Health inspection·September 5, 2025

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few outlined under Functional Assessment, Transfers = Max/2. Record review of Resident #1's incident report, dated 08/03/2025, revealed CNA A was helping Resident #1 to the restroom without the use of a gait belt and Resident #1 lost her balance as she was unable to bear weight and fell in the bathroom. LPCN B assessed Resident #1 immediately following the fall on 08/03/2025 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and responsible party was notified, and NP notified via copy of incident placed in provider box. CNA was not educated on significant change of 2x person assist as the care plan was not updated prior to care being provided. CNA A was suspended immediately pending the facility investigation and resigned from her position prior to facility concluding their investigation as she made false statements. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of Resident #1's physician order, dated 07/21/2025, reflected the following: PT/OT eval and treat for fall/ADLs. Record review of Resident #1's Physical Therapy PT Evaluation & Plan of Treatment, dated 07/30/2025, reflected the following: Functional transfers PLOF (prior level of function) was CGA (contact guard assist) and Resident #1's functional transfer baseline was Max/2 (highest level of assistance required for a transfer, performed w/ minimal help or no assistance at all). During an observation on 09/02/2025 at 12:15 PM Resident #1 was observed in the assisted dining room and staff was helping her eat. She was observed with her baby doll. Staff was communicating with resident, and she would not respond. She was observed trying to feed her baby doll her food. Resident #1 did not respond to surveyor. She was dressed well, groomed appropriately, and no odors. She was sitting in her walker with a food protector. During an interview on 09/02/2025 at 5:41 PM, DON stated the nurses should have completed assessments for 72 hours after the fall. If the nurses had done the ROM assessment post fall, they would have discovered the broken hip sooner or noted the pain Resident #1 was experiencing. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. During an interview on 09/03/2025 at 12:05 PM, CNA A stated she and other CNAs who cared for Resident #1 on 08/03/2025-08/05/2025 post-fall revealed Resident #1 was not her normal self after the fall on 08/03/2025. They stated she would not sit up in bed, did not eat and was not as interactive as usual. They stated they notified the charge nurse , but nothing was done for two days. They stated PRN Tylenol was administered. CNA A stated they believed the charge nurse was going to take care of concerns that were being addressed with them directly, so they did not go and speak to management. During an interview on 09/02/2025 at 1:38 PM, NP stated Resident #1 had advanced dementia and required assistance with most of her ADLs. He stated prior to this fall she was a 1 person assist transfer (as he was unaware of the recent change on 07/30/2025 to a 2x person transfer) and now he believed she was a 2x person assist transfer. The NP stated Resident #1 does have PRN Tramadol and was not having a lot of discomfort. He stated Resident #1 was s eating regularly, was doing well post operatively, was up in the wheelchair most of the day, and was participating in therapy. He stated this information does need to be passed along to the staff who work directly with the resident. During interviews on 09/02/2025 at 3:45 PM, CNA C stated he had been employed 18 months at the facility. He stated interventions to prevent falls includes skills check offs, review of the resident's electronic care plan (care plan), and monthly meetings. He stated he did not work directly with Resident #1 or Resident #2 and was not familiar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 2 of 24 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 09/05/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few with their care. During an interview on 09/02/2025 at 4:31 PM, CNA J stated she has been employed 6 months at this facility. CNA J stated she had received in-service training on ANE , falls, and use of gait belts. She stated staff needed to know about each resident's care plan and become familiar with their care if they are to provide them services. She stated she would review Resident #1's electronic care plan to determine if there were any changes prior to the start of her shift. She stated if she did see a change in the resident's care, she would see it documented in the electronic care plan. She stated she was not present when Resident #1 fell. During an interview on 09/02/2025 at 4:58 PM, CNA D stated she had been employed 6 months at this facility, was in-serviced on ANE, and provided examples of ANE. She stated she had also received in-services in the last 30 days on falls and gait belts. She stated she reviewed (care plan ADLs), to check if a resident was a mechanical lift, use of gait belt, 1x or 2x person assist. She stated she did not work with Resident #1 or Resident #2 directly and was not familiar with their care. During an interview on 09/02/2025 at 5:15 PM, RN C stated she had been in-serviced within the last 30 days and the ADM was the Abuse Coordinator. She stated she was in-serviced on safety precautions and fall provisions. She stated on her shifts she directs the aids to check the electronic care plan (care plan ADLs) for resident care information. She stated she did not work with Resident #1 or Resident #2 directly and was not familiar with their care. During an interview on 09/02/2025 at 5:41 PM, DON stated she was educated last month via online training site and she completed in-services regularly with nursing managers. She stated interventions or assistance needed to prevent falls included updating care plans, conducting in-services and education. She stated fall preventions that are usually in place for high-risk fall residents depends on what is in their care plan. She stated care plans are to be specialized in approach for each resident, it is a matter of what may benefit residents overall, each one is unique She stated Resident #1 was care planned as a 1x person transfer and staff are trained to use a gait belt with each transfer. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. During an interview on 09/03/2025 at 9:45 AM, CNA H stated she has been working at this facility for 2 weeks, she received training on ANE, falls, and gait belt use during orientation. She stated prior to her shift she is provided specific information of a resident and their needs. She stated she did not work with Resident #1 or Resident #2 directly and was not familiar with their care. During an interview on 09/03/2025 at 10:02 AM, RN E stated she has been employed with this facility for over 6 years, she stated she was in-serviced often, last month she completed in-service on ANE, and what to do during a fall. RN E stated staff should always check how the residents are transferred, review the care plan, determine if 1x or 2x person assist, or mechanical lift, make sure sling was the proper size for the resident, be aware of the care plan, always use body properly when transferring. During an interview on 09/03/2025 at 10:20 AM, CNA I stated she has been employed for 2 and 1/2 years at this facility. She stated she received training a few days back, completed videos on resident rights, what to do to prevent a fall, reporting, and ANE. She stated fall prevention interventions are in the electronic care plan and POC. She stated she did not work with Resident #1 or Resident #2 directly and was not familiar with their care. During an interview on 09/03/2025 at 10:40 AM, LPCN B stated she had been employed 2 years at this facility, she was in-serviced last month on ANE, reporting, and the Abuse Coordinator was the ADM. She stated last month she completed an in-service which covered precautions for falls. LPCN B stated the electronic care plan is available at the nurse's station, which has information of residents' needs and helps CNAs and CMAs with residents' level of care and if requires 1x person or 2x person transfer or mechanical lift was needed. She stated she was the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 3 of 24 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 09/05/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few charge nurse the day Resident #1 fell. She stated CNA A was helping Resident #1 to the restroom and Resident #1 lost her balance and fell in the bathroom. She stated she assessed Resident #1 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and she notified the responsible party, and the NP was notified via copy of incident placed in provider box. She stated she was off the next morning and when she returned, she was informed Resident #1's fall resulted in a fracture and surgery. She stated she received a write up - management stated no documentation for assessments, ROM, communication to the NP, and documentation was not thorough . She stated she was not explaining what happened in documentation reports, the interventions that she did, all assessments were not in the incident report, and she was to contact the NP by phone immediately following the incident. She stated she did not notify the NP immediately as Resident #1 did not seem in distress or pain, in her opinion . LPCN B stated directions would have been to continue to monitor, now knowing of the fracture and surgery, and x-ray was ordered Monday, stated she performed all the assessments, but did not enter the incident report, reason for the write up. She stated she is expected to enter Progress Report (PCC) and Incident Report (risk management system). During a phone interview on 09/03/2025 at 12:05 PM CNA A, stated she was employed for nearly 2 years at this facility before her resignation on 08/06/2025. CNA A stated she was in-serviced on ANE often, she was knowledgeable of ANE and provided examples. She stated she was in-serviced on falls but could not recall the date. She stated the in-service emphasized needing to use gait belt with transfer and the protocol was to use a gait belt to prevent the resident from falling. She stated the purpose of the gait belt was to help keep residents safe and if a resident were to fall it would help them ease into the fall and the impact wouldn't be as hard. CNA A stated it is important to use proper procedures for transfer of resident to prevent injuries or skin tears. She stated she assisted Resident #1 to the toilet on 08/03/2025 and Resident #1 fell. She stated she was not using a gait belt and did not know that Resident #1 required a 2-person She stated she was in a hurry and did not have a gait belt with her, so she assisted Resident #1 without a gait belt. She stated she does believe she is a 1-person transfer in her care plan, she was in-serviced on using gait belt immediately after the fall, and stated she does believe Resident #1's injury may have been prevented or lessened had the gait belt been used. CNA A stated rather than