Inspection·December 2, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an intense, excessive, and persistent worry and fear about everyday situations), major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), delusional disorders. Record review of Resident #34's clinical records revealed an OOH-DNR order which lacked a primary physician license number, date signed, and printed name. Record review of Resident #34's Comprehensive Care Plan, dated [DATE], revealed Yes marked under the question Resident has issued advance directives about his/ her care and treatment . In an interview on [DATE] at 1:46 PM, the Social Worker (SW) stated the admission process included educating the resident on advanced directives and how to obtain a DNR, if desired. The SW stated she was responsible for processing the DNR within 3 to 7 days and checked to ensure the DNR was filled out completely. The SW stated, if the DNR was not filled out completely, it was void and therefore went against the rights of the resident. The SW stated, Resident #13's OOH-DNR was invalid because it was missing the physician's license number on the form. The Social Worker stated she was unaware Resident #34's DNR was incomplete. The Social Worker stated she was auditing all DNRs within the facility to ensure they were adequately updated for residents and Resident #34's was slated to be evaluated within the next few weeks. The Social Worker stated the DNR was incomplete due to the previous Social Worker not evaluating the DNR properly upon reception. The Social Worker stated the facility would likely require a new DNR if the order did not include the date or physician's license number. She stated the risks associated with having an incomplete DNR would be an open liability to the facility. In an interview on [DATE] at 03:20 PM, the DON stated she could not answer whether the DNRs for Resident #13 or Resident #34 were received on admission. The DON stated she was unaware Resident #13 and Resident #34's DNRs were incomplete. The DON stated the current DNR within the clinical record for Resident #34 were incomplete based on the missing physician license and date. The DON stated risks associated with having an incomplete DNR would be the nurses would have to identify the code status during an instance of potential resuscitation and if resuscitation were to take place, then quality of life would be harmed. In an interview on [DATE] at 4:13 PM, the Admin stated she was unaware Resident #34's OOH-DNR was incomplete. The Admin stated the risk associated with having an incomplete DNR would be harm to the quality of life of the resident. Record review of the facility's undated advance directives policy, titled Advance Directive revealed once receiving the complete advance directive to notify the attending physician in order to have the ability to input physician's orders for the resident. Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.002, revealed in part, Definitions. In this chapter: (12) Physician means: (A) a physician licensed by the Texas Medical Board . Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed in part, Filling out the Out-of-Hospital Do-Not-Resuscitate Form . Physician's Statement: The patient's attending physician must sign and date the form, print or type his/her name and give his/her license number. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676271 If continuation sheet Page 2 of 8 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 676271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Onion Creek Nursing and Rehabilitation Center 1700 Onion Creek Pkwy Austin, TX 78748 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a medication error rate was not 5% or greater. The facility had a medication error rate of 18%, based on 5 errors out of 27 opportunities, which involved 1 of 5 residents (Resident #56) and 1 of 4 staff (LVN B) reviewed for medication administration. Residents Affected - Some The facility failed to ensure LVN B administered medications according to the physician's orders and per professional standards which resulted in an 18% medication administration error rate. This deficient practice could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions. The findings are: Record review of Resident #56's face sheet, dated 12/1/22 revealed a [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral palsy (physical disability that affects movement and posture), seizures, disorders of psychological development, adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), need for assistance with personal care, dysphagia (difficulty swallowing) and aphasia (a disorder that impacts speech and the ability to communicate). Record review of Resident #56's quarterly MDS assessment, dated 9/1/22 revealed the resident was rarely/never understood and utilized a feeding tube. Record review of Resident #56's person-centered comprehensive care plan, revision date 10/12/22 revealed the resident required tube feeding related to dysphagia with interventions that included Needs assistance/supervision/cueing with tube feeding and water flushes. See MD (Medical Doctor) orders for current feeding orders. Record review of Resident #56's order summary report for December 2022 revealed the following orders: -Cholecalciferol Tablet 1000 unit, give 1 tablet via PEG-tube one time a day for supplement -Loratadine Tablet 10 mg, give 1 tablet via PEG-Tube one time a day for allergies -Multiple Vitamin Tablet, give 1 tablet via PEG-Tube one time a day for supplementation -Baclofen Tablet 10 MG, give 1 tablet via PEG-Tube two times a day for Joint Stiffness -Topamax Tablet 100 MG, give 1 tablet via PEG-Tube two times a day for Seizures -Topamax Tablet 50 MG, give 1 tablet via PEG-Tube two times a day for Seizures Observation during the medication pass on 12/1/22 at 8:31 a.m., LVN B prepared Resident #56's aforementioned medications. LVN B crushed each medication separately in a pouch, except for the two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676271 If continuation sheet Page 3 of 8 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 676271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Onion Creek Nursing and Rehabilitation Center 1700 Onion Creek Pkwy Austin, TX 78748 