Health inspection·August 7, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few another room and 1:1 monitoring was initiated. Resident #3 was his own responsible party, and MD was notified of the resident altercation. Record review of Resident #3's nurse progress note authored by RN D indicated on 7/30/2025 at 5:00 p.m., Resident #3 was watching TV show featuring guns and made the comment at 4:45 p.m. that I need a gun, so I can shoot up some people in this place. RN D notified DON at 4:52 p.m. of the incident. Resident #3 was placed on q 15-minute behavioral monitoring. Psych services was notified of incident. 2. Record review of Resident #4's face sheet dated 08/07/2025 indicated he was a [AGE] year-old male, initially admitted on [DATE] and readmitted on [DATE], and his diagnoses included metabolic encephalopathy (brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), delusional disorders (mental health condition in which a person can't tell what's real from what's imagined), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated he usually made himself-understood and usually understands others. His BIMS was a 99 indicating that he was unable to successfully complete the interview to obtain a BIMS score. No behaviors of verbal or physical abuse were noted. Record review of Resident #4's care plan dated 07/26/2025 indicated verbal aggression of cursing at roommate and interventions included analyze key times, places, circumstances, triggers and what de-escalates behavior and document, assess and anticipate resident's needs; administer medications as ordered and give the resident as many choices as possible about care and activities. Record review of Resident #4's nurse's progress note authored by RN D indicated on 7/26/2025 at 11:28 p.m., Resident #3 (Resident #4's roommate) approached nurses' station and stated, Resident #4 (his roommate) threw the remote at me, so I threw it back and it busted his face. Resident #3 and Resident #4 were separated. RN D assessed Resident #4 and found a 2 cm laceration across his nose with a TV remote on floor next to Resident #4's bed. Resident #4 stated he was trying to fuck with me or something, I don't want him back in here. I'll beat his ass if he comes back in here. Resident #4 is bedbound/wheelchair bound with limited mobility. RN D notified MD/NP, DON, ADON, and the administrator of the incident. RN D inquired about local police department notification and the corporate nurse informed him this incident was not reportable to the local police department. NP provided orders for neurological checks, monitoring and wound care to laceration. RP notified of the incident. Wound care provided to nose laceration. Resident #3 (roommate) moved to a different room. Record review of the facility's provider investigation report (PIR) dated 08/01/2025 indicated the resident-to-resident incident (Resident #4 threw the TV remote at Resident #3 and Resident #3 threw the TV remote back at Resident #4 hitting him in the nose causing an injury) occurred on 07/26/2025 at 7:45 p.m. and was reported to the state agency on 07/27/2025 at 2:02 p.m. greater than two hours after the allegation was made. Record review of TULIP (state online abuse reporting portal) did not indicate any reports from facility regarding resident allegation of harm to self or others related to Resident #3's statement on 07/30/2025. During an interview on 08/06/2025 at 10:15 a.m., Resident #3 said he recalled the incident with him and his original roommate. He said Resident #4 had his TV up loud in a Spanish language and he told him to turn it down and off Spanish since he could not understand Spanish and he started cussing at him and threw the TV remote at him, so he threw it back at him hitting him on the nose causing an injury. He said he went to the nurses' station and told them what happen and said he just reacted and did not mean to harm Resident #4. Resident #3 denied the incident regarding wanting a gun to shoot up in this place, and he denied making any suicidal or homicidal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455001 If continuation sheet Page 2 of 4 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 08/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ideations. He said, but one of the reasons I am here is because I can't remember. He said he was pleased with his new room and TV. During an interview on 08/06/2025 at 10:35 a.m., Resident #4 did not recall the incident between him and Resident #3 and denied any abuse from staff or other residents and said he felt safe at the facility. During an interview on 08/06/2025 at 12:15 p.m., CNA H said she was in-serviced on types of abuse and to keep residents safe and report abuse allegations to the administrator immediately. During an interview on 08/06/2025 at 12:30 p.m., CNA J said she was in-serviced on types of abuse and to keep residents safe and report abuse allegations to her nurse, DON, and the administrator/AC. She said report any concerns related to resident safety to the administrator immediately. During an interview on 08/06/2025 at 1:45 p.m., LVN F & LVN G said they were in-serviced on abuse and neglect. They said if abuse or neglect alleged to make sure resident is safe and then notify the administrator/AC immediately. They said would complete assessment, report to RP, NP/MD. During an interview on 08/06/2025 at 4:45 p.m., RN D said on 07/26/2025 around 8:00 p.m. Resident #3 came to nurses' station and reported his roommate (Resident #4) had thrown a TV remote at him, so he threw it back at him and hit him in the face with it. He said he told another staff member to monitor Resident #3 while he went to assess Resident #4 in their room. He said Resident #4 did have a laceration across his nose that was bleeding, and he was upset regarding the incident and did not want Resident #3 back in the room. He said he notified the MD/NP, DON, ADON, and the administrator of the incident. He said he provided ordered wound care to Resident #4, assigned both residents to be monitored (Resident #3 was placed on 1:1 monitoring, and