Health inspection·September 26, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #45's admission Record dated 09/25/2024 revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #45's medical diagnoses included Alzheimer's disease (brain disorder that gets worse over time), constipation, type 2 diabetes mellitus without complications (high blood sugar), hyperlipidemia (high cholesterol), delirium (a state of confusion), psychotic disorder with hallucinations and delusions, Schizophrenia (mental disorder), heart failure, depression, insomnia (difficulty sleeping), and disturbances of salivary secretions (blockage of a salivary gland). Record review of Resident #45's Quarterly MDS assessment dated [DATE] revealed that Resident #45 had a BIMS score of 99 indicating the resident was unable to complete the interview. The MDS also revealed that Resident #45 required maximal assistance with feeding. Record review of Resident #45's care plan dated 07/14/2024 revealed that resident was dependent on one staff for eating. Review of Resident #10's face sheet dated 09/26/2024 revealed a [AGE] year old female admitted initially on 07/22/2022 with diagnoses of bipolar disorder (mental illness that causes extreme shifts in mood, energy and activity levels), paraplegia (chronic condition that involves loss of motor or sensory function in lower body, including the legs, feet and toes), and chronic kidney disease (a condition that occurs when the kidneys are damaged and can't filter blood properly). Review of Resident #10's annual MDS assessment dated [DATE] revealed resident had a BIMS score of 15 which indicated she was cognitively intact. Review of Resident #10's care plan dated 04/04/2024 revealed resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. Further review revealed Resident #10 had an ADL self-care deficit related to paraplegia and required assistance with 1-2 staff for bathing and dressing. Review of Resident #41's face sheet dated 09/26/2024 revealed a [AGE] year-old female initially admitted on 0007/2022 with diagnoses of Alzheimer's disease (brain disorder that gradually destroys memory and thinking skills), anxiety disorder (mental health condition that cause uncontrollable and excessive feelings of fear or anxiety), and dementia (a progressive condition that causes a decline in cognitive abilities). Review of Resident #41's quarterly MDS assessment dated [DATE] revealed resident was unable to complete BIMS. Further review revealed Resident #41 had a memory problem and her cognitive skills for daily decision making were severely impaired. Further review revealed resident had an ADL self-care deficit related to Alzheimer's and dementia with interventions that she required assistance with dressing. Review of Resident #41's care plan dated 10/03/2023 revealed that Resident #41 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. Observation of lunch dining services on 09/24/2024 at 12:35pm revealed that Resident #45's meal tray was placed in front of him by LVN B. Staff then walked off and did not come back to feed the resident until 12:43pm. At 12:39pm Resident #45 was observed trying to get his food so he could eat. Observation of lunch dining services on 09/24/2024 at 12:39pm revealed Resident #7's meal tray was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 2 of 20 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 09/26/2024 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 0550 placed in front of her and uncovered by CNA C. Staff did not come back to feed her until 12:46pm. Level of Harm - Minimal harm or potential for actual harm Observation on 09/25/2024 at 10:58 AM revealed Resident #7 was taken by CNA E in a shower wheelchair down the hall to the shower room. Further observation revealed that Resident #7's side of her leg up to her thigh and lower back was exposed through the shower chair. Residents Affected - Some Observation on 09/25/2024 at 11:00 AM revealed Resident #10 was taken by CNA F from the shower room in a shower wheelchair to her room. Further observation revealed Resident #10 had a towel wrapped around her body with her lower back and upper buttock exposed through the shower wheelchair. Observation on 09/24/2024 at 1:22 PM revealed Resident #41 sat in a common area without pants. Resident's brief was visible as well as her thigh and the side of her calves. An interview with Resident #7 on 09/24/2024 at 9:45am was unsuccessful resident did not respond to surveyor. She just looked at the surveyor. An interview with Resident #45 on 09/24/2024 at 12:39pm was unsuccessful, resident just continued to try to get his food. An interview with the ADM on 09/26/2024 at 10:36am revealed all staff have been trained on resident rights. He stated that the policy for feeding residents who need assistance was that staff were to alert the resident, give them a bite and the meal tray was not to be uncovered until staff were ready to feed the resident. He said that staff were to give the residents who could feed themselves their tray first and then go back and give the residents who need assistance feeding their tray. He said staff were to sit down and feed the resident when the resident got their tray. He said if staff did not feed the resident when he or she got their tray the resident could get missed or not eat at all. He said that the resident would probably feel left out or get upset if staff put their tray in front of them and did not feed them. He said the charge nurse was responsible for overseeing the residents got fed. He said that the nurses monitor this by observation only. He said he did not know why the residents had to wait to be fed. During an interview on 09/24/2024 at 1:25 PM, Resident #41 was unable to answer simple questions and was confused. During an interview on 09/26/2024 at 11:10 AM, CNA E stated that the process for showers was to get the resident's clothes ready and put them in a clean bag. CNA E stated that if a resident utilized the Hoyer Lift they were wheeled down to the shower room in the shower chair. CNA E stated that the residents are undressed for their shower in their rooms. CNA E stated that there is a shower cover and that the shower cover was supposed to cover the resident. CNA E stated that only the shower cover was supposed to be on and cover their whole body. CNA E stated that was no need to use sheets to cover the residents. CNA E stated that no part of their skin