was not a long-term solution. He revealed they might need to adjust Resident #29's medication regimen to have Resident #29 be participate with staff more. He revealed Resident #29 had a psychiatric disturbance with aggressive behaviors. He revealed there needed to be monitoring after a therapeutic hold for medication administration for Resident #29 to watch the resident for any injuries every few hours or every shift. He revealed it was important for these components to be in place so Resident #29 was not scared in the facility and felt comfortable, learning what it's like to not be scared or agitated. Interview on 06/20/25 at 04:20 PM, the DON revealed form 3713 (consent for antipsychotic or neuroleptic medication treatment) should be completed for Haldol. She revealed it was important because it went back to resident safety and resident rights. She revealed before they went into Resident #29's room they had a safety plan if resident was not cooperative with receiving the shot. She revealed each staff member were all assigned an extremity to hold. She revealed they did not practice. She revealed she instructed the nursing staff to hold the resident to make sure they would not cause a fracture. She revealed on June 17th Resident #29 sat on the edge of bed and this was all Resident #29 would comply. She revealed they tried non-pharmacologically interventions first. She revealed Haldol was given on June 2nd and RisperDAL was given on June 4th and June 17th, confirming the MAR was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 5 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some filled out accurately on June 4th and June 17th. She revealed it was important to fill out these administration times so nursing staff knew what medications were given. Interview on 06/20/25 at 04:37 PM, the ADON revealed she helped with Resident #29's medication administration on June 2nd and June 4th. She revealed the facility approached Resident #29 in a gentle manner and tried to educate her about the importance of her medications. She revealed after contacting Resident #29's doctor and RP, they were able to do a therapeutic hold for medication administration. She revealed the nursing staff spoke about what they were going to do before they entered Resident #29's room to make sure the staff and resident remained safe. She revealed they did not practice a therapeutic hold for medication administration. Interview on 06/20/25 at 05:17 PM, LVN C revealed she was never trained on restraining a resident for medication administration. She revealed Resident #29 had to be held down for their safety (to include not harming herself or the nursing staff) since the medication administration was an injection and involved a needle. She revealed Resident #29 had to be held down so the needle would not break when being injected. Interview with LVN B was attempted. A voicemail was left on 06/20/25 at 05:16PM for LVN. Record review of the facility's, undated, policy, Restraint Policy, reflected The use of restraints is expressly forbidden unless it is prescribed as a measure of treatment for the resident and issued by the treating physician. Physical Restraint is any method or device used to restrict the movement or to keep a resident in a certain position while sitting or lying down . A restraint may only be placed on a resident if it has been determined by the Licensed Staff and the Treating Physician that it is medically necessary and the order is include in the Care Plan of a resident . The LVN or RN may receive a verbal order and consent from the physician and approval by the resident's responsible party but for a period not to exceed 24 hours. A written order must be received by the facility before the 24-hour period expires. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 6 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0641 Ensure each resident receives an accurate assessment. 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 assessments accurately reflected the resident's status for 1 of 8 residents (Resident #10) reviewed for assessment accuracy. Residents Affected - Few The facility inaccurately assessed Resident #10 as not requiring a mechanical lift for transferring in the quarterly MDS submitted on 1/22/2025. This failure could lead to residents not receiving required care. Findings included: Record review of Resident #10's facesheet, printed 6/20/2025, revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Relevant diagnoses included muscle wasting and atrophy (muscle breakdown), other lack of coordination, and other reduced mobility. Record teview of the quarterly MDs submitted 4/24/2025 revealed a BIMS score of 06, indicating severely impaired cognition. Section GG of this MDS was not assessed. The prior quarterly MDS, submitted 1/22/2025, question GG0110 did not include mechanical lift in the assessment of prior device usage. Record review of Resident #10's comprehensive care plan, printed 6/18/2025, revealed care planning for fall prevention as evidenced by the use of the Hoyer lift. Attempted interview with Resident #10 on 6/17/2025 at 11:12 AM and again on 6/18/2025 at 10:30 AM revealed the resident was unable to be interviewed. The COTA indicated during an interview on 6/20/2025 at 09:09 AM, that Resident #10 has required use of the mechanical lift since initial admission to the facility. She also reported Resident #10 is unable to stand or bear weight at all. The ADON, serving as the MDS nurse, was interviewed on 6/20/2025 at 12:44 PM. She stated she was still receiving training for completing MDS assessments and had not completed the prior two MDS submissions for Resident #10. She was unsure why the 1/22/2025 assessment indicated that Resident #10 had not required the use of mechanical lift in the period prior, as she also recalled Resident #10 required the mechanical lift since admission. The ADON indicated potential harm of inaccurate assessments to residents was resident's not receiving required care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 7 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Residents #29) reviewed for care plans. The facility failed to develop care plan interventions to include Resident #29 needing a therapeutic hold for medication administration. This failure could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental and psychosocial well-being. The findings include: Record review of Resident #29's admission record revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29's had diagnoses which included schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, which indicated severe cognitive impairment. Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). It revealed Resident #29 rejected care daily. Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences. It further reflected a focus of risk for harm: self directed or other-directed, initiated 06/16/25, to include interventions administer medications as prescribed, encourage resident to verbalize cause for aggression, if resident poses a potential threat to injure self or others notify provider. It further reflected a focus of The resident has a behavior problem (schizoaffective disorder) r/t (refusal to comply with medication regimen, refusing to comply with standard tasks, becoming verbally aggressive with staff), initiated 06/09/25, with intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. dated 06/09/25. Interview on 06/20/25 at 12:18 PM, the DON revealed Resident #29's use of restraints was not care planned and it needed to be care planned for resident rights. The DON did not give a reason why it was not care planned, but it was important for resident care. Interview on 06/20/25 at 01:08 PM, the ADON, who oversaw care plans, revealed Resident #29 needing to be held down for medication administration should be care planned for resident safety and resident rights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 8 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 06/20/25 at 06:14 PM, the DON and ADM revealed care plans should be updated for residents being held down for medication administration, so staff knew how to provide resident care. Interview on 06/20/25 at 10:45 AM, the DON revealed she was present on June 2nd when Resident #29 was throwing things and being verbally aggressive to staff when they needed to give Resident #29 a medication, so they called the psychiatric NP, who ordered Haldol on 06/02/25. The DON revealed Resident #29 was not allowing staff to