Health inspection·April 10, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (Saline-Administration-Saline-Heparin used for flushing and delivering medicine to IV (intravenous) every shift. Further review revealed additional administration order dated 03/24/2025 revealed to administer ceFAZolin Sodium Injection Solution Reconstituted (treats many types of bacterial infections) 2 GM intravenously every 8 hours. Review of Resident #21's initial care plan reflected Resident #21 was at risk for complications related to infections. Goal included administering anti-viral and antibiotics as per MD orders, maintaining universal precautions when providing resident care, administering intravenous fluids as prescribed, changing tubing and site dressing as ordered, checking IV site as ordered and to observe for signs of infection, maintain rate of infusion as ordered, re-site IV per IV Therapy Protocol. Review of Resident #21's administration report dated March 2025 and April 2025 reflected two doses of antibiotics were not administered and 21 doses were administered late. ceFAZolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2 gram intravenously every 8 hours (12:00 AM, 8:00 AM, and 4:00 PM) Date Scheduled Administered Time 03/21/2025 8:00 AM 2:52 PM 03/22/2025 8:00 AM not administered 03/21/2025 4:00 PM 5:30 PM 03/22/2025 12:00 AM 3:29 AM 03/23/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 2 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 8:00 AM Level of Harm - Minimal harm or potential for actual harm 11:56 AM 03/24/2025 Residents Affected - Some 12:00 AM 6:52 AM 03/24/2025 8:00 AM 1:14 PM 03/25/2025 8:00 AM 1:56 PM 03/25/2025 4:00 PM 6:36 PM 03/26/2025 12:00 PM 2:42 AM 03/26/2025 8:00 AM 12:11 PM 03/26/2025 4:00 PM 6:49 PM 03/27/2025 8:00 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 3 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 not administered Level of Harm - Minimal harm or potential for actual harm 03/27/2025 4:00 PM Residents Affected - Some 8:12 PM 03/31/2025 12:00 AM 5:48 AM 04/02/2025 8:00 AM 2:33 PM 04/02/2025 4:00 PM 5:24 PM 04/03/2025 8:00 AM 2:37 PM 04/03/2025 4:00 PM 8:04 PM 04/04/2025 8:00 AM 3:48 PM 04/05/2025 4:00 PM 8:35 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 4 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 04/07/2025 Level of Harm - Minimal harm or potential for actual harm 12:00 AM 5:07 AM Residents Affected - Some 04/07/2025 8:00 AM 4:02 PM In an interview on 04/10/2025 at 11:54 AM LVN UM stated the expectation for admission nurses is to complete the initial assessment for new residents. She stated she is responsible for conducting head to toe assessment, entering diagnoses and medications received from discharging hospital or hospice into EMR. She stated discharge orders are usually received ahead of time and medications will be ordered before admission of resident or can go directly to the pharmacy. She stated when the charge nurse receives the medication list they will send to the NP or MD. She stated that antibiotics can usually be pulled from Pyxis system for quick access. She stated for narcotics the process is to reach the NP to send orders to the pharmacy and typically can be delivered within 30 minutes of orders being entered. In an interview on 04/10/2025 at 1:53 PM DON stated the expectations are for nurses to complete nursing admission assessments within 24 hours, entering medication orders, adding progress note at admission, transferring skill status (why at facility) and adding anything else that is pertinent to the resident admitting into the facility. He stated this also includes obtaining consent to treat resident, obtaining consent for bed rails, with an expectation of completing all admissions tasks within 24 hours. He stated that once medication orders are entered into the EMR system they are usually delivered within the first few hours after admission. He stated the more difficult medications that require triplicates (narcotics) would require an access code from the pharmacy to gain access to Pyxis machine. He stated antibiotics are usually easy to get ordered and not considered a difficult medication. He stated if there are medications not showing up on the MAR, not administered or missed then a nursing note would be documented under progress notes and he and the provider would be notified. In a phone interview on 04/10/2025 at 5:00 PM LVN A stated the MAR and physician orders are followed and provide staff with directions as to the time the dose should be administered and when the last dose was administered by staff. She stated the MAR outlines specific times the medication should be administered. She stated if medications are not given on time or administered this could cause the residents health problems or additional concerns. She stated the expectation is if medications could not be administered staff must make a note in the medical chart and notify the DON and NP or MD that it was missed. In an interview on 04/10/2025 at 6:00 PM DON and ADON stated the procedure for missed medications is to document in the chart and notify the DON and NP immediately. Both were not informed of any missed or late medications for Resident #21. Findings include: Review of Resident #345's face sheet reflected a [AGE] year-old female admitted [DATE] with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 5 