Health inspection·October 2, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #6 was cognitively intact. The MDS assessment indicated Resident #6 was independent with eating and oral hygiene, required set up personal hygiene, supervision of dressing, and dependent for toileting hygiene. Record review of Resident #6's care plan with a target date of 12/24/2025 indicated she was at risk for complications due to refusing care with a goal of no complications related to refusing care through next review. Record review of Resident 6's Order Summary Report dated 10/01/25 : Oxcarbazepine Oral Tablet 300 MG (Oxcarbazepine) Give 1 tablet by mouth two times a day related to bipolar disorder. During an interview on 09/27/25 at 06:30 PM, Resident #6 stated the facility removed Resident #7 from her room on or about 7/2025 and she was not told why. Resident #6 stated Resident #7 was her family member and wanted Resident #7 placed back into the same room. [During an interview on 10/01/25 at 1:15 PM, the Administrator stated a couple of months ago, Human Resources and the Maintenance Supervisor reported Resident #6 threatened to push Resident #7 out of a window like she did her first husband. The Administrator stated she immediately called Ombudsman M and reported the incident. The Administrator stated Ombudsman M advised her to separate Resident #6 and Resident #7. The Administrator stated she separated the residents but did not write a report or report it to HHSC. The Administrator stated she was the abuse coordinator. The Administrator stated allegations of abuse should have been reported to HHSC. The Administrator said it was important to ensure allegations of abuse were reported to HHSC to ensure a thorough investigation was completed and to protect the residents from further abuse. During an interview on 10/01/25 at 3:16 PM, the Maintenance Supervisor stated he was not present when Resident #6 threatened Resident #7. The Maintenance Supervisor stated Resident #6 would often talk over Resident #7. He stated he would hear Resident #6 yelling at times but was unsure if anything was said. During an interview on 10/01/25 at 3:24 PM, Human Resources stated a couple of months ago she was performing angel rounds on Resident #6 and Resident #7's hall. Human Resources stated she heard Resident #6 talking very rudely to Resident #7. Human Resources said Resident #6 stated, I'll do you like I did your [family member] and throw you out the window. Human Resources stated several of the CNAs stated Resident #6 was always saying things like that to Resident #7. Human Resources stated she immediately reported the incident to the Administrator, who was the abuse coordinator. During an interview on 10/01/25 at 3:57 PM, Ombudsman M stated she had years of history with Resident #6 and Resident #7. Ombudsman M stated Resident #6 was verbally abusive to Resident #7. Ombudsman M stated a few months ago with the Administrator called and stated the facility staff overheard Resident #6 threaten Resident #7. Ombudsman M said she recommended that the Administrator separate Resident #6 and Resident #7 unless she wanted to complete a self-report on verbal abuse to HHSC daily. Ombudsman M stated she recommended the Administrator report the incident to HHSC. Record review of the facility's Abuse , Neglect, Exploitation and Misappropriation Prevention Program with a revised date of 4/2021, indicated, Residents have the right to be free from abuse, neglect.Upon receiving an allegation of abuse committed against a resident, the staff member receiving the allegation must ensure the safety of the resident and immediately notify the supervisor on duty.Investigate and report all allegations within timeframes required by federal requirements. Event ID: Facility ID: 455429 If continuation sheet Page 2 of 22 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 10/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #4) reviewed for care plans. The facility failed to ensure a care plan was developed and implemented for Resident #4's use of a Foley catheter and leg band strap stabilizer. These failures could place residents at risk of not having individual needs met and a decreased quality of life.The findings include: Record review of a face sheet dated 09/29/25 indicated Resident #4 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included acute kidney failure and neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination),. Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #4 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #4 did not have BIMS score, which indicated Resident #4 was unable to complete the assessment. The MDS assessment indicated Resident #4 was dependent on staff for all ADLs. The MDS assessment indicated Resident #4 had an indwelling catheter. Record review of Resident #4's care plan did not indicate he had an indwelling catheter Resident #1's care plan did not address securing his Foley catheter. Record review of Resident #4's Order Summary Report dated 09/29/25 indicated: Foley catheter care every shift and as needed and may use leg strap to secure Foley tubing with a start date of 07/26/25. During an observation on 09/27/25 at 06:45 PM , Resident #4 was lying in the bed with the head of his bed elevated. Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During an observation on 09/28/25 at 12:00 PM Resident #4 was lying in the bed with the head of his bed elevated. Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During an observation on 09/29/25 at 11:13 AM, Resident #4 was lying in the bed with the head of his bed elevated. Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During an observation on 10/02/25 at 11:13 AM, Resident #4 was lying in bed with the head of his bed elevated. Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During an interview on 10/01/25 at 12:15 PM, the Administrator stated she expected the clinical nursing staff which included DON, ADON, and the MDS Coordinators to update and implement the residents' care plans quarterly and yearly. The Administrator said Resident 4's care plan should have included that he had a Foley catheter and reflected the care that was needed. The Administrator stated it was important for the care plans to be accurate to ensure all residents were provided with continuity of care. During an interview on 10/02/25 at 3:32 PM, the MDS Coordinator started working at the facility approximately 1 week ago. The MDS Coordinator stated the comprehensive care plan should be updated with every MDS assessment, any change in condition, any new or worsening behaviors, or any changes to the care or services received. The MDS Coordinator stated a Foley catheter should have been included in the care plan. She was unsure why Resident #4's Foley catheter was not care-planned. The MDS Coordinator stated she noticed comprehensive care plans were not being completed and developed a QAPI to fix it. The MDS Coordinator stated it was noticed today [10/02/25]. The MDS Coordinator stated it was important to ensure comprehensive care plans were implemented within appropriate timeframes to ensure residents received the care and services they needed. During an interview on 10/02/25 at 04:35 PM, ADON K said clinical nursing and the MDS Coordinator were responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 3 of 22 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 10/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete updating the care plans. ADON K stated the corporate MDS nurse had been assisting the facility because the MDS Coordinator was new to the position. ADON K stated the care plans should be person-centered so that staff were aware how to take care of the residents. ADON K stated Resident #4's care plan should have reflected the foley catheter was in place and needed to have a security band to keep the Foley tube from being pulled and potentially causing damage to a resident. During an interview on 10/20/25 at 4:45 PM, the interim DON said the ADON, DON and MDS Coordinator were responsible for ensuring the care plans actively related to the resident to show the necessary care needed to allow the residents to meet their goals. The interim DON stated the care plans were a pathway to provide proper and appropriate care for each resident specifically. Record review of the Care Plan , Comprehensive Person policy, revised on March of 2022, stated .This identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout assessment process for developing a comprehensive plan of care within 7 days and no [NAME] than 21 days after admission. The policy further indicated, Acute Care Plans .7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest . Event ID: Facility ID: 455429 If continuation sheet Page 4 of 22 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 10/02/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 8 residents (Resident #1 and Resident #4) reviewed for treatment and services related to indwelling catheters. 1. The facility failed to ensure Resident #1's foley catheter was secured on 09/11/2025. 