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Topamax tablets, and poured each medication into a separate medication cup. LVN B poured 10 cc of water into each medication cup but did not mix or stir the water into the medication. LVN B poured each medication from the cup into Resident #56's peg tube. Each medication cup, after it was poured into the peg tube, was observed with a copious amount of residual medication left in the cup. During an interview on 12/1/22 at 9:35 a.m., LVN B stated, she tried to get it (the medication) out of the cup but there was a lot of residual. LVN B stated she understood the physician's order for administering Resident #56's medications via a peg tube meant to put 10 cc of water into each medication cup before pouring the medication into the peg tube but realized she should have been flushing the peg tube with 10 cc of water after each medication. LVN B stated the excess residual of medication left in the medication cups meant Resident #56 did not really receive her medication and possibly didn't get the full dose. LVN B stated if the resident did not receive a full dose of medication, it could cause a reaction. LVN B stated Resident #56 took seizure medications and if the full dose was not administered it could lead to the resident having a seizure. During an interview on 12/1/22 at 4:28 p.m., the DON stated medication residual left in the medication cup during medication administration meant the resident did not receive a full dose of the medication. The DON stated LVN B should have put more water into the medication cup and stirred the medication to dissolve it and then try to dispense it. The DON stated Resident #56 had a seizure disorder and if she was not receiving a full dose of seizure medication the resident could have a seizure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676271 If continuation sheet Page 4 of 8 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 676271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Onion Creek Nursing and Rehabilitation Center 1700 Onion Creek Pkwy Austin, TX 78748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 nourishment refrigerators (MC Refrigerator and Refrigerator B) reviewed for food handling sanitation. 1. The facility failed to ensure temperature logs were completed and maintained. 2. The facility failed to ensure expired milk was removed from the reach-in nourishment refrigerators. 3. The facility failed to ensure foods in the memory care unit refrigerator were labeled and dated. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings include: Observation on 11/30/22 at 10:54 AM revealed The MC Refrigerator dedicated to resident use within the memory care unit without a corresponding temperature log. There were 14 units of 2% dairy milk found within the memory care refrigerator which indicated dates of expiration ranging between 11/05/2022 and 11/29/2022. There were 7 plastic food containers without an indicated of resident ownership, identification of food contents, or expiration date. Observation on 11/30/22 at 11:34 AM,the nourishment room between halls 100 and 200 revealed there was not a corresponding temperature log. Within the reach-in refrigerator B, were 6 units of 2% dairy milk with expiration dates ranging from 11/05/22 to 11/28/22. In an interview on 11/30/22 at 11:02 AM, the Dietary Manager stated the facility had two refrigerators outside of the kitchen, the memory care refrigerator and refrigerator B which are both the responsibility of the nursing staff to maintain and audit. In an interview on 11/30/22 at 11:26 AM, the DON stated the responsibility for maintaining the nourishment rooms was under nursing which included auditing the contents of the refrigerators along with maintaining a temperature log of the units. The DON stated audits of refrigerator B were assigned to be completed twice per shift but were not documented due to staff failure. The DON stated she was unsure of which staff did not complete the audit. The DON stated all food items brought by family are to be labeled and dated; the DON stated she was uncertain why the MC Refrigerator contained unlabeled and undated food containers. The DON stated the most recent audit of the refrigerator was inadequately completed by nursing staff. The DON stated the risks associated with failing to maintain food storage for residents would be a risk of foodborne illness due to expired food or malfunctioning equipment. In an interview on 12/2/22 at 4:13 PM, the Admin stated she was not aware of the nourishment room and memory care reach-in refrigerator lacked a temperature log or contained expired food. The Admin stated it was the responsibility of nursing to maintain the refrigerators within the resident areas of the facility. The Admin stated it was her expectation that expired food be removed during audits and all food not pre-packaged by labeled and dated. The Admin stated she understood the risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676271 If continuation sheet Page 5 of 8 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 676271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Onion Creek Nursing and Rehabilitation Center 1700 Onion Creek Pkwy Austin, TX 78748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 associated with not maintaining adequate food storage would be a risk of foodborne illness to residents. Level of Harm - Minimal harm or potential for actual harm Record review of the facility dietary policy titled Food Storage, dated 08/2007, revealed The dietary manager, or his/her designee, will check refrigerators and freezers two or three times daily for proper temperatures. Records of such information are maintained by the dietary manager. Residents Affected - Many Record review of the US Food Code, dated 2017, revealed EQUIPMENT is used for storage of PACKAGED or unPACKAGED FOOD such as a reach-in refrigerator and the EQUIPMENT is cleaned at a frequency necessary to preclude accumulation of soil residues. Record review of the US Food Code, dated 2017, revealed Processed reduced oxygen foods that exceed the use-by date or manufacturer's pull date cannot be used in any form and must be disposed of in a proper manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676271 If continuation sheet Page 6 of 8 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 676271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Onion Creek Nursing and Rehabilitation Center 1700 Onion Creek Pkwy Austin, TX 78748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 2 of 4 staff (CNA C and CNA D) and 1 of 2 residents (Resident #53) reviewed for infection control. Residents Affected - Few 1. The facility to ensure CNA C, while assisting CNA D with perineal/incontinent care to Resident #53, did not place the clear plastic bag with incontinent supplies on the floor. 