Inspection·November 11, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few [Resident #1] time to respond to directions or requests (due to dementia more time is required to absorb instructions); approach [Resident #1] slowly and from the front; be cognizant of not invading [Resident #1's] personal space; Do not argue or condemn resident; do not express [facility employee] anger or impatience verbally or with physical movements (i.e shaking head, pointing finger). These responses are likely to increase confusion and agitation; Document summary of each episode. Note cause & successful interventions, include frequency and duration; Give [Resident #1clear, concise explanation of anything about to occur; avoid information overload since the angry aggressive resident cannot assimilate many details; Help [Resident #1] identify activities that tend to decrease angry behavior and encourage their utilization; If aggressive, try and remove from recreational program, and provide individualized program; Initiate behavior charting to identify why the [Resident #1] became angry or agitated( note time of day, who was present, & what proceeded the incident).Record review of Resident #1's Progress notes indicated the following:-On 5/13/25 at 10:02pm (Late Entry); completed by MDS RN: [The local] PD was called to facility due to assault. [Two] officers arrived and interviewed [Resident #1] and witnesses. [Resident#1] was arrested for assault/injury of the elderly and walked out of facility with [the two] officers to patrol vehicle.-On 5/13/25 at 7:50pm; completed by LVN B: [Resident #1] came out of her room walking down the hallway. [LVN B] called out to [Resident#1] asking her to come back. [Resident #1] continued to walk down the hallway. The resident then stopped and grabbed both arms of [Resident #2] standing in the hallway and threw her into the wall. [Resident #1] was redirected back to her room at that time. Dr. notified, RN/DON notified, and Resident's [family member] notified. Record review of a psychiatric subsequent assessment completed on 5/13/25 by psych services indicated Resident #1 had an in-person visit at facility for an exacerbation of chronic problem requiring prescription management due to increased auditory and visual hallucinations, delusional thinking, forgetfulness, confusion, and difficulty completing tasks. Resident #1 reported trouble sleeping, including delayed sleep onset and frequent awakening. Recommended medication changes: effective 5/13/25; the Seroquel dose was increased from 25 mg BID to 50 mg BID due to continued hallucinations, delusional behavior, and worsening disorganization, indicating the previous dose was not effective. Record review of Resident #1's physical aggression initiated incident report dated 5/13/25 indicated the incident happened in the hallway on the secured unit. Incident Description: Nursing Description - [Resident #1] came out of her room walking down the hallway. [LVN B] called out to [Resident#1] asking her to come back. [Resident #1] continued to walk down the hallway. The resident then stopped and grabbed both arms of [Resident #2] standing in the hallway and threw her into the wall. [Resident #1] was redirected back to her room at that time. Resident Description: [Resident #1] did not respond at that time as to why she grabbed [Resident #2]. Immediate Action Taken: [Resident #1] was redirected back to her room to separate from peers, CNA assigned to stay with [Resident #1] as all times. Safety of all residents was ensured immediately. First aid was provided for [Resident #2] that was affected. EMS called for transport to hospital. Other information: [Resident #1] with schizophrenia and active delusions and upset about not having cigarettes. Agencies/People Notified: DON, physician, [Resident #1's] family member, administrator, local and police department. 2. Record review of an admission record dated 11/10/25 indicated Resident #2 was an [AGE] year-old female who initially admitted on [DATE] and readmitted on [DATE] to the secured unit with diagnoses including Dementia without behavioral disturbances (a general term for a group of conditions that cause a decline in cognitive function, memory, and thinking skills severe enough to interfere with daily life.), anxiety (an emotion characterized by feelings of worry, dread, and fear of future events) and cognitive communication deficit (a communication challenge caused by problems with thinking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 2 of 8 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 11/11/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few abilities like attention, memory). Record review of Resident #2's physical aggression received incident report dated 5/13/25 indicated the incident happened on the hallway on the secured unit. Incident Description: Nursing Description - [Resident #2] was standing at the end of the hallway when [Resident #1] walked up to [Resident #2 ], grabbed both of [Resident #2's] arms and threw her into the wall.