2. The facility failed to ensure Resident #4 foley catheter was secured on 09/27/25, 09/28/25, 09/29/25, and 10/02/25. These failures could place residents at risk for urinary tract infections, dislodgment, potential complications and a decreased quality of life.Findings included:1. Record review of a face sheet dated 09/29/25 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #1 did not have BIMS score, which indicated Resident #1 was unable to complete the assessment. The MDS assessment indicated Resident #1 was dependent on staff for all ADLs. The MDS assessment indicated Resident #1 had an indwelling catheter. Record review of Resident #1's care plan dated 05/27/25 with a target date of 10/21/25 indicated he had an indwelling catheter with a goal of he would be free from catheter related trauma through the review date. Resident #1's care plan did not address securing his Foley catheter. Record review of Resident #1's Order Summary Report dated 09/25/25 indicated: Foley catheter care every shift and as needed and may use leg strap to secure foley tubing with a start date of 06/23/24. Record review of Resident #1's Treatment Administration Record indicated Resident #1's Foley catheter tubing securement device placement had been checked daily. During an observation on 09/29/25 at 2:19 PM of a video, date stamped at 09/11/25 at 4:04 PM, showed Resident #1 was lying in the bed with the head of his bed elevated. Resident #1's Foley catheter was not secured to his leg. There was no securement device observed. 2. Record review of a face sheet dated 09/29/25 indicated Resident #4 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included acute kidney failure, and neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #4 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #4 did not have BIMS score, which indicated Resident #4 was unable to complete the assessment. The MDS assessment indicated Resident #4 was dependent on staff for all ADLs. The MDS assessment indicated Resident #4 had an indwelling catheter. Record review of Resident #4's care plan did not indicate he had an indwelling catheter Resident #1's care plan did not address securing his Foley catheter. Record review of Resident #4's Order Summary Report dated 09/29/25 indicated: Foley catheter care every shift and as needed with a start date of 07/26/25. check Foley catheter tubing secure device placement every shift. May use leg strap to secure Foley in place with a start date of care every shift and as needed with a start date of 07/26/25. Record review of Resident's # 4's electronic Treatment Administration Record dated 09/2025 indicated the Foley catheter tubing secure device placement had been verified every shift for 09/01/25 - 09/28/25. During an observation on 09/27/25 at 06:45 PM , Resident #4 was lying in the bed with the head of his bed elevated. Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During an observation on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 5 of 22 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 10/02/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 09/28/25 at 12:00 PM Resident #4 was lying in the bed with the head of his bed elevated. Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During an observation on 09/29/25 at 11:13 AM, Resident #4 was lying in the bed with the head of his bed elevated. Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During an observation on 10/02/25 at 11:13 AM, Resident #4 was lying in bed with the head of his bed elevated. Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During an interview on 10/01/25 at 01:15 PM, the Administrator stated she was not clinical, and she expected the ADONs and the DON to have oversight of the nursing staff to ensure the safety and well-being of the resident's health care needs and to ensure the physician orders were followed appropriately During an interview on 10/02/25 3:46 PM, RN B stated nurses were responsible for ensuring Foley catheters were secured. RN B stated it should have been checked every shift. RN B stated she was unaware Resident #4 had no securement device in place. RN B stated she probably overlooked it. RN B stated it was important to ensure Foley catheters were secured to prevent the catheter being jerked out, causing trauma or injuries. During an interview on 10/02/25 at 04:35 PM, ADON K said the nurse was responsible for making sure the catheter device was in place to secure the catheter. ADON K said it was important for the catheter to be secured so it did not pull out and for good placement for the urine to flow. During an interview on 10/20/25 at 4:45 PM, the interim DON said the nurses, and everyone needed to ensure the catheters were secured. The Interim DON said it was important for the catheters to be secured because if they were not, it could pull out and it could hurt the residents. Record review of the facility's policy revised July 2024, titled, Catheter Care, Urinary, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections.Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) . Event ID: Facility ID: 455429 If continuation sheet Page 6 of 22 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 10/02/2025 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide respiratory care, including tracheostomy care and tracheal suctioning consistent with professional standards of practice, the resident's care plan, and the resident's preferences, for 2 of 3 residents (Resident #1 and Resident #2) reviewed for respiratory care. The facility failed to ensure LVN C assessed Resident #1 when he exhibited abdominal retractions (a sign of respiratory distress) while breathing on 09/24/25. The facility failed to ensure LVN A, LVN C, LVN D, and the Interim DON used sterile technique while performing tracheotomy suctioning on Resident #1. The facility failed to ensure RN B used sterile technique while performing tracheotomy care on Resident #2 on 09/29/25. The facility failed to follow the tracheotomy care and suctioning policy and procedure. The facility failed to provide competency check offs for LVN A, LVN C and LVN D on tracheotomy care and suctioning. Immediate jeopardy (IJ) was identified on 09/30/25 at 04:00 PM. The IJ template was provided to the facility on [DATE] at 04:38 PM. While the IJ was removed on 10/02/25 at 05:13 PM, the facility remained out of compliance at a scope of a patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on the policy and procedure for sterile tracheotomy care and suctioning. These failures could place residents at risk of respiratory complications, infections and death.Findings included: 1. Record review of a face sheet dated 09/29/25 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of tracheostomy status. Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #1 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #1 did not have BIMS score, which indicated Resident #1 was unable to complete the assessment. The MDS assessment indicated Resident #1 was dependent on staff for all ADLs. The MDS assessment indicated Resident #1 had a tracheotomy. Record review of Resident #1's care plan dated 04/16/25 with a target date of 10/21/25 indicated he had a tracheotomy with a goal indicating he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #1's Order Summary Report dated 09/29/25 indicated: Change tracheotomy dressing with tracheotomy care every day and PM with a start date of 06/27/25. Record review of Complaint/Grievance dated 08/12/25 indicated Resident #1's family member complained the staff was not providing tracheotomy care and suctioning using sterile technique. Resident #1's family member provided videos of staff providing tracheotomy care without using sterile technique. The grievance indicated the resolution was all nurses on North Hall were in serviced on tracheotomy care and suctioning using sterile technique. Record review of Resident #1's electronic medical record did not indicate a re-assessment was performed by LVN C after 09/24/25 at 09:29 AM when Resident's #1 was showing signs and symptoms of respiratory distress . Record review of a nursing progress note dated 09/25/25 at 01:42 PM written by LVN C indicated [family member] called stated the hospital called and informed her that patient needed to go back to the hospital. I attempted to call the hospital and get more information but no luck. Doctor making rounds per his advice to send resident out to the hospital for further treatments since he was positive gram. Called [family member] informed of the situation of him going back to the hospital. Called EMS no estimated time of arrival on pick up time. ADON, DON aware of situation. Record review of a nursing progress note dated 09/25/25 at 05:20 PM indicated family at facility inquiring why resident was not yet transferred to hospital, this nurse explained that transportation had been set up but facility was waiting on non emergent EMS. Call placed to EMS for updated ETA. EMS stated that they had not received a call for Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 7 of 22 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 10/02/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some transport. This nurse relayed that resident was needing to be transported to [name] Hospital. EMS stated that they would be on they way to transport. Record review of the admission hospital records dated 09/25/25 indicated Resident #1 was admitted with chronic respiratory failure with tracheostomy in place. Laboratory results indicated Resident #1 had bacteremia (bacteria is present in the bloodstream), staph hominis (gram positive bacteria in the bloodstream), and pseudomonas (gram positive bacteria found in lungs, skin, ears) During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/16/25 at 05:09 AM, LVN A entered Resident #1's room wearing gloves and carrying a pitcher of water. LVN A flushed Resident #1's PEG tube (a feeding tube inserted into the abdomen into the stomach) and then provided incontinent care. LVN A did not change gloves or perform hand hygiene. LVN A proceeded to grab the suction catheter from the bedside table and suctioned Resident #1. LVN A did not change her gloves or use sterile technique during the suctioning procedure. LVN A repositioned Resident #1 in the bed, took off her gloves and exited the room. During an interview on 09/30/25 at 1:13 PM, LVN A stated LVN A stated tracheostomy care and suctions was considered a sterile procedure. LVN A stated the tracheostomy was direct airway into the lungs. LVN A stated the night of 09/15/25 into the morning of 09/16/25 was her last days as full time at the facility. LVN A stated she was unable to remember the care she provided to Resident #1. LVN A stated it was important to ensure sterile technique was maintained during tracheostomy care and suctioning to protect the staff and residents from infection. