Inspection·August 15, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few station. An Aide and I made a walk=through the entire facility and realized she was not in the building. The aide and I left the building at 1840and drive around to the front where we saw another resident coming back from a pass. We stopped and asked him if he has seen the missing resident and he had not. As we were turning around to leave, 2 patrol cars turned in to parking lot, I flagged the officer down in the 2nd car. I asked if they had found a lady walking down the street? He stated his buddy had her in the first patrol car. The officers escorted her back inside the facility and as she crossed the wanderguard barrier she set the alarm off. I gave the officer the information he required and called the resident's daughter while he was at the desk. As soon as the officer left I called the DON at 1918 and the administration. During an interview on 8/13/25 at 2:56 p.m. the ADM said on the evening of 8/10/2025 she was notified that Resident #1 had eloped from the facility and was brought back by police who reported that she was a few blocks from the facility. The ADM went to the facility on the evening of 8/10/2025 after being notified by staff that the elopement of Resident # 1 had taken place and she and the facility DON reviewed facility video of the hallways to see which door Resident #1 had eloped through. The ADM saw Resident #1 attempt to go through a door near her room on at least two occasions and the Wanderguard device (a small device worn on a bracelet that is fitted to the wrist or ankle of a resident. The device will sound an alarm when the wearer goes near an exit armed with the system to warn nearby staff that the wearer is in close proximity to the door) she was wearing triggered the alarm on the door which prompted the staff (name unknown) to redirect Resident#1 to a seat near the nurse's station. Resident #1 then walked down the hall and exited the facility through a door on the North side of the building. The ADM then went to the door where Resident #1 had eloped from the facility and discovered that the door was propped open by an unknown staff who knew the code to the door which is against their policy and procedure. The ADM said that she and the DON immediately implemented one to one supervision for Resident #1 and reminded present staff that all doors are to remain secured. The ADM said that Resident #1 was found outside in the smoking area on a different day and had to be redirected back inside the facility (she said that she did not remember the exact day but that it had to be between her admission on [DATE] and 8/10/2025) and she indicated that the physician and family were notified and Wanderguard was ordered and administered for Resident #1. On 8/11/2025 the ADM and DON began in-servicing all shifts and all staff regarding wandering and elopement, safety and supervision of residents, missing persons policy and procedure, and alarmed entrance and exit doors. The ADM said she implemented a new policy regarding door monitoring logs where maintenance or nursing staff are required to check that all doors are secure every 30 minutes and record this in a logbook kept at the East wing nurse's station. The ADM said that the Wanderguard system was working when Resident #1 eloped, however, due to the door being propped open the alarm did not sound. ADM said the video is not available for the investigator to review as it recycles every 24 hours. During an interview on 8/13/25 at 2:15 p.m. Resident #1's family member said they received a call on the evening of 8/10/2025 around 7:15 p.m. from the facility letting her know that Resident #1 had eloped from the facility and was found a few blocks away by police and returned to the facility with no injuries. The family member said that an unknown staff member had informed her that Resident #1 had eloped from the facility a few days before this incident but had only made it outside the facility before she was redirected back inside. The family member said that she was advised of this when the facility informed her that they would be implementing the use of the Wanderguard device on Resident #1 to prevent elopement. The family member said that she did not feel that the facility was the right place for Resident #1 as she needed to be in a memory care facility but that she feels the facility took good care of Resident #1 other than this incident. Record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 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 455429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Rose Trail 930 S Baxter Tyler, TX 75701 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete review of the facility's wandering and elopement policy dated March 2019 indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.if the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials.when the resident returns to the facility the director of nursing services or charge nurse shall: examine the resident for injuries; contact the attending physician and report findings and conditions of the resident; notify the resident's legal representative.complete and file an incident report; and document relevant information in the resident's electronic health record. The Administrator was notified on 8/14/25 at 12:15 p.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/14/25 at 12:18 p.m. The facility had corrected the noncompliance prior to surveyor entrance by the following: Implementing one to one supervision for Resident #1 until she could be transferred to a memory care unit. In-servicing all staff regarding wandering and elopement, safety and supervision of residents, missing persons policy and procedure, and alarmed entrance and exit doors. This was verified by the in-service sheets showing all staff signed off their attendance to the aforementioned in-services. Implemented a new policy requiring the checking of doors every 30 minutes and recording this task in a logbook. This is verified by the in-service sheets signed by all staff and the policy entitled Inservice Door Alarms/Checks. Transferred Resident #1 to a higher level of care at a neighboring memory care unit on 8/11/2025. