Health inspection·February 27, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she did not do the strike through on the note and as far as she knew that was what had happened. She said they moved the resident the same day. She said Resident #5 resided in room A8. She said she did not know what happed but there had been a lock on the door ever since. During an interview on 2/26/25 at 5:15 p.m. CNA F they were black stuff in some of the rooms on the lock unit. She said they put a lock on Room A8 when Resident #5 moved out. The family member came and moved her out. The family said they did carpenter work and knew what black mold looked like. She said Resident #5 was discharged to another facility. Record review of a Grievance Repot dated 2/19/25 indicated Resident #6's responsible party said there was black mold in the shower and shower tiles were missing. The report indicated the resident was moved to another room and the room was closed for repair. During an observation and interview on 2/27/25 at 9:50 a.m. Resident #6 said she was moved from Room C18 because they were doing remodeling in her room. She said that she really did not know why. During an interview on 2/27/25 at 11:53 a.m. a family member of Resident #6 said back in November 2024 Resident #6 was in a room that had mold. The family member said they had moved Resident #6 to another room and the same thing had occurred. The family member said they wanted answers and the facility to fix their problems. During an interview on 2/27/25 at 11:57 a.m. with Resident #6's responsible party. The responsible party said they had problems with mold in Resident #6's room back in November 2024. They moved her to a room on a different hall and now it was the same problem. The responsible party said she was very concerned when she saw what looked like mold in Resident #6's bathroom. She said then they moved her to Room C17, and the shower did not work in that room. During an observation on 2/26/25 at 4:03 p.m. of Room C18 showed in the bathroom the shower it was missing tile for about 8 inched across and 4 to 6 inches high. The board was showing in the wall was black with a little brown showing. The board was buckled and bumpy. There was large hole about 4 to f inches wide and 12 to 18 inches long. There was a pipe exposed behind the toilet with stuff sticking out that looked like someone had stuffed rag in the hole. The room still had the residents' personal belongings and there was a lock on the door, but it was not locked. During an interview on 2/26/25 at 5:15 p.m. CNA F said that they were not aware that there was anything going on in the room with C18. They were just told to move the residents out of the room. During observation and interview on 2/27/25 at 10:35 a.m. at 10:35 a.m. the shower in Room C18 showed the waferboard inside the shower had been removed, but the black debris and partials were still in the gap between the floors. There was a black substance on the exposed wall and on the remaining insulation. There were new tiles stacked in the doorway and some on the floor of the shower. The RDO said it appeared they had torn the damaged material out of the shower and was replacing the tile in the shower. He could not say if that was going to fix the problem of the black particles inside. During an observation and interview on 2/27/25 at 11:30 a.m. with CNA G she said the showerhead in Room C17 was broken and have been broke for a couple of months. She said that the residents were not able to get a shower. CNA F said they did not have a shower room. She said each room had their own shower, and she had let maintenance know on several occasions the shower was not working properly. Resident #9 resided in the room and said she had not had a shower in a while, she was only able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 2 of 9 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 455485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Petal Hill 900 S Baxter Ave 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some take bird baths. CNA G said when they have an empty room, they have taken Resident #9 to get a shower. Resident #6 said she had had been in the room about a week and she had not had a shower since she moved. Observation of the shower showed it had a pipe that came out of the wall but no shower head. During an observation and interview on 2/27/25 at 11:20 a.m. observation of the bathroom in Room C20 showed the light in the bathroom did not work and there was little light. The heat light was tuned on for extra light. The shower had black buildup in the corners of the shower and some of the tile had been replaced and there was black buildup in-between the spaced cracks in the wall. There were back spots in between some of the tiles on the floor in the shower. There was missing tile on the wall close to the 3-drawer cabinet about 4 feet off the floor. On the floor was missing tile and about two inches was filled with brown substance and brown debris was protruding out onto the floor. Under the cabinet the baseboard was missing, and it was brown with black and brown stains in the crack and onto the