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/23/25 at 11:09 AM, LVN C entered into Resident #1's room and put on non-sterile gloves. LVN C repositioned Resident #1's bedcovers. LVN C did not change her gloves or perform hand hygiene. Then LVN C grabbed the suction catheter from the bedside table drawer and unraveled Resident #1's TV control cord from the suction tubing. LVN C proceeded to suction Resident #1. LVN C took off her gloves and exited Resident #1's room. LVN C did not apply sterile gloves or use sterile technique for the suctioning procedure. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/23/25 at 09:30 PM, LVN D was in Resident #1's room and had a sterile field set up on the bedside table. LVN D appeared to be wearing sterile gloves. LVN D touched the suctioning machine with her dominant hand and proceed to suction Resident #1. After LVN D touched the suction machine contaminating her dominant hand. LVN D failed to follow sterile technique for the suctioning procedure. LVN D removed her gloves, discarded the used supplies and exited the room. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/24/25 at 09:29 AM, LVN C and Resident #1's family member entered the Resident #1's room. Resident #1's family member was heard stating he needs an assessment done. LVN C stated she already completed an assessment earlier and was not going to do it again. Resident #1''s family member told LVN C, it's obvious Resident #1 is having difficulty breathing - can you assess him. LVN C stated, and then what do you want me to do after I assess him - you are not a nurse - where do you work? Resident #1 was observed in his bed exhibiting abdominal retractions (a sign of respiratory distress) and gurgling was audible during the video. LVN C argued with Resident's #1's family member and refused to assess Resident #1's respiratory status. LVN C continued to argue and refused to provide tracheal suction. LVN C exited Resident #1's room without the necessary care provided. During an interview on 09/30/25 at 2:26 PM, LVN C stated she normally worked 6 AM - 2 PM shift on Monday through Friday. LVN C stated tracheostomy care and suctioning was a sterile procedure and sterile technique was required. LVN C stated she did not always have sterile tracheostomy care kits. LVN C stated sometimes she had to perform tracheostomy care without PPE or sterile supplies. LVN C stated supplies were unavailable on a regular basis. LVN C stated it was important to ensure sterile technique was used to prevent infection. LNV C stated everyone had issues with Resident #1's family member. LVN C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 8 of 22 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 10/02/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some stated on 09/24/25 she went into Resident #1's room during her morning rounds. LVN C stated she had performed a respiratory assessment, tracheostomy care, and suctioning. LVN C stated Resident #1 had some wet sounds that cleared after he was suctioned. LVN C stated later on the family called her in the room and stated Resident #1 had a temperature. LVN C stated she checked his temperature which was approximately 97.1. LVN C stated she attempted to remove the sheet, but did not perform another respiratory assessment as she was busy with another resident. LVN C stated she did not notice if Resident #1 was having trouble breathing. LVN C stated she did not obtain vital signs or an oxygen level. LVN C stated she notified the Interim DON because the family did not want her in the room. LVN C stated she notified the doctor, and a chest x-ray was ordered STAT (immediately). LVN C stated the family believed Resident #1 needed to be sent to the emergency room, so she called the doctor back and he gave the order to send to the emergency room. LVN C stated she was unable to recall if she called emergency transport. LVN C stated there was a lot going on that day. LVN C stated the Interim DON provided care to Resident #1 after she was asked to leave the room. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/24/25 at 09:54 AM, the Interim DON and Resident #1's family member entered Resident #1's room. The Interim DON performed an assessment by taking Resident #1's temperature, checked his oxygen levels with the pulse oximetry (device use the measure the amount of oxygen in the blood), and listened to his lungs. The Interim DON removed the suction catheter from the bedside table drawer and suctioned Resident #1. Resident #1's family member asked the Interim DON why she was not using sterile gloves. The Interim DON said, the facility did not have the correct size to fit her hands in stock. The Interim DON did not apply sterile gloves or use sterile technique for the suctioning procedure. During an interview on 09/30/25 at 2:08 PM, the Interim DON stated tracheostomy care and suctioning was considered a sterile procedure. The Interim DON stated sterile technique was required. The Interim DON stated it was important to maintain sterile technique during tracheostomy care and suctioning to decrease the risk of infection. The Interim DON stated on 09/24/25 she performed unsterile tracheostomy suctioning because the facility did not have any sterile gloves that fit her. The Interim DON stated Resident #1 needed to be assessed and had obvious signs of respiratory distress. The Interim DON stated Resident #1's family had reported that LVN C refused to assess Resident #1, which was why she was in the room. The Interim DON stated she expected the nursing staff to perform a focused assessment for any change of condition. The Interim DON stated she expected the nurses to utilize the nursing judgment and prioritize care. The Interim DON stated airway and breathing were the two top priorities. The Interim DON stated an assessment was performed to ensure patient safety and maintain well-being. 2. Record review of a face sheet dated 09/30/25 indicated Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included anoxic (lack of oxygen) brain damage acute respiratory failure, and tracheostomy (surgical procedure that creates an opening in the front of the neck (trachea) and inserts a tube to help a person breath). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #2 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #2 did not have BIMS score, which indicated Resident #2 was unable to complete the assessment. The MDS assessment indicated Resident #2 was dependent on staff for all ADLs. The MDS assessment indicated Resident #2 had a tracheotomy. Record review of Resident #2's care plan [dated 06/29/25 with a target date of 10/14/25 indicated he had a tracheotomy with a goal of he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #2's Order Summary Report dated 09/30/25 indicated: Change tracheotomy dressing with tracheotomy care every shift with a start date of 06/25/25. Record review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 9 of 22 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 10/02/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #2's Infection Screening Evaluation dated 07/29/25 indicated recent chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/02/25 indicated recent chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/10/25 indicated recent chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's chest x-ray dated 09/10/2025 indicated pneumonia (infection of the lungs). Increased opacity is present at the left lung base representing either infiltrate or plural effusion. There has been no improvement with a prior chest x-ray performed on 09/02/25. Record review of SBAR communication Form written by RN B dated 09/29/25, indicated Resident #2 was experiencing a fever with low oxygen sat of 77%. O2 increased to 10 liters and O2 now 93%. Record review of progress note dated 09/29/25 at 2:29 PM written by RN B indicated the physician ordered an x-ray related to fever. Record review of progress note dated 09/30/35 at 12:48 PM written by RN B indicated, Resident #2 had worsening pneumonia on the left side. Also reported that he has developed a temp of 101.8 along with O2 having to be increased to 10 Liters to keep oxygen saturations over 90%. Resident is on day 8 of 14 of his Bactrim. Secretions have become very thick, green in color and has a very foul odor. New order received to send resident out to ER for assessment. [family member] informed and agrees with plan.During an observation on 09/29/25 at 4:17 PM, the Treatment Nurse prepared