administer Haldol. The DON revealed she tried to explain to Resident #29 the RP and NP wanted them to give her the injection and gave Resident #29 options to sit in bed or in a chair to receive the injection. The DON revealed they tried to give the medication when Resident #29 was in the chair, but the resident physically swung. The DON revealed the psychiatric NP and attending physician said the nursing staff could hold the resident for medication administration. The RP gave verbal permission to hold Resident #29 for medication administration. The DON revealed they had 4 staff members hold Resident #29, 1 staff member for each limb, while LVN C gave the injection. She further revealed no nursing staff were trained or practiced doing a therapeutic hold for a resident. She revealed it was important for resident safety and Resident #29 sustained no injuries. Interview on 06/20/25 at 10:59 AM, Resident #29's RP (and guardian) revealed he gave written permission and verbal permission to give Resident #29 medication prescribed by the psychiatric NP. He revealed when the shot was wearing off for Resident #29, Resident #29 did not have reason and was combative. The RP revealed the facility always communicated with him about giving her these medications and he always gave them permission because it helped the resident. He further revealed he had been in contact with her psychiatrist, and they were all in agreeance that this helped the resident. He was okay the facility had to physically restrain her because it was for her benefit, health wise. Interview on 06/20/25 at 12:18 PM, the DON revealed Resident #29's use of restraints was not care planned and there was no assessment to show the need for physical restraints for the resident. She revealed the use of restraints was a verbal order from the doctor, but it needed to be signed and entered into the resident's medical record. She revealed when they entered the doctor's order, they would add what health condition it was used for in the additional comments. She revealed it was important for resident safety because restraints could lead to injury. Attempted interview with Resident #29 on 06/20/25 at 12:36PM was unsuccessful, the resident refused the interview. Interview on 06/20/25 at 12:57 PM, the DON revealed there was not an assessment available to complete for using restraints on Resident #29 for medication administration. She revealed the facility had created an assessment so they could complete this assessment before doing a therapeutic hold on Resident #29 for medication administration. She revealed when they used a therapeutic hold on Resident #29 on 06/17/25 and monitored Resident #29 every 5 to 15 minutes. The DON revealed she sat with Resident #29 for about 2 hours to ensure resident safety. She revealed after each therapeutic hold for medication administration, Resident #29 had no injuries and did not appear to be affected by the therapeutic hold. Interview on 06/20/25 at 02:01 PM, the MD revealed he was called before the nursing staff held Resident #29 down for medication administration. He revealed Resident #29 was on a special psychiatric medication and she has had, on more than one occasion, been held because she was yelling and throwing items. He revealed the facility called and asked him if this was appropriate to hold Resident #29 for medication administrator. He revealed for resident's comfort and well-being, medication was vital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 9 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 because there could be an emergency room trip if she had not received these medications. He revealed Resident #29 was not harmed in anyway, because the medication was administered in a respectful and non-violent manner. He revealed his orders were done verbally because the medication administration needed to be done quickly. He revealed there should be a doctor's order afterward. He revealed his order would have read: With familial consent and doctor approval, okay to hold patient for medication administration to improve uncontrolled symptoms of aggression and allow time for new medication to take effect. He revealed he may revise this order and have it read more eloquently. He revealed this should be a one-time thing and if the facility wanted to do it again, he would be contacted. He revealed this was not a long-term solution. He revealed they might need to adjust Resident #29's medication regimen to have Resident #29 be participate with staff more. He revealed Resident #29 had a psychiatric disturbance with aggressive behaviors. He revealed there needed to be monitoring after a therapeutic hold for medication administration for Resident #29 to watch the resident for any injuries every few hours or every shift. He revealed it was important for these components to be in place so Resident #29 was not scared in the facility and felt comfortable, learning what it's like to not be scared or agitated. Interview on 06/20/25 at 04:20 PM, the DON revealed form 3713 (consent for antipsychotic or neuroleptic medication treatment) should be completed for Haldol. She revealed it was important because it went back to resident safety and resident rights. She revealed before they went into Resident #29's room they had a safety plan if resident was not cooperative with receiving the shot. She revealed each staff member were all assigned an extremity to hold. She revealed they did not practice. She revealed she instructed the nursing staff to hold the resident to make sure they would not cause a fracture. She revealed on June 17th Resident #29 sat on the edge of bed and this was all Resident #29 would comply. She revealed they tried non-pharmacologically interventions first. She revealed Haldol was given on June 2nd and RisperDAL was given on June 4th and June 17th, confirming the MAR was not filled out accurately on June 4th and June 17th. She revealed it was important to fill out these administration times so nursing staff knew what medications were given. Interview on 06/20/25 at 04:37 PM, the ADON revealed she helped with Resident #29's medication administration on June 2nd and June 4th. She revealed the facility approached Resident #29 in a gentle manner and tried to educate her about the importance of her medications. She revealed after contacting Resident #29's doctor and RP, they were able to do a therapeutic hold for medication administration. She revealed the nursing staff spoke about what they were going to do before they entered Resident #29's room to make sure the staff and resident remained safe. She revealed they did not practice a therapeutic hold for medication administration. Interview on 06/20/25 at 05:17 PM, LVN C revealed she was never trained on restraining a resident for medication administration. She revealed Resident #29 had to be held down for their safety (to include not harming herself or the nursing staff) since the medication administration was an injection and involved a needle. She revealed Resident #29 had to be held down so the needle would not break when being injected. Record review of the facility's, undated, policy, Restraint Policy, reflected The use of restraints is expressly forbidden unless it is prescribed as a measure of treatment for the resident and issued by the treating physician. Physical Restraint is any method or device used to restrict the movement or to keep a resident in a certain position while sitting or lying down . A restraint may only be placed on a resident if it has been determined by the Licensed Staff and the Treating Physician that it is medically necessary and the order is include in the Care Plan of a resident FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 10 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 8 residents (Resident #18) reviewed for urinary catheters. 1. The facility failed to ensure Resident #5 received appropriate care and treatment for the indwelling catheter device placed after admission. 