floor. The sink had the facing on the side missing showing exposed waferboard. There was a hole in the wall to the left side of the shower along the base board with a crack of about ¼ inch with black substance along the wall for about 6 inches. There was a shower curtain on the rod rolled up and stuck in the corner on the left side of the commode. There was no shower curtain on the shower. The baseboard along the wall had dirty buildup between the top of the baseboard and the wall on the left side of the door for about 2 feet. The door posts on both sides of the door on the inside of the bathroom had dirt buildup around the base with holes and missing gaps. On the left side of the door above the base board was a brown stain or hole in the wall. The right side of the door going out of the bathroom was scared with several layers of paint showing. The area around the door was about 12 inches long and 12 inches wide. Resident #7 said the shower curtain had been down for quite some time. The Housekeeping Supervisor came in to clean the room. She said that there needed to be a light over the sink because that light did not work in the bathroom. She tried to clean his shower with bleach wipes and the black stains did not move. During observation and interview on 2/27/25 at 11: 27 a.m. Room C21 Resident #8 was laying in the bed. She said that her light in her bathroom did not work. She said sometimes it came on but most times not. An observation of the light show that the cover was missing, and the light was dim in the bathroom. There were baseboard missing under the sink for about 3 inches that showed the brown wall. Resident #8 said the staff were aware, she had requested the light be fixed several times. There was also missing tile at the threshold of the floor making the floor uneven and a trip hazard. In some places the missing tile was about 2 inches wide and 6 to 8 inches long and two others one-inch spots in the doorway. During an observation and interview 2/27/25 at 2:57 p.m. of Room C22 there was a large hole in the wall that was about 2 feet long and 4 inches high. The hole reached form the closet door to the bathroom door. The baseboard was propped against the wall and the wall was crumbled. There was an area above the hole that was about 12 inches high that was discolored. The wall that was crumbled did not appear to be wet at the current time. The sheet rock had basically disintegrated. Resident #10 said he had complained and been complaining ever since he had been in the room for about 3 months. Observation of the bathroom, the three-drawer cabinet the top drawer was missing. The wall along the side of the commode had been replaced at one time and appeared warped and buckled. Resident #10 said the commode was often stopped up, and he had complained several times. Record review of a Maintenance Request form dated 1/15/25 indicated Resident #10 said his toilet does not work and there is a hole in the wall. With no completion date or signature. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 3 of 9 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 455485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Petal Hill 900 S Baxter Ave 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 17 or 25 rooms (Room #'s A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, B10, B11, C12, C14, C15, C16, C17, C18, C19, C19, C20, C21, and C22) reviewed for environmental concerns. Rooms A1, A2, A3, A4, A5, A6, A7, A8, A9, and A10 had black spots around the air vents in the showers, holes in the walls, missing baseboards non-working lights, and showers not working properly. Rooms B10 had mold identified in the room and B11 was used for storage. Rooms C12, C14, C15, C16, C17, C18, C19, C19, C20, C21, and C22 had black spots in, no light in bathrooms or light covers, holes in the wall, missing tiles on the floor, holes in the walls, black buildup in showers, and baseboards missing. The facility failure could cause residents to have safety concerns. Findings included: Observation and interview were conducted of the locked Unit Hall 200 on 2/26/25 between 12:51 p.m. and 1:30 p.m. with the Administrator. He said the census on the unit was 19 female residents. During an observation on 2/26/25 at 12:51 p.m. Room A1 had a lock on the door, but the lock was not secured to the door. The door was blocked, and the Administrator pushed the door open. The room was used as storage room. There were things in the room like a popcorn machine, a dresser that was behind the door, boxes, trash bags, clothes littered the floor around the bed. There was a bulletin board propped on the bathroom door. The closet in the room had dark spots on the wall at the top of the closet. It looked like a spray of black dots on the wall. The bathroom ceiling had paint peeling and the spackle hanging down for about 1/3 of the ceiling. The bathroom was also used as storage area and the toilet had some feces in it that looked like it had not been flushed in a while, the water in the commode was brown. The Administrator said the room was not occupied. During an observation on 2/26/25 at 12:56 p.m. Room A2 the ceiling in the