Resident #4 had neurological checks with q 15-minute monitoring) and moved Resident #3 to another room. He said he questioned the DON and Corporate nurse about reporting the incident to the local police but was directed by the corporate nurse this incident was not to be reported. He said the administrator was on vacation, so the DON and corporate nurse was back up for her as the abuse coordinator. He said he was aware any resident-to-resident incidents had to be reported immediately to the abuse coordinator or designee, and he did report the incident immediately to the DON. RN D said he was the nurse on shift on 07/30/2025 when Resident #3 made a statement about needing a gun, so he could shoot up some people in this place which watching a TV show with guns (old western). He said he placed Resident #3 on behavioral monitoring because the resident was new to the facility, and he did not know if this was a behavior or post traumatic statement. He said Resident #3 did not have access to a gun nor was he acting aggressive during the statement just continued to watch the TV, but staff changed the channel to prevent in trigger of behaviors. He said he notified the DON of the statement and incident and was directed to continue to monitor the resident and notify MD/NP and psych services. RN D said that during the incidents with Resident #4 he followed facility protocol and reported the incidents to the DON who was the designated AC because the administrator was on vacation. RN D said he had been in-serviced on abuse, neglect, reporting allegations and timeframes to report. During an interview on 08/07/2025 at 1:30 p.m., CNA K said she was in-serviced on abuse and neglect including types of abuse and to report any abuse or neglect to the administrator immediately. During all interviews with staff on 08/06/2025 and 08/07/2025, including 2-RN's, 11- LVN's, 12 - CNA's, 2 - therapist, 2 - activity assistants, 1 - transportation aide, and 1 housekeeper, the staff were able to give examples of abuse and were able to identify interventions when dealing with behaviors. They said they had received training on identifying and reporting abuse immediately to the abuse coordinator, which was the administrator. During an interview on 08/07/2025 at 2:10 p.m., the DON said she was the acting abuse coordinator during the absence of the administrator, she said she was notified of the allegations with Resident #3. She said the first allegation between Resident #3 and Resident #4 was reported to her on 07/26/2025 but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455001 If continuation sheet Page 3 of 4 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 08/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete thought she had 24 hours to report after conferencing with her corporate nurse regarding the incident. She said she originally thought it needed to be reported to the state within two hours and should have reported it. She said she now realizes this was an allegation of resident-to-resident abuse and is required to be reported to the state agency within two hours. She said she had been re-trained by the administrator and all staff in serviced regarding abuse and neglect and reporting timeframes. She said the incident with Resident #3 making a statement regarding a gun on 07/30/2025 was not originally reported as stated in the nurses note, she said the reporting staff reported to her Resident #3 was watching a western and said he wanted a gun like the cowboys, and also seemed restless, so she instructed the nurse to contact Psych services for restlessness and to monitor Resident #3 every 15 minutes and if other behaviors noted to let her know. The DON said she assessed Resident #3 after the reported incident and he was in no distress and when asked about wanting a gun, he stated all cowboys have guns and I just wanted one. She said Resident # 3 denied having any intentions of harming others or himself. She said upon reviewing Resident #3's medical records after the reported incident she noticed RN D had not documented regarding the behavior, so he was counselled, and a late entry was documented. She said the late entry documented on 07/31/2025 in Resident #3's medical record was not the same verbiage that was originally reported on 07/30/2025 during the onset of the incident. She said when reviewed the late entry on 08/01/2025 she and the facility psych services reassessed Resident #3, and he denied suicidal or homicidal ideations and could not recall the incident regarding wanting to be a cowboy with a gun. She said if she would have been notified of a suicidal or homicidal ideation originally, she would have reported the allegation to the state agency within 2 hours. She said Resident #3 was a new resident to the facility and she did not know if his allegation was a behavior, experiencing sun downers, or the TV show triggered a post traumatic incident. She said she expected staff to report all allegations of abuse accurately to the abuse coordinator or designee and all allegations of abuse should be reported to the state agency within 2 hours of the allegations. During an interview on 08/07/2025 at 2:20 p.m., the Administrator said she was out on vacation during the last 2 weeks of July 2025, and the DON and corporate nurse were the designated abuse coordinators. She said reviewing back over the two incidents with Resident #3 she would have categorized the incidents as abuse and reported the allegations to the state agency within 2 hours. She said she had re-trained the DON regarding reporting abuse allegations and to utilize the long-term care regulatory provider letter issued in August of 2024 for guidance. She said her expectations was for all allegations of abuse to be reported to her/abuse coordinator immediately. She said allegations of abuse should be report within 2 hours to the State Agency. Record review of facility policy titled Abuse, Neglect and Exploitation dated 07/2022 indicated: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Event ID: Facility ID: 455001 If continuation sheet Page 4 of 4