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm diagnoses of Pneumonia, (air sacs in lungs may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing), Hypo-Osmolality (lower than normal levels of electrolytes, proteins, and nutrients in the blood) and Hyponatremia (low concentration of sodium in the blood), and Noninfective Gastroenteritis (lining of the intestines is inflamed and irritated) and Colitis (inflammation of the lining of the colon). Residents Affected - Some Review of Resident #345's admission MDS dated [DATE] reflected resident has active diagnosis of infection, pneumonia. Review of Resident #345's physician's order dated 04/08/2025 reflected to administer amoxicillin oral capsule 500 MG, 1 capsule by mouth three times a day related to pneumonia unspecified for 3 days. Review of Resident #345's clinical summary report dated 04/6/2025 generated in Epic (software that communicates the EMR between the facility and the hospital and uploaded into facility's primary EMR software on 04/06/2025 listed active medications at discharge, which included amoxicillin 500 mg capsule, take 1 capsule by mouth 3 times daily for 3 days, 9 capsule dispense quantity, 04/06/2025 start date, 04/09/2025 end date. Further review reflected that the hospital sent the physician's orders for Resident #345's antibiotics directly to the pharmacy on 04/06/2025. Review of Resident #345's hospital discharge report provided to resident dated 04/06/2025 reflected a list of Resident #345's medications at discharge and this list did not include antibiotics. Further review reflected this report was the limited version that the hospital typically provides to a patient at discharge. Review of Resident #345's initial care plan dated 04/07/2025 reflected Resident #345 had an infection and interventions included administering antibiotic as per MD orders. Further review reflected care plan revision on 04/08/2025 identified antibiotic as ordered through 4/11/2025. Review of Resident #345's nursing admission assessment dated [DATE] reflected admission was at 12:45 PM, vitals were taken at 5:45 PM and infection care plan listed: Focus: The resident has infection. Goal: The resident will be free from complications related to infection through the review date. Intervention: Administer anti-viral as per MD orders. Intervention: Administer antibiotic as per MD orders. Intervention: Follow facility policy and procedures for line listing, summarizing, and reporting infections. Intervention: Maintain universal precautions when providing resident care. Interventions: Monitor/document/report to MD changes in behavior. Review of Resident #345's administration report dated April 2025 reflected four doses of antibiotics were not administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 6 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Amoxicillin Oral Capsule 500 MG Level of Harm - Minimal harm or potential for actual harm Give 1 capsule by mouth three times a day (8:00 AM, 12:00 PM, and 8:00 PM schedule listed on MAR) Date Residents Affected - Some Scheduled Administered Time 04/06/2025 8:00 PM not administered 04/07/2025 8:00 AM not administered 04/07/2025 12:00 PM not administered 04/07/2025 8:00 PM not administered In an interview on 04/09/2025 at 10:55 AM LVN UM stated the admission nurse had medications ordered from the pharmacy immediately when Resident #345 was admitted . She stated there are no concerns with medications being delivered for any resident. The facility's protocol is to pull medications from reserves in Pyxis (pharmacy automation). She stated routine and non-routine medications can be easily and quickly filled. She stated the more challenging medications for example pain medication where a triplicate is required there would be a slight delay (few hours) and orders would be sent to Pyxis for distribution and a code would be provided to facility staff to access. LVN UM stated nurses are expected to review the resident's MAR for next dose and if there is a specific timeframe outlined for administration then this is what the nurse will follow for administration. She stated the protocol for missed or late medication administration is to document record and immediately notify the DON and NP or MD. She stated there could be a negative impact on the resident's progress if medication is missed or late. In an interview on 04/09/2025 at 03:26 PM ADON stated she didn't receive communication from the NP for orders for Resident #345. She stated the protocol is to obtain hospital discharge orders and at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 7 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some once notify the NP for reconciliation. She stated all nurses are expected to review the resident's MAR closely for scheduled times of all medications. She stated medications that are missed or late can affect resident's progress and stated the expectation is for nurses to report all medication errors (including missed or late) to DON and NP or MD. In an interview on 04/09/2025 at 4:15 PM DON stated the hospital discharge report provided to the resident includes the list of medications used to reconcile with the NP. The DON stated the NP reviewed the medication list by phone and provided verbal orders to administer. He stated this medication list did not include an antibiotic. The DON stated the protocol