bathroom had paint peeling about 8-inch circumference around the light. The shower in the bathroom had black stuff protruding out of the cracks on the side of the wall and the corner. The baseboard under the sink was loose and hanging from the wall. There was black buildup around the base of the commode. The base board under the toilet paper holder in front of the commode was loose from the wall about an inch and present a tip hazard. There was rust around the door posts, the rust was on the floor and up the side of the post that appeared to be metal. This room was occupied by two residents. During an observation on 2/26/25 at 1:01 p.m. Room A3 the vent in the ceiling of the bedroom had a large spot about 12 inches wide and 12 inches long with white paint that was a brighter color than the rest of the ceiling. The paint did not cover up the back spots in the ceiling. There were residents residing in the room. During an interview on 2/26/25 at 1:04 p.m. the Administrator said he had only been at the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 4 of 9 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 455485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Petal Hill 900 S Baxter Ave 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many since 1/27/25. He said he knew they had some pipes bust during the freeze last year. He said he knew they had the roof was replaced but the paint did not appear to be covering up a water stain in room A3. He said he could not say what it was under the paint. The Administrator said he could only say it was dark or black and not covered up well. He said when he began work at the facility there were 5 or 6 rooms that had locks on the doors. He said he was told last week by the RDO that they could take the padlocks off the doors the rooms were fine. The Administrator said he was not a carpenter and did not have any knowledge of the events that happened before his arrival. He said when he arrived there were locks on 6 rooms in the facility; Rooms 212, 217, 115, 111, 109, and 105. He said he had heard rumors from some staff about black mold, but he did not know any definite information. He said the corporate office had not informed him of any issues regarding mold. He said he only knew that some of the rooms had black particles around the air vents. He said two of the rooms Room C14 and Room C15 had to be repaired because the walls were missing. The Administrator said some of the rooms were being renovated but he did not know exactly what the rooms needed. He said the RDO had been the administrator before him and had not informed him of what was needed as of the current time. He said he had just hired a new Maintenance Director and the Maintenance Director had been at the facility for about a week. During an observation on 2/26/25 at 1:12 p.m. Room A4 the baseboard hanging from the wall beside the commode, and under the toilet paper holder. The baseboard was loose and hanging for about 4 to five feet. It was also loose and hanging behind the commode about 12 to 18 inches. During an observation on 2/26/25 at 1:15 p.m. Room A5 the bathroom had a 3-drawer cabinet with about a three-inch space on the floor where the base board was hanging off the wall with brown and black debris protruding from the sides, over the top, and under the cabinet. The baseboard on the right side of the commode was hanging from the wall about an inch out. The wall behind the commode had wrinkled paint with holes in it and dark spots. There were dark spots on the floor around the commode, a hole in the wall to the right side of the commode about an inch wide. The baseboard in front of the commode on the left side was loose and hanging off the wall. During an observation on 2/26/25 at 1:17 p.m. Room A6 the bathroom showed down the wall on the right side of the commode about 3 to 4 feet of missing base board and behind the commode about 12 inches of missing base board. The spacing between the wall and the floor was visible with debris, paint and parts of sheet rock hanging out. The space in the corner where the baseboard was missing was broken and had a hole in the wall about 3 inches long. During an observation on 2/26/25 at 1:18 p.m. of the common area bathroom on the locked unit, off the dining room area appeared to be used as a storage area. There were clothes on a tall rolling hanger, stored in the shower, and a shower chair. There was missing baseboard along the wall up to the commode on the left side of the wall. The floor had debris and brown particles on the floor. The shower in the common area had black buildup in the corners on both sides of the shower. Staff said they use the shower and the bathroom for residents. During an observation on 2/26/25 at 1:21 p.m. room [ROOM NUMBER] in the bathroom a large area by the paper towel dispenser with pealed pain. A towel rack may have once held the spot or a soap dispenser it was about 7 inched high and 4 inches wide. During an observation and interview on 2/26/25 at 1:22 p.m. Room A7 in the bedroom it has black substance around the air vent in the ceiling. The black substance was in spots some about an inch wide and