Health inspection·October 16, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the fingertip, middle finger fingernail (if she had five fingers) was 1/4 inch past the fingertip and jagged, her ring finger fingernail extended 3/4 inches past the fingertip, and her pinky finger fingernail was 1/2 inch past the fingertip. He right hand thumbnail extended 1/2 inch past the fingertip, her index finger fingernail was short and extended 1/8 inch past the fingertip, but curled down towards the fingertip, her middle finger fingernail was 3/4 inch past the fingertip, her ring finger fingernail extended 3/4 inches past the fingertip, and her pinky finger fingernail was 1/2 inch past the fingertip. Resident did not want to complain about her fingernail length, but felt they were too long and needed to be trimmed. Observations on 10/16/24 at 8:56 AM revealed Resident #33's fingernails had not been trimmed (matching the observation on 10/14/2024 at 12:34 PM). She was indifferent about her nails having been neglected. She was not aware staff were supposed to have been helping her with her nail hygiene, but overall felt she deserved more attention to her nails. Interview and record review on 10/16/24 at 9:28 AM with CNA M revealed residents who are bathed/showered were observed for skin abnormalities, which included the need for nail care. The resident either had a documented paper shower observation sheet, or the services were documented in PCC (the facility's documentation platform). Record review of the facility's binder of shower sheet observations, which was located at the nurse's station, did not contain a shower sheet for Resident #33. Interview on 10/16/24 at 9:36 AM with LVN O, revealed some residents received paper shower observation sheets or the shower observations were documented in PCC. Interview on 10/16/24 at 9:44 AM with CNA N revealed residents who received showers/baths received observation of skin and body, which were either documented in PCC or on a paper shower observation sheet. Observations of CNA N having searched PCC for shower/skin observations did not reveal shower observation documentation for Resident #33. Interview and observations on 10/16/24 at 10:02 AM with RN Q, revealed Resident #33 was a diabetic and licensed nursing staff would have been enlisted to perform nail care for diabetic residents. RN Q expected the CNA staff to document the skin observations, to include the need for nail care, on a paper shower observation sheet. Observations of RN Q having searched PCC for any documentation, revealed PCC did not allow for elaborations of shower observations. The options for CNA staff were limited to either yes-meaning task performed, or No-meaning task not performed. The risks for residents, with long or jagged fingernails, were scratches, infections, and lowered self-esteem. Safeguards in place to identify the need for nail care were regular rounds, paper shower observation sheets, and staff awareness. Interview on 10/16/24 at 10:13 AM with LVN O revealed she approached Resident #33, in her room, for a nail observation. She stated Resident #33 did not want her nails cut. LVN O, stated Resident #33 responded with the offer of nail care with, No. Not at all. Even though Resident #33 refused nail care on 10/16/24 at 10:13 AM, LVN O stated there should have been documentation of the refusal having been obtained prior to today, 10/16/2024. Observation and interview on 10/16/24 at 10:26 AM with Resident #33 revealed her being taken to physical therapy in her wheelchair. Resident #33 stated she did not refuse nail care and stated, I did not say no, I was in the bathroom when they asked. I do want my nails cut. Interview on 10/16/24 at 10:13 AM with LVN O revealed she revisited Resident #33's nail care. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 2 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she misunderstood Resident #33 earlier on room visit on 10/16/24 at 10:13 AM. Her revisit resulted in Resident #33 having desired to have her nails cut. Interview on 10/16/24 at 2:52 PM with the GM revealed she expected her staff to assess the need for grooming and let the resident make the choice to whether they wanted the service performed. If the resident's choice to refuse nail care ever reached the point of an accident, the facility staff would speak to the medical provider to address the concern. The GM deferred questions that pertained to negative consequences of long, or jagged nails, as they were of a clinical nature. Record review of the facility's ADL Policy, dated November 2020, revealed the facility would provide each resident with care, treatment, and services. The policy included: bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating, and communication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 3 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 3 of 7 Residents (Resident #32, Resident #152, and Resident #154) reviewed for facility activities. Residents Affected - Some 1. The facility failed to post the activity schedule in a prominent location, visible to residents and responsible parties. 2. The facility failed to hold activities that were on the activity schedule. 3. The facility failed to complete Resident #152's Activity Assessment. 4. The facility failed to perform Resident #154's Activity Assessment within the facility's required completion period. 