is for the admission nurse to use the limited hospital discharge report to reconcile medications with the NP or MD and if the NP does not agree with a medication order she will not provide a verbal order to administer, and a nursing note would be entered into EMR documenting this action. He stated that facility medications can be distributed and delivered quickly for new admissions and refills. He stated the more complex medications for example-controlled substances which require a triplicate will take a bit more time and require Pyxis codes and access. He stated typically it is a few hours (less than 4) from admission time to delivery of medication for a new admit. In an interview on 04/10/2025 at 11:30 AM LVN A stated the expectation is for all charge nurses to handle admissions and readmissions as a collective effort between LVNs and RNs. She sated nurses are provided in-services conducted by unit supervisors, the DON and ADON. She stated she is provided with an admission checklist of everything to be included in the admissions process. She is also responsible for assessing resident, providing a welcome packet of information, completing vitals and head-to-toe assessment, reconciling medication with the NP or MD available, inputting medications into EMR, and following up with pharmacy to confirm delivery. She stated that medication reconciliation is completed upon admission by using hospital discharge paperwork presented by the resident at admission. In an interview on 04/10/2025 at 11:54 AM LVN UM stated the expectation for admission nurses is to complete the initial assessment for new residents. She stated she along with all admission nurses are responsible for conducting head to toe assessment, entering diagnoses and medications received from discharging hospital or hospice into EMR. She stated discharge orders are usually received ahead of time and medications will be ordered before admission of resident or can go directly to the pharmacy. She stated when the charge nurse receives the medication list they will send to the NP or MD. She stated that antibiotics can usually be pulled from Pyxis system for quick access. She stated for narcotics the process is to reach the NP to send orders to the pharmacy and typically can be delivered within 30 minutes of orders being entered. In an interview on 04/10/2025 at 12:42 PM LVN UM stated there have been some issues with antibiotic orders coming over in their EMR system that the administration team is aware of and are working on. She would not provide additional details. In an interview on 04/10/2025 at 1:53 PM DON stated the expectations are for nurses to complete nursing admission assessments within 24 hours, entering medication orders, adding progress note at admission, transferring skill status (why at facility) and adding anything else that is pertinent to the resident admitting into the facility. He stated this also includes obtaining consent to treat resident, obtaining consent for bed rails, with an expectation of completing all admissions tasks within 24 hours. He stated that once medication orders are entered into the EMR system they are usually delivered within the first few hours after admission. He stated the more difficult medications that require triplicates (narcotics) would require an access code from the pharmacy to gain access to Pyxis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 8 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some machine. He stated antibiotics are usually easy to get ordered and not considered a difficult medication. He stated if there are medications not showing up on the MAR, not administered or missed then a nursing note would be documented under progress notes and he and the provider would be notified. In an interview on 04/10/2025 at 2:54 PM DON stated Resident #345's discharge orders were not present at admission. He stated Resident #345 did not present at the facility with antibiotics or orders for antibiotics. He stated the NP was notified of orders and after review of Resident #345's medical records she noted resident completed an antibiotic regimen in the hospital. He stated Resident #345's daughter notified the charge nurse that Resident #345 should be on a 3-day antibiotic. He stated that he provided daughter with the hospital's discharge instructions and antibiotics were not on the list of medications ordered. He stated a charge nurse notified him that an antibiotic was delivered for Resident #345 on 04/07/2025. He stated it appeared the hospital sent the antibiotic orders directly to the pharmacy to be filled. He stated the charge nurse notified the NP of antibiotic delivery and she was confused by this. He stated the NP reviewed Resident #345's medical history and discharge summary and afterwards she approved the administration of antibiotics. He also stated when the admission charge nurse was completing the admission assessment on Resident #345 it was done in error, as the resident did not have an antibiotic listed. He stated there seems to be a communication issue between Epic and PCC software and he is not sure why not sure why medical records staff are pulling the Epic report when the facility's process is to use discharge report directly from hospital or resident. In an interview on 04/10/2025 at 3:19 PM ADON stated she wanted to provide the surveyor with record review