was supposed to be exposed and this included the resident's lower back. CNA E stated that residents were supposed to have clothes on in the common areas and dining room and this includes bottoms, and their brief should not be exposed. During an interview on 09/26/2024 at 11:20 AM, CNA F stated that staff helped residents get undressed in their room before their shower. She stated that a shower cover is put over the resident and they were not supposed to leave their shirt on. She stated that the shower cover should cover all the resident and no part of the skin should be visible when they were taken to the shower room. CNA F stated that residents are supposed to be dressed for the day and this included to have pants on. CNA F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 3 of 20 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 09/26/2024 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 0550 stated that resident should not be in just their brief in the dining room or common areas. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/26/24 at 11:26 AM LVN A stated residents were undressed in their room before they were taken to the shower room. LVN A stated that the residents top was usually left on, and the shower cover is put over them. LVN A stated that the shower cover was supposed to cover all their skin and no part of the resident was supposed to be exposed and this included their lower back. She stated that the shower cover went down to the resident's knees. LVN A stated that residents were supposed to have clothes on in common areas and this included bottoms. LVN A stated that residents should not be in their brief in the dining room. Residents Affected - Some During an interview on 09/26/24 at 11:44 AM SS H stated when residents are being transferred to a shower, they were supposed to be fully covered. SS H stated that it was imperative that they were covered completely because they may have to go from one hall to another and go through common area. SS H stated that the harm would be that they would not have their dignity, privacy and common courtesy. SS H stated that no one would have wanted anyone to see them without clothes. SS H stated that residents should have their shirt and pants on when in the common areas. SS H stated that residents should not be in common areas in just a brief. An interview with LVN A on 09/26/2024 at 1:15pm revealed that she had been trained on resident rights. She stated the policy for assisting resident with meals was that staff were to pass all the trays to the residents and if a resident needs assistance with eating their food was to stay covered until the staff could feed the resident. She said if staff put the resident's food in front of them, they could get burned or their food could get cold. She said she did not know how it could make the resident feel because the ones that need help feeding cannot talk. She said she did not know why the residents had to wait to get fed or why the meal tray for Resident #7 was uncovered. An interview with CNA C on 09/26/2024 at 1:54pm revealed she had been trained on resident rights. She stated the policy for feeding residents that needed assistance was as soon as the tray was delivered to the resident, staff were to sit down and help the resident eat. She said that if staff put the resident's tray down in front of them and walked off the resident may not get fed. She said staff not feeding the resident when he or she got their tray could make the resident feel bad. She said staff should never put the resident's meal tray down in front of them and walk off without feeding the resident. She stated that she did not know why staff did not sit and feed the residents when their meals were delivered. An interview with the DON on 09/26/2024 at 2:18pm revealed she had been trained on resident rights. She stated that staff were to pass the meal trays and keep them covered until staff were ready to feed the resident. She said that if the meal tray was put down in front of the resident and staff walked off without feeding the resident, the food could get cold. She also said that if the food sat too long the resident could get sick. She said the resident could get hungry and upset as well. She said the resident may wonder why staff are not feeding them. She said she would hope that the staff were explaining to the resident what was going on. She stated she did not know why the resident's food was uncovered and both residents had to wait to be fed. She said that all of management were responsible for monitoring that residents were being fed. She stated that management monitors by checking the dining rooms to ensure that there were enough staff. During an interview on 09/26/24 at 02:26 PM the DON stated that it was her expectation that residents should be clean, their hair should be neat they should be shaved, and their outfit should be clean for the day. The DON stated that the residents should be wearing clothes and she would not expect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 4 of 20 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 09/26/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a resident to just be in their brief. The DON stated that residents should not be in their brief in the dining room or common area. The DON stated that when residents are being taken to and from the shower, she expects that the was resident is fully covered. She stated that the resident's dignity would be at risk if they were exposed or in only their brief. During an interview on 09/26/24 at 02:37 PM the ADM stated that he expected that residents be put together for the day, and this included hygiene and hair made. He stated that they should not be in only their brief and he would expect the residents to be the way he would want his mom or grandparent to be presented. The ADM stated that it was not acceptable to be able to see their brief in common areas. The ADM stated that he expected residents be fully covered going to and from the shower. The ADM stated that the top of their buttock, lower back and sides should not be showing. The ADM stated that the potential harm was that going down the hall there may be people around and the resident could be embarrassed if they are exposed. Review of facility in-service dated 02/14/2024 reflected that resident rights were reviewed which included that resident had the right to privacy and dignity. Review of facility policy titled Resident Right- Respect, Dignity/Right to have Personal Property dated 10/24/2022 reflected it is the policy of the facility to provide care and services in such a manger to acknowledge and respect resident rights. Further review revealed that residents have the right to be treated with dignity. Record review of Feeding the Resident Policy revealed the purpose of this policy was to provide nourishment to all who cannot or will not feed themselves. The policy did not cover feeding the resident as soon as the tray is passed. The policy is as followed. 