2. The facility failed to ensure Resident #5's foley catheter was secured appropriately. This failure could lead to infection or injury. Record review of Resident #5's facesheet, printed 6/17/2025, revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #5 diagnoses included benign prostatic hyperplasic without lower urinary tract symptoms (enlargement of the prostate gland that can cause difficulty or the inability to urinate). Record review of the quarterly MDS, submitted 5/21/2025, revealed a BIMS score of 9, which indicated moderately impaired cognition. Record review of Resident #5's EMR revealed Resident #5 was evaluated in the local emergency department on 5/7/2025 for weakness. The emergency department physician attributed the resident's symptoms to urinary retention, and the resident had an indwelling foley catheter placed, as well as treatment for a urinary tract infection. Discharge records included an order to change the foley catheter on 6/8/2025. Record review of additional hospital records from an evaluation in the local emergency department on 6/7/2025 reflected Resident #5 had the foley catheter changed while at the hospital. Record review of Resident #5's active physician orders, date printed 6/17/2025, included : a. Catheter care every shift (start date 5/9/2025) b. Check foley catheter tubing secure device placement every shift (start 5/9/2025) c. Change foley the 11th of every month (start date 5/19/2025) d. EBP precautions for duration of catheter (start 5/9/2025) e. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 11 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0690 Contact precautions (start 6/11/2025) Level of Harm - Minimal harm or potential for actual harm During an observation of Resident #5 on 6/18/2025 at 11:51 AM, no date was seen on the foley catheter bag, tubing, or securement device. Additionally, the foley catheter tubing was not attached to the securement device on the resident's right thigh. Residents Affected - Few In a subsequent observation on 6/20/2025 at 9:20 AM, the foley was again observed not to have a date. CNA J was observed performing catheter care at this time, and the following deficient practices were observed: a. CNA J donned PPE prior to entering Resident #5's room incorrectly by applying gloves prior to donning a disposable gown b. CNA J did not change gloves or perform hand hygiene after repositioning the resident and removing the resident's clothes. CNA J performed care to the catheter wearing the same, used gloves that were applied initially. c. At the completion of care, CNA J then removed the PPE incorrectly by taking off the used gloves, performed hand hygiene by washing her hands in the sink with soap and water, then removed the disposable gown. In an interview with CNA J on 6/20/2025 at 9:40 AM, she incorrectly stated the steps of applying PPE as applying gloves then donning the disposable gown. She stated she had incorrectly removed PPE, and she reported the steps for removal were to remove the disposable gown and then gloves prior to performing hand hygiene. CNA J stated she received training about infection control and PPE through the staffing agency of which she was employed. She stated the potential harm to residents from not properly utilizing PPE or changing gloves was cross contamination. In an interview with LVN E on 6/18/2025 at 12:20 PM, she reported Resident #5 had the foley catheter changed while at the emergency department recently. She was unsure of the exact date it was changed. LVN E stated the foley catheter should be dated so that staff would know when the device was last changed, and she was unaware that the current foley catheter was not dated. She attributed the lack of date to the insertion performed by the emergency department. LVN E was also unaware the foley catheter was not secured to the securement device. She reported potential harm of the unsecured foley catheter was the foley becoming obstructed, infected, or dislodged. The DON was interviewed on 6/19/2025 at 9:15 AM, and she stated the facility policy for foley catheters was the device must be dated when inserted and the tubing always secured to the securement device. The DON reported potential harm of an unsecured foley catheter was dislodgement or transmission of infection. She also reported potential harm of cross contamination by staff not donning PPE properly or changing gloves during care. Record review of the facility's policy titled Catheter Care, Urinary (2001, revised July 2024) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 12 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0690 revealed the following: Level of Harm - Minimal harm or potential for actual harm Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. Residents Affected - Few Record review of the facility's policy titled Standard Precautions (2001, revised September 2022) revealed the following: a. Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body side to another (when moving from a dirty site to a clean one) b. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident A policy for EBP precautions and general infection control was requested from the DON and the Admin but were not provided to the SSA prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 13 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for all nursing staff in 1 of 1 facilities where therapeutic holds were used. The facility failed to ensure nursing staff were trained to therapeutically hold Resident #29 for medication administration. This failure could place residents at risk for harm due to staff who lack the appropriate skills and competencies to provide and minimize infections. The findings include: Record review of Resident #29's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, which indicated severe cognitive impairment. Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). Resident #29 rejected care daily. Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences. Record review of Resident #29's June MAR reflected Haldol Injection Solution 5 MG/ML Inject 5 mg intramuscularly one time only related to Disorganized Schizophrenia, with start date 06/02/25, was given on 06/02/25 at 07:10PM by LVN B. Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly at bedtime every 14 day(s) related to disorganized schizophrenia, with start date 06/04/25 and D/C date 06/09/25, was blank on 06/04/25 at 08:00 PM. Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly every day shift every 14 day(s) related to Disorganized Schizophrenia, with start date 06/17/25, was blank on 06/17/25 Day. Record review of nurse's note, dated 06/17/25 at 10:30 PM and authored by LVN C, reflected, [Resident #29] informed of ordered IM Risperidone 50mg injection, increased agitation noted, resident quickly stated, no you will not! Get out of my room! Several attempts to educate the resident regarding the medication were unsuccessful, four employees assisted (unnamed) to ensure safety and protect the resident from hurting herself or others. Safety techniques effectively applied by staff, IM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 14 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Risperidone 50mg administered to the right upper outer gluteal quadrant without incident. Resident voiced frustration and yelled, I said get out of my room, staff exited room, visual safety checks applied and continued monitoring throughout the night to ensure safety and monitor for any possible side effects Interview on 06/20/25 at 10:45 AM, the DON revealed she was present on June 2nd when Resident #29 was throwing things and being verbally aggressive to staff when they needed to give Resident #29 a medication, so they called the psychiatric NP, who ordered Haldol on 06/02/25. The DON revealed Resident #29 was not allowing staff to administer the Haldol. The DON revealed she tried to explain to Resident #29 that the RP and NP wanted them to give her the injection and gave Resident #29 options to sit in bed or in the chair to receive the injection. The DON revealed they tried to give medication when Resident #29 was in the chair, but the resident physically swung. The DON asked the psychiatric NP and attending physician, and they said they could hold the resident for medication administration. The RP gave verbal permission to hold Resident #29 for medication administration. The DON revealed they had 4 staff members hold Resident #29, one staff member for each limb, while LVN C gave the injection. She further revealed no nursing staff were trained or practiced doing a therapeutic hold for a resident. She revealed it was important for resident safety. Interview on 06/20/25 at 12:57 PM, the DON revealed Resident #29 had no injuries and did not appear to be affected by the therapeutic hold. Interview on 06/20/25 at 02:01 PM, the MD revealed he gave verbal order for a therapeutic hold for medication administration for Resident #29 for Haldol once and Rispiradal consta twice. He revealed the nursing staff therapeutically held Resident #29 for medication