help and stated the facility gets a direct email from the discharge planner/coordinator from the hospital and that is what was received for Resident #345. She stated that the other clinical summary report received in the facility's EMR system is not used by admission nurses to reconcile medication with NP or MD. She stated the discharge clinicals vs. the discharge summary are two different reports and the facility staff are trained to review the discharge summary to reconcile medications. And she stated the admission nurse LVN B may have forgotten to uncheck the antibiotic box on the admission assessment or may have checked antibiotics because she was aware that Resident #345 had been administered antibiotics at the hospital earlier in the day and selected this option in error and not because she reviewed antibiotics on any discharge forms received. In an interview on 04/10/2025 at 4:15 PM DON stated the hospital representative/coordinator stated the discharge paperwork typically provided to patients at discharge is the same paperwork the facility receives and uses for reconciling medications. He stated the coordinator would need to speak with their legal team to confirm if a written statement noting this information could be provided to facility for survey purposes. In a phone interview on 04/10/2025 at 5:00 PM LVN A stated the MAR and physician orders are followed and provide staff with directions as to the time the dose should be administered and when the last dose was administered by staff. She stated the MAR outlines specific times the medication should be administered. She stated if medications are not given on time or administered this could cause the residents health problems or additional concerns. She stated the expectation is if medications could not be administered staff must make a note in the medical chart and notify the DON and NP or MD that it was missed. In a phone interview on 04/10/2025 at 5:39 PM NFA stated the facility receives the same discharge paperwork given to the patient at the hospital. He stated the facility will also have access to medical documentation as the full chart is available to the facility in Epic. He stated the after summary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 9 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is what is followed for discharge summary orders. He stated he cannot comment on whether the facility should be accessing only the hospital summary or in addition to the clinical chart. He stated the hospital's field representative directs the facility to use the hospital summary. He stated he cannot speak on facility only reviewing the discharge summary report as they have access to the clinical chart as well. He stated he would have to speak with the case manager at the hospital to gain more insight as to what the facility should be accessing for resident care services and after care. In an interview on 04/10/2025 at 6:00 PM DON and ADON stated the procedure for missed medications is to document in the chart and notify the DON and NP immediately. Both were not informed of any missed or late medications for Resident #345. In an interview on 04/10/2025 at 6:01 PM the ED stated the expectations for new admissions are for the charge nurses to completing the new admission assessment and orders. She stated the charge nurses are the primary staff accepting new admissions, but ADON and DON can also help with this task if necessary. She stated the admission nurses are responsible for completing a head-to-toe toe assessment of new admit and reconciling medications. She stated the nurse is responsible for entering orders the hospital may send to the facility. She stated nurses are responsible for reconciling orders from discharge paperwork, against what is received directly in EMR. She stated that typically when a new resident arrives a discharge summary from the hospital will accompany them. She stated some discharge information can be collected via phone with during a nurse-to-nurse report and then documented in the EMR. Review of Resident #90's face sheet reflected [AGE] year-old female admitted [DATE] with diagnoses of Osteomyelitis of the vertebral, sacral, and sacrococcygeal region (rare spinal infection that can occur due to injury, surgery, or spread from another part of the body through the bloodstream), Displaced Intertrochanteric Fracture of Right Femur (hip fracture), and Muscle Weakness (lack of muscle strength). Review of Resident #90's admission MDS dated [DATE] reflected resident had IV Medications as an infection treatment. Review of Resident #90's initial care plan reflected Resident #90 was at risk for complications related to infections. Goal included administering anti-viral and antibiotics as per MD orders, maintaining universal precautions when providing resident care, administering intravenous fluids as prescribed, changing tubing and site dressing as ordered, checking IV site as ordered and to observe for signs of infection, maintain rate of infusion as ordered, re-site IV per IV Therapy Protocol. Review of Resident #90's nursing admission assessment dated [DATE] reflected admission assessment was effective at 5:44 PM, vitals were taken at 4:10 PM and infection care plan listed: Focus: The resident has infection. Goal: The resident will be free from complications related to infection through the review