5. The facility failed to provide Resident #32, Resident #152, and Resident #154 a monthly activity calendar. This failure could have placed the residents at risk of isolation, depression, missed opportunities to work on fine motor skills, and a diminished quality of life. Findings Included: Observations on 10/14/2024 at 10:00 AM of the facility entrance, the facility hallways, and the facility information board did not display a resident activity schedule. Observations and record review on 10/14/2024 at 2:30 PM in the dining room did not reveal the AD providing the daily activity, which was supposed to be crafts. Record review of the activity calendar, provided at entrance conference, revealed the activity was scheduled to occur at 2:30 PM. Observations on 10/15/24 at 9:00 AM of the facility entrance, the facility hallways, and the facility information board did not display a resident activity schedule. Observations and record review on 10/15/2024 at 10:30 AM in the dining room did not reveal the AD providing the daily activity, which was supposed to be painting. Record review of the activity calendar, provided at entrance conference, revealed the activity was scheduled to occur at 10:30 AM. Resident #32 Record review of Resident #32's AR, dated 10/15/2024, reflected a [AGE] year-old woman, who admitted to the facility on [DATE]. She was diagnosed with Fracture of Right Lower Leg, an Anxiety Disorder (which was a mental health condition marked by heightened responses (worry) to certain situations and stimuli), a Bi-Polar Disorder (which was a mood disorder marked by elevated moods and de-elevated moods), and Major Depression (which was a mental condition characterized by depressed mood, loss of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 4 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 pleasure, or interest in life). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #32's admission MDS assessment, dated 10/7/2024 reflected the resident had a BIMS Score of 15. A BIMS Score of 15 indicated the resident had no cognitive impairment. The resident's mood interview indicated the resident felt down, depressed, or hopeless 2 to 6 days over the course of the last 2 weeks. Resident felt it was very important to do things with groups of people and somewhat important to do her favorite activities. Residents Affected - Some Record review of Resident #32's Activity Assessment, dated 10/7/2024, revealed the resident felt it was very important to do things with groups of people and somewhat important to do her favorite activities. The resident's leisure activities were card games, creative arts, learning/education, music, and parties/social. Other information gathered indicated an interest in bingo and painting. Record review of Resident #32's CCP reflected an area of Focus for leisure activities, initiated on 10/7/2024. The Goal initiated on 10/8/2024 indicated the resident would participate in their leisure activities as desired. The Interventions provided, initiated on 10/7/2024, listed card games, creative arts, learning/education, and parties/social. Interview and observation on 10/15/2024 at 2:50 PM with Resident #32 revealed she was unaware of activities at the facility. Resident #32 stated she had not received a copy of the activity calendar for the month of October 2024. Not knowing about the activities at the facility made her feel frustrated and isolated. She had not been approached by staff to remind her of any activity. She was alert and oriented to place and time. Observations of Resident #32's room did not reveal an activity calendar. Resident #154 Record review of Resident #154's AR, dated 10/15/2024, reflected a [AGE] year-old woman, who admitted to the facility on [DATE]. She was diagnosed with Acute Respiratory Failure (which was condition of the lungs having caused an inability for oxygen to enter the body) and Acquired Absence of Left Leg Below Knee. Record review of Resident #154's admission MDS assessment, dated 10/10/2024, reflected the resident had a BIMS Score of 15. A BIMS Score of 15 indicated the resident had no cognitive impairment. Section F. Preferences for Customary Routines and Activities had not been completed. Record review of Resident #154's Activity Assessment, located on the Assessment Page in PCC (Point Click Care,) the facility's documentation platform, reflected Resident #154's Activity Interview was due on 10/11/2024 and was 4 days overdue. Interview and observation on 10/15/24 at 4:34 PM with Resident #154 revealed she was not aware of activities provided by the facility. She had not received an activity calendar in her room, nor had staff informed her to attend any activities. She was unaware they had activities to do. She stated she felt aggravated that she had not been informed. She felt like she was cooped up in the room all day. She was alert and orientated to place and time. Observation of Resident #154's room did not reveal an activity calendar. Resident #152 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 5 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #152's AR, dated 10/15/2024, reflected a [AGE] year-old woman, who admitted to the facility on [DATE]. She was diagnosed with Depression (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life) and an anxiety disorder (which was a mental health condition marked by heightened responses of worry to certain situations and stimuli). Record review of Resident #152's admission MDS assessment, dated 10/15/2024, reflected the resident had not yet been assessed for a BIMS Score. Section F. Preferences for Customary Routines and Activities had not been completed. Record review of Resident #152's Activity Assessment, located on the Assessment Page in PCC reflected Resident #152's Activity Interview was opened, but was unedited, on 10/15/2024. The Activity Assessment was blank. Record review of Resident #152 CCP, with an admission date of 10/9/2024, did not reveal a care area section for Activities. Interview and observation on 10/15/24 at 4:39 PM with Resident #152 revealed she had not been informed about activities at the facility. She did