Inspection·July 28, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy and procedure titled Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy (undated) revealed According to CMS's RAI Version 3.0 Manual; the MDS is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The items in the MDS standardize communication about the resident problems and conditions, within nursing homes, between nursing homes and outside agencies .Federal regulations require that the assessment accurately reflects the resident's status. Event ID: Facility ID: 675980 If continuation sheet Page 2 of 9 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 675980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Dripping Springs 1505 W Hwy 290 Dripping Springs, TX 78620 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 - Some 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. Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys in 2 medication carts of 3 medication carts (the Nurses Medication Cart and the Treatment Cart) reviewed for medication storage, in that; The facility failed to ensure the Treatment Cart was locked when it was left unattended in the common area of the 200-hallway; and the facility failed to ensure the Nurses Medication Cart was locked when it was left unattended on two different occasions in a common area near the nurses' station. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 7/25/2023 at 3:38 PM, the Nurses Medication Cart was unlocked and unattended. The Nurses Medication Cart had prescription and over the counter medications in the drawers. The top drawer also had 3 plastic souffle cups with several pills in each souffle cup. Staff, visitors, and residents were in the immediate vicinity of the unlocked and unattended Nurses Medication Cart. This surveyor reviewed the contents of the unlocked drawers of the Nurses Medication Cart for approximately 4 minutes before being approached by facility staff. The nurse determined to be responsible for the unlocked and unattended Nurses Medication Cart was sitting at the far end of the nurses' station at a computer facing away from the cart. In an observation on 7/27/2023 at 2:18 PM, the Nurses Medication Cart was unlocked and unattended. The Nurses Medication Cart had prescription and over the counter medications in the drawers. Staff, visitors, and residents were in the immediate vicinity of the unlocked and unattended Nurses Medication Cart. The nurse determined to be responsible for the unlocked and unattended Nurses Medication Cart was sitting at the far end of the nurses' station facing away from the cart. In an observation on 7/27/2023 at 2:25 PM, the Treatment Cart was unlocked and unattended on the 200-hallway. A nurse was observed walking away from the cart and out of sight from the Treatment Cart. The Treatment Cart had a sheet of parchment paper spread out on the top of the cart, with a souffle cup of an unidentified ointment in it, along with gauze pads in a small plastic cup dampened with an unidentified fluid. The Treatment Cart had prescription and over the counter medications in it. Residents and visitors were in the immediate vicinity of the unlocked and unattended Treatment Cart. In an interview on 7/25/2023 at 3:45 PM, RN B stated she was responsible for the Nurses Medication Cart. RN B stated she had prepared the medications in the souffle cups and had not yet dispensed them for the following reasons: Residents were in a Resident Council Meeting called by another surveyor; RN B did not want to interrupt the prayer session one resident was engaged in; RN B stated some of the residents were new to her case load and she did not realize they would not be attending the Resident Council Meeting due to COVID-19 transmission based precautions (droplet isolation precautions) at the time. RN B stated she knew no one had messed with the medications in the souffle cups because she was very familiar with her case load, and RN B was the nurse who had pulled the medications. RN B stated the Nurses Medication Cart was unlocked and unattended for less than 2 minutes while she was consulting the computer for resident records. RN B stated she knew the facility policy was to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 3 of 9 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 675980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Dripping Springs 1505 W Hwy 290 Dripping Springs, TX 78620 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 - Some ensure medication carts were locked when not in active use. RN B stated she could not get back to the cart fast enough to prevent this surveyor from opening the drawers. RN B could not tell this surveyor how long the drawers had been opened. RN B declined to answer if there was any risk to residents or visitors having access to prescription or over the counter medications. In an interview on 7/26/2023 at 1:45 PM, the DON stated the facility policy was for medication carts to be locked when not in use. The DON stated her expectation is that the nurse or medication aide lock the cart as soon as they are done with it. The DON stated that a negative outcome could occur if a person took or used a medication found in the cart inappropriately. The DON stated that an In-Servicing on the topic of ensuring the cart is locked when not in used had been initiated as a refresher for nurses and medication aides. The DON stated