1. Wash hands 2. Bring equipment and prescribed diet to bedside table or feeding table. 3. Identify resident and explain procedure. 4. Cover resident's upper body with bib to prevent soiling of clothing. 5. Alternate food offered. a. Make sure food and liquids are not hot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 5 of 20 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 09/26/2024 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 0550 b. Level of Harm - Minimal harm or potential for actual harm Make sure to follow thickened liquids per diet card. 6. Residents Affected - Some If feeding a resident who is paralyzed on one side, place food in the side of the mouth that is not paralyzed. 7. Allow resident time to finish, do not rush the resident. 8. Make sure the resident has had enough to eat or drink according to their diet, offer seconds or substitutes. 9. Wipe the resident's mouth and hands when they are finished eating. 10. Wipe any clothing that has been soiled with food or change clothing if necessary. 11. Wash hands 12. Report any unusual events such as coughing or choking or decreased intake to the charge nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 6 of 20 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 09/26/2024 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 3 of 5 residents (Resident #6, Resident #14, and Resident #50) reviewed for resident rights. Residents Affected - Few The facility failed to ensure Resident #6, Resident #14, and Resident #50's call lights were within reach on 09/24/2024. This failure could place residents at risk of needs not being met. Findings included: Record review of Resident #6's admission Record dated 09/24/2024 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included psychotic disturbance, mood disturbance, anxiety, seizures, cerebral infarction (long term effects of a stroke), type 2 diabetes mellitus with hyperglycemia (high blood sugar), heart failure, sleep apnea (breathing pauses while sleeping), weakness, seasonal allergies, vitamin D deficiency, anemia (not enough healthy red blood cells), insomnia (difficulty sleeping), hyperlipidemia (high cholesterol), hypertension (high blood pressure), hypothyroidism (excessive production of thyroid hormones), and gastroesophageal reflux disease without esophagitis (reflux). Record review of Resident #6's Quarterly MDS assessment dated [DATE] revealed Resident #6 had a BIMS score of 15, indicating resident was intact cognitively. Resident #6's MDS also revealed that the resident was dependent on staff for transfers and needed maximal assistance with bed mobility and toileting. Record Review of Resident #6's care plan dated 07/14/2024 revealed be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Record review of Resident #14's admission Record dated 09/26/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia (high blood sugar), cramp and spasm, insomnia (difficulty sleeping), depression, anemia (not enough healthy red blood cells), hypothyroidism (excessive production of thyroid hormones), hyperlipidemia (high cholesterol), dementia (memory, thinking, difficulty), bipolar (extreme mood swings), heart disease, allergies, gastroesophageal reflux disease without esophagitis (reflux), and repeated falls. Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed Resident #14 had a BIMS score of 15, indicating resident was intact cognitively. Resident #14's MDS also revealed that the resident was dependent on staff for transfers. Record Review of Resident #14's care plan dated 08/29/2024 revealed be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. A working and reachable call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 7 of 20 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 09/26/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #50's admission Record dated 08/12/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (memory loss), type 2 diabetes mellitus with hyperglycemia (high blood sugar), dementia (memory, thinking, difficulty), depression, anxiety, hypertension (high blood pressure), and angina pectoris (chest pain caused by reduced blood flow to the heart). Residents Affected - Few Record review of Resident #50's Quarterly MDS assessment dated [DATE] revealed Resident #50 had a BIMS score of 07, indicating resident was severely cognitively impaired. Resident #50's MDS also revealed that the resident was independent for transfers and bed mobility. Record Review of Resident #50's care plan dated 08/30/2024 revealed be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Observation of Resident #6 on 09/24/2024 at 9:00am revealed that the resident was sitting in her wheelchair watching television. Resident #6's call light was observed on the floor by the resident out of the residents reach. Observation of Resident #14 on 09/24/2024 at 11:03am revealed that the resident was sitting in her wheelchair approximately two feet from her bed. Resident #14's call light was hanging straight down to the floor with the bed pushed up against the wall. Observation of Resident #50 on 09/24/2024 at 11:05am revealed that the resident was in the bed laying down. Resident #50's call light was hanging straight to the floor and the bed was pushed up against the wall. An interview with Resident #14 on 09/26/2024 at 10:12am revealed that her call light is not always in her reach. She said that when she cannot reach her call light, she would get a hanger out of her closet and use it to pull the call light to her. She also said if the hanger does not work, she would try to get a staff member who is passing by. She said she does not get upset she would just figure out how to get the call light. An interview with Resident #6 on 09/26/2024 at 10:16am was unsuccessful. Resident #6 refused to talk to surveyor. An interview with Resident #50 