date. Intervention: Administer anti-viral as per MD orders. Intervention: Administer antibiotic as per MD orders. Intervention: Follow facility policy and procedures for line listing, summarizing, and reporting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 10 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 infections. Level of Harm - Minimal harm or potential for actual harm Intervention: Maintain universal precautions when providing resident care. Interventions: Monitor/document/report to MD changes in behavior. Residents Affected - Some Review of Resident #90's physician's orders dated 03/26/2025 reflected to administer Daptomycin Intravenous Solution Reconstituted Use 650 mg intravenously one time a day. Review of Resident #90's administration report dated March 2025 and April 2025 reflected 01 dose of antibiotics were not administered and 06 doses were administered late. DAPTOmycin Intravenous Solution Reconstituted (Daptomycin) Use 650 mg intravenously in the evening (5:00 PM schedule listed on MAR) Date Scheduled Administered Time 3/27/2025 5:00 PM 9:27 PM 03/28/2025 5:00 PM not administered 3/29/2025 5:00 PM 10:33 PM 3/30/2025 5:00 PM 9:17 PM 4/01/2025 5:00 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 11 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 8:00 PM Level of Harm - Minimal harm or potential for actual harm 4/04/2025 5:00 PM Residents Affected - Some 7:27 PM 4/05/2025 5:00 PM 7:43 PM Review of Resident #90's administration report dated March 2025 and April 2025 reflected 16 doses of antibiotics were administered late. Meropenem Intravenous Solution Reconstituted 2 GM (Meropenem) Use 2 gram intravenously every 8 hours (12:00 AM, 8:00 AM, and 4:00 PM schedule listed on MAR) Date Scheduled Administered Time 3/27/2025 12:00 AM 2:07 AM 3/27/2025 4:00 PM 7:50 PM 3/28/2025 4:00 PM 6:32 PM 3/29/2025 4:00 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 12 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 & Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 13 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the drug regiment review recommendations from the pharmacy consultant were received and acted upon for 1 (Resident # 144) of 4 residents reviewed for drug regimen review. The facility failed to follow their policy regarding the pharmacy consultant and did not follow up on new admission pharmacy consultant recommendations dated 3/28/25. These failures could place residents being at risk for medication errors, unnecessary medications, and incorrect administration. Findings included: Review of Resident # 144's admission record dated 4/10/25 reflected an [AGE] year-old female admitted on [DATE]. Resident #144 had diagnoses of traumatic subdural hemorrhage with loss of consciousness of unspecified duration (brain bleed with loss of loss of consciousness), fracture of sacrum (fracture of bone that connects the spine to the pelvis), type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar levels), muscle weakness, fracture of occiput left side (skull fracture on the left side), cognitive communication deficit (difficulties with communication that arise from problems with cognitive processes like attention and memory), hypothyroidism (underactive thyroid), hyperlipidemia (increased fat particles in the blood), hypertension (high blood pressure), pain, and vitamin D deficiency. Review of Resident # 144's admission MDS dated [DATE] reflected a BIMS score of 5 indicating severe cognitive impairment. Review of section I active diagnoses reflected traumatic brain dysfunction as primary admitting diagnosis. Review of section J health conditions reflected for pain management Resident # 144 received scheduled pain medication regimen. Further review of pain assessment reflected no pain presence for last 5 days. Review of Resident # 144's care plan dated 3/27/25 and revised on 4/8/25 reflected problem of Resident # 144 is at risk for pain and is on pain medication therapy as ordered. Interventions include administer analgesic medications as ordered by physician, monitor/document side effects and effectiveness every shift, ask physician to review medication if side effects persist, review pain medication efficacy, monitor/document/report PRN adverse reactions to analgesic (pain reliever) therapy, and monitor for increased falls. Review of Resident # 144's MAR for April dated 4/10/25 reflected record of medication administration of the following medications and dosages with start date of 3/27/25 for Lipitor 40 mg 1 tablet by mouth at bedtime, metformin 500 mg give 1 tablet by mouth two times a day with recorded administration times of 9:00 am and 9:00 pm with start date of 3/30/25, Hydrocodone-Acetaminophen 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain with start date of 3/27/25, cholecalciferol oral tablet 125 mcg (5000 UT) give 2 tablets by mouth one time a day every Monday, Tuesday, Wednesday, Thursday, and Friday with start date of 3/31/25. Review of Resident # 144's Clinical physician orders revealed orders for metformin 500 mg give 1 tablet by mouth two times a day with a start date of 3/30/25, cholecalciferol oral tablet 125 mcg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 14 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (5000 UT) give 2 tablets by mouth one time a day every Monday, Tuesday, Wednesday, Thursday, and