Health inspection·September 20, 2024

F 0758 - Alprazolam 0.25 mg was administered prn on 8/21/24. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 9/19/24 at 11:01 a.m., Resident #11 was observed in bed awake and alert. Resident #11 stated she needed the anxiety medication sometimes. Residents Affected - Few On 9/19/24 at 12:02 p.m., during an interview, LVN A disclosed that she had previously given Alprazolam to Resident #11 to help with anxiety. LVN A explained that psychotropic medications like Alprazolam should be used for a limited time, usually up to 14 days. After 14 days, the nurse is required to contact the physician to reassess the resident's need for the medication. LVN A was unsure why the order for Alprazolam for Resident #11 was written for an indefinite period, and she expressed concern that the resident was at risk of falls by taking the medication for more than 14 days. During an interview and record review on 9/20/24 at 11:19 a.m., the Director of Nursing (DON) revealed that Resident #11 required the use of Alprazolam as recommended by the physician due to the resident's diagnosis. The DON stated that if the medication was taken all the time, it could result in Resident #11 being overmedicated. After reviewing Resident #11's order summary, the DON confirmed that there was no stop date on the order for prn Alprazolam. The DON revealed that the order for Alprazolam was possibly overlooked, as Resident #11 had transferred from assisted living to skilled nursing on 8/12/24, and a different set of regulations apply in skilled nursing. The DON stated that she was currently responsible for overseeing that psychotropic drugs are limited to 14 days, and her Assistant Director of Nursing (ADON) was to start monitoring this monthly moving forward to prevent this from occurring again. Record review of the facility policy and procedure titled, Policy and Procedure for Psychotropic medication use, dated 2001, updated July 2022, revealed in part, PRN orders for psychotropic medication are limited to 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 2 of 4 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 676198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Querencia at Barton Creek 2500 Barton Creek Blvd Austin, TX 78735 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 kitchens. Residents Affected - Some The facility failed to ensure staff (the cook) covered their facial hair with a hair restraint in the main kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 09/18/2024 at 9:57 a.m. revealed the [NAME] in the main kitchen at the serving line placing uncovered sauces on the serving table while not wearing a beard restraint properly. The [NAME] was observed to have his facial hair restraint down around his neck. The [NAME] upon noticing the state surveyor placed his facial hair restraint over his mustache and beard. During an interview on 09/18/2024 at 10:04 a.m. with the [NAME] he stated staff were to use beard guards (facial hair restraints) so hair did not go into the food. The [NAME] further stated it prevents cross contamination. The [NAME] stated the beard guard (facial hair restraint) was to be worn when handling food or doing prep. During an interview on 09/19/2024 at 11:00 a.m. the Culinary Director stated the [NAME] was currently on a disciplinary action plan from August related to the [NAME] not wearing a facial hair restraint. The Culinary Director further stated due to the [NAME] not wearing his beard restraint properly on 09/18/2024 and having been written up regarding the issue previously a final disciplinary notice was issued. The Culinary Director stated the staff were to wear beard restraints (facial hair restraints) anytime they were handling and prepping food. During an interview on 09/20/2024 at 10:08 a.m. with the Culinary Director he stated hair restraints and facial hair restraints were to be worn to prevent hair from falling in the food or any other sort of contaminate that might be on the beard. The Culinary Director further stated hair falling into the food could cause food poisoning and many other issues. During an interview on 09/20/2024 at 10:16 a.m. the Dietician stated anytime staff were dealing with food items hair restraints should be used. The Dietician further stated hair and facial hair restraints were important in keeping hair out of the food during prep and service. Review of facility's policy Orientation and Education, Subject: Uniform Dress Code, revised date 01/2024, read Procedures: Associates Working with Food: Wear approved hair restraints when on duty regardless of length or presence of hair. The only exception is to remove hair restraints when delivering trays to patients/residents . Restrain all facial hair with a beard net/restraint. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 3 of 4 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 676198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Querencia at Barton Creek 2500 Barton Creek Blvd Austin, TX 78735 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 4 of 4