administration in a safe manner. He revealed it was important so Resident #29 was not scared in the facility and felt comfortable, learning what it's like to not be scared or agitated. Interview on 06/20/25 at 04:37 PM, the ADON revealed she helped with Resident #29's medication administration on June 2nd and June 4th. She revealed the facility approached Resident #29 in a gentle manner and tried to educate her about the importance of her medications. She revealed after contacting Resident #29's doctor and RP, they were able to do a therapeutic hold for medication administration. She revealed the nursing staff spoke amongst themselves about what they were going to do before they entered Resident #29's room to make sure the staff and resident remained safe. She revealed they did not practice a therapeutic hold for medication administration. She revealed she was not trained on restraining a resident Interview on 06/20/25 at 05:17 PM, LVN C revealed she was never trained on restraining a resident for medication administration. She revealed Resident #29 had to be held down for their safety (to include not harming herself or the nursing staff) since the medication administration was an injection and involved a needle. She revealed Resident #29 had to be held down so the needle would not break when being injected. Attempted interview with LVN B on 06/20/25 at 05:16PM was unsuccessful. A voicemail was left for LVN B. There were no trainings done (no records available) to ensure staff knew how to therapeutically hold residents for medication administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 15 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 - Some 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 provide pharmaceutical services to meet the needs for 5 of 9 residents (Residents #4, #5, #9, #15, and #134), and the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconcilitation for 1 of 9 residents (Resident #4) reviewed for medication administration. 1. The facility failed to ensure accurate documentation of medications administered to Resident #134. 2. The facility failed to ensure Residents #4, #5, #9, and #15 received medications as ordered by the physician. 3. The facility failed to prevent the loss of 2 tablets of Resident #4's hydrocodone-acetaminophen, a narcotic pain medication. 4. The facility failed to discard expired insulin for Resident #15. These failures could lead to inaccurate administration of medications, ineffective therapeutic effects, and injury or illness. Findings included: 1. Record review of Resident #134's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE], with relevant diagnoses including type 2 diabetes mellitus with hyperglycemia (elevated blood sugar levels resulting from the body's inability to self-regulate glucose) and chronic pulmonary embolism (a blood clot in the lung). Record review of Resident #134's admission MDS, submitted on [DATE], indicated a BIMS score could not be assessed due to the cognitive status of the resident. Record review of Resident #134's EMR contained the following medication orders: a. Insulin lispro injection solution 100 unit/mL, inject as per sliding scale . subcutaneously before meals and at bedside related to type 2 diabetes mellitus with hyperglycemia (order date [DATE]) b. Eliquis oral tablet 2.5mg (apixaban), given 1 tablet via PEG-tube every morning and at bedside related to chronic pulmonary embolism (order date [DATE]) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 16 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 - Some Record review of Resident #134's MAR revealed no documentation on [DATE] for 8:00 PM administration of medication Eliquis and 8:00 PM administration of subcutaneous insulin. In an interview on [DATE] at 4:00 PM, LVN E stated he was responsible for administering the above listed medications. He stated Resident #134 received both medications, and the missing documentation was the result of a computer error. LVN E reported potential the possible harm of incorrect medication documentation was potential overdose or other staff not knowing what medications a resident had received. 2. Record review of Resident #4's facesheet, printed [DATE], reflected a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #4 had a relevant diagnosis of dementia, unspecified (a progress that impairs the thought processes). Record review of Resident #4's quarterly MDS, submitted [DATE], did not include a BIMS score assessment due to the resident's cognitive status at the time of the assessment. Record review of Resident #4's EMR contained the following physician's order: Divalproex sodium DR 125 mg tab, given 1 tablet orally two times a day related to unspecified dementia (order date [DATE]) While observing routine medication administration on [DATE] at 7:32 AM, the DON was observed crushing the divalproex DR tablet before mixing it with pudding to administer to Resident #4 orally. In a telephone interview on [DATE] at 8:20 AM, the RPh stated Resident #4's divalproex DR should not be crushed prior to administration, as crushing it would affect the absorption and cause the medication to become absorbed more quickly. The RPh also stated that he was unaware Resident #4 required medications to be crushed, and if he would have known, he would have contacted the facility to recommend a different formulation of the medication. The RPh then stated the potential harm to Resident #134 by receiving the medication crushed inappropriately was ineffective therapeutic effect due to quicker absorption. The DON was interviewed on [DATE] at 14:20. She stated the divalproex DR should not have been crushed. She then stated the divalproex had been discussed with the RPh, and the order was modified to the alternate formulation appropriate for crushed medications. She reported the potential harm to Resident #4 from receiving the improperly crushed medication was the resident not getting the intended therapeutic effect or seizures. Record review of Resident #5's facesheet, printed [DATE], reflected a [AGE] year-old male, originally admitted to the facility on [DATE], and with a relevant diagnosis of drug induced subacute dyskinesia (a movement disorder that develops as a result of starting or increasing the dosage of certain medications). Record review of Resident #5's quarterly MDS, submitted [DATE], revealed a BIMS score of 9, indicating moderately impaired cognition. Resident #5's EMR contained the following order: Austedo XR oral tablet extended release 24 hour 6mg (Deutetrabenazine) give 6mg by mouth at bedtime for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 17 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 tardive dyskinesia related to unsteadiness on feet (order state [DATE] 20:00 [8:00 PM]) Level of Harm - Minimal harm or potential for actual harm Review of Resident #5's MAR for [DATE], printed [DATE], reflected the following documentation for Austedo XR: Residents Affected - Some a. [DATE] 8:00 PM: no documentation/blank b. [DATE] 8:00 PM: code 9 documented by LVN C c. [DATE] 8:00 PM: code 9 documented by CMA A d. [DATE] 8:00 PM: code 9 documented by LVN C e. [DATE] 8:00 PM: documented as administered by LVN C f. [DATE] 8:00 PM: code 9 documented by CMA A g. [DATE] 8:00 PM: code 9 documented by CMA A h. [DATE] 8:00 PM: code 9 documented by CMA A i. [DATE] 8:00 PM: code 9 documented by LVN C j. [DATE] 8:00 PM: code 9 documented by LVN C k. [DATE] 8:00 PM: code 9 documented by ADON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 18 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 l. Level of Harm - Minimal harm or potential for actual harm [DATE] 8:00 PM: code 9 documented by ADON Residents Affected - Some The code key for the MAR revealed 9 indicated other/see progress notes. Record review of Resident #5's progress notes for [DATE] did not reveal any documentation related to the administration of the Austedo XR. CMA A was interviewed on [DATE] at 5:05 PM. She stated she was responsible for administering medications to Resident #5 on [DATE]. She explained the Austedo XR was not able to be administered to Resident #5 because it was not available in the facility and did not arrive until [DATE]. She explained if a medication is not in stock, the process was to inform the charge nurse or the ADON or DON, if they were available. She stated she informed the charge nurse and the DON of the need for the Austedo XR and the pharmacy told the staff it would be delivered. She was unsure why the administration