2. The facility failed to ensure CNA D changed gloves when going from dirty to clean sites when providing perineal/incontinent care to Resident #53. These deficient practices could place residents at risk for cross contamination and/or spread of infection. The findings were: Record review of Resident #53's face sheet, dated 12/2/22 revealed a [AGE] year old female admitted on [DATE] with diagnoses which included acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and need for assistance with personal care. Record review of Resident #53's admission MDS assessment, dated 10/16/22, revealed the resident was cognitively intact for daily decision-making skills, was occasionally incontinent of bladder and frequently incontinent of bowel. Record review of Resident #53's comprehensive person-centered care plan, revision date 11/9/22 revealed the resident had bowel and bladder incontinence with interventions that included, Check as required for incontinence. Wash, rinse and dry perineum. Observation on 12/1/22 at 2:02 p.m., during perineal/incontinent care, CNA C took a clear plastic bag with incontinent supplies into Resident #53's room. CNA C placed the clear plastic bag with incontinent supplies on the floor and removed a towel from the clear plastic bag and draped the towel over the bedside table. CNA C then removed disposable incontinent wipes, additional towels and gloves from the clear plastic bag and placed the items on the towel draped bedside table. Observation on 12/1/22 at 2:02 p.m., after CNA C placed the incontinent supplies on the bedside table, CNA D performed hand hygiene, put on gloves and then pulled back Resident #53's blanket, pulled up the resident's gown, unfastened the resident's incontinent brief and pulled back the brief away from the resident's groin area. CNA D, still wearing the same pair of gloves, provided perineal/incontinent care to Resident #53. CNA D, still wearing the same pair of gloves assisted the resident onto her left side, removed the soiled incontinent brief, rolled the incontinent brief into a ball and placed in the trash. CNA D, still wearing the same pair of gloves continued with perineal/incontinent care. CNA D, still wearing the same pair of gloves retrieved a clean incontinent brief and placed it on the resident's bed. CNA D assisted the resident onto her back and brought the incontinent brief over the resident's groin area and fastened the brief. CNA D, still wearing the same pair of gloves pulled down the resident's gown, pulled up the resident's blanket, placed the call light on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676271 If continuation sheet Page 7 of 8 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 676271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Onion Creek Nursing and Rehabilitation Center 1700 Onion Creek Pkwy Austin, TX 78748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 bed, took the bed remote to adjust the bed and placed the bed remote on the resident's bed. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/2/22 at 2:15 p.m., CNA D stated she worked for the facility since April 2022 and had recently completed competency training on perineal/incontinent care yesterday (12/1/22). CNA D stated she realized she did not change her gloves when she moved from a dirty area to a clean area and should have because it was considered cross contamination. CNA D stated cross contamination could result in the resident getting a bacterial infection in the private area. CNA D stated she never provided peri care/incontinent care in front of a State Surveyor and admitted she was nervous. CNA D stated she was thrown off after observing CNA C put the clear plastic bag of incontinent supplies on the floor. CNA D stated, CNA C also did cross contamination when he put the bag on the floor. Residents Affected - Few During an interview on 12/2/22 at 2:27 p.m., CNA C stated the clear plastic bag with incontinent supplies should not have been placed on the floor because it was considered cross contamination. CNA C stated, I should have tossed out the supplies in the bag and started over. CNA C stated the bag with incontinent supplies placed on the floor would not have directly impacted the resident because the actual supplies never touched the floor. CNA C stated, if cross contamination had actually occurred the resident could get infected such as with a UTI (urinary tract infection.) During an interview on 12/2/22 at 10:32 p.m., the DON stated, placing the clear plastic bag with incontinent supplies was not ok because the floor is dirty. The DON stated glove changes and hand hygiene should have occurred after the aide went from a dirty area to a clean area because it was considered cross contamination. The DON stated, that is not ok, it would place the resident at risk for infection. Record review of the competency training titled, Hand Hygiene - Traditional, dated 11/15/22 revealed CNA D had satisfied the requirement for hand hygiene/sanitation. Record review of the competency training titled, Peri Care -Female, dated 12/1/22 revealed CNA C had satisfied the requirement for performing peri care. The record revealed in part, .Perform hand hygiene .Gather supplies .Put on clean gloves .Assemble supplies on clean, appropriate surface . Record review of the competency training titled, Peri Care - Female, dated 11/30/22 revealed CNA D had satisfied the requirements for performing peri care. The record revealed, in part, .Perform hand hygiene .put on clean gloves .dispose of soiled linen, remove and dispose of gloves, without contaminating self .perform hand hygiene . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676271 If continuation sheet Page 8 of 8