[Resident #2 ] hit the back of her head on the corner of the wall and fell to the floor. [Resident #2] noted to have laceration to the back of her head. [LVN E] held pressure to area and another nurse called 911. [Resident #1] complained of back pain, [LVN E] instructed [Resident #2] not to move and held pressure to laceration until EMS arrived.[Resident #2] was placed in a neck brace then [Resident #2 was transferred onto the stretcher x4 persons. [Resident #2 was awake and alert at time of transfer to ER. Resident Description- [Resident #2] unable to give description. Immediate Action Taken: Description- [Resident #1 and #2] were separated and safety was ensured for residents on the secured unit. [Resident #1] who pushed [Resident #2] went to her room and sat calmly on her bed with staff outside of the door to monitor. First aid was provided by a nurse to [Resident #2] to laceration on head with firm pressure applied to control bleeding, [Resident #2] complained of back pain and was moved until EMS arrived and applied c-collar and was transferred to stretcher. [Resident #2's] family member was notified by nurse of incident. Injuries Observed at Time of incident: Injury Type- Laceration; Injury Location - Top of Scalp. Level of pain - 6. Other information: [Resident #2] was pushed down by [Resident #1] in the hallway. Record review of Resident #2's hospital physician progress notes dated 5/14/25 indicated the following: [Resident #2] was a [AGE] year-old female who had a primary diagnosis of a closed head injury. Length of Stay: 1 Day. admitted overnight for a closed head injury, and a 4cm laceration to a posterior scalp closed with staples. On 5/13/25 a CT Reconstruction of the Lumbar Spine (a special type of CT scan that focused on the lower back region or the spine) conducted at the hospital revealed there was an L1 compression fracture (break) which is one of the bones in the lower part of Resident #2 spine. 24 Hour Events: Scalp Wound stable - hemostatic (anything that stops or slows bleeding). Reviewed and Discussed L1 Endplate Fx with Neurosurgery, non op Fx, with LSO support brace. [Resident #2] to follow up Neurosurgery clinic in 4-6 weeks. Plan: Mobilized with use of LSO-to be used for OOB activity/ambulation. Okay to leave off when sitting up in chair and/or short distance ambulation, such as going to bathroom. [Resident #2] cleared to return to SNF . Record review of 76-hour neuro checks report dated effective 5/14/25 indicated Resident #2 had no change in neuro status. Resident #2's neuro remained at baseline, and she voiced no pain complaints. Record review of quarterly MDS assessment dated [DATE] indicated Resident #2 had clear speech, was able to make her self-understood by expressing ideas and wants; had clear comprehension. She had BIMS score of 9 out of 15 indicating she had moderate cognitive impairment with thinking and memory. Section E - Behaviors was marked none of the above indicating no hallucinations nor delusions and no physical, no verbal and no other behavioral symptoms directed towards others; She was independent with most ADLs and no DME required. Resident #2 was incontinent of bladder and bowel. The MDS assessment indicated Resident #2 had no fractures and/or other multiple traumas, and no skin condition, no skin injury/wound or treatment, and no recent falls since admission. Record review of Resident #2's undated revised care plan indicated the following:-Focus: [Resident #2] care planned for a potential psychosocial well-being problem due to receiving physical aggression from [Resident #1]. -Goal: [Resident #2] will have no indications of psychosocial well-being problem.-Intervention: Monitor/document [Resident #2] usual response to problems; Monitor/document [Resident #2] feelings relative to receiving aggression; When conflict arises, remove [Resident #2] to a calm safe environment and allow to vent/share feelings. Record review of Resident #2's Progress notes indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 3 of 8 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 11/11/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few following:-On 5/13/25 at 7:50pm; completed by LVN B: [Resident #3 ]was standing at the end of the hallway when [Resident #1] walked up to [Resident #2], grabbed both [Resident #2] arms and [Resident #1] threw [Resident #2] into the wall.[Resident #2] hit the back of her head on the corner of the wall and fell to the floor. [Resident #2] noted to have laceration to the back of her head. [LVN B] held pressure to area while another nurse called 911. [Resident #2] c/o back pain. [LVN B] instructed [Resident #2] not to move. [LVN B] held pressure to [Resident #2] head laceration until EMS arrived.[Resident #2] was placed in a neck brace then [Resident #2] was transferred onto the stretcher x4 persons. [Resident #2] is awake and alert at time of transfer to ER. Dr. was notified, RN/DON notified, and Resident's family member was notified.-On 5/14/25 at 8:42pm; completed by LVN B:[Resident #2] returned to the facility from the hospital via facility transportation. [Resident #2] vitals were taken, skin assessment completed, [Resident #2] family was notified, Dr. was notified and was DON notified.-On 6/2/25 at 2:02pm; completed by LVN D: [Resident #2] allowed the ADON and DON to take her [11] staples out [located back of head].