scheduled for 8:00 PM on [DATE] did not contain any documentation, as the facility policy for medications not administered was to use code 9 and type a progress note, if needed. In an attempted interview on [DATE] at 5:29 PM, LVN C was contacted by telephone but there was no answer, and the voicemail recording indicated the mailbox was full. The ADON was interviewed on [DATE] at 5:15 PM. She stated she noticed on [DATE] the medication was not in stock, so she contacted the pharmacy personally to request the medication. She said the pharmacy was unaware of the new order, and they delivered it on [DATE]. An interview on [DATE] at 5:20 PM revealed the DON was not aware that Resident #5 had not received 11 doses of the Austedo XR. She did not recall being notified by any staff member during that time. She stated Austedo XR was not contained with the facility emergency stock of medications, so the documentation of Resident #5 receiving the medication on [DATE] was likely charted in error. She then said her expectation of staff was they would notify her and the Admin of any medications that were out of stock. Record review of Resident #9's face sheet, printed [DATE], reflected a [AGE] year-old male, initially admitted to the facility on [DATE], with a relevant diagnosis of cognitive impairment of uncertain or unknown etiology. Record review of Resident #9's quarterly MDS submitted on [DATE] revealed a BIMS score of 11, indicating moderately impaired cognition. Record review of Resident #9's EMR revealed the following physician's order: Memantine HCl oral tablet 5mg, give 5mg by mouth at bedside related to mild cognitive impairment of uncertain or unknown etiology for 7 days (start date [DATE] 20:00 [8:00 PM]). Record review of Resident #9's [DATE] MAR, printed [DATE], revealed the following documentation for Memantine HCl: a. [DATE] 8:00 PM: no documentation/blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 19 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 b. Level of Harm - Minimal harm or potential for actual harm [DATE] 8:00 PM: no documentation/blank c. Residents Affected - Some [DATE] 8:00 PM: no documentation/blank d. [DATE] 8:00 PM: no documentation/blank CMA A was interviewed on [DATE] at 5:05 PM. She stated she was responsible for administering medications to Resident #9 on [DATE] and [DATE]. She stated the order for administration of the Memantine HCl was not present on [DATE] or [DATE], as she did not remember seeing an alert. Per the staffing schedule, LVN C was responsible for administering Resident #9's medications on [DATE] and [DATE]. LVN C was contacted by telephone on [DATE] at 5:29 PM, but there was no answer, and the voicemail recording indicated the mailbox was full. Record review of Resident #15's facesheet, printed [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE], with a relevant diagnosis of schizoaffective disorder, bipolar type (a chronic mental health condition that causes difficulty distinguishing reality with frequent mood swings). Record review of Resident #9's admission MDS submitted [DATE] reflected a BIMS score of 13, indicating intact cognition. Record review of Resident #15's EMR revealed the following physician's order: Quetiapine fumarate oral tablet, give 12.5 mg by mouth in the morning related to schizoaffective disorder, bipolar type for 7 days (start date [DATE] 08:00 [AM]). Record review of Resident #15's [DATE] MAR, printed [DATE], reflected the following documentation for Quetiapine: a. [DATE] 8:00 AM: no documentation/blank b. [DATE] 8:00 AM: no documentation/blank Per the staffing schedule, LVN D was responsible for administering Resident #15's Quetiapine on [DATE] and [DATE]. LVN D was contacted by telephone on [DATE] at 4:20 PM, and a voicemail with contact information was left to obtain an interview. LVN D did not contact the state survey team prior to exit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 20 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 - Some In an interview with the ADON on [DATE] at 5:33 PM, she explained that Resident #9 did not receive the ordered Memantine HCl and Resident #15 did not receive the ordered Quetiapine because the electronic orders were pending confirmation from the nursing staff administering the medication in the EMR. She further explained that both orders were confirmed late (after the ordered start date), so the MARs populated with the missed doses. She reported the potential harm to residents as missed doses of medication. She reported there was no formal process for confirming medication orders and that this needed to be addressed by herself and the DON. Record review of the facility's policy titled Administering Medications (2001, revised [DATE]) revealed the following: a. Medications are administered in accordance with prescriber orders, including any required time frame b. If a drug is withheld . the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 3. As noted previously, record review of Resident #4's facesheet, printed [DATE], reflected a [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #4 had a relevant diagnosis of dementia, unspecified (a progress that impairs the thought processes). Record review of Resident #4's quarterly MDS, submitted [DATE], did not include a BIMS score assessment due to the resident's cognitive status at the time of the assessment. Record review of Resident #4's EMR revealed the following physician's order: Hydrocodone-acetaminophen oral tablet 10-325mg Give 1 tablet by mouth four times a day related to pain, unspecified (Order date [DATE]) Record review of the facility's investigation report included copies of the individual narcotic record dated [DATE] through [DATE], in which 2 tablets of the medication were not dated or signed as administered by nursing staff. During an observation of medication administration on [DATE] at 7:00 AM, Resident #4's hydrocodone-acetaminophen tablets (45) were verified to match the documentation on the individual narcotic record (45). LVN E was interviewed on [DATE] at 12:26 PM,. she stated a discrepancy of 4 tablets was discovered during the routine narcotic count on the [DATE] morning shift handoff between LVN F and herself. She stated she counted the actual tablets present, and LVN F read the number she recorded in the book during her overnight shift, and the numbers did not match. She reported signing the paper to indicate the number of tablets on hand and notified the DON later that day. She stated Resident #4 did not appear to be in pain during her shift or to have suffered any harm because of the missing medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 21 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 LVN E denied knowledge of the missing hydrocodone-tablets. Level of Harm - Minimal harm or potential for actual harm LVN F was interviewed on [DATE] at 2:06 PM. She reported no medication was missing on the handoff that occurred on the morning of [DATE], and she was unsure why she was questioned about the missing tablets, as the handoff was recorded by herself and the oncoming nurse which indicated a proper count of actual tablets versus recorded amount. She denied any knowledge of Resident #4's misappropriated hydrocodone-acetaminophen. She stated she was no longer employed at the facility. Residents Affected - Some In an interview with the DON on [DATE] at 9:03 AM. She explained the process for narcotic counts at shift change was the off-going and oncoming would review the narcotics and the documentation in the binder containing the individual narcotic records to verify the documentation was correct. The two nurses would then sign the front page of the binder to indicate mutual verification. When asked about Resident #4, she explained initially four tablets of the hydrocodone-acetaminophen were missing, but her investigation and audit revealed two of the four tablets were administered by LVN F on the PM shift of [DATE] and not documented properly . She reported 2 tablets were not able to be reconciled, despite the investigation. Record review of the facility's policy titled Controlled Substances (dated 2001, revised [DATE]) revealed the following: 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. The director of nursing services documents irreconcilable discrepancies in a report to the administrator. 