Resident #2's bedside table for tracheostomy care. The Treatment Nurse placed a piece of wax paper on the table, on the wax paper she placed the following: *two unopened bottles of sterile water, *a tracheostomy care kit, which was slightly opened, *unopened suction tubing, and *4 x 4 unsterile gauze pads from a multiuse package. RN B rearranged the items and positioned the bedside table for use. RN B washed her hands, then applied her sterile gloves, using sterile technique. RN B immediately picked up the unopened suction tubing package and opened it, which contaminated her sterile gloves. RN B then grabbed the unopened bottles of sterile water, opened it, and poured it into the sterile field. RN B then picked up the unsterile 4 x 4 gauze pads and placed them into sterile water. RN B did not reapply sterile gloves, after she contaminated her sterile gloves, and used the same gloves during the following care activities. RN B took the cotton-tipped applicators from the tracheostomy kit and then cleaned around the stoma (opening in the neck). RN B used the 4 x 4 gauze pads that were soaked in sterile water to clean around Resident #2's neck. RN B then cleaned inside the tracheostomy tubing with the 4 x 4 gauze pads. RN B removed her gloves and applied hand sanitizer. RN B replaced her gloves and replaced the tracheostomy neck ties. During an interview on 09/29/25 at 5:06 PM, RN B stated tracheostomy care was a sterile procedure. RN B stated the packaging should have been opened prior to applying her sterile gloves. RN B stated the outside packaging was not sterile. RN B stated everything completed after the sterile gloves were contaminated would not have been considered sterile. RN B stated she had not realized she broke sterile field during the procedure. RN B stated using sterile techniques during tracheostomy care was important to prevent the introduction of bacteria into the airway to prevent infections. RN B stated Resident #2 was currently being treated for pneumonia [TT15] (lung infection). During an interview on 09/30/25 at 11:44 AM, the Medical Director stated, nothing to do with tracheostomy care and suction was a sterile procedure The Medical Director stated the throat was not sterile and tracheostomy care and suctioning was a dirty procedure. The Medical Director stated nurses were required to be certified and competent to perform tracheostomy care and suctioning. The Medical Director stated staff should have received frequent in-service training from a certified respiratory therapist. The Medical Director stated there was a minimal risk for improperly performing tracheostomy care and suctioning. The Medical Director stated there was no risk of infection. The Medical Director stated having a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 10 of 22 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 10/02/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some tracheostomy placed residents at risk for bacterial infections from their own flora (bacteria) from their skin. During an interview on 09/30/25 at 12:46 PM, ADON K stated she was unable to locate the competency nurse check offs for sterile tracheotomy care and suctioning. ADON K stated the DON was responsible for completing competency checks for the nurses. ADON K stated the DON left a few weeks ago. During an interview on 09/30/25 at 1:53 PM, the Administrator stated tracheostomy care and suctioning was considered a sterile procedure and sterile technique was required. The Administrator stated she expected the nurses to ensure sterile technique was used during tracheostomy care and suctioning. The Administrator stated sterile supplies were always available. The Administrator stated it was important to ensure sterile technique was maintained during tracheostomy care and suctioning to protect the residents from infection. Record review of in service dated 08/12/25 with a subject of tracheotomy care and suctioning using sterile technique indicated twelve nursing staff signatures including LVN C, the Interim DON, RN B. Record review of the following staff competency nurse check offs for sterile tracheotomy care and suctioning included:Interim DON dated 02/25/2025RN B dated 07/16/2025. Record Review of the facility's undated policy titled Suctioning the Tracheostomy Tube, indicated, The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.b. Suctioning the lower airway is a sterile procedure. Record Review of the facility's undated policy titled Tracheostomy Care, indicated, The purpose of this procedure is to guide tracheostomy care.2. Gloves must be used on both hands during any or all manipulation . sterile gloves must be used during performing these procedures. Record review of the NCBI Bookshelf (A service of the National Library of Medicine and National Institutes of Health) in Chapter 22 Tracheostomy Care & Suctioning reflected .Tracheostomy suctioning uses a sterile catheter that is inserted through the surgical opening into the neck to the trachea to create an artificial airway. always review and follow agency policy regarding this specific skill.put on sterile gloves.the dominant hand will manipulate the catheter and must remain sterile.tracheostomy care provided with sterile technique. The Administrator was notified on 09/30/25 at 04:38 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator provided the Immediate Jeopardy template on 09/30/25 at 04:38 PM and a Plan of removal; (POR) was requested. The following plan of removal was submitted by the facility and accepted on 10/01/25 at 04:30 PM and included the following: Problem: Respiratory/Tracheostomy Care and SuctioningAlleged Issues: The facility failed to ensure LVN C assessed resident #1 when he exhibited abdominal retractions while breathing (a sign of respiratory distress), on 9/24/25The facility failed to ensure LVN A, LVN C, LVN D, and the Interim Don, use sterile technique while performing tracheotomy sectioning on resident number one.The facility failed to ensure RN B used sterile technique while performing tracheotomy care on resident #2 on 9/29/25.The facility failed to follow the tracheotomy care suctioning policy and procedureThe facility failed to provide competency check offs for LVN A, LVN C, LVN D on tracheotomy care and suctioning. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Approaches: RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. RN/DON A was in serviced by Facility Respiratory Therapist with documented competencies on file at the facility. The Administrator is not clinical but is aware of all in-services per the VP of Clinical Operations 1. Nursing staff will be in-serviced on the proper procedure tracheostomy care and suctioning. This in-service was initiated on 09/30/2025 by the RN/DON A. All nursing staff will be in-serviced prior to them arriving to the facility for their next shift. RN A, trained by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 11 of 22 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 10/02/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some facility respiratory therapist RN A was trained July 16, 2025, and will deliver all following in service education to nurses one on one. Return demonstration by all nurses will be documented, and competency checklists will be kept in diners in the DON / Administrator's offices at the facility. All nurses will be trained before they accept residents for their next scheduled shift in Tracheostomy care and suctioning. 2. The regional nurse consultant will provide education regarding assessment of residents if changes in condition. This education will be provided to each nurse prior to the start of their next shift on the floor. This education will begin on 09/30/25 and continue until all staff are educated. An in-service on Respiratory assessments will be taught and any changes in condition will be documented and the physician will be notified of those changes. Changes in condition will include but not limited to shortness of breath; changes in respiratory status; using accessory muscles to breathe; drainage from trach; or decrease in 02 saturation. If provider orders transfer resident will be sent to the hospital via EMS transport as soon as possible. The facility respiratory therapist will be in the facility to provide further education with return demonstration, and competency checklists completed for facility nurses and interim DON on 10/1/2025. The Respiratory Therapist will visit monthly to ensure competency. 3. The facility medical Director was informed of the IJ on 09/30/25 in person, by the Facility Administrator. 4. Resident #1 is in the hospital 09/30/25. 5. Resident #2 is currently being treated with antibiotics for active infection. Resident #2 assessment was completed and resident sent to the hospital per physician orders. Resident #2 assessed on 9/29 /25 E interact change in condition form was completed and entered into the EMR. Resident was sent to the hospital on 9/30/25.Resident #3 assessment was completed on 10/1/2025; Resident #4 assessment was completed on 10/01/2025. 6. RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All nursing staff will be in service prior to them arriving to the facility for their next shift. This will begin immediately, 09/30/2025. 