not know there were scheduled activities and she had not received an activity calendar. She was disappointed there were no activities to do and even more so when she learned the facility was supposed to have provided them. She did not get reminders from staff since her arrival. Observation of her room did not reveal an activity calendar. Observations on 10/16/24 at 11:00 AM of the facility entrance, the facility hallways, and the facility information board did not display a resident activity schedule. Interview and Record review on 10/16/24 at 11:48 AM with the AD revealed she had been the AD at the facility for the last 8 months. She did not have any certificate, nor had she attended any formal training, for the position. The AD, stated new residents were supposed to have been assessed for activities in Section F of the MDS. The AD stated she either looked at the Assessment Page in PCC for the dates the assessments were due or the MDS Nurse, MDSN, would tell her. There were no Activity Calendars posted on the walls, or on any information boards, in the facility. Record review of the facility's welcome packet revealed 10 pages of facility information but no information about activities. The AD acknowledged there was no information about activities in the welcome packet; she had not asked to be included in the facility's welcome packet. The AD stated she had not provided residents with a copy of the activity calendar. The activity (crafting) planned for Monday, 10/14/2024 at 2:30 PM in the dining room, was canceled due to staffing shortages; the activity (painting) planned for Tuesday, 10/15/2024 at 10:30 AM in the dining room, was canceled due to a resident council meeting 4 hours later that same day. The AD stated activities for residents were important because activities got the residents out of their rooms, promoted socialization, helped fine motor skills, and kept them active. Without activities, the residents may have become isolated, or depressed, and would have missed opportunities for work on their fine motor skills. A safeguard in place, to ensure residents were informed of activities, was a daily room visit. Staff would tell the resident about activities and wrote those names down, to know who to collect at the scheduled time. The lists were not kept on file. The AD stated the facility had not been meeting the standards of the facility's Activity Policy. Interview on 10/16/24 at 2:37 PM with GM revealed the current AD was trained and supervised by the SAD, who was over multiple facilities in the region. The AD had not had a great deal of experience with activities, but the facility thought she was a good fit, since residents liked her. She had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 6 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some taken an Activity Director Course. The GM stated morning rounds, a daily administrative walk through of the facility, was performed daily to let residents know of activities. Benefits for the residents having attended activities highlight social interaction, increased joy, and practice with fine motor skills; The GM deferred any questions to negative outcomes due to the lack of activities. Record review of the facility's activity calendar, for the month of October 2024, revealed a planned activity for each day of the month. Record review of the facility's Activity Policy, dated November 2020, revealed group activities will be offered to all residents and guests. Residents will be offered a variety of activities based on their preferences. A calendar of activities will be made available to all residents upon admission and each month thereafter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 7 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 - Minimal harm or potential for actual harm 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 reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 2 residents (Residents #37 and Resident #42) reviewed for accidents and supervision. The facility failed to ensure Resident #37, and Resident #42 were provided safety when facility staff were directing the residents to going outside to smoke in the roadway without supervision. Findings Included: Record review of Resident #37's face sheet reflected a [AGE] year-old male with an admission date of 09/04/24. Resident #37 had diagnoses which included fall subsequent encounter, generalized muscle weakness and need for assistance with personal care. Resident #37's admission MDS assessment dated [DATE] reflected he had a BIMS Score of 12, and moderate cognitive impairment. Resident #37 used a wheelchair for mobility. The MDS did not have that the resident was a smoker. Record review of Resident #37's Care Plan dated 09/04/24 revealed Resident #37 was at risk for falls. Resident #37 had an actual fall. On 09/07/24 at 8:54 PM a guest observed Resident #37 on the floor. Resident #37 had an ADL self-care performance deficits and limitations in physical mobility and required substantial/maximal assistance with transfers. The care plan reflected Resident #37 was a cigarette smoker prior to admission. Resident non-compliant with no smoking policy of facility, observed by staff smoking outside. Education provided and smoking cessation alternatives offered, resident has refused. Record review of Resident #42's face sheet reflected a [AGE] year-old male with an admission date of 09/04/24. Resident #42 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (paralysis and weakness on right side after stroke), Repeated falls, muscle weakness, unsteadiness on feet, cognitive communication deficit (problems with communication), and need for assistance with personal care. Record review of Resident #42's Quarterly MDS assessment, dated 09/30/24, revealed