4. Record review of Resident #15's facesheet, printed [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE], with a relevant diagnosis of type 2 diabetes mellitus without complications (inability of the body to regulate blood glucose levels.) Record review of Resident #15's admission MDS submitted [DATE] reflected a BIMS score of 13, indicating intact cognition. Record review of Resident #15's EMR contained the following physician's order: Insulin lispro infection solution 100 unit/mL . subcutaneously before meals and at bedside related to Type 2 diabetes mellitus without complications (order date [DATE]) In an observation on [DATE] at 4:03 PM of the medication cart used for the 200 and 300 residence halls, two multi-dose insulin vials affixed with pharmacy labels for Resident #15 were observed in the drawer. Both multi-dose vials were labeled as opened on [DATE]. LVN B explained during this observation that the facility process was to discard insulin after 29 days and Resident #15's insulin should be thrown away. LVN B had just arrived for his shift and was unsure if Resident #15 had been administered the expired insulin. LVN B reported the potential harm to residents receiving expired insulin was hyperglycemia as the expired insulin may be less effective. In an interview with the DON on [DATE] at 4:17 PM, she reported the facility policy was to keep (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 22 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 insulin for 28 days after removing from the fridge. The DON stated unlabeled insulin in the medication cart should be discarded and not administered. Review of the facility policy titled Medication Labeling and Storage (dated 2001, revised February 2023), revealed the following: Residents Affected - Some Multi-dose vials that have been opened or accessed . are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 23 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles and the expiration date when applicable for 1 of 2 medication carts (200-300 halls cart) reviewed for medication storage. The facility failed to label the expiration dates of opened/unrefrigerated insulin stored in the medication cart for Resident #2. This failure could lead to ineffective insulin therapy, hyperglycemia, and illness. Findings included: Record review of Resident #2's facesheet, printed [DATE], revealed a [AGE] year-old female, originally admitted to the facility on [DATE] with a relevant diagnosis of type 2 diabetes mellitus with hyperglycemia (the body's inability to self-regulate blood sugar leading to elevated levels). Review of the quarterly MDS, submitted [DATE], revealed a BIMS score of 8, indicating moderately impaired cognition. Record review of Resident #2's EMR contained the following physician's order: Lantus Solostar 100 unit/mL Inject 10 unit subcutaneously at bedtime related to type 2 diabetes mellitus with hyperglycemia (Order date [DATE]) In an observation on [DATE] at 4:03 PM of the medication cart used for the 200 and 300 residence halls, an insulin pen affixed with a pharmacy label for Resident #2 was observed in the drawer. The insulin pen was not labeled with any additional dates other than the information printed by the pharmacy. LVN B assisted with the observation and was interviewed concurrently. LVN B was unsure of when Resident #2's insulin pen was removed from the fridge and opened, and he denied administering insulin to the resident using that device on [DATE] as her insulin was not due until the evening. He stated the facility process is to label insulin pens and vials with the date they are removed from the fridge and opened. He also stated the insulin can be kept for 29 days once removed from the fridge and then must be discarded. LVN B had just arrived for his shift and was unsure if Resident #2 had been administered the unlabeled insulin. LVN B reported the potential harm to residents was hyperglycemia as the insulin may expired and may be less effective. In an interview with the DON on [DATE] at 4:17 PM, she reported the facility policy was to apply a date when the insulin is opened and to keep insulin for 28 days after removing from the fridge. Review of the facility policy titled Medication Labeling and Storage (dated 2001, revised February 2023), revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 24 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0761 Multi-dose vials that have been opened or accessed . are dated and discarded within 28 days unless the Level of Harm - Minimal harm or potential for actual harm manufacturer specifies a shorter or longer date for the open vial. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 25 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The DM did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This failurecould place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. Record review of the staff roster revealed DM's hire date was 6/24/2024. In an interview on 6/17/2025 at 11:19 AM, the DM reported to the SSA that he was not currently certified as a food services manager. He stated he was enrolled in an educational program to obtain certification. He stated his prior professional experience helped him to prepare for his role as the current DM. The Admin confirmed the DM was not a certified food services manager during an interview on 6/20/2025 at 8:34PM. She stated she was aware of the certification requirement for food services managers and had been cited for the deficiency in a prior survey. She felt that because the DM was currently working towards being certified and because this was accepted in a prior plan of correction, the DM's position was acceptable. She reported the potential harm to the residents was inaccurate dietary procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 26 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on record review, interview and observation, the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times for 1 of 1 facility reviewed. The facility failed to ensure residents were offered snacks at bedtimes. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. The findings were: Record review of the Mealtimes, undated, reflected: Dining Room: Breakfast 07:45 AM, Lunch 11:45 AM, and Supper 05:45 PM; Hall Trays: Breakfast 07:30 AM, Lunch 11:30 AM, and Supper 05:30 PM. Record review of the snack times, undated, reflected 09:30 AM, 02:30PM, and 07:00 PM. Confidential interviews during the Resident Meeting on 06/18/25 at 01:03 PM revealed the facility did not offer snacks at bedtime and they would like to be offered snacks at bedtime. Interview on 06/19/25 at 07:05 PM, the ADM revealed the facility did not have a nourishment room to keep items from the kitchen like snacks to give out to the residents at night. She revealed there were three times a day when the facility gave out snacks to include a 7PM snack. She revealed for the 7 PM snack the kitchen staff would leave the snacks on ice, in the dining room, for the nursing staff to pass out. She revealed there were items to make peanut butter and jelly sandwiches at the nurse's station, if residents wanted a snack, because when they did offer bedtime snacks for residents, they would have to discard snacks that were not used. Interview on 06/19/25 at 07:15 PM, Resident #13 revealed she had not received a snack tonight and had not been offered snacks at night. She revealed she would like to be offered a snack and would probably accept a snack at times but did not need a snack tonight. Interview on 06/20/25 at 04:08 PM, the Dietary Manager revealed the kitchen had not been preparing snacks for bedtime snacks. He revealed this was due to their budget, but they stocked up snacks for the residents from dry food storage. He revealed it was important for residents to have snacks, especially diabetics so they can maintain their blood sugars. Interview on 06/20/25 at 05:29 PM, CNA L revealed she worked doubles Friday to Sunday and had never seen snacks passed out for bedtime. She revealed she had only seen snacks passed out to residents one time. Interview on 06/20/25 at 06:07 PM, the ADM revealed she was not aware that bedtime snacks were required to be offered at night. She had not heard of any resident complain about not having nighttime snacks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 27 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Observation on 06/19/25 at 07:18PM revealed there were no snacks left on ice to be passed out, in the dining room. The kitchen appeared to have the lights off with no staff in the kitchen. There was a sign posted right outside of the kitchen that revealed there was a snack time at 7 PM. Record review of facility's policy, Food and Nutrition Services, revised October 2017, reflected 4. Reasonable efforts will be made to accommodate resident choices and preferences . 