-On 7/31/25 at 1:08pm; completed by LVN D: [Resident #2] went to her [follow up Neurologist] appointment via facility van.-On 7/31/25 at 2:47pm; completed by LVN B: [Resident #2] returned from her appointment with new orders for PT to evaluate and treat 3x/wk x4 weeks for chronic low back pain, DDD L5-S1, bilateral trochanteric bursitis inflammation of the bursa on both sides of the hips, causing pain, tenderness, and swelling on the outer hips that may radiate down the thighs). Record review of facility's typed post investigation submission report dated 5/20/25 Incident Type: Abuse and Neglect/ Resident to Resident Altercation. Agency Immediate Response to prevent recurrence/protect individuals: Agency contacted the local police department and self-reported the incident to HHS. Notified RP, the MD, Ombudsman and Administrator. Investigation Summary: On 05/13/2025 2p-10p shift [Resident #1] (Alleged Perp) was advised that she could not go out the side patio door of the secured memory care unit to smoke. [Resident #1] became angry and verbally aggressive while ambulating away from the entry door. In Passing [Resident #1] came into contact with [Resident #2] (Alleged Victim). During the interaction there was a verbal altercation between the two which escalated to [Resident #1] physically assaulting [Resident #2] before staff could intervene between the two. [Resident #1] grabbed [Resident #2] by her shoulders and pushed [Resident #2], causing [Resident #2] to fall backwards and sustain a head injury. Staff present in the area were able to redirect other residents from the scene of the incident while the assigned nurse provided first aide to [Resident #2] (Alleged Victim). [Resident #2] sustained a noticeable laceration to the head which was bleeding while the nurse applied pressure EMS was notified while comfort and safety continued to be provided to the injured resident. The alleged perpetrator [Resident #1] was placed on one-to-one supervision. [Resident #1] remained very agitated and returned to her room cursing and making obscenities at nearby staff. EMS arrived shortly thereafter triaged the[Resident #2] onsite and transported her to the ER for further evaluation. Due to the level of aggression and agitation the local police department were notified who arrived to the facility to address the safety risk of [Resident #1] and due to [Resident #1] current state and active behaviors she was removed by law enforcement and transferred to the ER for a psych hold. Upon further follow up from the facility to accepting hospital the facility was advised that [Resident #2] was admitted due to her acute injuries. The alleged perpetrator [Resident #1] was being detained and pending transferred to jail due to new charges and of assault on elderly and prior criminal convictions prior to [Resident #1] initial admission. Investigation Findings: Confirmed. Agency Actions Post Investigations: Notifications Provided to RP, MD, DON, Administrator and Regulatory Agency. Facility had In-serviced and trained staff on the following areas. Abuse and Neglect and Resident Rights, De-Escalation and Effective Communication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 4 of 8 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 11/11/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Methods, Safe Surveys throughout the facility. Resident Plan of Care Reviews and Increased monitoring for patients who may be at risk. IDT team members reviewed the incident and reported findings to QAPI committee for recommendations. The committee reviewed the findings and provided recommendations and ongoing monitoring to reduce the risk patient needs not being met. Record review of handwritten statement dated 5/13/25 at 7:50pm provided by the facility completed by: LVN B indicated the following: [LVN B] was standing at the med cart on the secured unit, dispensing bedtime medications, when [Resident #1] was walking out of her room down the hallway. [LVN B] called out to [Resident #1] to return back so [LVN B] could check her blood sugar, but [Resident #1] had ignored her and continued to down the hallway. [LVN B] called out again but [Resident #1] continued to ignore [LVN B} because [Resident #1] was upset about not getting to go outside to smoke; LVN B] yelled out Nooo and [Resident #2's name] and she then threw [Resident #2] into the wall causing [Resident #2] to his her head on the corner of the wall and fell to the floor. During an observation and attempted interview on 11/7/25 at 6:00pm, Resident #2 was in the tv room with the other resident on secured memory care unit, she introduced herself and said that she was getting ready to have a meeting and started talking about life. Resident #2 was clean, well-groomed with no unpleasant odor and there were no visible bruising, skin tears or marks. During an interview on 11/10/25 at 11:59am, CNA K said that she was the CNA for the secured memory care unit during the 2pm-10pm shift and worked there since March 2025. She said she did work the day of the incident between Resident #1 and Resident #2 but she did not witness the actual resident to resident altercation because she was on the other end of the