Friday with start date of 3/31/25, Lipitor 40 mg 1 tablet by mouth at bedtime with a start date of 3/27/25, and Hydrocodone-Acetaminophen 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain with start date of 3/27/25. Interview on 4/10/25 at 12:26 PM with the DON regarding the pharmacist's recommendations concerning Resident #144 the DON stated, that yes, Resident # 144's recommendations were missing from the pharmacy binder for the month of March. The DON stated he contacted the Pharmacist on 4/10/25 and the Pharmacist responded that Resident # 144 had been reviewed and recommendations sent on 3/28/25. The DON stated he told the Pharmacist that he never received the 3/28/25 email of recommendations. The DON stated the Pharmacist responded they would check the emails that were sent to the DON and saw that the 3/28/25 email did not go through. The DON stated the Pharmacist re-sent email with 3/28/25 recommendations on 4/10/25. The DON stated he received the recommendations from the pharmacist for 3/28/25 on 4/10/25. The DON stated after he received the recommendations, he took them to the NP for review and signatures. The DON stated he was unsure what the contract for pharmacy stated as to who checked to ensure recommendations were received or as to how often that was occurring. Review of Resident # 144's pharmacist recommendations dated 3/28/25 reflected to change metformin to BID with meals -breakfast/dinner per manufacturer, consider 30 day hold on Lipitor for [AGE] year old with anorexia (Megace daily), due to fracture, being calcium 600mg/Vitamin D 400IU 1 tab BID, set 14 day stop to PRN Norco for post fracture pain. Further review of pharmacist note dated 4/10/25 to the attending physician reflected the physician declined setting a 14 day stop to prn Norco, the physician wrote they would consider the 30 day hold on the Lipitor, and the physician agreed with the recommendation for the calcium/Vitamin D. Interview on 4/10/25 at 5:53 PM the ED stated it was her expectation the Pharmacist came in person or communicated through email monthly to the DON their recommendations. The ED stated the DON would be responsible for ensuring communication from the pharmacy is received and implemented. The ED stated it could negatively affect a resident if medication recommendations are not received and implemented. The ED stated the new admission orders and changes to orders are discussed in the daily morning meeting (stand up) with the DON, ADON, and unit manager and at the end of day meeting (stand down) the completion status is updated concerning any medication recommendations and reviews. Attempted telephone interview with the Pharmacist on 4/11/25 at 4:30 pm and 4/17/25 at 11:55 am revealed no answer and a message left with contact information. Call not returned. Review of the Consultant Pharmacist policy with a revision date of April 2019 reflected under policy interpretation and implementation. 5. The consultant pharmacist will provide specific activities related to medication regimen including: a. a documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines. b. appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 15 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen that was reviewed for kitchen sanitation in that: - Food items were not labeled and/or dated. Some food items were not labeled at all. - The grease in the fryer was dirty. - Drawers where the serving utensils were stored were not clean with debris in in the drawer. - Staff serving food in hall 100 were not sanitizing their hands before getting food trays to take to the resident. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness. Findings include: Observation on 4/08/2025 at 9:15 am of the walk-in refrigerator reflected the following: Lemons in a box were dated 3-17-2025 with no discard date. Lemonade in a serving container dated 2-10-2025 was expired. Lettuce dated 4-7-2025 with no discard date. Cucumbers in a box dated 3-10-2025 with no discard date. Raw meat in a pan covered in plastic dated 4-6-2025 with no discard date. Raw ground Sausage dated 4-7-2025 with no discard date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 16 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 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 Puree meat dated 4-7-2025 with no discard date. Level of Harm - Minimal harm or potential for actual harm Brown Puree that was not labeled in a metal container with plastic wrap dated 4-5-2025. Residents Affected - Some Flour tortillas with an expiration date of 4-16-2025. Observation on 4/08/2025 at 9:25 am of the kitchen reflected the following: Serving utensils were in a drawer under a table that had food debris in the bottom of the drawer. The fryer grease appeared old, with a lot of food debris on the top of the grease. Observation on 4/08/2025 at 11:30 am KC taking food temps reflected the following: The KC did not take temperatures of the fried chicken, mixed vegetables, or pureed bread. Observation on 4/08/2025 at 12:35 PM on the 100 hall reflected the following: CNA E was not sanitizing their hands in between grabbing food from the food cart and taking it to resident's room. CNA did this several times on the hall before taking residents their food. Interview on 4-10-2025 at 2:30 PM, KC F stated that all food was not temped before it is served to the facility's