10. Nourishing snacks are available to residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. Event ID: Facility ID: 675169 If continuation sheet Page 28 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Residents Affected - Some 1. The facility failed to label the drink containers in the dining room, which were used by residents for hydration. 2. The facility failed to store raw protein food items below fully cooked foods in the freezer. 3. The facility failed to not store personal beverages in the food preparation area. These failures could place residents at risk for food borne illness. The findings included: 1. Interview and observation on 06/17/25 at 11:19 AM, the drink containers in the dining room were not labeled. The DM revealed the kitchen staff knew to date and label kitchen items, but he had to keep reminding them because they tended to forget. 2. Interview and observation on 06/17/25 at 11:19 AM, there were raw proteins (chicken and beef patties) stored in a freezer above biscuit dough. The DM revealed raw proteins should be stored below fully cooked items. 3. Interview and observation on 06/17/25 at 09:56 AM, there was a personal water bottle in a carton of potatoes. [NAME] M revealed she knew her personal beverage should not be put here. During this same interview on 06/17/25 at 09:56 AM, The DM revealed he oversaw personal beverages being stored in their designated spot, foods being stored properly like the raw proteins, and drink containers being labeled appropriately. He revealed it was important for labeling the drink containers, so they knew when the beverages were no longer good to drink. Dietary Aide N joined the interview and revealed she knew to date and label the drink containers. Combined interview on 06/20/25 at 04:08 PM, Dietary Staff O, Dietary Staff P, and the CDM revealed raw protein food items needed to be stored below fully cooked food items to prevent cross contamination and food poisoning. They revealed it was important to label foods and beverages, so they knew when to discard these items so that it was good when the resident ate or drank it. They revealed it was important to not have personal beverages in the food preparation area so there would not be contamination. Record review of facility's policy, Food Receiving and Storage, revised November 2022, reflected 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 29 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Food services, or other designated staff, maintain clean and temperature/humidity appropriate food storage areas at all times .9. Uncooked and raw animal products and fish are stored separately in drop-proof containers and below fruits, vegetables, and other ready-to-eat foods to prevent meat juices from dripping onto these foods. Record Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of the FDA Food Code 2022 reflected, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3- 403.11(E) may be held at a temperature of 54°C (130°F) or above; or (2) At 5°C (41°F) or less. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 30 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #29) reviewed for antipsychotic medication administration. Resident #29's June MAR did not reflect that RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG was given on 06/04/25 and 06/17/25. The deficient practices could place residents at risk for side effects for which they did not consent. The findings included: Record review of Resident #29's admission record revealed Resident #29 was a [AGE] year-old female admitted on [DATE] with diagnoses to include schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, indicating severe cognitive impairment. It further reflected Resident #29 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). It revealed Resident #29 rejected care daily. Record review of Resident #29's care plan reflected a focus of at risk for complications due to refusing care refusing medication, initiated on 06/10/25, with interventions to include If resident refuses care, try another staff member or approach, Notify family as needed, Notify MD as needed, Provide alternate approaches/settings in accordance with resident preferences, It further reflected a focus of risk for harm: self directed or other-directed, initiated 06/16/25, to include interventions administer medications as prescribed, encourage resident to verbalize cause for aggression, if resident poses a potential threat to injure self or others notify provider. And it further reflected a focus of The resident has a behavior problem (schizoaffective disorder) r/t (refusal to comply with medication regimen, refusing to comply with standard tasks, becoming verbally aggressive with staff), initiated 06/09/25, with intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. dated 06/09/25. Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly at bedtime every 14 day(s) related to DISORGANIZED SCHIZOPHRENIA, with start date 06/04/25 and D/C date 06/09/25, was blank on 06/04/25 at 08:00PM. Record review of Resident #29's June MAR reflected RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG Inject 50 mg intramuscularly every day shift every 14 day(s) related to DISORGANIZED SCHIZOPHRENIA, with start date 06/17/25, was blank on 06/17/25 Day. Interview on 06/20/25 at 10:59 AM, Resident #29's RP (and guardian) revealed he gave written permission and verbal permission to give Resident #29 medication prescribed by the psychiatric NP. The RP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 31 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 revealed the facility always communicated with him about giving her these medications and he always gave them permission because it helped the resident. Attempted interview with Resident #29 on 06/20/25 at 12:36PM was unsuccessful, the resident refused the interview. Residents Affected - Few Interview on 06/20/25 at 04:20PM, the DON revealed RisperDAL was given on June 4th and June 17th, confirming the MAR was not filled out accurately on June 4th and June 17th. She revealed it was important to fill out these administration times so nursing staff knew what medications were given Record review of facility's policy, revised April 2019, reflected 22. The individual administering the medication initials the resident's MAR and the appropriate line after giving each medication and before administering the next ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 32 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 to prevent the development and transmission of communicable diseases and infections for 2 of 3 staff members (CNA G and CNA I) reviewed for pre-employment TB screenings, 3 of 3 staff members (CNA G, CNA I, and LVN E) reviewed for pre-employment vaccinations, and 2 of 2 residents (Resident #5 and Resident #134) reviewed for transmission-based precautions. Residents Affected - Some 1. The facility failed to screen staff members CNA G and CNA I for TB prior to hire, per CDC guidelines. 2. The facility failed to offer a vaccination for hepatitis B upon hire to staff members CNA G, CNA I, and LVN E per OSHA and CDC guidelines. 3. The facility failed to utilize proper PPE procedures during TBP for Resident #5 and Resident #134. These failures could result in the development and spread of infection or illness. Findings included: Record review of employee files revealed the following: a. CNA G: hire date of 4/21/2025 and a copy of a chest x-ray dated 4/19/2021 for listed indication screening examination for pulmonary tuberculosis b. CNA I: hire date of 4/29/2025 and a form documenting negative results of a TB skin test dated April 2024. c. LVN E: hire date of 4/18/2025 and a TB screening form dated 3/26/2025 No documentation of the hepatitis vaccination being offered to these staff members was in the employee files. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 33 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 - Some An interview with the Admin was conducted on 6/20/2025 at 12:04 PM. She was unsure if the staff members had been offered the hepatitis B vaccination. In an interview with the DON on 6/20/2025 at 4:27 PM, she reported newly hired staff members wereposed to have a TB skin test within the previous year prior to hire. She was unsure if the facility should perform an additional screening questionnaire of newly hired staff members. The DON stated the importance of screening staff for TB before hire and annually was to prevent transmission of infection. She reported the risk of transmission in the nursing facility setting was higher and would be catastrophic. She was unsure if the staff members had been offered the hepatitis B vaccination. In an interview with the ADON on 6/20/2025 at 12:40 PM, she stated CNA G and CNA I were not screened for baseline TB risks using the facility form prior to employment. She explained that when CNA G and CNA I provided the TB testing documentation, she accepted the documents to meet the pre-employment requirement. She was not aware a baseline screening questionnaire should have also been performed. She agreed that CNA G and CNA I could have been exposed to or contracted TB since their testing performed prior to hire and should have been screened. The ADON also stated she had not offered the hepatitis B vaccination to CNA G, CNA I, or LVN E while performing her responsibilities in the hiring process. She provided documentation at that time of TB screenings for CNA G and CNA, as well as hepatitis B vaccination status for CNA I, all documents dated 6/20/2025. Record review of the facility document titled New Employee Orientation Checklist (not dated) revealed TB test agreement and results as an item listed under tasks to be completed prior to day 1. Additionally, the item hepatitis vaccine was listed under the section titled Day 1 onboarding forms: employee logs onto [system] and completes the following forms on day 1. Record review of Resident #5's facesheet, printed 6/17/2025, revealed a [AGE] year-old male, originally admitted to the facility on [DATE], and with a relevant diagnosis of benign prostatic hyperplasic without lower urinary tract symptoms (enlargement of the prostate gland that can cause difficulty or the inability to urinate). Record review of quarterly MDS, submitted 5/21/2025, revealed a BIMS score of 9, indicating moderately impaired cognition. Record review of Resident #5's active physician orders, date printed 6/17/2025, included: a. Catheter care every shift (start date 5/9/2025) b. Check foley catheter tubing secure device placement every shift (start 5/9/2025) c. Change foley the 11th of every month (start date 5/19/2025) d. EBP precautions for duration of catheter (start 5/9/2025) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 34 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 e. Level of Harm - Minimal harm or potential for actual harm Contact precautions (start 6/11/2025) Residents Affected - Some In an observation on 6/17/2025 at 1:58 PM, the DON was observed entering Resident #5's room without donning PPE. The DON was interviewed on 6/20/2025 at 2:20 PM. She stated any staff or visitor entering a resident's room with contact precautions should don a gown and gloves prior to entering, regardless of whether or not direct care is providing to the resident. She acknowledged she entered Resident #5's room without donning PPE, and she reported the potential risk of not appropriately donning PPE was the transmission of infection. Record review of Resident #134's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE], with a relevant diagnosis of encounter for attention to gastrostomy (a surgical opening in the stomach allowing for the intake of nutrition and medication). Record review of the admission MDS, submitted on 3/29/2025, indicated a BIMS score could not be assessed due to the cognitive status of the resident. Record review of Resident #134's active physician orders, date printed 6/18/2025, included resident to be on enhanced barrier precaution (start 4/17/2025). In an observation of routine medication administration on 6/19/2025 at 7:59 AM, the DON was observed donning a disposable gown and gloves and administering one medication to Resident #134 via the gastrostomy tube. The DON was then observed maintaining the same pair of gloves to remove additional medications from the medication cart and perform documentation on the laptop affixed to the top of the cart. The DON then administered additional medications to Resident #134's gastrostomy tube while wearing the same pair of gloves. In an interview with the DON on 6/18/2025 at 8:10 AM, the DON stated she should have changed her gloves and performed hand hygiene before accessing Resident #134's gastrostomy tube and before accessing the medication cart. The DON reported the potential harm to residents of not changing gloves or performing hand hygiene was transmission of infection. Record review of the facility policy titled Isolation- Categories of Transmission Based Precautions (dated 2001, revised September 2022) revealed the following: Contact precautions: .Staff and visitors wear gloves (clean, nonsterile) when entering the room . Staff and visitors wear a disposable gown upon entering the room . Record review of the facility policy titled Standard Precautions (dated 2001, revised September 2022) revealed the following: Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. After gloves are removed, hands are washed immediately to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 35 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 avoid Level of Harm - Minimal harm or potential for actual harm transfer of microorganisms to other residents or environments. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the CDC guidelines for TB screening and testing of health care personnel, published May 2019, recommend a baseline screen and individual risk assessment at baseline (preplacement) as well as TB testing for new employees. OSHA standard 1910.1030(f)(1)(i) requires employers to make available the hepatitis B vaccine and vaccination series to all employees who have occupational exposure . The CDC also published recommendations in 2018 that included offering the hepatitis B vaccination to all adults working in health care settings. Event ID: Facility ID: 675169 If continuation sheet Page 36 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a minimum of 80 square feet per resident for residents in 9 of 9 multiple occupancy resident rooms (Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317). Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317 did not have the required 80 square feet per resident. These failures could affect the residents placed in these multiple occupancy rooms and place them at-risk by reducing their living space and posing problems in their activities of daily living. The findings were: Record review of Form 3740 Bed Classifications, completed by the Administrator on 06/18/2025, revealed rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were classified to have 3 resident beds in each room. Room size measurements in 2024 and 2023 of the rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were as follows: 1. room [ROOM NUMBER] (3-person room - 0 residents in room) 14.9 ft x 14.83 ft = 221.7 sq ft / 3 residents = 73.9 sq. ft/resident 2. room [ROOM NUMBER] (3-person room - 0 residents in room) 14.9 ft x 14.75 ft = 220.9 sq ft / 3 residents = 73.6 sq. ft/resident 3. room [ROOM NUMBER] (3-person room - 0 residents in room) 14.75 ft x 15 ft = 221.3 sq ft / 3 residents = 73.8 sq. ft/resident 4. room [ROOM NUMBER] (3-person room - 1 resident in room) 14.83 ft x 15 ft = 222.4 sq ft / 3 residents = 74.2 sq. ft/resident 5. room [ROOM NUMBER] (3-person room - 0 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident 6. room [ROOM NUMBER] (3-person room - 0 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident 7. room [ROOM NUMBER] (3-person room - 0 residents in room) 14.9 ft x 14.75 ft = 219.8 sq ft / 3 residents = 73.3 sq. ft/resident 8. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.9 ft = 222.0 sq ft / 3 residents = 74 sq. ft/resident 9. room [ROOM NUMBER] (3-person room - 1 resident in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 37 of 38 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 06/19/2025 at 04:47PM, the Administrator stated the facility will have to continue completing the room waiver for the rooms less than regulation size. The Administrator revealed they were still using the same rooms that needed waivers in the last 2 years, with no changes. The Administrator revealed she had not signed a room waiver. Asked the ADM for confirmation of room sizes during survey and on 06/26/25 at 08:55 AM. The ADM has not confirmed these room sizes. Event ID: Facility ID: 675169 If continuation sheet Page 38 of 38