a BIMS score of 15, suggesting intact cognition. Resident #42 used a wheelchair for mobility. The MDS did not have that the resident was a smoker. Record review of Resident #42's Care Plan, dated 09/24/24, revealed Resident #42 was at risk for falls. Resident #42 has ADL self-care performance deficits and limitations in physical mobility. Resident #42 was a cigarette smoker prior to admission. Resident non-compliant with no smoking policy of facility, observed by staff smoking outside. Education provided and smoking cessation alternatives offered, resident has refused. Observation of Facility on 10/14/2024 at 8:54am revealed Residents #37 and #42 were outside on the sidewalk approximately 30 feet from the front door smoking with no staff members. Interview on 10/14/2024 at 7:11 PM with Resident #37 revealed he was a resident who smokes while a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 8 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 - Minimal harm or potential for actual harm Residents Affected - Few resident at the facility. To smoke, he stated administration, no one in specific, had instructed him to exit the building and ambulate, in his wheelchair, to a smoking area just off the property and out of public view. He stated he kept his own lighter and his own cigarettes; he had not been assessed for smoking safety. He had no visible burns and stated he had not burned himself. Interview on 10/14/2024 at 7:17 PM with Resident #42 revealed he was a resident who smokes while a resident at the facility. To smoke, he stated the Activity Director (AD) had instructed him to exit the building and ambulate, in his wheelchair, to the end of the property out of public view. He stated he kept his own lighter and his own cigarettes; he had not been assessed for smoking safety. He had no visible burns and stated he had not burned himself. Observation on 10/15/24 at 08:39 AM revealed Resident #37 outside smoking and accompanied by facility staff. The resident was observed in his wheelchair on the road. The road has a downward slope, coming from the facility. Observations on 10/15/2024 at 8:50 AM revealed Resident #37, with the GM, on the outer edge of the facility, which was observed as public property. He was in his wheelchair smoking in the road. Interview on 10/15/24 at 09:19 AM with GM revealed they had a meeting this morning (10/15/24) to review of the smoking policy and conduct a smoking assessment with Resident #37. GM stated Resident #37's POA was coming today to discuss financial stuff and will be taking Resident #37's smoking paraphernalia home. The GM said she discussed the policy about smoking with him and did a smoking evaluation with him this morning. GM stated Resident #37 knew where the sign in /out book is and had been compliant in signing in and out of the book. She stated Resident #37 had one cigarette on him, and she had Resident #37's lighter. POA was contacted and stated he would be taking the cigarette paraphernalia home. Interview on 10/15/24 at 09:56 AM with Resident #37 revealed he was instructed to follow the smoking policy this morning. Resident #37 stated the smoking rules have kept changing since he had been here, and he wished there would be consistency with the rules for smoking. Record review of a Progress Note for Resident #37 dated 10/15/24 at 8:50 AM reflected, Resident is a smoker. Resident smokes cigarettes. Resident carries matches or lighter. Resident asks others for a light or lights from another cigarette. Resident smokes in unauthorized areas. Resident begs or steals smoking materials from others. Resident refuses to wear appropriate clothing/footwear to go outdoors to smoke. Resident refuses to follow the facility safe smoking policy. Resident Risk Score is 6.0, Unsafe Smoker follow facility policy. Record Review of Resident #42's Progress Note dated 10/15/2024 at 8:57am reflected Resident is a smoker. Resident smokes cigarettes. Resident smokes less than hourly. Resident smokes in unauthorized areas. Resident has Extrapyramidal Symptoms (involuntary movements that cannot be controlled), History of CVA (a brain attack), Parkinson's (a disorder of the central nervous system) or other diagnosed syndrome or disease that would limit the safe physical act of smoking. Resident refuses to follow the facility safe smoking policy. Resident Risk Score is 6.0, Unsafe Smoker - follow facility policy. An interview with Resident #37 on 10/15/2024 at 1:00pm revealed that the ADM was showing Resident #37 the property line. Resident #37 said the ADM instructed him to go to that spot he was at this morning. He said that his nurse wants him in for the night by dark. He said that the ADM did not tell (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 9 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 - Minimal harm or potential for actual harm him he needed anyone to go with him when he goes to smoke. He said the facility would prefer his POA to go with him. He said he had not been almost hit by a car but fears that he will be hit one day. Resident #37 said if the road were even ground it would be acceptable, but it is not and it is difficult going and coming back from the spot offsite. He also said because of the uneven ground that he does not feel safe because he is sitting in the roadway smoking. Residents Affected - Few An interview with Resident #42 on 10/15/2024 at 2:22pm revealed that he was instructed to go down the same road that Resident #37 was told. He stated he does not go out past 6:30pm. He also said that the facility did not tell him that he needed anyone to go with him. He said that he had almost been hit by a car about a week ago while going to the spot the facility told him to, and he fears he will be hit one day. He said he did not report it to anyone. He also said it was hard for him to get down to the spot because he only had one arm to use to push himself down there and back. He said he did not feel safe going to the designated spot. Record review of No Smoking Policy dated September 2020 revealed: Non-smoking shall be defined as: No cigarettes, cigars, pipes, e-cigarettes or any other type of inhaled tobacco are allowed inside or outside on the grounds of the [facility]. Any resident or guest with known tobacco products in their possession will be asked to voluntarily surrender them to [facility] staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 10 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for the facility's only kitchen reviewed for food service safety. 