7. Both the Administrator and DON will review new hire orientation packets to ensure these above in services are completed, and competency checklists are on file at the facility, prior to the first shift on the floor, including tracheostomy competencies including tracheostomy care per sterile technique and suctioning of the tracheostomy per sterile technique. RN/DON A who has been trained by the facility respiratory therapist and by the facility respiratory therapist provided this in-service to all facility nurses on staff at the time of the immediate jeopardy, nurses coming on shift at 10pm on 09/30/25 and all nurses coming on shift at 6am on 10/01/2025. The facility respiratory therapist will continue training on 10/01/2025 for any nurses who did not attend training, prior to their next scheduled shift on the floor. VP of Clinical will in-service the Administrator on this process ensuring all nurses will be trained on tracheostomy care and suctioning prior to their first shift on the floor caring for residents. DON and or RN trained by RT will complete the required tracheostomy training for nurses prior to their first shift on the floor, the administrator will ensure this training is completed. 8. All residents with enhanced barrier precautions were reviewed by the Don, ADON, and administrator, to ensure proper PPE was available outside the resident room. Monitoring:The DON, or designee will perform random in person audits with nursing staff to ensure they understand the tracheostomy suctioning/care via sterile technique procedure, at least 3 nursing staff weekly X1 month. This process will begin 10/03/2025. DON/ADON's will make rounds daily M-F, the weekend RN supervisor will round on all residents on the weekend, on all residents in facility to ensure nurses are properly performing trach care/suctioning per sterile technique. This process will be ongoing effective 09/30/2025. Assessment: All nurses on staff at the time of the immediate jeopardy were educated on tracheostomy suctioning and care of tracheostomy, with return demonstration by RN DON A is a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 12 of 22 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 10/02/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some DON from a sister facility assisting with training who has been trained by the facility respiratory therapist, with competency checklist on file at the facility on 09/30/25. QAPI Committee review: An interim QAPI committee meeting was completed on 09/30/25. IDT will review for compliance monthly in QAPI X3 months. On 10/02/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the immediate jeopardy (IJ) by: 1. Record review of DON GG ‘s competency, dated 07/16/25, reflected DON GG was competent with tracheostomy care and suctioning. DON GG was the DON from a sister facility who provided education to the facility nurses' on tracheostomy care and suctioning, including a competency check off and return skilled demonstration. 2. Record review of the in-service training report, dated 10/01/25, reflected the nurses were provided education on the proper procedure for tracheostomy care and suctioning. There were 11 nurse signatures. 3. Record review of the competency checkoffs dated between 09/30/25 and 10/01/25 reflected LVN A, LVN C, LVN D, LVN Y, LVN Z, LVN BB, RN B, RN X, RN AA, ADON K, ADON V, the Treatment Nurse, the MDS Coordinator, and the Interim DON were provided competency checks off with a return demonstration. The competencies reflected the nurses were competent with tracheostomy care and suctioning. 4. Record review of the in-service training report, dated 09/30/25, reflected nurses were provided education on how to perform a respiratory assessment, when it should be performed, notifying the physician, and implementing interventions. There were 5 nurse signatures. 5. During an interview on 10/02/25 at 4:01 PM, the Medical Director stated he was informed of the IJ from the Administrator at the facility. 6. Record review of Resident #1's hospital records, printed 09/29/25, reflected he was admitted on [DATE] with a diagnosis of bacteremia (blood infection). 8. Record review Resident #2's progress notes, dated 09/30/25, reflected Spoke with [Medical Director] after sending him the x-ray that resulted today showing worsening pneumonia on the left side. Also reported that he has developed a [temperature] of 101.8 along with [oxygen] having to be increased to 10 liters to keep oxygen saturations over 90%. Resident [2] is on day 8 of 14 of his [antibiotic]. Secretions have become very thick, green in color and has a very foul odor. New order received to send resident [#2] out to the [emergency room] for assessment. [Family member] informed and agrees with plan. 9. Record review of Resident #3's progress notes, dated 10/01/25 reflected [Resident #3] up to wheelchair with Foley catheter draining with amber color urine. No [complaints of] pain or discomfort at this time. No nausea or vomiting noted or reported. Resident continues on [antibiotics]. 10. Record review of Resident #4's progress notes, dated 10/01/25, reflected Skilled nurse assessed [Resident #4]. [Resident #4] bed at 45 degrees. [Respirations] 20, [Temperature] 98.0, [Blood Pressure] 132/87, saturation 95. Trach patent in place and air open. Secretions thin and clear. No odor at this time. No nasal flaring, no wheezing or grunting. No chest retractions. No coughing at this time. [Resident #4] rests at this time. 11.During an observation on 10/02/25 at 10:15 AM of PPE supplies outside the doors of all enhanced barrier precautions of the appropriate residents. Signage outside their door indicated the required PPE to be worn inside the room. There were isolation carts outside the rooms, which had face shields, isolation gowns, and gloves with hand sanitizer on top. The hand sanitizer dispensers were noted down the hallway. A staff member was dressed in an isolation gown and gloves and was preparing to enter Resident #4's resident room. 12.During an observation on 10/02/25 at 02:45 PM of proper sterile tracheostomy care and suction performed by RN B for Resident # 4. 13. During interviews on 10/02/25 conducted between 2:01 PM and 4:52 PM, LVN A, LVN C, LVN Y, LVN Z, LVN BB, RN B, RN X, RN AA, the Treatment Nurse, the MDS Coordinator, ADON K, ADON V, the Interim DON, and Administrator were able to verbalize sterile technique was required during tracheostomy care and suctioning. The nurses said tracheostomy care and suctioning should not have been performed without the proper supplies or equipment, which included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 13 of 22 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 10/02/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete sterile gloves and care kits. The nurses verified they were provided education and competency checkoffs on tracheostomy care and suctioning. The nursing managers were able to verbalize that monitoring will continue during rounds daily and checkoff competencies will be completed for new hires and nursing staff prior to working their next scheduled shift. 16. Record review of the Quality Assessment and Performance Improvement Plan, dated 09/30/25, reflected an impromptu meeting was conducted and 9 staff members were in attendance. The Administrator was informed the IJ was removed on 10/02/25 at 05:13 PM. The facility remained out of compliance at a scope of patterned and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 455429 If continuation sheet Page 14 of 22 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 10/02/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (Resident's #1, # 2, #3) reviewed for infection control practices. The facility failed to ensure LVN A, LVN C, LVN D, and the Interim DON used sterile technique while performing tracheotomy suctioning on Resident #1. The facility failed to ensure RN B used sterile technique while performing tracheotomy care on Resident #2 on 09/29/25. The facility failed to follow the tracheotomy care and suctioning policy and procedure. The facility failed to ensure LVN A, LVN C, LVN D, the interim ADON, LVN G and CNA H wore enhanced barrier precautions while performing care on Resident #1, who had a feeding tube, tracheostomy tube, wound, and Foley catheter. The facility failed to ensure CNA E and CNA F wore enhanced barrier precautions while providing care to Resident #3 who had a Foley Catheter. The facility failed to ensure the nursing staff knew how to access PPE and sterile supplies for enhanced barrier precautions. Immediate jeopardy (IJ) was identified on 09/30/25 at 04:00 PM. The IJ template was provided to the facility on [DATE] at 04:38 PM. While the IJ was removed on 10/02/25 at 05:13 PM, the facility remained out of compliance at a scope of a patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on providing sterile tracheotomy care and suctioning and enhanced barrier precautions. These failures could place residents and staff at risk for cross contamination and serious injury, harm, impairment, and death from the spread of an infectious disease.Findings included: 1. Record review of a face sheet dated 09/29/25 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included autistic disorder (difficulties in social communication and interaction, strong preference for routine, sensory processing differences, focused interest and repetitive behaviors), schizoaffective disorders (symptoms of delusional, hallucinations, depressed episodes followed by manic periods of high energy), anemias, and neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination), tracheostomy status, encounter for attention to gastrostomy (feeding tube). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #1 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #1 did not have BIMS score, which indicated Resident #1 was unable to complete the assessment. The MDS assessment indicated Resident #1 was dependent on staff for all ADLs. The MDS assessment indicated Resident #1 had a tracheotomy. Record review of Resident #1's care plan with a target date of 10/21/25 indicated he had a tracheotomy with a goal of he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #1's Order Summary Report dated 09/29/25 indicated: Change tracheotomy dressing with tracheotomy care every day and PM with a start date of 06/27/25. Record review of Complaint/Grievance dated 08/12/25 indicated Resident #1's family member complained the staff was not providing tracheotomy care and suctioning using sterile technique. The grievance indicated the resolution was all nurses on North Hall were in serviced on tracheotomy care and suctioning using sterile technique. Record review of the admission hospital records dated 09/25/25 indicated Resident #1 was admitted with chronic respiratory failure with tracheostomy in place. Laboratory results indicated Resident #1 had bacteremia (bacteria is present in the bloodstream), staph hominis (gram positive bacteria in the bloodstream), and pseudomonas (gram positive bacteria found in lungs, skin, ears) 2. Record Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 15 of 22 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 10/02/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some review of a face sheet dated 09/30/25 indicated Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included anoxic (lack of oxygen) brain damage, flaccid neuropathic bladder (central nervous system or nerves involved in the control of urination) , anemia, epilepsy (seizures), mild protein-calorie malnutrition, cerebral infarction due to embolism (stroke), acute respiratory failure, tracheostomy (surgical procedure that creates an opening in the front of the neck (trachea) and inserts a tube to help a person breath). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #2 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #4 did not have BIMS score, which indicated Resident #4 was unable to complete the assessment. The MDS assessment indicated Resident #4 was dependent on staff for all ADLs. The MDS assessment indicated Resident #4 had a tracheotomy. Record review of Resident #2's care plan with a target date of 10/14/25 indicated he had a tracheotomy with a goal of he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #2's Order Summary Report dated 09/30/25 indicated: Change tracheotomy dressing with tracheotomy care every shift with a start date of 06/25/25. Record review of Resident #2's Infection Screening Evaluation dated 07/29/25 indicated current active infection related to chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/02/25 indicated a current active infection related to chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/10/25 indicated current active infection related to chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's chest x-ray dated 09/10/2025 indicated pneumonia (infection of the lungs). Increased opacity is present at the left lung base representing either infiltrate or plural effusion. There has been no improvement with a prior chest x-ray performed on 09/02/25. Record review of SBAR communication Form dated 09/29/25, indicated Resident #2 was experiencing a fever with low oxygen sat of 77%. O2 increased to 10 liters and O2 now 93%. Record review of Resident #2 progress note dated 09/29/25 at 14:29 PM, indicated the physician ordered an x-ray related to a fever. Record review of progress note dated 09/30/35 at 12:48 PM indicated, Resident #2 had worsening pneumonia on the left side. Also reported that he has developed a temp of 101.8 along with O2 having to be increased to 10 Liters to keep oxygen saturations over 90%. Resident is on day 8 of 14 of his Bactrim. Secretions have become very thick, green in color and has a very foul odor. New order received to send resident out to ER for assessment. Wife informed and agrees with plan. Record review of in service dated 08/12/25 with a subject of tracheotomy care and suctioning using sterile technique indicated twelve nursing staff signatures including LVN C, the Interim DON, RN B. Record review of the following staff competency nurse check offs for sterile tracheotomy care and suctioning included:Interim DON dated 02/25/2025RN B dated 07/16/2025 During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/15/25 at 09:20 PM, CNA H and LVN G entered Resident #1's room wearing a mask, CNA H and LVN G donned gloves and repositioned Resident #1, provided incontinent care and adjusted the bed covers. CNA H and LVN G did not wear a gown for enhanced barrier precautions. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/16/25 at 05:09 AM, LVN A entered Resident #1's room wearing gloves and carrying a pitcher of water. LVN A flushed Resident #1's PEG tube (a feeding tube inserted into the abdomen into the stomach) and then provided incontinent care. LVN A did not change gloves or perform hand hygiene. LVN A proceeded to grab the suction catheter from the bedside table and suctioned Resident #1. LVN A did not change her gloves or use sterile technique during the suctioning procedure. LVN A repositioned Resident #1 in the bed, took off her gloves and exited the room. LVN A did not wear a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 16 of 22 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 10/02/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some gown for enhanced barrier precautions. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/23/25 at 11:09 AM, LVN C entered into Resident #1's room and put on non-sterile gloves. LVN C repositioned Resident #1's bedcovers. LVN C did not change her gloves or perform hand hygiene. Then LVN C grabbed the suction catheter from the bedside table drawer and unraveled Resident #1's TV control cord from the suction tubing. LVN C proceeded to suction Resident #1. LVN C took off her gloves and exited Resident #1's room. LVN C did not apply sterile gloves or use sterile technique for the suctioning procedure. LVN C did not wear a gown for enhanced barrier precautions. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/23/25 at 09:30 PM, LVN D was in Resident #1's room and had a sterile field set up on the bedside table. LVN D appeared to be wearing sterile gloves. LVN D touched the suctioning machine with her dominant hand and proceed to suction Resident #1. After LVN D touched the suction machine contaminating her dominant hand. LVN D failed to follow sterile technique for the suctioning procedure. LVN D removed her gloves, discarded the used supplies and exited the room. LVN D did not wear a gown for enhanced barrier protection. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/24/25 at 09:54 AM, the Interim DON and Resident #1's family member entered Resident #1's room. The Interim DON performed an assessment by taking Resident #1's temperature, checked his oxygen levels with the pulse oximetry (device use the measure the amount of oxygen in the blood), and listened to his lungs. The Interim DON removed the suction catheter from the bedside table drawer and suctioned Resident #1. Resident #1's family member asked the Interim DON why she was not using sterile gloves. The Interim DON said, the facility did not have the correct size to fit her hands in stock. The Interim DON did not apply sterile gloves or use sterile technique for the suctioning procedure. The Interim DON did no wear a gown for enhanced barrier protection. During an observation on 09/29/25 at 4:17 PM, the Treatment Nurse prepared Resident #2's bedside table for tracheostomy care. The Treatment Nurse placed a piece of wax paper on the table, then placed the following on the wax paper: two unopened bottles of sterile water, a tracheostomy care kit, which was slightly opened, unopened suction tubing, and 4 x 4 unsterile gauze pads from a multiuse package. RN B rearranged the items and positioned the bedside table for use. RN B washed her hands, then applied her sterile gloves, using sterile technique. RN B immediately picked up the unopened suction tubing package and opened it, which contaminated her sterile gloves. RN B then grabbed the unopened bottles of sterile water, opened it, and poured it into the sterile field. RN B then picked up the unsterile 4 x 4 gauze pads and placed them into sterile water. RN B did not reapply sterile gloves, after she contaminated her sterile gloves, and used the same gloves during the following care activities. RN B took the cotton-tipped applicators from the tracheostomy kit and then cleaned around the stoma (opening in the neck). RN B used the 4 x 4 gauze pads that were soaked in sterile water to clean around Resident #2's neck. RN B then cleaned inside the tracheostomy tubing with the 4 x 4 gauze pads. RN B removed her gloves and applied hand sanitizer. RN B replaced her gloves and replaced the tracheostomy neck ties. During an interview on 09/29/25 at 5:06 PM, RN B stated tracheostomy care was a sterile procedure. RN B stated the packaging should have been opened prior to applying her sterile gloves. RN B stated the outside packaging was not sterile. RN B stated everything completed after the sterile gloves were contaminated would not have been considered sterile. RN B stated she had not realized