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Record review of the Resident #1's monitoring log dated 8/10/25 indicated Resident #1 was on one-to-one monitoring beginning 8/10/25 at 7:00 p.m. and continued until 8/11/25 at 11:00 a.m when she was transferred to a memory care unit at another facility. Record review of in-services dated 8/11/25 indicated all active staff were in-serviced regarding wandering and elopement, safety and supervision of residents, missing persons policy and procedure, and alarmed entrance and exit doors and the new door monitoring log policy. Staff interviewed (LVN A, LVN B, LVN C, RN D, RN E, CNA F, CNA G, CNA H, and CNA J) on 8/13/25 between 11:00 a.m. and 4:07 p.m. were able to articulate the content of the new door log book policy, and what to do in the event of an elopement. Staff interviewed said that they would notify the charge nurse and attempt to redirect the resident if they saw someone attempting to elope from the facility. Investigator ensured all exits armed with Wanderguard system were in working order by approaching each exit with a Wanderguard device and hearing the alarm sound. The noncompliance was identified as PNC IJ. The noncompliance began on 8/10/2025 and ended on 8/11/2025. The facility had corrected the noncompliance before the survey began. Event ID: Facility ID: 455429 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 455429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Rose Trail 930 S Baxter Tyler, TX 75701 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy (an opening through the neck into the trachea to provide and airway) care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #2) reviewed for tracheostomy care. The facility failed to ensure Resident #2 had replacement tracheostomy supplies (tracheostomy tubes (a curved tube inserted into the tracheostomy to keep the airway open)) in the facility or at the bedside. This failure could place residents at risk of respiratory distress and prolong emergency care being provided.Findings included:1. Record review of the face sheet dated 8/14/25 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including anoxic brain damage (brain damage that occurs when the brain does not receive enough oxygen), epilepsy (seizure disorder), hypertension (elevated blood pressure), and heart failure (the hearts inability to pump blood around the body properly). Record review of the MDS dated [DATE] indicated Resident #2 rarely/never understood others. The MDS indicated Resident #2 was rarely/never understood by others. The MDS indicated Resident #2 had a BIMS of 02 and was severely cognitively impaired. The MDS indicated Resident #2 required special treatments of oxygen therapy, suctioning, and tracheostomy care. Record review of the care plan revised on 8/8/25 indicated Resident #2 had a tracheostomy and was at risk for increased secretions, congestion, respiratory infections and infections to tracheostomy site. Record review of the physician orders dated 8/14/25 indicated Resident #2 had an order for emergency tracheostomy supplies are to be kept at bedside to include oxygen source, suction machine, additional tracheostomy tubes, and Ambu bag (a handheld device used to provide positive pressure ventilation to individual experiencing respiratory distress). During an observation and interview on 8/14/25 at 10:49 a.m. there was one size smaller replacement tracheostomy tube in the emergency kit at bedside that had been opened, and no replacement tracheostomy tube the same size as Resident #2's in the emergency tracheostomy kit. RN D showed the surveyor the tracheostomy tube size (number printed on the tracheostomy tube itself) on Resident #2's tracheostomy tube and verified to the surveyor Resident #2's tracheostomy tube size was an 8. RN D said the tracheostomy tube one size smaller could not be used due to the fact it was already opened and no longer sterile, RN D said there was not a usable replacement tracheostomy tube at bedside. RN D said in the event of respiratory distress, cardiac arrest, or decannulation (removal of the tracheostomy tube) the facility would be in trouble, and it could hamper efforts to provide emergency care to Resident #2 by not having a usable emergency tracheostomy tube replacement at bedside. During an observation and interview on 8/14/25 at 12:00 p.m. the facility had Silicone (specific type of tracheostomy tube without an inner cannula) replacement tracheostomy tubes in size 6 and 7. The facility did not have any Silicone replacement tracheostomy tubes in size 8 (the same size trach as Resident #2 currently had in place). RN D said the facility did not carry Silicone tracheostomy tubes in size 8. RN D said the DON stocked the tracheostomy emergency kits that were at bedside. During an interview on 8/14/25 at 12:01 p.m. the DON said she was responsible for stocking the emergency tracheostomy kits at bedside. The DON said she had checked the emergency tracheostomy kits on 8/8/25 and all kits had the proper, unopened supplies. The DON said she usually checked the emergency kits 1-2 times a week. The DON said the facility had not had any Silicone size 8 tracheostomy tubes since mid-July 2025. The DON said she had ordered the Silicone size 8 tracheostomy tubes in mid-July 2025. The DON said not having the proper supplies in the tracheostomy emergency bedside kits would prolong care and make the situation worse in the event of an emergency such as respiratory distress, cardiac arrest, or Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 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 455429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Rose Trail 930 S Baxter Tyler, TX 75701 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete decannulation. During an interview on 8/14/25 at 2:56 p.m. the Physician said he did not know about tracheostomies and did not want to give his medical opinion as he is not familiar with facility policy. The Physician said the nurses should call emergency medical services in the event of an emergency and should be able to care for Resident #2 in the event of an emergency. The Physician said the surveyor should talk to a respiratory therapist regarding the importance of having necessary supplies in the facility for tracheostomy treatment as he was not sure of the facility policy. During an interview on 8/15/25 at 9:45 a.m. the RT said the facility should have in the emergency tracheostomy kit at bedside a tracheostomy tubes the same size and one size smaller than what the resident has inserted, an ambu bag, and a suction catheter. The RT said most of the time in the event of decannulation a tracheostomy tubes the same size was not able to be re-inserted and a tracheostomy tube one size smaller was required. The RT said in the event of a life-or-death emergency a tracheostomy tube one size smaller that the sterile packaging had been opened on could be used. The RT said most tracheostomy patients were able to breath without the tracheostomy unless it was a brand-new tracheostomy. Record review of the facility's Tracheostomy Care policy dated 2001 indicated, The purpose of this procedure is to guide tracheostomy care ant the cleaning of reusable tracheostomy cannulas.A replacement tracheostomy tube must be available at the bedside at all times. Event ID: Facility ID: 455429 If continuation sheet Page 5 of 5