1. The facility failed to properly seal, label, and date foods stored in the kitchen's freezer, refrigerator , activity room snack bar, and walk-in cooler. 2. The facility failed to clean and sanitize the kitchen's only industrial can opener. 3. The HC failed to wear effective hair restraint while preparing food. This failure could have placed residents at risk of ingesting food borne pathogens, ingesting adulterated foods, and becoming ill. Findings Included: Record review and observation on 10/14/2024 at 9:05 AM of the facility's only kitchen revealed a sign on the small refrigerator/freezer (side by side) door, which reflected the correct way to fill out a food label. The sign indicated:1. Fill in the item name; 2. Current date/ Prep date: 3. Use by date was 6 days after prep date; 4. Your initials. Observations in the small freezer revealed an opened, yet re-sealed with a banana clip, bag of frozen tater tots without a label to signify date opened, or a use by date; a bag of frozen spicy black bean hamburger patties in an unsealed bag, without a label to signify date opened, or a use by date; a 1.5 foot by 2.5 foot metal sheet pan with 6 small plastic cups of a white liquid, wrapped in plastic wrap, and 43 small 2 ounce covered plastic cups of colorful mixed shapes of food, without a label to signify date prepared, or a use by date; a 2 quart square plastic container with a green lid, containing a red substance, without a label to signify date opened, or a use by date. Record review and observation on 10/14/2024 at 9:14 AM of the facility's walk-in cooler revealed a sign on the walk-in's door, which reflected the correct way to fill out a food label. The sign indicated:1. Fill in the item name; 2. Current date/ Prep date: 3. Use by date was 6 days after prep date; 4. Your initials. Observations in the walk-in cooler revealed a clear plastic medium sized container, with no lid, containing an assortment of items; 1 bottle of BBQ sauce; 1 box of bread sticks, 1 opened jar of banana peppers (dated 10/3/2024,) and 3 small plastic containers of a cubed cheese like item; none of the individual items in the clear plastic medium sized container, minus the jar of banana peppers, possessed a label to signify date opened, or a use by date; furthermore, the 1 opened jar of banana peppers (dated 10/3/2024,) was supposed to have been used by 10/9/2024. On a separate shelf, in the facility's walk-in cooler, there was an opened box of cooked chicken breasts (meaning unsealed and open to the air) without a label to signify date opened, or a use by date. On a separate shelf, there was an opened plastic bag (meaning unsealed and open to the air) of parmesan cheese (dated 10/8/2024); a 3 inch by 3 inch wide and 8 inch long rectangular slab of a cheese like substance, which was partially sealed (meaning unsealed and open to the air) without label to signify date opened, or a use by date. Observation and interview on 10/15/24 at 11:46 AM revealed the kitchen's only industrial can opener had a 1.5 inch by 1.5-inch mounting bracket attached to a metal food preparation table. The seams, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 11 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 where the 1.5 inch by 1.5-inch mounting bracket was attached to the table, had a black sticky substance in the cracks and crevices. The 1.5 inch by 1.5 inch by 10-inch-long metal shaft, which fit into the 1.5 inch by 1.5-inch mounting bracket had the same black sticky substance. On the top end of the 1.5 inch by 1.5 inch by 10-inch-long metal shaft, was a 6-inch-long handle mechanism. The 6-inch-long handle mechanism rotated a metal gear (like the size and shape of a hockey puck,) which in turn rotated a metal can. On the underside of the 6-inch-long handle mechanism, was a 1-inch piece of sharp metal, which ended at a point, which pierced the top of the can. Inside the metal gear, and on the 1-inch piece of sharp metal, was the same black sticky substance. Interview with the dishwasher, KA, revealed he did not remember the last time the industrial can opener was washed. Observations on 10/15/24 at 12:01 PM in the facility's only kitchen revealed HC preparing food. He was observed with effective hair restraint over his head, lower mouth, and neck, but he did not have any effective hair restraint covering his mustache. Observation on 10/15/2024 at 1:54 PM in the activity bar snack refrigerator, located on the side wall of the main dining room, revealed two bottles of ketchup and two bottles of yellow mustard. All 4 bottles were without a label to signify date opened, or a use by date. Observations on 10/16/24 at 1:07 PM in the facility's only kitchen revealed the HC without effective hair restraint. He was observed with effective hair restraint over his head, lower mouth, and neck, but he did not have any effective hair restraint covering his mustache. Interview and observation on 10/16/24 at 1:10 PM with the HC revealed the label and dating