on 09/26/2024 at 10:19 am revealed that half the time her call light was not in her reach. She stated when she could not reach her call light she would have to yell for help. She stated she gets upset and frustrated when her call light is not in her reach. An interview with the ADM on 09/26/2024 at 10:32am revealed that he had been trained on resident rights. He stated that the call light was to be always in the reach of the resident and available. He stated all staff were responsible for ensuring the call light was in the residents' reach. He said if the call light was not in reach of the resident, then the resident would not be able to call staff in an emergency or when they need something. He said he did not know why the residents' call lights were not in their reach. He said that the management staff were responsible for monitoring that the call lights are in the residents' reach. He said that they have a checklist that was filled out and given to him. An interview with LVN A on 09/26/2024 at 1:12pm revealed that she had been trained on resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 8 of 20 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 09/26/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm rights. She said that the call light had to be always in the reach of the resident. She said it should be placed next to the resident so they could have easy access to the call light. She said that if the call light is not in reach of the resident the resident could fall and that the resident used the call light for a reason. She said all residents were to have their call light in reach and she was not sure why the residents did not have their call lights in reach. Residents Affected - Few An interview with MA B on 09/26/2024 at 1:29pm revealed that he had been trained on resident rights. He stated that the policy was that the call light was to be always in the reach of the resident. He said that all staff were responsible for placing the call light in the reach of the resident. He said if the resident could not reach the call light they could fall or must yell out for help. He said that he thought that the call lights were not in the reach of the residents because everyone was running around, and it got missed. An interview with the DON on 09/26/2024 at 2:07pm revealed that she had been trained on resident rights. She said that the call light was to be in reach of the resident even if the resident was not in their bed. She said all staff were responsible for ensuring the call light was in the reach of the resident. She said if the call light were not in reach of the resident they could fall and injure themselves. She said that all of management were responsible for monitoring the call light placement. She said the facility monitors the call light placement by filling out the ambassador round sheet and giving it the ADM. Record review of Call Lights Policy not dated revealed the call light must always be within patients' reach. Record review of Ambassador Rounds Checklist revealed call light in reach and call light functioning were on the checklist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 9 of 20 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 09/26/2024 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 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 the resident's assessment accurately reflected the resident's status for 1 (Resident #11) of 4 residents reviewed for MDS assessments. Residents Affected - Few The facility failed to include Resident #11's psychiatric diagnose on his quarterly MDS and significant change MDS. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided. Findings included: Review of Resident #11's face sheet dated 09/26/2024 revealed an [AGE] year-old male with initial admission date of 09/01/2022 and with diagnoses of Alzheimer's disease, anxiety disorder, major depressive disorder, and atherosclerotic heart disease. Review of Resident #11's physician orders revealed order for Zyprexa with start date of 06/13/2024. Order revealed medication was indicated for Paranoid Schizophrenia. Further review revealed behavior monitoring order for Zyprexa to monitor for delusions and paranoia with start date of 06/06/2024. Review of Resident #11's significant change assessment dated [DATE] revealed a BIMS score of 12 which indicated he had a moderate cognitive impairment. Review of active diagnoses section on significant change assessment revealed neither bipolar disorder nor schizophrenia were selected as active diagnoses. Review of Active Diagnoses section on Resident #11's Quarterly MDS assessment dated [DATE] revealed anxiety disorder and depression were selected for psychiatric/mood disorders. Bipolar Disorder and Schizophrenia were not selected. Review of Resident #11's care plan with revision date of 06/06/2024 revealed Resident used an antipsychotic related to schizophrenia. Review of Resident #11's progress notes dated 06/2024 to 09/26/24 revealed no information regarding diagnosis change for Zyprexa. Review of Resident #11's psychiatric provider visit note dated 06/06/2024 revealed resident had some paranoia and delusions and changes would be made to help with symptoms of schizophrenia. Review revealed resident continued Olanzapine (Zyprexa) for Schizophrenia. Diagnoses included Paranoid Schizophrenia. Review of Resident #11's psychiatric provider note dated 06/13/2024 included resident would continue Olanzapine (Zyprexa) for Schizophrenia. Review of Resident #11's psychiatric provider note dated 07/18/24 included resident continued Olanzapine (Zyprexa for Schizophrenia). Review of Resident #11's psychiatric provider note dated 07/25/2024 included updated diagnosis of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 10 of 20 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 09/26/2024 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 0641 Bipolar for Olanzapine (Zyprexa). Level of Harm - Minimal harm or potential for actual harm Review of Resident #11's psychiatric provider note dated 08/01/2024 included Resident would continue Olanzapine (Zyprexa) for Bipolar. Residents Affected - Few Review of Resident #11's consent for antipsychotic medication treatment revealed that the consent for Zyprexa for bipolar disorder was signed on 07/25/2024 by the DON and NP. During an interview on 09/26/2024 at 9:55 AM, PNP she stated that Resident #11 was on Zyprexa for