Health inspection·May 7, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appropriately in the inner puncture proof container which should also be removed when full and changed. The DON said they do weekly rounds to ensure the sharps containers are checked and changed, but she also said it was her expectation that the nurses assigned to the med carts or treatment carts also check it regularly and change it as needed. The DON stated they have a biohazard room which is secured, and all biohazard material should be sent there for disposal. The DON said it is not approved for anyone to leave sharps in a metal bin without the inner red puncture resistant container. The DON said that a potential negative outcome to leaving sharps in an unsecured location would be a resident could have an accidental needle stick or injury from the cart which is also an infection control issue. She stated the used syringe was identified as a Lovenox syringe. The DON identified the ADON as the facility infection preventionist. Record review of the undated facility Sharps Injury Prevention and Engineering Controls policy revealed: Policy: It is the policy of [this facility] to comply with OSHA regulations regarding sharps injury prevention. Purpose: To assist in decreasing the risk of workplace injury associates. Procedure: The community will focus on needlestick prevention by eliminating unnecessary needles and sharps wherever possible and not recapping needles. Puncture resistant, leakproof containers, color coded red will be utilized to discard contaminated items such as sharps, broken glass, scalpels, lancets, or other items that could cause a puncture wound. The Wellness Director will inspect, maintain, and replace sharps disposal containers to prevent overfilling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675533 If continuation sheet Page 2 of 5 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 675533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Spicewood Summit 4401 Spicewood Springs Rd Austin, TX 78759 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 Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Hall 100-A to 108A) of 3 halls reviewed for infection control practices. Residents Affected - Few The facility failed to remove an exposed blood soiled scalpel, needle, syringe, and 2 lancets from an unlocked and opened metal sharps container holder with no red, puncture resistant, leak-proof safety container insert on a wound treatment cart. These failures could place residents and staff at risk for blood/ bodily fluid exposure, contamination, and the spread of infection. Findings included: An observation on 05/07/24 at 11:15 AM, on Hall 100-A to 108-A a wound treatment cart was seen with its metal biohazard sharps containment door unlocked and wide open; there was not a red, puncture resistant, leakproof safety container insert in the metal containment and there were 5 items observed sitting at the bottom of the metal exposed containment which included an exposed size 15 scalpel with blood visible on the blade, 2 lancets, a needle, and a used medication syringe. The bottom of the metal container and its door were soiled with a dark yellow substance that appeared tacky and viscous in texture . An observation and interview with the ADON on 05/07/24 at 11:23 AM, revealed that the ADON and wound care physician were doing wound care rounds and the ADON stated it was the wound care physician who placed the sharps items in the unlocked open containment box. The ADON stated it was her expectation that all metal containments on the med carts or wound treatment carts remain secured (locked) and hold a red, puncture resistant, leak-proof safety container insert were sharps can be safely disposed of. The ADON stated that any of the nurses can replace the red inserts and dispose of full containers properly in the biohazard room. She stated she should have caught that considering she was doing the wound treatment rounds that day with the wound treatment doctor which happens every Tuesday. The ADON stated that a potential negative outcome to residents by leaving sharps in an open unsecured location is the potential for somebody to get a hold of them which would lead to an accidental stick or injury. The ADON was observed pushing the wound treatment cart to the nurse's station where she said she would dispose of the sharps items properly and clean the metal containment bin. An interview with the DON (who was also filling in for the Administrator that day) on 05/07/24 at 03:05 PM she stated it was her expectation that there was an individual biohazard container on every cart and that they be used according to policy. The DON said that every metal container should have the inner red insert and the metal container should be clean and sharps should be disposed of appropriately in the inner puncture proof container which should also be removed when full and changed. The DON said they do weekly rounds to ensure the sharps containers are checked and changed, but she also said it was her expectation that the nurses assigned to the med carts or treatment carts also check it regularly and change it as needed. The DON stated they have a biohazard room which is secured, and all biohazard material should be sent there for disposal. The DON said it is not approved for anyone to leave sharps in a metal bin without the inner red puncture resistant container. The DON said that a potential negative outcome to leaving sharps in an unsecured location would be a resident could have an accidental needle stick or injury from the cart which is also an infection control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675533 If continuation sheet Page 3 of 5 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 675533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Spicewood Summit 4401 Spicewood Springs Rd Austin, TX 78759 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few issue. She stated the used syringe was identified as a Lovenox syringe. The DON identified the ADON as the facility infection preventionist. Record review of the undated facility Infectious waste, Handling Of policy revealed: Purpose: The purpose of this procedure is to provide a definition of and guidelines for handling infectious waste. Procedure: Infectious waste includes human blood and blood soiled articles, contaminated items (i.e., soiled dressings), items contaminated with feces body fluids and disposable sharps (i.e., needles/ scalpels). Sharps are considered infectious waste, placed in approved sharps containers, and sent for eventual incineration. Disposable items contaminated with residents' excretions or secretions must be placed in red plastic bags, sealed, and placed in biohazard storage until removal from premises. Disposable items soiled with visible blood or feces will be placed in red plastic bags or containers and placed in biohazard storage until removed from the premises. Biohazard storage will be locked when not in use. Record review of the undated facility Infection Control policy revealed: Policy: The community has an established policy and procedure related to Infection Control and Infection Prevention. Purpose: To assist in preventing the spread of infection. Procedure: The Wellness Director in coordination with the Executive Director is responsible for infection control and infection prevention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675533 If continuation sheet Page 4 of 5 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 675533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Juniper Village at Spicewood Summit 4401 Spicewood Springs Rd Austin, TX 78759 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 Associates will be educated related to all infection control procedures including personal hygiene requirements. Residents Affected - Few The community will follow guidelines for the prevention and control of Nosocomial Infections and standard precautions as provided by the Centers for Disease Control and Prevention in Atlanta Georgia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675533 If continuation sheet Page 5 of 5