system, used by the kitchen staff, was designed to keep food from being held for too long and becoming unsafe to eat. The dating system indicated when the food was opened, or prepared, and when the fold was no longer to be used (or thrown away) if not used by the 6th day. Foods were supposed to be sealed tight, like in a bag or a container, to have protected them from exposure to the frigid air in the refrigerator, freezer, and walk-in cooler. Foods not properly sealed, and exposed to the air, could have begun to grow mold, grow bacteria, or become stale. If a resident ingested food that was moldy, or with bacteria, the resident was exposed to food borne pathogens. A safeguard in place to ensure food was properly sealed, labeled, and dated was a weekly walk through of the kitchen to spot check items for labels and safe storage. Observation of HC revealed he had effective hair restraint over his head, lower mouth, and neck, but he did not have any effective hair restraint covering his mustache. He stated hair restraints were provided to staff and were required to cover both the hair on the head and on the face. Each entrance to the kitchen had a small plastic box, attached the door frame, with disposable hair restraints. No one was allowed to enter the kitchen without their hair restraint. The HC stated it was hard to breathe at times, so he lowered the cloth fabric from his mouth and mustache. He was then observed raising the fabric covering his neck and lower mouth over his lips and to cover his mustache. He stated hair restraints were utilized to keep hair out of resident's food. The HC, stated He had not been corrected about his mustache hair restraint, from the KM. Having heard the verbal description of the facility's only industrial can opener, he acknowledged the industrial can opener could have been contaminated with food borne pathogens. At times, the facility served fruit from a can, which had been opened with the industrial can opener. Canned fruit did not get heated to 165 degrees for 15 seconds, which was the temperature to kill food borne pathogens. The canned fruit, or any other food items opened with the industrial can opener (not heated to 165 degrees for 15 seconds) could have been contaminated with a food borne pathogens. A resident who ingested food borne pathogens could have become sick. The effects of food borne pathogens could have caused a resident to have had an upset stomach, diarrhea, and unintended weight loss. The kitchen did not have a posted cleaning schedule for kitchen areas, or equipment. No tasks were assigned, cleaning was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 12 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 team effort. Level of Harm - Minimal harm or potential for actual harm Interview and record review on 10/16/24 at 3:15 PM with the KM revealed the policy of the facility's only kitchen was to follow time/temperature guidelines and make sure the food served to the residents was fresh, appealing, and met dietary requirements. She expected staff to securely wrap, or use a clean storage container, with the label system described in record review, 10/14/2024 at 9:05 AM. Record review of a cleaning schedule (undated,) provide by the KM during interview, instructed staff to wash the can openers, which meant the industrial can opener. The cleaning schedule had been posted on the wall in the kitchen, but its vertical edges curled inwards on both sides covering the instructions for cleaning. Kitchen staff were required to wear effective hair restraint prior to having entered to the kitchen. Effective hair restraint meant having covered hair on the head and facial hair, if applicable. The KM stated the hair restraint equipment, provided by the facility, was of sufficient design to cover hair, beards, and mustaches. Staff wore hair restraints, so the food did not get contaminated; foods not stored in appropriate time and temperature guidelines were at higher risk for the growth of food-borne pathogens. Residents exposed to contaminated food, or food-borne pathogens, were at risk of diarrhea, vomiting, stomach pain, and unintended weight loss. Residents Affected - Many Interview on 10/16/24 at 3:47 PM with LVN P revealed a food-borne pathogen was a bacterium that grew on, and in, food that was not cooked, handled, or stored properly. Residents exposed to food borne pathogens were at risk to have experienced diarrhea, nausea, food poisoning, vomiting, dehydration, and unintended weight loss. Interview on 10/16/24 at 4:04 PM with the GM revealed she expected her kitchen staff to follow proper sanitization and proper food handling techniques. Kitchen staff was trained per policy. The failure for the kitchen staff to follow policy fell upon training and education. Record review of the facility's Infection Prevention & Control for Food Service Policy, dated 2022, revealed the facility stored, prepared, and distributed food in a sanitary manner to prevent food borne illness, cross contamination, and to assure infection prevention and control. Staff were instructed to wear effective hair restraint and a beard guard, if needed. Counters, equipment, and utensils were supposed to be washed, and rinsed, after each use, with a detergent solution. Food was supposed to be labeled, with a use by date. Record review of the Food and Drugs Administration 2022 Food Code, 1/18/2023 Edition, reflected guidance for Hair Restraints. Section 2-402 Hair Restraints indicated food employees were supposed to wear hair restraints, such as hats, hair coverings, nets, beard restraints, and clothing that covered body hair; Designed, and worn, to effectively keep their hair from contacting exposed food. Record review of the Food and Drugs Administration 2022 Food Code, 