bipolar disorder. NP stated that she had changed the diagnosis for Zyprexa from Schizophrenia to bipolar disorder because she did not think the diagnoses was accurate. NP stated Resident #11 hallucinated, and had delusions, aggression and behavioral disturbances. She stated that Resident #11's Alzheimer's diagnosis could have contributed to his behaviors and that was why she revisited his diagnosis. NP stated that she believed it has been at least a month or two since she changed the diagnoses for Resident #11's Zyprexa. The NP stated that she talked to the DON about the change, and she also talks to nurses and the ADM about changes. During an interview on 09/26/2024 at 11:31 AM, LVN A stated that Resident #11's Zyprexa was for his schizophrenia and bipolar disorder. LVN A stated that Resident #11 had a diagnosis of schizophrenia and bipolar disorder. LVN A reviewed Resident #11's diagnoses list and stated that she did not see diagnoses of schizophrenia and bipolar disorder. LVN A reviewed Resident #11's order for Zyprexa and stated it was indicated for paranoid schizophrenia. LVN A stated that she would expect to see the diagnoses on the Resident's diagnosis list. LVN A stated she knew the resident had the diagnoses because of his behaviors. During an interview on 09/26/2024 at 11:38 AM he SW stated that Resident #11 was being seen by psychiatric provider for agitation and verbal abuse to staff. SW stated that Resident had a lot of behaviors. SW stated that he was seen weekly. SW stated that Resident #11's order read he was taking Zyprexa for Schizophrenia and that it was started in June. SW stated that they would not have attached the schizophrenia diagnosis to the order if the resident did not have the diagnosis. The SW stated that any diagnoses changes made by the psychiatric provider are communicated to the DON. The SW stated that Resident #11 did not have schizophrenia or bipolar disorder on his diagnoses list. The SW stated that she does not complete the diagnoses portion of the MDS. During an interview on 09/26/2024 at 11;31 AM, the DON stated that the MDS should have accurately reflected the resident's status. The DON stated that she does not complete the MDS, so she is unsure if the MDS accurately reflected a resident's status if it was missing diagnoses. The DON stated that information on the resident's care plan and MDS should match. The DON stated that information for the MDS assessment is gathered based off the assessment nurses completed and therapy provide to MDS coordinators. The DON stated that if a resident's order is indicated for a specific diagnosis, she would have expected it on the diagnosis list. The DON stated that she usually put a progress note in when updates are made. During an interview on 09/26/2024 at 2:37 PM, the ADM stated that he would expect a resident to have a diagnosis for which a medication was ordered. The ADM stated that the potential harm for a resident who received a medication but does not have a diagnosis for it would be an adverse effect. The ADM stated that the MDS assessment should include resident's diagnoses. The ADM stated that he expected the MDS assessment should accurately reflect a resident's status. The ADM stated that he expected resident's information on the MDS and care plan to be very similar. The ADM stated that there was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 11 of 20 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 09/26/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few corporate MDS that oversees what information goes on the MDS. The ADM stated that information and changes were gathered during weekly UR calls to review any updates. During an interview on 09/27/2024 at 10:34 AM, the regional MDS nurse stated that she made sure everything was completed on the MDS. She stated that the MDS automatically pulled information from the Resident's active diagnoses list. She stated that she expected that they were corrected and added on the list. She stated that if there were changes then it would have been reflected on the next MDS and pull it from the list. The regional MDS stated that any new psychiatric diagnosis is communicated by the SW. The regional MDS stated that they also review information from the hospital for any changes or updates. Review of undated facility policy titled Policy for Resident Assessments revealed a reassessment shall be performed to all substantial changes in the resident's condition. This policy and procedure shall ensure that staff consistently and accurately gathers information regarding resident needs, strengths, which provides the foundation for an individualized plan of care for each resident, developed by the Interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 12 of 20 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 09/26/2024 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 0679 Provide activities to meet all resident's needs. 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 provide an ongoing program of activities based on the comprehensive assessment to meet the interests and support the physical, mental, and psychosocial well-being of 4 of 4 (Residents #7, #13, #29 and #30) residents reviewed for activities. Residents Affected - Some 1. The facility did not provide Resident #7, , #29 and #30 with individual or group activities. These failures placed residents at risk for a decline in their physical, mental, and psychosocial well-being due to a lack of ongoing activities. Findings included: Review of the September 24-26 2024 Activity Calendar for the week of 09/01/2024- 09/07/2024 reflected the following: Tuesday 09/24/2024 08:45 Daily Chronicle word search 09:45 Exercise 10:00 Question of the day 10:30 Red Hat w/pop corn 2:00 Beading 3:00 Dominoes Group Wednesday 09/25/2024 08:45 a.m. Daily Chronical Word Search 09:45 Rosary 11:00 a.m. Music on request 02:30 Rummikub 3:00 pm Dominoes Group Thursday 09/26/2024 08:45 Daily Chronicle Word Search 09:45 Exercise (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 13 of 20 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 09/26/2024 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 0679 10:00 Question of the Day Level of Harm - Minimal harm or potential for actual harm 10:30 Bingo with [NAME] 02:00 p.m. Pretty Nails Residents Affected - Some 03:00 p.m. Dominoes Group Review of the 09/25/2024 face sheet for Resident #7 reflected a [AGE] year-old female had an original admission date of 09/18/2016 and re-admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Type 2 Diabetes Mellitus without complications, Hyperlipidemia (high cholesterol essential (primary) Hypertension (high blood pressure), Heart failure, Psoriasis (skin Disease), Hypothyroidism (excessive production of thyroid hormones, Alzheimer's disease (type of dementia that affects memory, thinking and behavior), Vitamin Deficiency, Constipation, Age-related osteoporosis without current pathological fracture, pain (joint pain), unspecified dementia (memory, thinking difficulty), , without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the annual MDS assessment for Resident #7 dated 08/08/2024 reflected a BIMS score of 00, indicating that the resident's cognition was too impaired to participate in the assessment. The MDS also revealed that the resident was dependent on staff for activities. Review of the care plan for Resident #7 dated 02/22/2019 reflected the following: Resident #7 is dependent on staff for meeting emotional, intellectual, physical and social needs r/t: cognitive deficits, physical limitations. Observation of Resident #7 on 09/25/2024 at 9:37 a.m. resident has been sitting in front of TV today after meals. Resident was not observed in any activities. Observation of Resident #7 on 09/25/2024 at 2:47 p.m. revealed the resident, sitting in front of TV again. Activity was scheduled for 2:30 p.m. and scheduled resident council for 2:30 p.m. as well. Resident along with other residents were sat by staff in front of the TV with no activity. At 3:10 p.m. Observed resident sitting in front of the TV. Review of the undated face sheet for Resident #29 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, Chronic obstructive pulmonary disease (chronic progressive lung disease), edema (swelling), Hypokalemia (low potassium), Chronic embolism and thrombosis of unspecified deep veins of left lower extremity (blood clot in blood vessels), Circadian rhythm sleep disorder (pause in heart during sleep), delayed sleep phase type, Bipolar disorder (severe mood disorder), constipation, major depressive disorder, recurrent, insomnia (difficulty sleeping) , Essential (primary) Hypertension (high blood pressure), Tachycardia (fast heart rate), Anxiety disorder, Anemia (not enough healthy red blood cells), Polyneuropathy (damage affecting the nerves) , and Allergic rhinitis (allergies). Review of the annual MDS assessment for Resident #29 dated 07/12/2024 reflected a BIMS score of 15 , indicating she is cognitively intact. Review of the care plan for Resident #29 dated 07/26/2022 reflected the following: Resident does not attend activities due to personal choice and/or acute/chronic medical condition. There was not an activity assessment completed for the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 14 of 20 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 09/26/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 09/24/2024 with Resident #29 at 08:42 am resident stated she does not attend activities because they are elementary style, and she just stays in her room. Reading books, knitting and doing crossword puzzles. Resident stated I would be more open to do them if they were higher level things, but they are not. So, I rather be alone in my room. Asked resident how she felt about not having group activities that met her interests and she voiced I don't care to be out with other residents. I prefer to stay in my room and do my own things such as knitting, watching TV and crossword puzzles. Review of the 08/29/2024 progress notes for Resident #29 reflected There is no change in residents' activity preferences. Observation on 09/24/2024 at 08:42 a.m. revealed Resident #29 was sitting up in bed watching TV. Observation on 09/25/2024 at 11:15 a.m. revealed Resident #29 was sitting up in bed watching TV and working on a cross word puzzle. No observations were made of Resident #29 involved in any group activities. Review of the face sheet for Resident #30 reflected an [AGE] year-old male admitted to the facility with an initial admission date of 10/03/2019 and a re-admission date on 3/15/2020 with diagnoses of other seasonal, allergic rhinitis (allergies), Bilateral Primary Osteoarthritis of knee (arthritis in the knee), Personal history of COVID-19, anxiety disorder, Atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), Left bundle-branch block (a delay or block of electrical impulses to the left side of the heart), and constipation. Review of the annual MDS for Resident #30 dated 06/27/2024 reflected a BIMS score of 10, indicating a moderate cognitive impairment. In section F (F0400) on his MDS assessment the resident was asked the following question: How important is it to you to do your favorite activities. Resident rated this question with a 1 indicating it is very important. Review of the care plan item for Resident #30 dated 3/15/2024 reflected the following: The resident is dependent on staff for meeting emotional, intellectual, physical and social needs related to impaired cognitive function/dementia. Resident's activity preferences are reading, nature, snacks and live entertainment. Resident has bonding with facility bird named Mango. He spends most of his time with his bird. Review of progress notes for Resident #30 dated 09/25/2024 reflected: There is no change in resident's activity preferences. Observation on 09/26/2024 at 09:29 a.m. resident #30 was sitting in common area where other residents were watching TV and he was sitting with the facility bird Mango. During an interview on 09/24/2024 at 11:49 a.m., Resident #30 stated he does not really have many activities to do here at the facility. Resident stated he used to work for a company where he was outdoors all the time. Asked the resident how he felt about not having many activities to do at the facility and how he felt about it, he responded they keep this place so clean, we can't really do much. During an interview on 09/26/2024 at 9:29 a.m., Resident #30 stated all we do here is sit and watch people. They keep the place so neat and clean. I would like to have activities outdoors such as a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 15 of 20 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 09/26/2024 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 0679 washer's game, with other residents. Level of Harm - Minimal harm or potential for actual harm In an interview on 09/24/2024 at 2:51 p.m., DON stated she has observed bed-bound residents listen to music in their room as an activity. DON verbalized that BINGO is an important thing at the facility. Residents Affected - Some In an interview on 09/24/2024 at 1:28 PM the Activities Director (AD). stated that bed bound residents are provided with music and hand massages on Fridays from her. AD stated that she is also charges the phone for bed bound residents so they can call their families AD explained that the activities calendar is color coded, black is regular activities, red is for popular activities and blue is for new activities. AD stated that she gets residents engaged in activities by asking residents that attend resident council for choices or ideas. AD stated that morning activities are provided in the morning because residents usually take naps in the afternoons. She has smaller group activities in the afternoon because of this reason. AD will be on vacation for the next 3 weeks; therefore, she will have volunteers coming in to assist with daily activities and when they cannot come in the resident council president will step in to provide daily activities for all the residents. When asked AD if resident #29 had other activities offered other than knitting, crossword puzzles and watching TV in her room. The AD replied Resident #29 doesn't come out of her room much, so I just give her things she requests, I bring her knitting materials and take her crossword puzzles if she asks for them. When asked AD if resident #30 got to go outside often, she voiced he likes to talk to our bird Mango and walk the halls. In an interview on 09/26/2024 at 9:55 a.m., CNA E stated she has observed residents doing BINGO and music for activities. But mainly BINGO. CNA E stated she has not seen residents that are bed-bound do any activities. In an interview on 09/26/2024 at 1:45 p.m., CNA F stated she has observed residents doing BINGO, exercises and on Mondays they do the bucks they earned, they turn them in for snacks, nail care, therapy takes them out to do activities to play volleyball. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 16 of 20 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 09/26/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 medication carts reviewed in that: The medication cart Contained 3 loose pills. These deficient practices could affect residents and result in a drug diversion due to medications not being properly disposed and secured. The findings were: Observation and interview with MA B on 09/25/2024 at 9:40 am of the medication cart Revealed 1 blue tablet in the right middle drawer. MA B was able to identify the 1 blue tablet as Zoloft. DON was standing next to the cart and made the same observation. Interview with MA B on 09/25/2024 at 09:45 am, he said that the loose blue pill indicated that a resident did not get their Zoloft medication today. MA B stated he holds onto the pill bags after he takes out the medications daily and places them in the middle drawer because of HIPAA rules. He said the medication bags have the resident identifiers on them. Therefore, the empty pill bags after given to the resident are placed in that drawer. MA B stated he may have missed a pill in a bag and that is why it is there. Observed MA B and DON on 09/25/2024 at 09:50 am immediately destroy the blue loose pill. DON verbalized it would be destroyed because they cannot pinpoint to whom it belongs. Observation with MA B on 09/25/2024 at 10:20 am of the medication cart for the whole building revealed 1 peach oblong tablet imprinted 68 and one peach round pill in the middle-left drawer. DON was standing next to the cart and made the same observation. The pills were immediately destroyed by both MA B and DON. Interview with MA B on 09/25/2024 at 10:20 am confirmed that there were 3 loose pills. MA B was able to identify 1 blue pill as Zoloft and 1 pink oblong tablet as Eliquis and 1 pink round tablet as Plavix. When MA B was asked if he knew why the pills were loose he voiced the blue pill was loose because it must have stayed in the package and he didn't notice. He then voiced the Eliquis and Plavix were probably loose because they are all smooshed in the cart. Interview with DON on 09/25/2024 at 10:30 AM confirmed there were loose pills in the medication cart for the whole building. DON stated the pink oblong and pink round tablet were probably loose in the cart because they are stored in pill packs and there are duplicates in that drawer which makes it tighter in such a small spot that the pill packs have so much pressure the pills come out of the packets. DON verbalized to MA B to take out all duplicates from the cart and place them in the medication room until needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 17 of 20 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 09/26/2024 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 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 and to help prevent the development and transmission of communicable diseases and infections for 4 (CNA D, HK G, MA B, and AD) staff members reviewed for hand hygiene. Residents Affected - Some HK G, CNA D, MA B, and AD failed to perform hand hygiene when performing tasks for or around residents and their environment. 1. HG failed to perform hand hygiene in between cleaning resident rooms and failed to remove gloves after cleaning in resident rooms. 2. CNA D failed to perform hand hygiene after she removed bagged dirty linen from a resident room and entered another resident's room and proceed to assist another resident. 