Health inspection·October 24, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some department to be made aware of any issues. She said she could not recall the last time she made environmental rounds in the facility. She said residents were at risk of injury if the facility was not in good repair. During an interview on 10/23/24 at 8:52 a.m., the Maintenance Director said he was not made aware of the disrepair in the shower on Unit 100 Hall D. He said he checked TELS daily and there was no requests for repairs in TELS. Record review of the TELS print out for work order requests from 08/01/24 through 10/24/24 indicated there were no requests related to the observed environmental condition of the shower room on Unit 100 Hall D. 2. During an observation on 10/24/24 at 1:50 p.m., there were cockroaches in the nightstand drawers of Resident #1 and Resident #2. During an interview on 10/24/24 at 1:50 p.m., Resident #1, who resided in room [ROOM NUMBER], said he reported the cockroaches a few weeks ago to the lady at the front of the facility. He said the cockroaches had infested his room for weeks. He said the cockroaches crawled on his face and woke him up at night. He said he should not have to deal with roaches crawling on him in his bed. He said the facility should have addressed the issue after he reported to staff. During an interview on 10/24/24 at 2:00 p.m., Resident #2, who resided in room [ROOM NUMBER], said she had reported the roaches to staff but could not recall the name of the staff or when she reported the roaches. She said the cockroaches were in the drawers of the nightstand, closet, and bathroom. During an interview on 10/24/24 at 2:10 p.m., the Administrator said the facility has monthly pest control and as needed. She said she was not aware of any reports of cockroach infestation. She said the facility has a pest control log located at the receptionist's desk. She said any staff could document issues in the log for the pest control company to review for treatments. She said the pest control company reviewed the log during the monthly visit to ensure the address any target areas. She said RT F should have notified her and the maintenance director immediately of Resident #1's report of cockroaches. She said she would have contacted the pest control company to address the issues immediately so the pest control company could treat for the cockroaches. She said residents were at risk of allergies and illness from cockroaches if they were left untreated by pest control. During an interview on 10/24/24 at 2:25 p.m., RT F said Resident #1 reported on 10/01/24 he had cockroaches in his room, in his drawers and that crawled on him and woke him up at night. She said she wrote the Resident #1's allegation of cockroaches in the pest control log book on 10/01/24. She said she did not inform the Administrator or the Maintenance Director. During an interview on 10/24/24 at 2:31 p.m., the maintenance director said he was not made aware of the cock roaches reported by Resident #1 or Resident #2. He said if he was made aware he would have contacted the pest control company. He said he did not know when the pest control company was scheduled to come to the facility for October 2024. He said residents were at risk of allergies and illness from cockroaches if they were left untreated by pest control. Record review of the pest control log dated 10/01/24 indicated there were cock roaches witnessed by staff (staff were not identified) on the entire D hall on unit 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455001 If continuation sheet Page 2 of 5 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 455001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Beaumont 4195 Milam St Beaumont, TX 77707 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 0584 Record review of the pest control treatment records indicated the facility was treated for cockroaches on 09/02/24. The pest control service would return in October 2024 or as needed to continue service. 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: 455001 If continuation sheet Page 3 of 5 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 455001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Beaumont 4195 Milam St Beaumont, TX 77707 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain an effective pest control program to keep the facility free from pests in 2 of 2 resident rooms. Residents Affected - Some The facility failed to ensure two of two resident nightstands and rooms on Unit 2 were treated for cockroaches. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: During an observation on 10/24/24 at 1:50 p.m., there were cockroaches in the nightstand drawers of Resident #1 and Resident #2. During an interview on 10/24/24 at 1:50 p.m., Resident #1, who resided in room [ROOM NUMBER], said he reported the cockroaches a few weeks ago to the lady at the front of the facility. He said the cockroaches had infested his room for weeks. He said the cockroaches crawled on his face and woke him up at night. He said he should not have to deal with roaches crawling on him in his bed. He said the facility should have addressed the issue after he reported to staff. During an interview on 10/24/24 at 2:00 p.m., Resident #2, who resided in room [ROOM NUMBER], said she had reported the roaches to staff but could not recall the name of the staff or when she reported the roaches. She said the cockroaches were in the drawers of the nightstand, closet, and bathroom. During an interview on 10/24/24 at 2:10 p.m., the Administrator said the facility has monthly pest control and as needed. She said she was not aware of any reports of cockroach infestation. She said the facility has a pest control log located at the receptionist's desk. She said any staff could document issues in the log for the pest control company to review for treatments. She said the pest control company reviewed the log during the monthly visit to ensure the address any target areas. She said RT F should have notified her and the maintenance director immediately of Resident #1's report of cockroaches. She said she would have contacted the pest control company to address the issues immediately so the pest control company could treat for the cockroaches. She said residents were at risk of allergies and illness from cockroaches if they were left untreated by pest control. She said the facility did not have a policy for pest control. During an interview on 10/24/24 at 2:25 p.m., RT F said Resident #1 reported on 10/01/24 he had cockroaches in his room, in his drawers and that crawled on him and woke him up at night. She said she wrote the Resident #1's allegation of cockroaches in the pest control log book on 10/01/24. She said she did not inform the Administrator or the Maintenance Director. During an interview on 10/24/24 at 2:31 p.m., the Maintenance Director said he was not made aware of the cock roaches reported by Resident #1 or Resident #2. He said if he was made aware he would have contacted the pest control company. He said he did not know when the pest control company was scheduled to come to the facility for October 2024. He said residents were at risk of allergies and illness from cockroaches if they were left untreated by pest control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455001 If continuation sheet Page 4 of 5 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 455001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Beaumont 4195 Milam St Beaumont, TX 77707 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 0925 Level of Harm - Minimal harm or potential for actual harm Record review of the pest control log dated 10/01/24 indicated there were cock roaches witnessed by staff (staff were not identified) on the entire D hall on unit 2. Record review of the pest control treatment records indicated the facility was treated for cockroaches on 09/02/24. The pest control service would return in October 2024 or as needed to continue service. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455001 If continuation sheet Page 5 of 5