she broke sterile field during the procedure. RN B stated using sterile techniques during tracheostomy care was important to prevent the introduction of bacteria into the airway to prevent infections. RN B stated Resident #2 was currently being treated for pneumonia (lung infection).During an interview on 09/30/25 at 11:44 AM, the Medical Director stated nothing to do with tracheostomy care and suction was a sterile procedure. The Medical Director stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 17 of 22 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 10/02/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some throat was not sterile and tracheostomy care and suctioning was actually a dirty procedure. The Medical Director stated nurses were required to be certified and competent to perform tracheostomy care and suctioning. The Medical Director stated staff should have received frequent in-service training from a certified respiratory therapist. The Medical Director stated there was minimal risk for improperly performing tracheostomy care and suctioning. The Medical Director stated there was no risk of infection. The Medical Director stated having a tracheostomy placed residents at risk for bacterial infections from their own flora (bacteria) from their skin. During an interview on 09/30/25 at 12:46 PM, ADON K stated she was unable to locate the competency nurse check offs for infection control. ADON K stated the DON was responsible for completing competency checks for the nurses. ADON K stated the DON left a few weeks ago. During an interview on 09/30/25 at 1:13 PM, LVN A stated enhanced barrier precautions should have been used on any resident with a gastrostomy tube, Foley catheter, wounds, or a tracheostomy tube. LVN A stated enhanced barrier precautions was PPE, that included: an isolation gown, gloves, and shoe covers. LVN A stated hand hygiene should have been performed between patient care, or when visibly soiled. LVN A stated gloves should have been changed and hand hygiene performed between different procedures. LVN A stated tracheostomy care and suctions was considered a sterile procedure. LVN A stated the tracheostomy was direct airway into the lungs. LVN A stated the night of 09/15/25 into the morning of 09/16/25 was her last days as full time at the facility. LVN A stated she was unable to remember the care she provided to Resident #1. LVN A stated the PPE required for enhanced barrier precautions were not always available for use by the staff. LVN A stated she was unable to recall if it was available for use on the morning of 09/16/25. LVN A stated if the PPE was not available, she was probably in a hurry to get everything completed. LVN A stated it was important to ensure enhanced barrier precautions were used and sterile technique was maintained during tracheostomy care and suctioning to protect the staff and residents from infection. During an interview on 09/30/25 at 1:53 PM, the Administrator stated she expected direct care staff to ensure enhanced barrier precautions were worn into residents' room as required. The Administrator stated tracheostomy care and suctioning was considered a sterile procedure and sterile technique was required. The Administrator stated she expected the nurses to ensure sterile technique was used during tracheostomy care and suctioning. The Administrator stated sterile supplies and PPE supplies were always available. The Administrator stated it was important to ensure enhanced barrier precautions were used and sterile technique was maintained during tracheostomy care and suctioning to protect the residents from infection. During an interview on 09/20/25 at 2:08 PM, the Interim DON stated enhanced barrier precautions were utilized for residents with a tracheostomy, Foley catheter, or infection. The Interim DON stated the PPE required for enhanced barrier precautions included: face shield, mask, gown, gloves, and sometimes goggles. The Interim DON stated she expected PPE to be utilized, when it is available. The Interim DON stated she had issues with PPE supplies being unavailable. The Interim DON stated when PPE supplies was unavailable, she attempted to find it or borrow it from the nursing facility next door. The Interim DON stated it was reported to the person who reorders supplies. The Interim DON stated tracheostomy care and suctioning was considered a sterile procedure. The Interim DON stated sterile technique was required. The Interim DON stated it was important to maintain sterile technique during tracheostomy care and suctioning to decrease the risk of infection. The Interim DON stated not having the appropriate equipment and PPE supplies could have contributed to Resident #1, Resident #2, and Resident #4's infections. The Interim DON stated on 09/24/25 she performed unsterile tracheostomy suctioning because the facility did not have any sterile gloves that fit her. The Interim DON stated Resident #1 needed to be assessed and had obvious signs of respiratory distress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 18 of 22 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 10/02/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some The Interim DON stated Resident #1's family had reported that LVN C refused to assess Resident #1, which was why she was in the room. The Interim DON stated she expected the nursing staff to perform a focused assessment for any change of condition. The Interim DON stated she expected the nurses to utilize the nursing judgment and prioritize care. The Interim DON stated airway and breathing were the two top priorities. The Interim DON stated an assessment was performed to ensure patient safety and maintain well-being. During an interview on 09/30/25 at 2:26 PM, LVN C stated she normally worked 6 AM - 2 PM shift on Monday through Friday. LVN C stated enhanced barrier precautions were utilized for resident's who had wounds or infections, a tracheostomy tube, a Foley catheter, or a feeding tube. LVN C stated a gown, gloves, mask, and goggles as needed should have been worn when providing care. LVN C stated tracheostomy care and suctioning was a sterile procedure and sterile technique was required. LVN C stated she did not always have access to the PPE supplies or sterile tracheostomy care kits. LVN C stated sometimes she had to perform tracheostomy care without PPE or sterile supplies. LVN C stated supplies were unavailable on a regular basis. LVN C stated it was important to ensure sterile technique was used to prevent infection. 3. Record review of a face sheet dated 10/01/25 indicated Resident #3 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paraplegia (medical condition characterized by the partial or complete loss of motor and sensory function in the lower half of the body including both legs), chronic cystitis without hematuria (bladder infections), infection and inflammatory reaction due to indwelling urethral catheter, anemias, and neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system, or nerves involved in the control of urination), traumatic amputation at level between left hip and knee, colostomy status (surgical procedure creates opening in the abdominal wall through which the large intestine is brought to the surface of the body). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #3 was able to make himself understood and was able to understand others. The MDS assessment indicated Resident #3 had a BIMS score of 14, which indicated Resident #3 was cognitively intact. The MDS assessment indicated Resident #3 was dependent on staff for transfers, showers, toileting and dressing and required assistance for eating and personal hygiene. The MDS assessment indicated Resident #3 had a Foley catheter colostomy and wounds Record review of Resident #3's care plan with a target date of 09/28/2025 indicated he had indwelling Foley catheter with a goal of resident #3 would remain free from any catheter related trauma. Record review of Resident #3's Order Summary Report dated 10/01/2025 indicated: EBP: Staff must use gowns and gloves during high contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every shift for EBP Precautions with a start date of 04/16/2025. Record review of Resident #3's Infection Screening Evaluation dated 09/13/25 indicated a current active diagnosis of infection related to new or increasing purulent drainage. Record review of Resident #3's nursing progress note dated 09/13/2025 indicated during wound care, noted resident wound to the sacrum increasing slough and drainage. Physician notified and new orders received. During an observation on 09/27/25 at 03:33 PM, CNA E and CNA F entered Resident #3's room. CNA E and CNA F donned gloves. CNA E and CNA F transfer Resident #3 from wheelchair to bed. CNA E and CNA F reposition Resident #3 once he was placed into the bed. CNA E and CNA F adjust bed covers. CNA E and CNA F exit Resident #3's room. During an interview on 09/27/25 at 04:15 PM, CNA E stated she should have put on a gown due to enhanced barrier precautions because Resident #3 has a wound and has a Foley catheter. CNA E said it was important to use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 19 of 22 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 10/02/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some enhanced barrier precautions to protect the residents from risk of infections. During an interview on 09/27/25 at 04:35 PM, CNA F stated she had forgotten to grab a gown when she transferred Resident #3. CNA F stated the importance of wearing the gown for enhanced barrier precautions was to prevent the spread of bacteria between residents during close contact. Record review of the facility's Infection Surveillance Monthly Report as of September 30. 