waiting for the facility investigation to conclude while on suspension she resigned via email. During an interview on 09/03/2025 at 1:20 PM, DOR stated she was the program manager under a third-party contract. She stated she doesn't receive training through the facility, but through her company. She stated a therapy evaluation was conducted after the fall on 07/20/2025. She stated the therapy evaluation on 07/30/2025 documented Resident #1 required 2x person transfer. She stated evaluation resulted in significant change and this information would be passed along in meetings and documented in Resident #1's EMR. DOR stated the next day after the therapy evaluation staff will notify the facility management team in the morning meetings that are conducted daily. DOR stated there is a form used for significant changes, incidents, written on piece of paper and scanned and presented to facility management to be entered into the care plan and MDS. She stated significant change of transfer status of 1x person to 2x person assist is considered significant and nursing staff need to be aware of this information to provide direct care services for the residents. DOR stated a therapy evaluation was conducted on Resident #1 on 0 7/30/2025 and it is documented that she required a 2-person transfer. She stated this information was passed along in the following morning huddle meeting with the nursing management team. She stated in this meeting this information was passed along to the management team at the facility and they in turn are responsible for entering into the electronic plan of care. During an interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 4 of 24 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 09/05/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 09/03/2025 at 2:39 PM DON stated there is no mention during the 07/30/2025 thru 08/1/2025 morning management meetings where the Director of Rehab notified the team of ADL changes. She stated the team was not notified that Resident #1's evaluation had a significant change and a 2x person transfer was now required. She stated the MDS Coordinator is responsible for reviewing physical therapy updates. She reviewed Resident #1's EMR with Surveyor during this interview and confirmed there were no updates to the MDS Assessment or the care plan. Record review of Resident #1's incident report, dated 08/03/2025 at 6:20 AM revealed CNA A was helping Resident #1 to the restroom without the use of a gait belt and Resident #1 lost her balance as she was unable to bear weight and fell in the bathroom. LPCN B assessed Resident #1 immediately following the fall on 08/03/2025 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and responsible party was notified, and NP notified via copy of incident placed in provider box. Record review of Initial Post Fall Notification, dated 08/03/2025 revealed LPCN B documents initial post fall and notification to NP was via note to box. No phone call, no page message or text message notification was provided to NP. Record review of Resident #1's Health Status Note, dated 08/04/2025 at 4:52 PM revealed RN A's late entry progress note doesn't provide actual date and time of this entry). Note Text: Resident has an increasing pain on her left leg/hip possibly from her recent fall incident per report from the CNA. Resident was observed to have difficulty with transferring. NP notified of the pain and received order for STAT left hip x-ray. PRN pain medication administered. MAR Tylenol 325 MG administered at 4:52 PM. Record review of Resident #1's Physician Note dated, 08/05/2025 9:41 AM revealed NP Chief Complaint, Acute Issue - Fall, left hip pain. Record review of Resident #1's EMR on 8/2/2025 revealed there were no clinical records of x-ray results; however, interview with NP stated he received x-ray results the morning of 08/05/2025 and identified the fracture and started the process to transfer resident to the hospital. Record review of Resident #1's Hospital Transfer form dated 08/05/2025 at 2:19 PM revealed facility vitals last conducted before transfer to hospital. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of facility document titled, #594 Fall, dated 08/03/2025, 6:20 AM, revealed this document served as the Incident Report for Resident #1's fall sustained on 08/03/2025. The individual statements provided by the nursing staff who were on shift for Resident #1's fall and post-fall shifts (72 hours) from 08/03/2025 - 08/05/2025. Statements reflect late entries from 08/05/2025 - 08/08/2025: 08/03/2025 2 PM - 10 PM shift: 08/06/2025 RN A statement captured, I worked Sunday [08/03/2025] 2p-10p, the same day resident had fallen. I received report from charge nurse [LPCN B] that resident fell but no concerns. I do not remember receiving any report from CNA A that resident was having pain or unable to bear weight.The CNA had transferred resident during shift, so I did not think there was a problem. I did not officially conduct skin assessment or ROM evaluation on resident on Sunday. RN A also added that she worked the following day, Monday 2 PM - 10 PM shift and she was notified before dinner that Resident #1 was unable to transfer or get out of bed. She did notify the NP following this information and the NP informed her that he was aware and had placed order for STAT x-ray. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 CNA E statement captured, I received report from CNA A.she did not say anything about the resident [Resident #1] having pain or issues with transferring. When I went to change her on my first rounds, I noticed that she did not seem comfortable due to her facial grimacing. I informed the nurse about the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 5 of 24 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 09/05/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few pain. On my second rounds with her [Resident #1] I felt she seemed like she was in more pain, so I moved her more gently and again I informed the nurse [RN B]. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 RN B statement captured, I was the RN on the 10-6 shift on Sunday August 3rd.On my initial assessment I did not note any indicators of pain with Resident #1. Late in my shift the CNA informed me that the resident looked uncomfortable while being changed. I administered PRN Tylenol for pain. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 CNA I statement captured, I worked as a CNA on Monday the 6a-2p shift with [Resident #1]. I did not get report from the 10p-6a shift.I arrived to the floor so I was unaware of the fall on the previous day.I noticed something was off when I went to get her out of bed that morning and she was unable to bear weight.I did not notice any visual or verbal signs of pain so I thought maybe she was just stiff from the night sleep. I noted that when I was assisting her with breakfast she was not eating well, and food was dropping out of her mouth. This was not unusual for her, but I did ask the other team members at the table if they felt there was something wrong. She was unable to bear weight I got assistance.to transfer into her bed so that I could change her. It was during this change that I noted her grimacing and noted the bruising to her hip. I then got her back up and into the wheelchair with assistance and she was at the nurse's station until lunch. She did not eat much at lunch. After lunch I again got assistance.to transfer her back to bed. I notified the nurse of my concerns, and she went and checked on her. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 LPCN C statement captured, I was the charge nurse for [Resident #1] on Monday 6a-2p.CNA I reported to me that the resident seemed to be in pain and was having a hard time transferring. I went and completed an assessment of her and noted bruising to her left hip. I did not complete a full range of motion because I could see she was in pain. I gave her some pain medication and put an ice pack on her hip. I did not say anything to the NP, but I did tell the oncoming nurse [RN A] about the bruising and pain complaints and to keep an eye on her. 08/04/2025 2 PM - 10 PM shift: 08/06/2025 RN A statement captured that on her shift on she was notified by CNA F on this shift that before dinner that resident was unable to transfer or get out of bed.notified NP and he stated he already placed order for STAT x-ray. 08/04/2025 2 PM - 10 PM shift: 08/08/2025 CNA F statement captured, I worked on the hallway where [Resident #1] lives on Monday morning 6a-2p and was assigned to her on the 2p-10p shift.I noted that she was unable to bear weight and it took 3 people to assist her which was unusual.I saw her grimacing when I changed her. I notified my charge nurse [RN A]. Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated March 2021, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition. Record review of the facility's Resident Rights Policy, dated 10/10/2024 reflected the following: The facility is committed to providing a safe and secure environment for our residents. philosophy of care is founded upon its commitment to promote and protect the rights of each resident, is dedicated to enhancing residents' quality of life, treating residents as individuals with dignity, courtesy and respect, and promoting the right to choose the way they live and the care they receive. Record review of the facility's Assessing Falls and Their Causes Policy, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 6 of 24 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 09/05/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few dated March 2018 reflected the following: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. General Guidelines 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. 4.Residents must be assessed upon admission and regularly afterward for potential risk of falls. Record review of the facility's undated Provision of Quality-of-Care Policy, reflected the following: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 2. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. 3. Responsibility for interventions on the care plan will be clearly identified. 4.Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. 6.Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. Record review of Skilled Nursing In-Service: Kardex/Gait Belt Use, dated 08/05/2025 and conducted by DON and ADON, reflected all nursing team members must review the residents electronic care plan prior to delivering care to ensure they are following care plan. Failure to follow according to plan of care will result in disciplinary action and may result in potential harm to the resident. Additionally, failure to follow plan of care is considered neglect. Team members are allowed to use more assistance but never less. Notify on-call nurse manager immediately if you see someone was not care planned or needing updates to Kardex/care plan. This was determined to be an Immediate Jeopardy (IJ) on 09/04/2025 at 12:21 PM. The ADM was notified. The ADM was provided with the IJ template on 09/04/2025 at 12:21 PM. The following Plan of Removal submitted by the facility was accepted on 09/05/2025 at 10:08 AM: On 9/3/25 Resident #1 assessed by RN, the comprehensive care plan reviewed by RN and Director of Therapy for accuracy of interventions post fall and functional performance. There were no new orders obtained from assessment and no new revisions to the care plan were required. On 9/4/25 The affected resident's responsible party was notified by the Administrator of alleged deficiencies and plan of correction. On 9/3/25 All current residents care plans for transfer status were audited by the RN MDS Coordinator for accuracy. in comparison to Therapy documentation. The only changes that needed to be made were to upgrade residents transfer status due to improvements made in therapy. Those changes required were made at the time of the audit. The audit was documented on a resident roster. On 9/4/25 All current residents' care plans for fall interventions were audited by the RN MDS Coordinator for accuracy. No new interventions were required. The audit was documented on a resident roster. All residents with falls from 08/25/2025 through 9/4/2025 (past 10 days) are in the process of being audited by the DON for compliance with policy and procedure including evaluations, care plans and functional ability. Results of the audit will be reported and evaluated during the next monthly QAPI meeting. Documentation of the audit is being completed on the post fall audit form. The Director of Nursing, MDS Coordinator, and Administrator were educated on Comprehensive Care Plans by the Regional Director of Health Services on 9/4/2025. This was documented on an in-service form. Team members verbalized comprehension and signed acknowledgement of education. Starting on 9/4/2025 Licensed Nurses have been educated by Director of Nursing /Designee on assessment immediately after the fall, including updating the care plan with new preventative interventions per the Provisions of Quality-of-Care Policy. Staff verbalized comprehension and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 7 of 24 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 09/05/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete signed acknowledgement of education. Staff will not be allowed to work until they receive training. Ad-Hoc QAPI meeting was held on 9/3/2025, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Regional Director of Clinical Services, RN, [NAME] President of Health Services Operations, Executive Director, Regional [NAME] President of Operations, and Chief Clinical Officer to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Starting on 9/4/2025 the Director of Nursing or designee will monitor compliance daily (Monday through Friday) and Charge Nurse (Saturday and Sunday) by monitoring residents with falls for appropriate care plan revisions post fall. Care plan updates will be noted in the residents Electronic Health Record with an IDT note. Starting on 9/4/2025 the Director of Therapy and other therapists will notify the DON, ADON, MDS Coordinator and Administrator. An email was sent the Therapy Director and therapist outlining this procedure. The Therapist acknowledged receipt and understanding with a return email. The MDS Coordinator or his designee will update the resident's care plan. Staff will be educated to review each resident's electronic are plan at the beginning of their shift. Staff will verbalize comprehension and signed acknowledgement of education. Starting on 9/4/25 the Director of Nursing or designee will monitor compliance during the weekly QOC Meeting. Results of the audit will be reported to the QAPI committee. The Administrator/designee will monitor compliance by completing an audit of five (5) residents care plans per week for four (4) weeks. This was initiated on 9/4/2025. Documentation of this audit will be made on the post fall audit form. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The Regional Director Health Services will provide oversight of the Administrator to ensure that the items on the plan of removal are reviewed and completed. 09/05/2025 4:20 PM DON, Discharge MDS 9/52025; prior to this one, ARD 8/24/2025 admission 5 day; 8/18/2025 Entry MDS/Accepted and completed; 8/24/2025 Admission/Medicare - 5 Day, In Progress; 9/5/2025 Discharge Return Anticipated in Progress. The Surveyor monitored the POR from 09/04/2025 - 09/05/2025 as followed: Record review of the facility's ADHOC meeting agenda, dated 09/03/2025, reflected ADM, DON, MD, and RDHS were in attendance. Record review of Resident #1's EMR and care plan, dated 05/23/2022 with revision on 09/04/2025 reflected review of interventions post fall and functional performance measures. Care plan updated to Event ID: Facility ID: 676198 If continuation sheet Page 8 of 24 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 09/05/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 9 residents reviewed for quality of care. The facility failed to notice a change in condition after Resident #1 experienced a fall on 08/03/2025 and had visible signs of pain for 48 hours before being sent to the ER for a broken hip.The facility failed to complete post-fall assessments per policy for Resident #1 which caused Resident #1 to have an untreated hip fracture for up to 48 hours before outside medical attention was sought. The facility failed to address Resident #1's pain which was evidenced by facial grimacing and other non-verbal signs of pain for 48 hours and failed to assess whether PRN Tylenol was sufficient to relieve pain caused by the fractured hip. These failures could place residents at risk of negative outcome to a resident's physical, mental, or psychosocial health or well-being Findings include: Record review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis including other spondylosis, lumber region (refers to degenerative changes in the lower back, often leading to symptoms like pain, numbness, and weakness due to nerve compression), age related osteoporosis without current pathological fracture (condition characterized by the weaking of bones due to aging), Alzheimer's disease (progressive decline in memory, thinking, and behavior), unsteadiness on feet, muscle weakness, and fracture of left femur. Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 01, which indicated cognition was severely impaired. Section GG - Functional Abilities reflected Resident #1 required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of Resident #1's care plan dated 05/19/2022 and last revised 06/24/2025, reflected the following, Current Functional Performance. Interventions Resident performance: Transfer - Extensive assist/one-person physical assist. Further Record review of Resident #1's care plan dated 12/14/2022 and last revised on 05/12/2025, reflected the following, Resident #1 was on palliative care and request comfort care only and will remain free from pain/discomfort and live to the end of my life with dignity. Interventions Refrain from sending me to the hospital unless I (Resident #1) sustain a traumatic injury or my RP or I (Resident #1) request transfer. Further review of Resident #1's care plan reflected that the PT Evaluation & Plan of Treatment completed on 07/30/2025 did not reflect the physical therapy recommendation of a 2-person transfer outlined under Functional Assessment, Transfers = Max/2. Record review of Resident #1's MAR revealed Resident #1 was administered pain medication Tylenol PRN 325 mg two tablets as followed: 08/04/25 at 12:34 AM08/05/25 at 4:52 PM There was no documentation regarding effectiveness or pain level assessment. Record review of Resident #1's incident report dated 08/03/2025 revealed that CNA A was helping Resident #1 to the restroom and Resident #1 lost her balance and fell in the bathroom. LPCN B assessed Resident #1 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and Responsible Party was notified and NP notified via copy of incident placed in provider box. CNA A had not been notified of the resident's significant change prior to her fall on 08/03/2025. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 9 of 24 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 09/05/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few orthopedic surgery the morning of August 6. Record review of Resident #1's physician order, dated 07/21/2025, reflected the following: PT/OT eval and treat for fall/ADLs. Record review of Resident #1's Physical Therapy PT Evaluation & Plan of Treatment, dated 07/30/2025, reflected the following: Functional transfers PLOF (prior level of function) was CGA (contact guard assist) and Resident #1's functional transfer baseline is Max/2 (highest level of assistance required for a transfer, performed w/ minimal help or no assistance at all). During an interview on 09/02/2025 at 5:41 PM, DON stated the nurses should have completed assessments for 72 hours after the fall. If the nurses had done the ROM assessment post fall, they would have discovered the broken hip sooner or noted the pain Resident #1 was experiencing. DON stated she was in-serviced last month, she completes in-services regularly with nursing managers. DON stated the policy for transferring/bathroom assisting a resident depends on assistance resident is needing, reviewing the electronic care plan, and best practice is to use the gait belt for 1x or 2x assist with mechanical lift. DON then stated the staff are in-serviced that the facility expects a gait belt, unless resident is refusing to be use. She stated it is encouraged overall to use the gait belt. Each of the rooms are to be supplied with a gait belt and located in the linen room. She stated the purpose of the gait belt is for safety measure, best practice if someone has a fall, can use to guide them to limit any further injuries that might occur. Helpful not to cause any other injuries when utilizing the gait belt, potential of pinching the skin or causing other issues, the device is to help with safety of the resident. She stated it is important to use proper procedures for transferring a resident keeping in mind safety first, maintaining ones' health and quality care. DON stated the Resident's fall was reported to her the day it occurred. She stated the details of the fall were in the incident report. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. During an interview on 09/02/2025 at 1:38 PM, NP stated Resident #1 had advanced dementia and required assistance with most of her ADLs. He stated he was made aware that Resident #1 fell over the weekend. He stated he was at the facility making rounds on the afternoon of 08/04/2025 and was notified that Resident #1 had discomfort of her hip area and staff was unsure what side was hurting. He stated Resident #1 was non-verbal and showed discomfort with facial grimacing. The NP stated he ordered an x-ray on the afternoon of 08/05/2025 and the results were obtained the following morning, 08/06/2025 and Resident #1 had a fracture of left femur. Resident #1 is unable to provide details of her pain level, and she was not helpful to determine the severity of the injury. NP stated Resident #1's pain symptoms were not provided to him until about 4:00 PM on 08/4/2025 . Symptoms included facial grimacing. He stated the responsible party decided to have an orthopedic evaluation. Resident #1 was transferred to the emergency room. He stated an orthopedic surgeon evaluated her and determined she required surgery. He stated the following day Resident #1 had a total hip replacement surgery. He stated prior to this fall she was a 1 person assist transfer (as he was unaware of the recent change on 07/30/2025 to a 2x person transfer) and now he believed she was a 2x person assist transfer. He stated CNA A was assisting Resident #1 to the restroom, she was a 1x person assist at this time, gait belt required, The NP stated Resident #1 does have PRN Tramadol and was not having a lot of discomfort. He stated Resident #1 was s eating regularly, was doing well post operatively, was up in the wheelchair most of the day, and was participating in therapy. During interviews on 09/02/2025 at 3:45 PM, CNA C stated he has been employed 18 months at the facility, he was in-serviced on the use of gait belts and fall procedures. He stated charge nurse will complete an assessment of resident after a fall and will provide further instructions following fall on how to care for a resident. He stated he was not familiar with Resident #1's care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 10 of 24 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 09/05/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few During an interview on 09/02/2025 at 3:57 PM, CNA M stated she has been employed 18 months at this facility, she has received ANE, gait belt, and fall procedure training. She stated if a resident falls staff are expected to call the nurse immediately, and the charge nurse will assess the resident and provide CNAs and CMAs with directions for care following the fall. During an interview on 09/02/2025 at 4:31 PM, CNA J stated she has been employed 6 months at this facility, she has received in-service on ANE, she provided examples of ANE. She stated she also received in-service recently on falls and gait belts which covered how to get the resident up, ensure to use gait belt, depending on injuries, if notice resident is in pain, act according in how to respond, getting them up, or if bleeding, check for everything, the nurse will come in and assess. CNA J said it was always best to keep an eye on residents and stay available. She stated she would constantly go back and forth to residents throughout her shifts. She stated staff should observe what is visible to their eyes and report ASAP. Nurse will assess the resident, check for neuro if resident can get up or if they need to be sent out. She cannot assess, this is the responsibility of the nurse. CNA J stated Resident #1 needs assistance with feeding, it is hard for her to communicate what she needs, she will nod, has limited communication, and she is unable to communicate pain and she is familiar with her body language, such as facial expressions when she doesn't want care or refuses care. She stated Resident #1 required the use of a gait belt as she was unsteady. During an interview on 09/02/2025 at 4:58 PM, CNA D stated she had been employed 6 months at this facility, she has been in-serviced on ANE and provided examples of ANE. She stated she has also received in-services in the last 30 days on falls and gait belts. She stated if resident falls staff are to go and get the charge nurse and let them assess the resident. During an interview on 09/02/2025 at 5:15 PM, RN C stated he has been in-serviced within the last 30 days, ADM was the Abuse Coordinator. He stated he was in-serviced on safety precautions, fall provisions, use of gait belt, not to move resident after a fall. He stated if he were to be notified that a resident has fall he is expected to assess for pain, ROM, if not complaining of pain, will use the gait belt to lift them up and sit them up, and this requires 2x person assist. If not witnessed would do facility protocol, which includes neurological checks, medicate resident for pain, call the NP and on call manager, and family members. If resident complains of any pain, then suggest to NP to conduct x-rays. RN C stated it is important to follow post-fall procedures with monitoring resident as this helps to know if there are concerns with resident. He stated he was familiar with Resident #1 but had not worked with her in more than six months. He stated he could not recall Resident #1's functional abilities and he was not present for the fall. During an interview on 09/02/2025 at 5:24 PM, RN D stated he was in-serviced on ANE and fall preventions and protocol. He stated as the charge nurse he is to immediately enter the room if notified of a resident fall. He stated he is expected to report how the fall occurred, what position the resident is in, what injuries were sustained. He stated he is expected to conduct assessments of resident, which include a head to toe, skin assessment, injuries, any fractures, ROM. other assessments competed include neurological assessments. He stated nurses are required to enter, reports in PCC, notify NP, RP, DON and family. The nurses are required to check the resident every 15 minutes, every 1 hours, 4 hours, and this is done daily, for 6 days. He stated he is required to complete the nursing report, progress report, and incident report in detail. RN D stated nurses are required to immediately notify the NP of any fall with and without injury. He stated falls could cause a fracture or bleeding and head to toe assessments after fall (72 hours) will help to identify any change of condition and help nurse to know what type of care to provide the resident. He stated other shifts such as the night shift the nurse must be careful as sometimes injuries appear with delay. He stated documentation is a good source for next (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 11 of 24 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 09/05/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few shift and other staff. He stated he was not familiar with Resident #1's car and became familiar with her fall during in-service. During an interview on 09/02/2025 at 5:41 PM, DON stated she was in-serviced last month, she completes in-services regularly with nursing managers. She stated the procedures and protocols for falls are given by ADM, interventions in place to reduce falls, step by step, someone falls they need to make sure the charge nurse comes in immediately, provides an assessment, checking ROM, identify if major injury, don't want to move to make things worse, call NP, vitals, neuro if they hit their heads, interventions right away for nurse to investigate, nurse manager follows up with nurse interventions, and DON provides education to staff afterwards if need be. Nurses are required to conduct what is triggered on risk management, they have been educated to open risk management to place in progress fall, triggers assessment, skin, fall assessments, neurons if needed, if check off on risk management, what is clicked on will trigger for falls, check list for the nurses. Notifying NP with major injury then it should be immediately, if minor or no injuries it would be the following day or placed in the box for the NP to see the following day. She stated interventions or assistance needed to prevent falls include updates to the electronic care plan, in-service and education, if something all staff need to be notified of. The DON stated there is a risk to the resident's health and care if not conducting head to toe assessments, failure to provide could cause further harm to the resident if staff are not evaluating thoroughly as this could cause more concerns and this should be reported to the NP immediately. She stated if residents were to fall and injure themselves it could make them feel hurt and sad and cause mental anguish. She stated she was familiar with Resident #1's care, she typically goes off MDS, depending on and not sure of her care specifically. She stated she was not present for the fall on 08/03/2025, she was notified, unsure date and time specific. She stated interventions put in place during notification, notified x-rays, spoke to NP, not moving her when waiting for the x-rays, she was bedridden, any assistance was increased to 2x person, interventions then changed over to 2x person, updated for the interventions. DON stated nurses, RN A, LPCN C, LPCN B, and CNA M received verbal counseling regarding the concerns with post fall assessment, ROM to identify anything post fall for further injuries, skin assessment is also one of the post fall assessments, always good to assess, go through all triggered areas. She stated ROM was not identified, she stated LPCN B and CNA assisted Resident #1 back into the wheelchair, her ROM ability to get up and move her legs, she didn't suspect anything, full range of motion, full extremities assessment, post fall assessments. She stated the expectation is that post fall assessments include 48 hours of monitoring residents who have fallen. She stated the notification to the NP could have been quicker than 24 hours had the post ROM assessment been completed with the post fall assessments. DON stated it is difficult to say as resident doesn't indicate having any discomfort. DON stated she is unsure why only (2) nurses were counseled during the Provider Investigation Report as there were (4) nurses who were identified as not providing post fall assessments for each of their shifts. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. During an interview on 09/03/2025 at 9:45 AM, CNA H stated she has been working at this facility for 2 weeks, she received ANE, falls and gait belt training during orientation. She stated in-service covered not moving a resident if they were to fall, to get the charge nurse immediately to assess them. She stated it is important to verify what care is required for the resident via the electronic care plan provided. During an interview on 09/03/2025 at 10:02 AM, RN E stated she has been employed with this facility for over 6 years. She stated she was in-serviced last month on ANE, and what to do during a fall. She stated if an aid reports a resident fall, they are expected to leave the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 12 of 24 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 09/05/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few there and notify the charge nurse immediately. The charge nurse expected to assess the resident for any injuries, complete a skin assessment, performs ROM assessment, pain assessment. RN E stated if some residents are unable to be moved, she would decide to contact 911, followed by notification to the NP, DON, and family. RN E stated post fall expectations requires nurses to conduct 3-day checks/assessments on the resident. She stated assessments are conducted for 3 days, first every 15 minutes then 1 hour. She stated nurses are to assess the level of consciousness, delayed injuries, interventions, why the fall, place interventions in place, pain assessment is performed on every shift. She stated information is entered in EMR, TAR, skin assessment is every shift, ROM assessment every shift, or anytime the resident complains. She stated if anything else is noticed with resident, such as level of consciousness, any change of daily activities they are to be documented in the progress notes. She stated if post fall assessments are not performed staff could miss delayed bruising, delayed pain, miss dislocation, miss wounds, can miss decline in mental status. She stated she was not familiar with Resident #1's care. During an interview on 09/03/2025 at 10:20 AM, CNA I stated she has been employed for 2 and 1/2 years at this facility. She stated she received training a few days back, completed videos on resident rights, what to do to prevent a fall, reporting, and ANE. She stated she has completed online trainings that covered CNAs do not touch resident that falls until nurse comes in and does vitals and assessments, she just needs to notify charge nurse immediately. During an interview on 09/03/2025 at 10:40 AM, LPCN B stated she's been employed 2 years at this facility, she was in-serviced last month on ANE, reporting, and Abuse Coordinator is ADM. She stated last month she completed an in-service, which covered precautions for falls, attend promptly to call lights, VSG sensors, when one falls, skin assessment, ROM, assessing for pain, notify the physician and family. She stated witnessed and unwitnessed falls staff tells what occurred, nurses go and assess the resident, ensure not in pain, able to move extremities, conduct vital signs, skin assessment, if witnessed and they hit their heads, start neuro checks, contact doctor, family and nurse supervisor. Follow-up 3 days after - witnessed/unwitnessed, neuro assessment 15 minutes monitoring during shift, then shifts to 30/45/60 minutes every day for every shift; She stated the level of consciousness assessment is performed every shift, movement of extremities (ROM), 1st day 15 minutes for an hour, 30 minutes, every hour of each shift. LPCN B stated unwitnessed fall or witnessed fall, neuro checks are required, it will say vital signs, progress notes, goes on assessments. Follow-up 3 days once per shift, every shift check for pain, new injuries, check for bruising, skin tears; ROM, pain, skin, alert, without neuro checks would be a progress note - incident reports (system). She stated if the post fall assessments are not completed by the nurses, then the resident can be in pain and their concerns weren't approached, a new injury or cut can get infected if no orders. She stated she was present for Resident #1's fall, she was the charge nurse for the morning shift. She stated at about 6:20 AM CNA A notified her Resident #1 was on the floor, said she did not hit her head, she was assessed Resident #1's skin and she had a small skin abrasion on her left elbow, she was nonverbal, unable to communicate pain. She stated the on-call nurse was notified, family was notified, and the NP communication note was left in provider box, which is checked daily when the NP is onsite at the facility. She stated she was off the next morning and when she returned, she was informed Resident #1's fall resulted in a fracture and surgery. She stated she received a write up - management stated no documentation for assessments, ROM, communication to the NP, and documentation was not thorough. She stated she did not explain what occurred in detail. She did not list interventions that she provided for the Resident. She stated she did not provide completed information on assessments, and they were not in the incident report. She stated she was to contact the NP by phone immediately following the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 13 of 24 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 09/05/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few incident. She stated she did not notify the NP immediately as Resident #1 did not seem in distress or pain. LPCN B stated she believes NP directions would have been to continue to monitor. She stated she performed all the assessments, but did not enter them in the incident report, which is the reason for the write up. She stated she is expected to enter Progress Report in PCC and Incident Report into the risk management system. During a phone interview on 09/03/2025 at 12:05 PM, CNA A stated she was employed for nearly 2 years at this facility before her resignation on 08/06/2025. CNA A stated she was in-serviced on ANE often, she was knowledgeable of ANE and provided examples. She stated she was in-serviced on falls but could not recall the date. She stated she worked with Resident #1 often, before the fall she was normally a 1x person assist, then after the fall she was a 2x person assist as she was unable to bear any weight. She stated she assisted Resident #1 to the toilet on 08/03/2025 and Resident #1 fell. CNA A stated the charge nurse did not instruct her to do anything different with Resident #1's care for the remainder of her 16-hour shift. She stated the resident went to breakfast, returned to her room about 1:00/2:00 PM she put her in bed as a 1x person assist, and Resident #1 was making a face, grimacing like her leg was bothering her. She stated she mentioned this change of condition to the Charge Nurse and Med Aide, who then administered Resident #1 Tylenol. She stated she changed Resident #1's brief before putting her in bed after dinner around 6:00 PM and she noticed she was grimacing. She stated she informed the overnight CNA that Resident #1 seemed to be in pain. During an interview on 09/03/2025 at 1:00 PM, LPCN C stated she has been employed 18 months with this facility, she has received training on ANE, resident rights, privacy, how to approach residents with dementia. She stated she has also been in-serviced on gait belts and fall procedures. She stated last month she was trained on fall and in-service covered completing ROM assessment, pain assessments following a fall to ensure there are no change of condition. LPCN C stated fall prevention interventions included training on an individual basis and review of Resident's care plan prior to performing care. She stated the procedures for falls are to first assess the resident and their breathing, check their vitals, perform ROM assessment, pain assessment and to notify doctor, family, and 911 if necessary. She stated post fall assessments are to be performed every shift every 15 mins, 30 mins, 60 mins. She stated post falls without neuro checks, initial injury, check a few times on their shifts, in a matter of hours things can change. She stated nurses are expected to, assess the resident and make sure they are not in pain, LPCN C stated post fall assessments include skin assessment, neuro, ROM, and are to be documented in incident reports and in the progress note to ensure it is documented. She stated a few times per shift nurses are expected to observe the resident and depending on injury, may get orders from doctor. She stated the general rule is to check them twice during shift along with aid checks. She stated there is a 3-day monitoring window, progress notes, vitals, pain assessment, skin, and ROM need to be completed on each shift. LPCN C stated what you see and what residents show you are documented. She stated staff are to report all falls to on-call charge nurse, NP, family, notify the doctor by phone -page them, if on the weekend or no injuries - notify NP with a note vs phone. She stated on weekdays NP was present and nurses can verbally inform them of change of condition. LPCN C stated if the post fall assessments are not completed staff can potentially miss an injury on that resident and they are super important after a fall. She stated she was familiar with Resident #1's care and stated when she came on shift on 08/03/2025 from 6 AM - 2 PM day shift, she was provided with limited report that resident slipped onto the floor from the bed and had no injuries, she was doing fine, on her shift, aid reported that Resident #1 was in pain about 12-1 PM, she went in resident's room and checked in on her and she was in a lot of pain. She stated she opted not to complete ROM as she didn't want to hurt her any further, she administered PRN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 14 of 24 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 09/05/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few pain medication and reported it to the next nurse coming on shift to page the doctor. She stated she didn't notify the doctor herself as Resident #1 was on her baseline, normal throughout the day, she was given an ice pack and PRN medications to make her comfortable. She stated she didn't believe Resident #1 displayed any concerns with pain. She stated ROM not done to not hurt Resident #1 further and no reason why she didn't notify the NP directly as he is next door to her, she stated it was stupidity on her part, she went off what she was told on report and did not do her own shift change report and comes to find out this is not what occurred at all with Resident #1's incident. She stated she has been a nurse a long time and she knows not to believe what another nurse tells you, don't assume, need to do your own assessments.During an interview on 09/03/2025 at 2:39 PM DON stated there is no mention during the 07/30/2025 thru 08/1/2025 morning management meetings where the Director of Rehab notified the team of ADL changes. She stated the team was not notified that Resident #1's evaluation had a significant change and a 2x person transfer was now required. She stated the MDS Coordinator is responsible for reviewing physical therapy updates. She reviewed Resident #1's EMR with Surveyor during this interview and confirmed there were no updates to the MDS Assessment or the care plan. Record review of Resident #1's incident report, dated 08/03/2025 at 6:20 AM revealed CNA A was helping Resident #1 to the restroom without the use of a gait belt and Resident #1 lost her balance as she was unable to bear weight and fell in the bathroom. LPCN B assessed Resident #1 immediately following the fall on 08/03/2025 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and responsible party was notified, and NP notified via copy of incident placed in provider box. Record review of Initial Post Fall Notification, dated 08/03/2025 revealed LPCN B documents initial post fall and notification to NP was via note to box. No phone call, no page message or text message notification was provided to NP. Record review of Resident #1's Health Status Note, dated 08/04/2025 at 4:52 PM revealed RN A's late entry progress note doesn't provide actual date and time of this entry). Note Text: Resident has an increasing pain on her left leg/hip possibly from her recent fall incident per report from the CNA. Resident was observed to have difficulty with transferring. NP notified of the pain and received order for STAT left hip x-ray. PRN pain medication administered. MAR Tylenol 325 MG administered at 4:52 PM. Record review of Resident #1's Physician Note dated, 08/05/2025 9:41 AM revealed NP Chief Complaint, Acute Issue - Fall, left hip pain. Record review of Resident #1's EMR on 8/2/2025 revealed there were no clinical records of x-ray results; however, interview with NP stated he received x-ray results the morning of 08/05/2025 and identified the fracture and started the process to transfer resident to the hospital. Record review of Resident #1's Hospital Transfer form dated 08/05/2025 at 2:19 PM revealed facility vitals last conducted before transfer to hospital. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of facility document titled,#594 Fall, dated 08/03/2025, 6:20 AM, revealed this document served as the Incident Report for Resident #1's fall sustained on 08/03/2025. The individual statements provided by the nursing staff who were on shift for Resident #1's fall and post-fall shifts (72 hours) from 08/03/2025 08/05/2025. Statements reflect late entries from 08/05/2025 - 08/08/2025: 08/03/2025 2 PM - 10 PM shift: 08/06/2025 RN A statement captured, I worked Sunday [08/03/2025] 2p-10p, the same day resident had fallen. I received report from charge nurse [LPCN B] that resident fell but no concerns. I do not remember receiving any report from CNA A that resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 15 of 24 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 09/05/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was having pain or unable to bear weight.The CNA had transferred resident during shift, so I did not think there was a problem. I did not officially conduct skin assessment or ROM evaluation on resident on Sunday. RN A also added that she worked the following day, Monday 2 PM - 10 PM shift and she was notified before dinner that Resident #1 was unable to transfer or get out of bed. She did notify the NP following this information and the NP informed her that he was aware and had placed order for STAT x-ray. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 CNA E statement captured, I received report from CNA A.she did not say anything about the resident [Resident #1] having pain or issues with transferring. When I went to change her on my first rounds, I noticed that she did not seem comfortable due to her facial grimacing. I informed the nurse about the pain. On my second rounds with her [Resident #1] I felt she seemed like she was in more pain, so I moved her more gently and again I informed the nurse [RN B]. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 RN B statement captured, I was the RN on the 10-6 shift on Sunday August 3rd.On my initial assessment I did not note any indicators of pain with Resident #1. Late in my shift the CNA informed me that the resident looked uncomfortable while being changed. I administered PRN Tylenol for pain. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 CNA I statement captured, I worked as a CNA on Monday the 6a-2p shift with [Resident #1]. I did not get report from the 10p-6a shift.I arrived to the floor so I was unaware of the fall on the previous day.I noticed something was off when I went to get her out of bed that morning and she was unable to bear weight.I did not notice any visual or verbal signs of pain so I thought maybe she was just stiff from the night sleep. I noted that when I was assisting her with breakfast she was not eating well, and food was dropping out of her mouth. This was not unusual for her, but I did ask the other team members at the table if they felt there was something wrong Event ID: Facility ID: 676198 If continuation sheet Page 16 of 24 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent avoidable accidents for 2 (Resident #1 and Resident #2) of 9 residents reviewed for quality of care. The facility failed to ensure CNA A used a gait belt when assisting Resident #1 with transfer on 08/03/2025 which resulted in Resident #1 falling and breaking her hip. The facility failed to ensure CNA A used two people assist with transfers as recommended on Resident #1's therapy evaluation on 07/30/2025, which determined Resident #1 should be transferred with two staff members. Resident #1 experienced a fall on 08/03/2025 and 48 hours later was diagnosed with a hip fracture from the fall. The facility failed to ensure CMA B used a gait belt when assisting Resident #2 with transfer on 09/02/2025. On 09/03/2025 at 7:17 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/05/2025, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of avoidable accidents resulting in serious harm and injury and a decreased quality of life. Findings include: Record review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis including other spondylosis, lumber region (refers to degenerative changes in the lower back, often leading to symptoms like pain, numbness, and weakness due to nerve compression), age related osteoporosis without current pathological fracture (condition characterized by the weaking of bones due to aging), Alzheimer's disease (progressive decline in memory, thinking, and behavior), unsteadiness on feet, muscle weakness, and fracture of left femur. Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 01, which indicated cognition was severely impaired. Section GG Functional Abilities reflected Resident #1 required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of Resident #1's care plan dated 05/19/2022 and last revised 06/24/2025, reflected the following, Current Functional Performance. Interventions Resident performance: Transfer - Extensive assist/one-person physical assist. Further review of Resident #1's care plan dated 12/14/2022 and last revised on 05/12/2025, reflected the following, Resident #1 is on palliative care and request comfort care only and will remain free from pain/discomfort and live to the end of my life with dignity. Interventions Refrain from sending me to the hospital unless I sustain a traumatic injury or my RP or I request transfer. Further review of Resident #1's care plan reflected that the PT Evaluation & Plan of Treatment completed on 07/30/2025 did not reflect the physical therapy recommendation of a 2-person transfer outlined under Functional Assessment, Transfers = Max/2.Record review of Resident #1's incident report dated 07/20/2025 revealed Resident #1 fell but did not suffer any injuries. Resident #1's care plan was not updated after the fall. Record review of Resident #1's physician order, dated 07/21/2025, reflected the following: PT/OT eval and treat for fall/ADLs. Record review of Resident #1's Physical Therapy PT Evaluation & Plan of Treatment, dated 07/30/2025, reflected the following: Functional transfers PLOF (prior level of function) was CGA (contact guard assist) and Resident #1's functional transfer baseline is Max/2 (highest level of assistance required for a transfer, performed w/ minimal help or no assistance at all). Record review of Resident #1's PT evaluation conducted on 07/30/2025 revealed Resident #1 required two people to transfer and a gait belt. Record review of Resident #1's incident report dated 08/03/1015 revealed that CNA A was helping Resident #1 to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 17 of 24 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few restroom and Resident #1 lost her balance and fell in the bathroom. LPCN B assessed Resident #1 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and Responsible Party was notified and NP notified via copy of incident placed in provider box. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of Resident #2's face sheet dated 09/05/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including arthritis (inflammation of the joints), dementia (loss of cognitive functioning), major depressive disorder, muscle wasting and atrophy (refers to the wasting or thinning of muscle tissue). Record review of Resident #2's annual MDS, dated [DATE], reflected a BIMS score of 09, which indicated cognition was moderately impaired. Section GG - Functional Abilities reflected Resident #2 required Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for sit to stand, chair/bed-to-chair transfer, and toilet transfer. Section J-Health Conditions reflected Resident #2 listed number of falls since admission/entry or reentry at 1 with no injury. Record review of Resident #2's care plan, dated 05/10/2024 and last revised 05/25/2025, reflected the following, The resident is risk for falls. Interventions Anticipate and meet the resident's needs and Current Functional Performance. Interventions Resident performance: Transfer - Extensive assist / one-person physical assist' and Resident performance: Toilet use - Extensive assist / one-person physical assist. Record review of Resident #2's progress note, dated 04/07/2025, reflected resident had an unwitnessed fall in the bathroom, no injury occurred because of the fall. Record review of Resident #2's Physical Therapy PT Evaluation & Plan of Treatment dated 04/09/2025, reflected, Reason for Referral: Patient referred to OT due to exacerbation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate.reduced static and dynamic balance placing patient at risk for immobility, falls and further decline in function Record review of Resident #2's Fall Risk Evaluation, dated 05/20/2025, reflected no falls in past 3 months, level of consciousness/mental status at intermittent confusion, and no interventions were documented. Record review of Resident #2's IDT progress note dated 06/04/2025, reflected, Therapy notes, Resident requires extensive, one person, weight bearing assistance. See fall risk assessment 5/20/25 score 13 high risk. Record review of Resident #2's Kardex report dated 09/02/2025, reflected special instructions for CNAs and CMAs, Resident performance: Transfer - Extensive assist /one-person physical assist and Resident performance: Toilet use - Extensive assist /one-person physical assist. Interview with Administrator on 9/2/2025 at 10:32 AM revealed CNA A failed to use a gait belt, Resident #1 required one person to transfer, and nurses failed to document assessments entirely. During an interview on 09/02/2025 at 5:41 PM, DON stated the nurses should have completed assessments for 72 hours after the fall. If the nurses had done the ROM assessment post fall, they would have discovered the broken hip sooner or noted the pain Resident #1 was experiencing. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. Observation on 09/02/2025 at 12:04 PM revealed CMA B assisting Resident #2 without a gait belt when assisting resident up from a sitting position to the restroom. During an interview on 09/02/2025 at 3:45 PM CNA C stated he has been employed 18 months at the facility, he has been in-serviced on the use of gait belts and fall procedures. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 18 of 24 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated staff should always use gait belt when assisting residents during a transfer or walking regardless of 1x person or 2x person helper. He stated the gait belt is a chance to support a resident, assist the staff to break a fall, will not stop residents from falling but could help lessen the impact. He stated interventions to prevent falls include skills check offs, r eview, and monthly meetings. CNA C stated fall procedure are to ensure scene is secure, do not move the resident, call the nurse, pull the emergency light to get attention, let the nurse know resident is on the floor, nurse comes and completes an assessment, nurse will direct you to grab a belt to get resident up, you follow what the nurse tells you and any further instructions following fall. He was not familiar with Resident #1 or Resident #2's care . During an interview on 09/02/2025 at 3:57 PM CNA M stated she has been employed 18 months at this facility, she has received ANE, gait belt, and fall procedure training. She stated resident care information was in the electronic care plan, she was provided in-service on how to perform a transfer, 1x or 2x person assist transfer needs to have a gait belt. She stated the fall procedures include, if witnessed or not call the nurse, do not pick up the resident, nurse needs to assess the resident, will then help the nurse with directions to get them up. She stated Regardless of if 1x or 2 x person assist you need to use the gait belt as it is more secure for both resident and staff. Think of you and the patient. CNA M stated it is important to use proper procedures for transfer of a resident as you can harm yourself or you can harm the resident. During an interview on 09/02/2025 at 4:31 PM, CNA J stated she has been employed 6 months at this facility, she has received in-service on ANE, she provided examples of ANE. She stated she also received in-service recently on falls and gait belts which covered how to get the resident up, ensure to use gait belt. CNA J stated Gait belt is in every room, staff given a gait belt during orientation, and expected to always use them for 1x and 2x person assists. During an interview on 09/02/2025 at 4:58 PM, CNA D stated she's been employed 6 months at this facility, she has been in-serviced on ANE and provided examples of ANE. She stated she has also received in-services in the last 30 days on falls and gait belts. She stated if resident falls go and get the nurse and let them assess the resident. She stated she reviews the electronic care plan to check if resident is a mechanical lift, use of gait belt, 1x or 2x person assist. She stated it is important to use proper procedures for transferring a resident to not hurt self or resident. She stated she has assisted other aids with transferring Resident #1 and Resident #2. She stated residents require gait belt for transfer if 1x or 2x person assist. During an interview on 09/02/2025 at 5:15 PM, RN C stated she has been in-serviced within the last 30 days, in-services covered safety precautions, fall previsions, use of gait belt, she stated the purpose of the gait belt is to not harm the resident, not to lift them with the arms, to avoid injuries, transfers, and safety. RN C stated it is important to use proper procedures for transferring a resident to not hurt the resident or the staff. During an interview on 09/02/2025 at 5:24 PM, RN D stated depending on the resident's need for 1x or 2x person transfer to restroom, must follow rules, the gait belt is most important matter for the transfer . During an interview on 09/02/2025 at 5:41 PM, DON stated she was in-serviced last month on ANE, she completes in-services regularly with nursing managers. DON stated the policy for transferring/bathroom assisting a resident depends on assistance resident is needing, reviewing the electronic care plan, and best practice is to use the gait belt for 1x or 2x assist with mechanical lift. DON then stated the staff are in-serviced that the facility expects a gait belt, unless resident is refusing to be use. She stated it is encouraged overall to use the gait belt. Each of the rooms are to be supplied with a gait belt and located in the linen room. She stated the purpose of the gait belt is for safety measure, best practice if someone has a fall, can use to guide them to limit any further injuries that might occur. Helpful not to cause (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 19 of 24 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few any other injuries when utilizing the gait belt, potential of pinching the skin or causing other issues, the device is to help with safety of the resident. She stated it is important to use proper procedures for transferring a resident keeping in mind safety first, maintaining ones' health and quality care. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. During an interview on 09/03/2025 at 9:45 AM, CNA H stated she has been working at this facility for 2 weeks, she's received falls and gait belt training during orientation. She stated the electronic care plan provides information or rundown on resident and their needs. If independent have the gait belt, if weak, mechanical lift is 2x person, but no matter what they need to have a gait belt if transferring 1x or 2x person assist. She stated the gait belt protects the resident and helps to avoid injuries. She stated it is important to follow proper procedures for transferring a resident as you can hurt them, they are more [NAME], if they have minor injuries, you can make them worse. During an interview on 09/03/2025 at 10:02 AM, RN E stated staff should always check how the residents are transferred, review the care plan, determine if 1x or 2x person assist, or mechanical lift, make sure sling is the proper size for the resident, be aware of the care plan, always use body properly when transferring. She stated the importance of the gait belt is to prevent falls, safety, and proper transfers. RN E stated it is important to use proper procedures for transferring a resident to prevent injuries to self and the resident. She stated during orientation and in-services, the facility is stressing the use of gait belts. During an interview on 09/03/2025 at 10:20 AM, CNA I stated she has been employed for 2 and 1/2 years at this facility. She stated she received training on fall prevention interventions are in and POC. She stated anyone assisting a resident with transfer needs to use a gait belt unless the resident has refused it, the purpose of the gait belt is to provide more ability to help the resident from falling. CNA, I stated it is important to use proper procedures for transferring a resident as anything can go wrong, make it less complicated as possible to avoid injuries to the resident. She stated she is familiar with Resident #1 and Resident #2's care. She stated Resident #1 requires 2x person assist with a gait belt, Resident #2 requires 1x person assist with a gait belt, she can walk. During an interview on 09/03/2025 at 10:40 AM, LPCN B stated she did not see a gait belt on Resident #1 after her fall on 08/03/2025 and when she was transferred from the floor to the wheelchair no gait belt was used. She stated CNA A got her dressed, she went to the dining room for breakfast and returned to her room her normal routine, then she went back out for lunch and back to her room. During a phone interview on 09/03/2025 at 12:05 PM CNA A, stated she was employed for nearly 2 years at this facility before her resignation on 08/06/2025. CNA A stated she was in-serviced on ANE often, she was knowledgeable of ANE and provided examples. She stated she was in-serviced on falls but could not recall the date. She stated the in-service emphasized needing to use gait belt with transfer and the protocol was to use a gait belt to prevent the resident from falling. She stated the purpose of the gait belt was to help keep residents safe and if a resident were to fall it would help them ease into the fall and the impact wouldn't be as hard. CNA A stated it is important to use proper procedures for transfer of resident to prevent injuries or skin tears. She stated she assisted Resident #1 to the toilet on 08/03/2025 and Resident #1 fell. She stated she was not using a gait belt and did not know that Resident #1 required a 2-person She stated she was in a hurry and did not have a gait belt with her, so she assisted Resident #1 without a gait belt. She stated she does believe she is a 1-person transfer in her care plan, she was in-serviced on using gait belt immediately after the fall, and stated she does believe Resident #1's injury may have been prevented or lessened had the gait belt been used. CNA A stated rather than waiting for the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 20 of 24 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few investigation to conclude while on suspension she resigned via email. During an interview on 09/03/2025 at 1:20 PM, DOR stated Resident #1 was able to use a walker to walk with 1x person assist with 25% assistance, could use the walker to walk, gait belt is required on all residents. She stated her 3rd party company requires a gait belt. She stated if modified supervision all requires gait belt. DOR stated 3rd party company's policy is that all residents should use gait belt, and all physical therapists are required to use a gait belt regardless of type of transfer. She stated she believes facility aids are to use contact guard (hand on them) any resident listed as such needs a gait belt. She stated gait belt gives a safe place to hang on to, helps residents to be steady, staff could grab wrong area, gait belt helps to grab easily, steady them, safely lower to the floor if they fall. DOR stated PT will complete an evaluation and list the resident's interventions and recommendations. DOR stated a therapy evaluation was conducted on Resident #1 on 0 7/30/2025 and it is documented that she required a 2-person transfer. She stated this information was passed along in the following morning huddle meeting with the nursing management team. She stated in this meeting this information was passed along to the management team at the facility and they in turn are responsible for entering into the electronic plan of care. During an interview on 09/03/2025 at 2:39 PM DON stated there is no mention during the 07/30/2025 thru 08/1/2025 morning management meetings where the Director of Rehab notified the team of ADL changes. She stated the team was not notified that Resident #1's evaluation had a significant change and a 2x person transfer was now required. She stated the MDS Coordinator is responsible for reviewing physical therapy updates. She reviewed Resident #1's EMR with Surveyor during this interview and confirmed there were no updates to the MDS Assessment or the care plan. Record review of Resident #1's incident report, dated 08/03/2025 at 6:20 AM revealed CNA A was helping Resident #1 to the restroom without the use of a gait belt and Resident #1 lost her balance as she was unable to bear weight and fell in the bathroom. LPCN B assessed Resident #1 immediately following the fall on 08/03/2025 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and responsible party was notified, and NP notified via copy of incident placed in provider box. Record review of Initial Post Fall Notification, dated 08/03/2025 revealed LPCN B documents initial post fall and notification to NP was via note to box. No phone call, no page message or text message notification was provided to NP. Record review of Resident #1's Health Status Note, dated 08/04/2025 at 4:52 PM revealed RN A's late entry progress note doesn't provide actual date and time of this entry). Note Text: Resident has an increasing pain on her left leg/hip possibly from her recent fall incident per report from the CNA. Resident was observed to have difficulty with transferring. NP notified of the pain and received order for STAT left hip x-ray. PRN pain medication administered. MAR Tylenol 325 MG administered at 4:52 PM. Record review of Resident #1's Physician Note dated, 08/05/2025 9:41 AM revealed NP Chief Complaint, Acute Issue - Fall, left hip pain. Record review of Resident #1's EMR on 8/2/2025 revealed there were no clinical records of x-ray results; however, interview with NP stated he received x-ray results the morning of 08/05/2025 and identified the fracture and started the process to transfer resident to the hospital. Record review of Resident #1's Hospital Transfer form dated 08/05/2025 at 2:19 PM revealed facility vitals last conducted before transfer to hospital. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of facility document titled, #594 Fall, dated 08/03/2025, 6:20 AM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 21 of 24 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few revealed this document served as the Incident Report for Resident #1's fall sustained on 08/03/2025. The individual statements provided by the nursing staff who were on shift for Resident #1's fall and post-fall shifts (72 hours) from 08/03/2025 - 08/05/2025. Statements reflect late entries from 08/05/2025 08/08/2025: 08/03/2025 2 PM - 10 PM shift: 08/06/2025 RN A statement captured, I worked Sunday [08/03/2025] 2p-10p, the same day resident had fallen. I received report from charge nurse [LPCN B] that resident fell but no concerns. I do not remember receiving any report from CNA A that resident was having pain or unable to bear weight.The CNA had transferred resident during shift, so I did not think there was a problem. I did not officially conduct skin assessment or ROM evaluation on resident on Sunday. RN A also added that she worked the following day, Monday 2 PM - 10 PM shift and she was notified before dinner that Resident #1 was unable to transfer or get out of bed. She did notify the NP following this information and the NP informed her that he was aware and had placed order for STAT x-ray. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 CNA E statement captured, I received report from CNA A.she did not say anything about the resident [Resident #1] having pain or issues with transferring. When I went to change her on my first rounds, I noticed that she did not seem comfortable due to her facial grimacing. I informed the nurse about the pain. On my second rounds with her [Resident #1] I felt she seemed like she was in more pain, so I moved her more gently and again I informed the nurse [RN B]. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 RN B statement captured, I was the RN on the 10-6 shift on Sunday August 3rd.On my initial assessment I did not note any indicators of pain with Resident #1. Late in my shift the CNA informed me that the resident looked uncomfortable while being changed. I administered PRN Tylenol for pain. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 CNA I statement captured, I worked as a CNA on Monday the 6a-2p shift with [Resident #1]. I did not get report from the 10p-6a shift.I arrived to the floor so I was unaware of the fall on the previous day.I noticed something was off when I went to get her out of bed that morning and she was unable to bear weight.I did not notice any visual or verbal signs of pain so I thought maybe she was just stiff from the night sleep. I noted that when I was assisting her with breakfast she was not eating well, and food was dropping out of her mouth. This was not unusual for her, but I did ask the other team members at the table if they felt there was something wrong. She was unable to bear weight I got assistance.to transfer into her bed so that I could change her. It was during this change that I noted her grimacing and noted the bruising to her hip. I then got her back up and into the wheelchair with assistance and she was at the nurse's station until lunch. She did not eat much at lunch. After lunch I again got assistance.to transfer her back to bed. I notified the nurse of my concerns, and she went and checked on her. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 LPCN C statement captured, I was the charge nurse for [Resident #1] on Monday 6a-2p.CNA I reported to me that the resident seemed to be in pain and was having a hard time transferring. I went and completed an assessment of her and noted bruising to her left hip. I did not complete a full range of motion because I could see she was in pain. I gave her some pain medication and put an ice pack on her hip. I did not say anything to the NP, but I did tell the oncoming nurse [RN A] about the bruising and pain complaints and to keep an eye on her. 08/04/2025 2 PM - 10 PM shift: 08/06/2025 RN A statement captured that on her shift on she was notified by CNA F on this shift that before dinner that resident was unable to transfer or get out of bed.notified NP and he stated he already placed order for STAT x-ray. 08/04/2025 2 PM - 10 PM shift: 08/08/2025 CNA F statement captured, I worked on the hallway where [Resident #1] lives on Monday morning 6a-2p and was assigned to her on the 2p-10p shift.I noted that she was unable to bear weight and it took 3 people to assist her which was unusual.I saw her grimacing when I changed her. I notified my charge nurse [RN A]. Record review of the facility's Care Plans, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 22 of 24 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Comprehensive Person-Centered Policy, dated March 2021, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition. Record review of the facility's Resident Rights Policy, dated 10/10/2024 reflected the following: The facility is committed to providing a safe and secure environment for our residents. philosophy of care is founded upon its commitment to promote and protect the rights of each resident, is dedicated to enhancing residents' quality of life, treating residents as individuals with dignity, courtesy and respect, and promoting the right to choose the way they live and the care they receive. Record review of the facility's undated Provision of Quality-of-Care Policy, reflected the following: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 2. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. 3. Responsibility for interventions on the care plan will be clearly identified. 4.Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. 6.Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. Record review of the facility's Bathroom, assisting a Resident procedure, dated February 2018, reflected the following: The purpose of this procedure is to assist the resident with ambulating to the bathroom. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. Steps in the Procedure 9. If necessary for support, use a gait belt for safety. Documentation The following information should be recorded on the resident's ADL record and/or in the resident's medical record: Any changes in the resident's ability to ambulate to the bathroom. Reporting Report other information in accordance with facility policy and professional standards of practice. Record review of the facility's undated document titled, Assist to Chair and steps table provided for CNAs and MAs providing direct care to residents reflected the following: The following table lists the steps that are expected of you in order properly assist a patient into a chair. The table also provides rationales that explain why you perform some of these steps. Procedure Description Apply transfer belt. Be sure that it completely circles the waist. Rationale Transfer belt allow you to maintain stability of patient during transfer and reduces risk of falling. Record review of Skilled Nursing In-Service: Care plan/Kardex, communication, resident rights & providing appropriate care, dated 06/20/2025 and conducted by the DON, reflected all nursing staff are responsible for checking the electronic care plan prior to delivery of care to ensure following plan of care. Failure to follow according to plan of care will result in disciplinary action and is a safety concern. Record review of Skilled Nursing In-Service: Kardex/Gait Belt Use, dated 08/05/2025 and conducted by DON and ADON, reflected all nursing team members must review the residents electronic care plan prior to delivering care to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676198 If continuation sheet Page 23 of 24 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete ensure they are following care plan. Failure to follow according to plan of care will result in disciplinary action and may result in potential harm to the resident. Additionally, failure to follow plan of care is considered neglect. Team members are allowed to use more assistance but never less. Notify on-call nurse manager immediately if you see someone was not care planned or needing updates to the electronic care plan. It is a requirement to use gait belt for x1-x2 assist for transfers/ambulation due to safety reasons. This was determined to be an Immediate Jeopardy (IJ) on 09/03/2025 at 7:17 PM. The ADM was notified. The ADM was provided with the IJ template on 09/03/2025 at 7:17 PM. The following Plan of Removal submitted by the facility was accepted on 09/05/2025 at 10:08 AM: On 9/3/25 Resident #1 assessed by RN for change in condition and acute pain. There were no new orders obtained. Results of the assessment were documented in the resident's Electronic Health Record (EHR). On 9/4/25 the affected resident's responsible party was notified by the Administrator of alleged deficiencies and plan of correction. On 9/3/2025 all current residents were assessed by RN for change in condition and acute pain, no negative findings noted. Results of the assessment were documented in the resident's Electronic Health Record (EHR). The Medical Director was notified - no new orders were obtained. CNA A is no longer employed at the facility as of 8/7/2025. On 9/3/25 Director of Nursing/Designee completed 1:1 education with CNA C on the use of gait belt during ambulation with a resident who requires assistance with ambulation. CNA C performed return demonstration, verbalized understanding and signed acknowledgement of training. On 9/3/25 an audit of all resident rooms was conducted by the Executive Director to ensure that each room had one gait belt per resident hanging on the bathroom door. Additional gait belts can be located within Central Supply. The Central Supply Clerk is re Event ID: Facility ID: 676198 If continuation sheet Page 24 of 24