1/18/2023 Edition, reflected guidance for Reduced Oxygen Packaging. Annex 6, Food Processing Criteria indicated the shelf life of foods was based on storage temperature for a certain time and other factors of the food. Each package of food was supposed to display a [use-by date.] Record review of the Food and Drugs Administration 2022 Food Code, 1/18/2023 Edition, reflected guidance for Can Openers. Section 4-204.19 indicated the cutting, or piercing, surfaces of a can opener could directly contact food as the container was opened. These surfaces must be protected from contamination. Record review of the HC's food handler's card revealed it was current and was dated to expire on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 13 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 6/27/2025. Level of Harm - Minimal harm or potential for actual harm Record review of the KM's food handler card revealed it was current and was dated to expire on 5/18/2028. Record review of the KM's associate degree, in the Culinary Arts, revealed it was effective as of 3/31/2017. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 14 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 0926 Have policies on smoking. 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 policies regarding smoking for 2 of 2 (Resident #37 and Resident #42) residents reviewed for smoking. Residents Affected - Few 1. The facility failed to enforce the no smoking policy for Resident #37 and #42. 2. The facility failed to ensure that the residents did not have their cigarettes and lighters in their rooms. This failure could place all residents at risk of injury, burns, and unsafe environment. Findings included: Record review of Resident #37's face sheet reflected a [AGE] year-old male with an admission date of 09/04/24. Resident #37 had diagnoses which included fall subsequent encounter, generalized muscle weakness and need for assistance with personal care. Record review of Resident #37's admission MDS assessment dated [DATE] reflected he had a BIMS Score of 12, and moderate cognitive impairment. Resident #37 used a wheelchair for mobility. The MDS did not have that the resident was a smoker. Record review of Resident #37's Care Plan dated 09/04/2024 revealed Resident #37 was a cigarette smoker prior to admission. Resident non-compliant with no smoking policy of facility, observed by staff smoking outside. Education provided and smoking cessation alternatives offered, resident has refused. Record review of Resident #42's face sheet reflected a [AGE] year-old male with an admission date of 09/04/24. Resident #42 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (paralysis and weakness on right side after stroke), repeated falls, muscle weakness, unsteadiness on feet, cognitive communication deficit (problems with communication), and need for assistance with personal care. Record review of Resident #42's Quarterly MDS assessment, dated 09/30/24, revealed a BIMS score of 15, suggesting intact cognition. Resident #42 used a wheelchair for mobility. The MDS did not have that the resident was a smoker. Record review of Resident #42's Care Plan dated 09/08/2024 revealed Resident #42 was a cigarette smoker prior to admission. Resident non-compliant with no smoking policy of facility, observed by staff smoking outside. Education provided and smoking cessation alternatives offered, resident has refused. Observation of the facility on 10/14/2024 at 8:54am revealed Resident #37 and Resident #42 outside the front entrance approximately 30 ft. from the front entrance smoking cigarettes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 15 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the GM on 10/14/2024 at 9:21am revealed that the facility was a nonsmoking facility. She stated that the facility will educate residents who are caught smoking. Observations on 10/14/2024 at 6:45 PM revealed the main entrance had a trash can, which had a metal adaptation on the top to extinguish cigarettes or cigars. There was small courtyard, to the left of the main entrance (from facing the building.) In the small courtyard, there was a small, raised flower bed (5 feet across in diameter). Inside the small, raised flower bed were 14 cigarette butts and an empty pack for cigarettes. There was a side entrance to the facility from the courtyard with a small [No Smoking] sign attached to the door. An interview on 10/14/2024 at 7:11 PM with Resident #37 revealed he was a resident who smokes while a resident at the facility. To smoke, he stated administration, no one in specific, had instructed him to exit the building and ambulate, in his wheelchair, to a smoking area just off the property and out of public view. He stated he kept his own lighter and his own cigarettes; he had not been assessed for smoking safety. He had no visible burns and stated he had not burned himself. An interview on 10/14/2024 at 7:17 PM with Resident #42 revealed he was a resident who smokes while a resident at the facility. To smoke, he stated the Activity Director (AD) had instructed him to exit the building and ambulate, in his wheelchair, to the end of the property out of public view. He stated he kept his own lighter and his own cigarettes; he had not been assessed for smoking safety. He had no visible burns and stated he had not burned himself. He did state that the facility did offer smoking cessation materials and informed them of where to go to smoke. Observation on 10/15/24 at 08:39 AM revealed Resident #37 outside smoking and accompanied by facility staff. Observations on 10/15/2024 at 8:43 AM revealed Resident #37, with the GM, on the outer edge of the facility, which was observed as public property. He was in his wheelchair smoking. The spot he