she and the current ADON both did random spot checks of the medication carts for security. In an interview on 7/27/2023 at 2:20 PM, RN D stated she was responsible for the Nurses Medication Cart. RN D stated she thought she had pushed in the lock before she went to make a temporary name badge with the tape she had in the drawer and needed a permanent marker from a drawer on the far side of the nurses' station in order to write her name. RN D stated the cart had been left unlocked and unattended for less than 30 seconds. RN D stated she knew the facility policy was to lock the medication cart if you were walking away. RN D stated anything could happen if a resident, staff, or visitor took a medication not prescribed to them or used it in the wrong way. In an interview on 7/27/2023 at 2:25 PM, LVN D stated she was responsible for the Treatment Cart. LVN D stated she thought she would be close enough to see the Treatment Cart as she went to the nurses' station to obtain a roll of trash bags that she would need to provide wound care to her assigned residents. LVN D stated she did not expect any of their residents would take anything off the top of the Treatment Cart as we don't have those kinds of behaviors here. In an interview on 7/27/2023 at 5:40 PM, the ADM stated he was not happy that the medication carts were observed unlocked after the first cart was found unlocked several days ago. The ADM stated training had been initiated and random checks would be made going forward. The ADM stated he expected the medication carts to be locked except when being used. In an interview on 7/28/2023 at 10:10 AM, LVN E stated he would be assuming the role of ADON soon. LVN E stated the medication carts should be secured when not being used. LVN E stated this would prevent anything from happening. Review of the facility policy entitled, Medication Ordering, Receiving and Storage, dated 4/01/2011, revealed a policy statement that the facility, shall store all medication .in a safe secure, and orderly manner. Under General Guidelines in step 7.) Compartments containing medications and biologicals shall be locked when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 4 of 9 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 675980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Dripping Springs 1505 W Hwy 290 Dripping Springs, TX 78620 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 maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 22 residents (Resident #13) reviewed for accurate medical records, in that: Resident #13's electronic medical record inaccurately care planned an anti-convulsive medication as an anti-Parkinson's medication. This failure could cause confusion about the residents diagnoses and place residents at risk for harm due to inaccurate records. The findings included: Record review of Resident #13's face sheet dated 7/27/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs), paraplegia unspecified (a type of paralysis that affects movement of the lower half of the body), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar/glucose), cognitive communication deficit, and essential hypertension (abnormally high blood pressure that is not the result of high blood pressure). Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, which indicates the resident was cognitively intact, and she requires extensive assistance of 2 staff members with bed mobility, dressing, and toilet use. Record review of Resident #13's care plan revealed a care plan initiated 7/26/2022, noting, The resident is on anti-Parkinson's therapy (medication used to treat Parkinson's disease-a disorder of the central nervous system where nerve cell damage causes dopamine levels to drop) Depakote (an anti-convulsant, dopamine antagonist used to treat seizures and bipolar disorder) r/t bipolar disorder. Review of Resident #13's diagnoses listed in the resident electronic record revealed the resident did not have Parkinson's disease. In an interview on 7/27/2023 at 11:10 a.m. with the DON she reported she created the care plan for Resident #13's bipolar disorder and prescribed Depakote. The DON reported she was aware that Depakote was an anti-convulsant medication that could also aide in mood stabilization of bipolar disorder. The DON reported the computer generates the care plans and there was not an option for anti-convulsant medication. The DON reviewed Resident #13's care plan and reported she was able to correct it. In an interview on 7/27/2023 at 11:20 a.m. with the DON she reported she created the care plans based on Resident #13's record and diagnoses, and that a corporate nurse completed the MDS. The DON reported there could be some confusion with the resident's care due to referring to the resident's anti-convulsive medication as an anti-Parkinson's medication when Resident #13 did not have Parkinson's disease. Review of an In-Service Training Report, not dated, provided by the facility revealed, Care plans (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 5 of 9 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 675980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Dripping Springs 1505 W Hwy 290 Dripping Springs, TX 78620 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 should be developed for each resident that reflects an accurate picture of the resident's needs and should always be resident specific. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 6 of 9 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 675980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Dripping Springs 1505 W Hwy 290 Dripping Springs, TX 78620 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections, in that; Residents Affected - Few The facility failed to ensure that staff sanitized the blood pressure cuff between 2 of 3 residents (Resident # 44 and Resident #18) to prevent cross contamination. This deficient practice had the potential to affect residents in the facility by placing them at risk of contracting, spreading and/or exposing them to pathogens that could lead to the spread of communicable diseases. The findings included: Record review of the quarterly MDS assessment dated [DATE], revealed Resident #44 was a [AGE] year-old female admitted on [DATE]. Primary medical condition was debility related to cardiorespiratory conditions. Other active diagnoses included hypertension. Record review of the quarterly MDS assessment dated [DATE], revealed Resident #18 was a [AGE] year-old female admitted on [DATE]. Primary medical condition was non-traumatic brain dysfunction. Other active diagnoses included hypertension. In an observation on 7/26/2023 between 6:54 AM and 7:28 AM, MA F was observed to not sanitize a blood pressure cuff between residents (Resident # 44 and Resident #18) who needed to have their blood pressure assessed before administering medications. In an interview on 7/26/2023 at 7:34 AM, MA F stated she was not aware of any of the residents to whom she had administered medications that morning who might have a communicable illness. MA F stated it was possible that any of the residents might be asymptomatic for a contagious illness such as COVID as it could take several days before symptoms appeared. MA F stated she was unaware of any policy or procedure that required her to sanitize the blood pressure cuff or other equipment between residents. MA F stated she would check with her supervisor on how to sanitize the blood pressure cuff between residents. In an interview on 7/26/2023 at 1:45 PM, the DON stated the facility policy was for multiuse equipment to be sanitized after each use to ensure cross contamination did not occur. The DON stated when she first learned of an issue with the blood pressure cuff she misunderstood it as an issue with calibration of the blood pressure cuff, but now that she understood it was an issue of cleaning the blood pressure cuff between residents, she would initiate an In-Service as a refresher to the nurses and medication aides. The DON stated her expectation was that equipment be cleaned after each resident to prevent the spread of illness. Review of an undated facility policy entitled Cleaning, Disinfection and Sterilization revealed the following policy statement: Supplies and equipment will be cleaned immediately after use. Review of In-Service dated 7/28/2023, entitled Sanitizing Equipment Between Residents revealed the following Practice Standards: All staff are responsible for cleaning all direct patient care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 7 of 9 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 675980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Dripping Springs 1505 W Hwy 290 Dripping Springs, TX 78620 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 equipment between patient use Under Procedure, in step 2f. Medical equipment used between patients such as pulse oximeter probes, thermometers, blood pressure cuffs .will be cleaned between patients. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 8 of 9 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 675980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Dripping Springs 1505 W Hwy 290 Dripping Springs, TX 78620 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 0908 Keep all essential equipment working safely. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stovetop grill in the kitchen reviewed for essential equipment. Residents Affected - Many The facility did not ensure the stovetop grill was in working order. This failure could place the residents at risk of not having safe operating equipment. Findings included: During an observation on 7/26/2023 at 12:22 p.m. in the kitchen, there was a large grill on the stovetop. Further observation of the grill revealed a hand-written sign, Grill out of order. During an interview on 7/26/2023 at 12:23 p.m. with [NAME] #G revealed the stovetop grill had not worked for about a month. During an interview on 7/26/2023 at 4:35 p.m. with the facility owner he reported, This was the first time I heard about this. He reported he would investigate it. During an interview on 7/26/2023 at 4:35 p.m. with the Maintenance Director he reported he was aware the stovetop grill was not working, reporting, They don't use it. The Maintenance Director reported the staff used the 2 small burners next to the grill and they had a small, portable grill they used. During an interview on 7/27/2023 at 12:02 p.m. with the Administrator he reported he knew the stovetop grill was not working, stating, I did not realize it had been that long that the grill had not been working. During an interview on 7/28/2023 at 1:23 p.m. the Administrator reported he did not have a policy that addressed essential equipment in operating condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 9 of 9