some just specks but it was mostly in the front of the vent with some black areas all around the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 5 of 9 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 455485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Petal Hill 900 S Baxter Ave 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many vent. Observation of the bathroom the left side of the commode baseboard was hanging off the wall for about 3 feet. The Administrator said he did not know what it was the substance was in the ceiling, but it was black. During an observation on 2/26/25 at 1:27 p.m. Room A9 had some dark spot around the air vent. A base board was coming off the wall in the bathroom. During an interview on 2/26/25 at 1:31 p.m. RN A said that she had no complaints about any residents with respiratory issues. During and observation of 2/26/25 at 1:35 p.m. Observation of Room B11 showed a lock hanging from the door, but the door was not locked. The room had 4 beds and mattresses and odds and ins. I was just enough space to walk into the room. Observation of the bedroom showed there was some black areas around the air vent in the ceiling. During an interview on 2/26/25 at 1:37 p.m. Ombudsman said she had complaints from residents and families about concerns with black mold before Thanksgiving 2024. She said it was a different Administrator at that time. She said that Administrator told her that the corporate office had a plan to ensure the wellbeing of the residents. She said she had asked what those plans were but was never given an answer. She said there continued to be reported concerns from some staff, residents, and family members about maintenance issues and the black substance that is suspected to be mold throughout the facility. She said she was unable to close her concerns until the matter was resolved. During an observation on 2/26/25 at 1:40 p.m. Room C16 had an orange sign of the door that said, Please excuse this area currently under renovation. There was a place for a lock on the door but there was no lock. The closet in the room had exposed pipes and insulation hanging out of the wall. The area in the closet had holes on two sides about a 12 to 18 inches high. There was debris all over the floor in the closet. During an observation on 2/26/25 at 1:42 p.m. of Room C15 had an orange sign on the door and it had a lock but was not locked. It had a hole cut in the wall in the closet and wall along the bathroom wall about 2 and half feet high, the sink was propped against the wall and behind the commode the wall was out all along the wall. During an observation on 2/26/25 at 1:50 p.m. there was a sign on the door of Room C14 that said the room was under construction. There was a lock on the door, but it was not locked. The wall in that room was also missing about 2 feet high. That room connected to Room C15. During an interview on 2/26/25 at 1:56 p.m. LVN B said she worked on the unit and Resident #2 had gone to the hospital with a cough, but they said she had COPD. She said Resident #3 had frequent falls, but she was on the unit and was very confused. She said there were no resident on the unit had really been sick. She said that they did have a water damage and there were some damages in Room A1. During an interview on 2/26/25 at 2:00 p.m. CNA C said there was some black stuff in several of the rooms on the lock unit and that they had some in the hallway at one time. She said the roof had been repaired a while back. She said she was not aware of any Resident that had respiratory issues. She said that she had asthma, but that she has not had any problems. During an interview on 2/26/25 at 2:05 PM CNA D said it had been several months since Room A9 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 6 of 9 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 455485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Petal Hill 900 S Baxter Ave 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many locked. She said she heard that it had something to do with mold, but she was not sure. She said she was not aware of any residents on the locked unit complaining of respiratory issues. During an interview on 2/26/25 at 2:10 p.m. CNA E said she noticed the black stuff in several of the rooms on the locked unit. She said that there were no residents had coughs or respiratory issues that she was aware of on the locked unit. She said she had allergies, but she did not have any more problems at the facility than she did at home. During an observation on 2/26/25 at 2:30 p.m. the former DON's office showed a dark spot on the ceiling, and one in the hallway outside her office around the vents. However, they appeared to be painted over. During an interview on 2/26/25 at 2:36 p.m. the RDO said he oversaw the facility as the acting administrator for 3 weeks in January. He said the old administrator left on the first of January 2025; he worked between administrators. He said the current administrator came the last week in January. He said the Ombudsman brought some concerns about Room A5 missing toilet tank cover, and an emergency light in the bathroom. He