3. MA B failed to perform hand hygiene in-between medication pass with residents and failed to sanitize a blood pressure cuff in-between resident use. 4. AD failed to perform hand hygiene before passing snacks to residents and after she touched her face and hair. These failures placed residents at an increased risk of exposure to infections to include COVID-19, decreased quality of life or hospitalization. Findings include: Observation on 09/24/2024 at 7:53 AM revealed MA B did not perform hand hygiene before he prepared medications for a resident. Further observation revealed MA B exited a resident room and did not perform hand hygiene. MA B prepared medication for another resident and did not perform hand hygiene prior to preparing medications. Observation on 09/24/2024 at 7:55 AM revealed MA B did not sanitize the community blood pressure cuff prior to it being utilized. Observation on 09/24/2024 at 8:05 AM revealed MA B did not perform hand hygiene prior to preparing medications for a resident. MA B utilized the blood pressure cuff on a resident and did not sanitize it prior to or after use. Further observation revealed MA B exited a resident room and did not perform hand hygiene prior to entering another resident room. Observation on 09/24/2024 at 8:18 AM revealed that MA B did not sanitize the blood pressure cuff and utilized it on a resident. MA B proceeded to exit the resident room and did not perform hand hygiene. Observation on 09/24/2024 at 10:48 AM, revealed HK G took gloves off after she exited a resident's room and did not perform hand hygiene. HK G then entered another resident's room to clean. Observation on 09/24/2024 at 10:51 AM revealed AD passed out snacks during an activity and did not perform hand hygiene in between residents. AD did not have gloves on while snacks were passed out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 18 of 20 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 09/26/2024 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 Level of Harm - Minimal harm or potential for actual harm Observation on 09/24/2024 at 10:54 AM revealed AD pushed hair out of her face and then proceeded to pass out snacks and drinks to residents in a common area without performing hand hygiene. Observation on 09/24/2024 at 10:57 AM revealed AD continued to pass out snacks and did not perform hand hygiene. Further observation revealed hand sanitizer was not present on the snack cart. Residents Affected - Some Observation on 09/25/2024 at 11:20 AM revealed CNA D exited a resident room with a bag of dirty clothes. CNA D placed the bag in the dirty clothes bin and did not perform hand hygiene. CNA D then entered another resident room. CNA D exited the resident room without performing hand hygiene and assisted another resident in their wheelchair. Observation on 09/26/2024 at 10:29 AM revealed HK G put on gloves and did not perform hand hygiene. HK G took out a resident's trash from their room and placed the trash bag in a cart. HK G kept the gloves on and proceeded to get the roommate's trash and placed the trash bag in the cart. Observation revealed HK G kept the same pair of gloves on and then proceeded to clean the residents' room with the gloves she took out the trash with. During an interview on 09/26/2024 at 10:36 AM, CNA D stated that they were supposed to perform hand hygiene anytime to enter a resident's room and when they exited a resident's room. She stated that they should clean their hands after they have taken dirty clothes or linen to the bin. CNA D stated that hands were also supposed to be cleaned after they removed gloves. During an interview on 09/26/2024 at 10:42 AM HK G stated that she has worked at the facility for 17 years. She stated that she had received training on hand hygiene and when to wash her hands. She stated that she used gloves, took them off, and washed them per room. She stated that when she was done cleaning the room, she was supposed to take off her gloves. During an interview on 09/26/2024 at 11:10 AM, CNA E stated that staff were supposed to perform hand hygiene often. She stated that staff should wash their hands after they remove gloves and after they take out dirty clothes. During an interview on 09/26/2024 at 11:20 AM, CNA F stated that staff were supposed to perform hand hygiene after they removed gloves. CNA F stated that they should also wash hands after removing dirty linen and after leaving a resident's room. During an interview on 09/26/2024 at 11:26 AM, LVN A stated that hand hygiene should be performed prior to going into a patient's room and after they exit. She stated that if they are taking out dirty linen or trash, hand hygiene should be performed after. LVN A stated that anytime they are going to work with a resident they should wash or sanitize their hands. During an interview on 09/26/2024 at 1:29 PM, MA B stated that he has worked here for almost a year. He stated that he had not been trained on hand hygiene when he first started. He stated that hand hygiene should be performed between every three residents during medication pass unless they are going to do nose or eye drop then they would wash their hands before and after. He stated that community supplies such as blood pressure cuffs are wiped down once a shift and that it is not usually cleaned in between residents. During an interview on 09/26/2024 at 2:07 PM, the DON stated that hand hygiene should be performed before starting anything with residents, in between gloves changes and if staff noticed their hands (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 19 of 20 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 09/26/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some are dirty. She stated that she expected hand hygiene also be performed when passing out snacks. The DON stated that blood pressure cuffs should also be sanitized in between resident use. The DON stated that hand hygiene should also be performed after gloves are taken off in between working with residents. During an interview on 09/26/2024 at 2:00pm, the ADM stated that he expected hand hygiene be performed before any treatments and in-between treating residents. She stated that hand hygiene should be performed when staff go from one resident to another. He stated that staff should not have the same gloves on from one resident to another after taking out their trash. He stated that community equipment such a blood pressure cuff should be sanitized in between each resident. He stated that the potential harm of not sanitizing or performing hand hygiene was the transmission of bacteria, illness and viruses and spreading germs. Review of undated facility policy titled Hand Washing revealed the purpose of hand washing is to decrease the risk of transmission of infection by appropriate hand hygiene. Further review reflected that hand washing is required before and after a procedure that involved direct or indirect contact with a resident, after contact with any wastes or contaminated materials, before handling any food or food receptacle, or at any time the hands are soiled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675980 If continuation sheet Page 20 of 20