was smoking had approximately 50 cigarette butts on the grass. The distance, from a centralized point of the facility to the observed smoking location, was 249 feet. An interview on 10/15/24 at 09:19 AM with the GM revealed they had a meeting this morning (10/15/24) to review the smoking policy and conduct a smoking assessment with Resident #37. The GM stated Resident #37's POA was coming today to discuss financial stuff and will be taking Resident #37's smoking paraphernalia home. She said she discussed the policy about smoking with him and did a smoking evaluation with him. She said Resident #37 knew where the sign in /out book was and had been compliant in signing in and out of the book. She said Resident #37 had one cigarette on him, and she had Resident #37's lighter. She said the POA was contacted and stated he would be taking the cigarette paraphernalia home. An interview on 10/15/24 at 09:56 AM with Resident #37 revealed he was instructed to follow the smoking policy this morning. Resident #37 stated the smoking rules have kept changing since he had been at the facility, and he wished there would be consistency with the rules for smoking. Record review of a Progress Note for Resident #37 dated 10/15/24 at 8:50 AM reflected, Resident is a smoker. Resident smokes cigarettes. Resident carries matches or lighter. Resident asks others for a light or lights from another cigarette. Resident smokes in unauthorized areas. Resident begs or steals smoking materials from others. Resident refuses to wear appropriate clothing/footwear to go outdoors to smoke. Resident refuses to follow the facility safe smoking policy. Resident Risk Score is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 16 of 17 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 676440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717 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 0926 6.0, Unsafe Smoker-follow facility policy. Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #42's Progress Note dated 10/15/2024 at 8:57am reflected Resident is a smoker. Resident smokes cigarettes. Resident smokes less than hourly. Resident smokes in unauthorized areas. Resident has Extrapyramidal Symptoms (involuntary movements that cannot be controlled), History of CVA (a brain attack), Parkinson's (a disorder of the central nervous system) or other diagnosed syndrome or disease that would limit the safe physical act of smoking. Resident refuses to follow the facility safe smoking policy. Resident Risk Score is 6.0, Unsafe Smoker - follow facility policy. Residents Affected - Few An interview with the GM on 10/16/2024 at 1:43pm revealed that the facility is a non-smoking facility. She said if a resident smoked, they offer alternatives such as nicotine gum or lozenges. She stated she did not have smoking residents because it was a nonsmoking facility. She said staff just started (today) to take two residents out to smoke because they were non-compliant with the smoking policy. She said the residents are not happy when staff tell them to go off property to smoke but the residents comply with the request. She said she and the DON are responsible for ensuring residents are not smoking on property. She said when the resident was caught not complying, she and the DON would reeducate and ask if staff can hold the resident's smoking supplies. She said when residents still do not comply the facility will talk to the resident and family members and offer for staff to take resident off property to smoke. She stated she did not know what the negative outcome could be with a resident keeping their cigarettes and lighter on them. An interview with the AGM on 10/16/2024 at 1:56pm revealed that there was a no smoking policy. He said the hospital- marketing team advises a no smoking policy before the resident gets to the facility. Interventions include offer alternatives such as lozenges and patches. He said the facility had two residents that were smokers. He said that staff do take the residents off site to smoke. He said the two Residents that currently smoke have been appreciative of the staff working with them by taking them off site to smoke. He said Staff asks to hold his smoking items . Recently the two Residents decided to keep the cigarettes and lighters and would not allow Staff to hold on to the items. He said if a resident is agreeable the facility would assist with locating a smoking facility for the resident. He said the negative outcome would vary from resident to resident. An interview with RN A on 10/16/2024 at 2:17pm revealed that the facility was a no smoking facility. He stated he did not know how many residents there were in the facility that smoked. He also said that staff do not take the residents out to smoke. He said if a resident brings smoking supplies with them the staff will ask to hold them until the resident is discharged . He stated that a resident could get burned or cause an issue due to oxygen tanks being near and it was not safe for residents to have smoking supplies. He stated when a resident does not comply with the smoking policy the facility would educate the resident, staff would notify the GM and DON, offer nicotine patches or gum. He said when a resident does not comply with the smoking policy the resident has to go. Record review of No Smoking Policy dated September 2020 revealed: Non-smoking shall be defined as: No cigarettes, cigars, pipes, e-cigarettes or any other type of inhaled tobacco are allowed inside or outside on the grounds of the [facility]. Any resident or guest with known tobacco products in their possession will be asked to voluntarily surrender them to [the facility] staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676440 If continuation sheet Page 17 of 17