said she had some concerns about Rooms C14 and C15 with some black mold looking areas in the bathroom. He said those two rooms connect. He said they had called a plumber and when Plumber came in to repair the area mold was identified. The RDO said there were residents in those rooms, and they were moved. He said there are no residents in those rooms now. He said Rooms C14 and C15 shared a wall, and both of those rooms were mediated. He said remediating was when the cleanup company came out and removed the contaminated areas. The RDO said they had called an environmental services company that identified the black stuff as mold, they then had to contact a different company to complete the cleanup. He said after the cleanup they had to have the environmental services company come back and say it was clear. He said they had done those things with those two rooms only. He said mold was also identified in Room B10 and they were getting ready to start remediating that room. He said they started the process in November 2024 but did not know the exact dates. The Director said the dark stuff on the ceiling in the facility rooms was lint like in any homes where the vent blows. He said they were trying to get the rooms in order, it was not something they could not do overnight. He said they required a different company to come in and test the air quality and then they had to have different company to come in clean up the area. He said once the room it cleaned then the other company comes back to do the air testing again. The RDO said he was not aware of the areas on the locked unit that had suspected mold. He said they only had specific areas of the facility tested. He said he did not know why the locks were on two doors on the locked unit and several doors throughout the facility. He said they had a former employee that said she had mold toxicity and they had the area where her office was tested also. He said the only identified areas of mold concern was Rooms B14, B15, and B10. The RDO said they had gotten the air ducts cleaned back in December 2024. During an observation on 2/26/24 at 3:29 p.m. of Room B17 showed that room was used as an office. There were curtains on the window, chairs and tables set up along with a coffee pot and refrigerator. RN A said they turned Room B17 into a work area. Observation of the room showed the door had a place for a lock but there was no lock present. RN A said she was told by someone up front (she did not specify who) that the room was fine to use. She would not have just opened the room on her own. She said she got the key from up front. During an observation and interview on 2/26/25 at 3:31p.m. the RDO said he did not know why there was a hole in the closet of room C16. He said that in Room C14 and C 15 the environmental cleanup crew came in and cleaned those rooms and that was why they were missing walls. However, they should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 7 of 9 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 455485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Petal Hill 900 S Baxter Ave 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 0921 still be locked until they were repaired. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 2/26/25 at 3:40 p.m. with RDO Room A 7 had black stuff in the ceiling around the air vent. The RDO said that he did not know what the black substance was. He said it was not lint. The RDO said it was black substance and they would need to get it tested. Residents Affected - Many During an interview on 2/26/25 at 4:24 p.m. Administrator said last week came the environmental company that did cleanup work came to the facility. He said they looked at to look at one room, and only communicated about one room. He said the RDO said told him he did not know why the locks was on some of the doors. The Administrator said on last week 2/19/25 the family member of Resident #6 was upset because they felt there was mold her room, RoomC18. He said he informed the RDO because the family was upset and taking pictures of the area. He said he had not gotten a response from the RDO but had written a grievance regarding the family concerns. He said he had removed Resident #6 and her roommate to another room. During an observation and interview on 2/26/25 at 5:19 p.m. Maintenance Director said that he was a new maintenance man. He had only been there a week. He was observed putting a lock on the door of Room C12. He said that he was told to make sure that room A1 had a lock and he had already placed that one. He said he was instructed by RDO to put locks on C12, C14 C15, B10 and B11. He said 6 rooms total had locks on them. He said he knew some of the rooms required some work, but he did not know about the other rooms. Doing an observation and interview on 2/26/25at 5:20 p.m. showed room B10 was basically empty. RNA had the key, and the door was locked. During an interview on 2/27/25 at 10:08 a.m. the RDO said for rooms C14 and C15 they had received an all clear on 1/5/25. He said on room B 10 they are waiting on permit from the city. He said they had just gotten an update this morning. Could not say why