residents. KC F said the drawer where the serving utensils are stored should be cleaned once per week. KC F said a walk-through is done every morning in the pantry, walk-in fridge, and walk-in freezer to check for out-of-date products. KC F said if he finds out-of-date products, he will inform the supervisor about them and discard the out-of-date food. KC F said if the grease is not changed once a week, it can make the food taste bad. KC F said that if residents are served food that is outdated or not temped, then residents can get sick with a food-borne illness. Interview on 4-10-2025 at 2:40 PM, KC G said the pantry walk-in and freezer should be checked for out-of-date products daily. He said the drawers containing the serving utensils are cleaned after each shift. If he finds out-of-date products, he will inform the supervisor and discard the food. KC G said that when he is cooking, he temps the food after it is cooked and before it is served to the residents. KC G said that all cooks are responsible for changing the grease when it is dirty. KC G said that if food is not temped and expired food is used, residents can get a food-borne illness and get sick. Interview on 4-10-2025 at 2:40 PM, the KA said the kitchen is checked twice weekly for outdated food. KA said the drawers containing serving utensils are cleaned daily. The KA said he does not do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 17 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 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 - Some temperatures on food. KA said that residents could get food poisoning if outdated food is served to residents. Interview on 4-10-2025 at 2:48 PM, the DM stated that all food should be tempted before serving it to the residents. The DM said that the grease in the fryer is changed once or twice a week, depending on what is cooked in the fryer. The DM said that the cooks are responsible for changing the grease in the fryer. The DM said the drawers are cleaned weekly or as needed. The DM said that serving utensil drawers should be checked regularly for cleanliness. The DM said there could be cross-contamination if the drawers are not cleaned. The DM said residents could get sick if outdated food is served or if the temperature of the food is not taken before serving it to the residents. DM manager said that food that is opened and not in the original package should have a discard date. DM was made aware of the items in the walk-in cooler that there were items in boxes that did not have a discard date. Interview on 4-10-2025 at 2:58 PM, the RDM said staff should check for outdated food once a week. She said the temperature of all prepared food should be taken before serving it to the residents, and the grease in the fryer should be changed weekly. The RDM said that the drawers with clean utensils are expected to be cleaned regularly. The RDM said that if food is not temped and outdated food is served to residents, they could get sick. Interview on 4-10-2025 at 3:23 p.m., CNA D said that when serving residents on the hall, she sanitizes her hands each time she gets another tray for a resident to prevent contamination. CNA D said that if she sees other staff doing it the wrong way, they will correct them. Interview on 4-10-2025 at 3:40 p.m., CNA E said that she cleans her hands between each meal she serves the residents are not clean, it would be an infection control issue. CNA E said that she has been trained on food safety and infection control. Interview on 4-10-2025 at 3:40 p.m., the RN said she sanitizes her hands before taking each resident's meal. If hands are not sanitized, the resident could get an infection. The RN said that she has had food safety training. Interview on 4-10-2025 at 5:58 PM, the ED stated that kitchen staff should take the temperature of all prepared food before it is served to the residents. The ED also said that kitchen staff should check for outdated food regularly to ensure that no outdated food is being served to residents. The ED said that the kitchen should be cleaned regularly. ED said the residents risk getting sick if these things are not done. The ED said that staff should sanitize their hands between food trays that are delivered to the residents. Residents' tickets should be checked with the tickets to make sure the resident is getting the correct food. Food is supposed to be temped after cooking and before service. Outdated food is to be checked daily or weekly and discarded. Depending on the food cooked, the grease should be changed twice weekly. Drawers should be cleaned daily to prevent contamination. Record Review Food Temperature Policies: 1. All hot food items must be served to the Resident at the temperature of at least 140 degrees F at the time the Resident receives the food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 18 of 19 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 676345 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air at Teravista 4105 Teravista Club Drive Round Rock, TX 78665 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 4. Level of Harm - Minimal harm or potential for actual harm Cooking temperatures must be reached and maintained according to regulations. Laws and standardized recipes while cooking. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676345 If continuation sheet Page 19 of 19