2025 indicated 13 total infections and 5 confirmed infections. 4. Record review of a face sheet dated 09/29/25 indicated Resident #4 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included acute kidney failure, chronic respiratory failure, diffuse traumatic brain injury with loss of consciousness, disturbances of salivary secretions, neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination), tracheostomy status, encounter for attention to gastrostomy (feeding tube). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #4 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #4 did not have BIMS score, which indicated Resident #4 was unable to complete the assessment. The MDS assessment indicated Resident #4 was dependent on staff for all ADLs. The MDS assessment indicated Resident #4 had an indwelling catheter. Record review of Resident #4's care plan did not indicate he had an indwelling catheter Resident #1's care plan did not address securing his Foley catheter. Record review of Resident #4's Order Summary Report dated 09/29/25 indicated: Foley catheters care every shift and as needed and may use leg strap to secure Foley tubing with a start date of 07/26/25. EBP: Staff must use gowns and gloves during high contact resident care activities that could possibly result in the transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every shift for EBP Precautions with a start date of 07/25/25. Record review of Resident #4's hospital admission record dated 07/08/25 indicated a diagnoses of septic shock bronchopneumonia due to Escherichia coli. Record review of Resident #4's hospital admission record dated 08/12/25 indicated a diagnosis of catheter associated urinary tract infection. Record review of Resident #4's nursing progress note dated 09/26/25 indicated Resident #4 has developed a fever with increased respiratory effort. A new order was received for a chest x-ray. 5. Record review of a face sheet dated 10/0/25 indicated Resident #5 was a [AGE] year-old female initially admitted to the facility on 05/2020 and a readmission date of 09/27/25 with diagnoses which included type 2 diabetes , neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination), dehydration, abnormal weight loss, anxiety disorder (excessive worry), insomnia, encounter for attention to gastrostomy (feeding tube), colostomy status Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #5 was able to make herself understood and was able to understand others. The MDS assessment indicated Resident #5 had a BIMS score of 9, which indicated Resident #5 was moderately cognitively impaired. The MDS assessment indicated Resident #5 was dependent on staff for transfers, toileting, showering, with set up assistance needed for eating and personal hygiene. The MDS assessment indicated Resident #5 had a colostomy and indwelling catheter Record review of Resident #5's care plan did not indicate he had an indwelling catheter Resident #1's care plan did not address securing his Foley catheter. Record review of Resident #4's Order Summary Report dated 09/29/25 indicated: Foley catheter care every shift and as needed and may use leg strap to secure Foley tubing with a start date of 06/03/25. Colostomy care every shift and as needed with a start date of 02/03/25. EBP: Staff must use gowns and gloves during high contact resident care activities that could possibly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 20 of 22 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 10/02/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every shift for EBP Precautions with a start date of 02/03/2025 Record review of Resident #5's hospital Discharge summary dated 09/2725 indicated a diagnosis of E Coli bacteremia, urinary tract infection secondary to ESBL producing E Coli upon admission.[TT3] Record Review of the facility's undated policy titled Suctioning the Tracheostomy Tube, indicated, The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.b. Suctioning the lower airway is a sterile procedure. Record Review of the facility's undated policy titled Tracheostomy Care, indicated, The purpose of this procedure is to guide tracheostomy care.2. Gloves must be used on both hands during any or all manipulation . sterile gloves must be used during performing these procedures. Record review of the NCBI Bookshelf (A service of the National Library of Medicine and National Institutes of Health) in Chapter 22 Tracheostomy Care & Suctioning reflected .Tracheostomy suctioning uses a sterile catheter that is inserted through the surgical opening into the neck to the trachea to create an artificial airway. always review and follow agency policy regarding this specific skill.put on sterile gloves.the dominant hand will manipulate the catheter and must remain sterile.tracheostomy care provided with sterile technique. Record Review of the facility's undated policy titled. Enhanced Barrier Precautions, indicated, Enhanced Barrier Precautions refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organism that employs targeted gown and glove used during high contact resident care activities.Enhanced Barrier Precautions are indicated for residents with wounds and/or indwelling medical devices. The Administrator was notified on 09/30/25 at 04:38 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator provided the Immediate Jeopardy template on 09/30/25 at 04:38 PM and a POR was requested. The following plan of removal was submitted by the facility and accepted on 10/01/25 a 04:30 PM and included the following: Problem: Infection ControlAlleged Issues: The facility failed to Implement the infection control policy and procedure for tracheostomy care/suctioning and enhanced barrier precautions.The facility failed to ensure LVN A, LVN C, LVN D, and the interim [NAME] used sterile technique while performing tracheostomy suctioning on resident number one.The facility failed to ensure RN B used sterile technique while performing tracheostomy care on resident #2 on 9/29/25.The facility failed to ensure LVN A, LVN C, LVN D, the interim Don, LVN G and C NA H wore enhanced barrier precautions while performing care on resident #1, who had a feeding tube, tracheostomy tube, wound, and Foley catheter.The facility failed to ensure LVN E LVN F wore enhanced barrier precautions while providing care to resident #3 who had a Foley catheter and wound.The facility failed to ensure the nursing staff knew how to access PPE and sterile supplies for enhanced barrier precautions and tracheostomy care/suctioning. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Approaches: RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. RN/DON A was serviced by Facility Respiratory Therapist with documented competencies on file at the facility and kept in binders in the DON's office and Administrator's office. The Administrator is not clinical but is aware of all in-services per the VP of Clinical Operations.Nursing staff will be in-serviced on the proper procedure for enhanced barrier precautions and the policy and procedure for enhanced barrier precautions. This in-service was initiated on 09/30/2025 by the RN/DON A. All nursing staff will be in-serviced prior to them (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455429 If continuation sheet Page 21 of 22 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 10/02/2025 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete arriving to the facility for their next shift. The Director of Nursing, Regional nurse consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All facility staff will receive training on enhanced barrier precautions on 09/30/2025. Any staff who did not receive training on enhanced barrier precautions on 09/30/2025 will receive this education prior to their next scheduled shift on the floor caring for residents. The facility medical Director was informed of the IJ on 09/30/25 by the VP of Clinical Operations.1. Resident #1 is in the hospital 09/30/25. 2. Residents #2 was assessed on 9/29/2025; resident #3 was assessed on 8/21/25 & 9/13/25, resident #4 was assessed on 9/26/25; resident #5was assessed on 9/18/25. All are currently being treated with antibiotics for active infections. The Interim DON performed new assessments on 10/01/25 for residents 3, 4, and 5 on 10/01/2025. No further complications identified. Resident #1 is currently in the hospital. 3. All nurses will be trained in suctioning and care of tracheostomy per sterile technique and suctioning of tracheostomy by RN/DON A who has been trained by the facility respiratory therapist and by the facility respiratory therapist, on 09/30/2025. All nurses will be trained before they accept residents for their next scheduled shift. 4. RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All nursing staff will be in-serviced prior to them arriving at the facility for their next shift. This will begin immediately, 09/30/2025. All facility staff will receive training on enhanced barrier precautions on 09/30/2025. Any staff who did not receive training on enhanced barrier precautions on 09/30/2025 will receive this education prior to their next scheduled shift on the floor cari Event ID: Facility ID: 455429 If continuation sheet Page 22 of 22