put locks on the other rooms need work to be done. Not saying it is not suspected mold. but could not say that it is not had the rooms tested. He said he was not aware of Room C18 having any issues. He said the Administrator said he sent an email, but did he did not see it. He said he was going to get the rooms tested. During an observation and interview on 2/27/25 at 10:30 a.m. Room A8 with the RDO showed that the vent in the bathroom had been painted over and there was also a vent that was in the bedroom and there was also been in the bathroom that had black stuff on the vent and around the vent also in Room A7 it had been painted over but you could see over the paint and it still had black stuff on the outer surface During observation and interview on 2/27/25at 10:40 a.m. Room C19 was not locked. It had dirty black stains on the floor. The room appeared to be used for storage. It had three beds two wheelchair as a trap bar stand in the potty chair and a wheelchair in the bathroom and that door was not locked. Record review of an invoice from a restoration cleaning company dated 12/3/24 commercial duct cleaning was performed at the facility on vents and HVAC systems. Record review Remediation Clearance report number CS24688 dated 1/10/25 indicated remediation work was completed on 1/2/25. The report indicated Room C14 and Room C15 were clear of fungal spores. Record review Remediation Clearance report number CS5040 dated 1/24/25. indicated there was water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 8 of 9 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 455485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Petal Hill 900 S Baxter Ave 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 0921 Level of Harm - Minimal harm or potential for actual harm damage and potential fungal growth found in Room B10 Recommendation indicated no airborne spore levels of concern. Recommended mold protocol be completed for Room B10, and the bathroom enclosed all material to be disturbed by remediation activities. The back wall of Room B10 should include the repair or replacement of window flashing to ensure against future water intrusion. Other areas tested conference room, DON office and Hallway by DON office. No notable concerns listed. Residents Affected - Many During an interview on 2/27/25 at 12:13 p.m. the environmental services company director said regarding Job SS24688 the rooms looked when where at the facility was C 14 and C 15 and they only looked at those two rooms. He said they were first contacted on 11/21/24. He said they did the initial assessment on 11/26/24. They did a written protocol a work procedure that needed to be followed to get the work completed. He said the cleanup is complete by a different company and once they finish the cleanup then his company came back to retest the air quality and determined on 1/2/25 they had some additional items to take care of. The facility corrected that issue and they came back on 1/5/25 and gave them an all clear for Rooms C14 and C15. He said Job CS25040 was a different cite area. He said they were initially called on 1/15/25 regarding room B10 and they came out on 1/21/25. He said they determined mold in that room also. He said that the mold that was discovered was common mold penicillium spores. It was not black mold. He said if they had determined anything toxic with their testing they would have had the residents evacuated, and notified the city and the proper authorities. He said the State of Texas is not equipped to handle black mold. What they do when they come out is take a swab of the area that looked suspicious. They then test the air quality outside and inside the area to determine the concentration of mold in the area. He said the testing they conducted indicated some high levels of mold but not to a toxic level. They assessed the mold and made recommendations that it be cleaned by environmental specialist. He said Room B10 had some water damage and they needed to remove the wall panels. He said if an area had black substance sometimes it could just be cleaned but they needed to determine the root of the problem that was causing the damage. If there was water in the walls or if the area was left damp for an excessive amount of time. He said just because something looked suspicious did not mean it was mold, but it could be. During an interview on 2/27/25 at 2:33 p.m. the Medical Director said he was aware the facility had a problem with mold, but he was informed it was not toxic mold. He said he worked at the hospital and had not seen anything that suggested respiratory issues. He said if it was something going on with the mold it would have been something that have shown up at the hospital since it had been several months. He said the owners standpoint was that it was mold but not toxic. He said he had heard rumors about black mold. However, it had not shown up in residents UTIs and there had been no respiratory that indicated any fungal infections. He said different people have allergies to multiple things, but he did not see any issues with mold. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 9 of 9