hall assisting another resident on the secured memory care unit finishing up with patient care at that time and she heard a loud BOOM like sound and at that time she stepped into the hall to find out what the loud sound had come from and that was when she witnessed Resident #2 laying on her left side in fetal like position making moaning like sounds and Resident #1 was standing up over Resident #2. CNA K said learned the BOOM sound was the sound of Resident #2 head hitting/bouncing off wall. CNA K said then several staff started running from all over, and after she had already been with Resident #2 for about 5 or 10 minutes, she got out the way so the nurses could have room, she said LVN B had been there the entire time with Resident #2 and applying pressure because Resident #2 head was bleeding. CNA K said Resident #1 at that time was in her room, and CNA K said she was with the other resident on the secured memory care unit and making sure that they were okay. CNA K said on the day of incident around 7:00pm or not too long afterwards she had just assisted Resident #1 with getting her clothes laid out for bed, and Resident #1 did not appear to be aggressive or to have had been in a bad mood alarming her that in less than an hour later Resident #1 would have a physical resident to resident aggressive altercation with another resident. CNA K described Resident #1 as a resident who stayed to herself and said she was very surprised by what had happened. During an interview on 11/10/25 at 12:22pm, CNA L said that she was a CNA for the secured memory care unit during the 2pm-10pm shift and worked there since March 2025. She said she did work the day of the incident between Resident #1 and Resident #2, but she did not witness the actual resident to resident altercation because she had taken another resident outside to smoke. CNA L said Resident #1 did not give her any problems but did get the feeling if Resident #1 did not get what she wanted then Resident #1 would probably become angry, aggressive, and would become scary to be around. She described Resident #1 with having childlike behaviors, if Resident #1 got everything she wanted, she was good, if Resident #1 did not, then that's when the aggressive behaviors were initiated. CNA L said since working there she had only seen Resident #1 get triggered maybe 1 time it was not frequent and could not remember about what or what happened. CNA L said during the smoke break the day of the incident she heard a loud noise, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 5 of 8 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 11/11/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few described Big BOOM, she said she did not know what happened, but she knew immediately Resident #1 had did something, and assumed it was because it was because Resident #1 did not get her way about something. CNA L said brought the other resident back inside facility to find out what had happened and where the sound had come from, later found out the Big Boom sound was Resident #2's head hitting wall. CNA L witnessed Resident #1 standing next to Resident #2 and Resident #2 was on the floor screaming and Resident #2 head was bleeding. LVN B was on the floor next to Resident #2 holding bandages to Resident #2 head. CNA L said she saw Resident #1 walking and pacing the hallway outside of Resident #1's room back and forth at the moment and appeared to be talking to herself loudly, she was cursing, and staff could not get Resident #1 to calm down. CNA L said Resident #2 targeting anyone particularly, but at that point no one did not know what she may do, and she could potentially harm another resident, staff or herself and at that time, they determined it was best to call the local police for everyone's safety, since Resident #1 would not calm down, CNA L said she was the assigned staff who did one-on-one monitoring until the police arrived and during that time, Resident #1 was back her room and sitting on her bed. Resident #1 behavior did appear to change after she was notified the police were called.During an interview on 11/10/25 at 5:46pm, LVN B said that she was the charge nurse for the secured memory care unit during the 2pm-10pm shift and worked there since May 2022. LVN B said the incident between [Resident #1 and Resident #2] happened a while back and she could not recall all the details. LVN B said she provided a witness statement and the information on her statement was accurate. LVN B said that it was herself, CNA K, and CNA L who were working that day and she remembered it was after dinner, so they [CNA K and CNA L] were busy CNA K was doing patient care at one end of the hall, CNA L was assisting another unknown resident outside. LVN B said she remembered she was doing her evening meds pass and was standing right outside of Resident #1's room door, possibly just had given her some meds she could not remember. LVN B said Resident #2 had been standing at the exit door near the end of the hall that had led into the main part of the building with bags of her own belongings, LVN B explained of Resident #2's dementia diagnosis Resident #2 will forget and think she's waiting to get picked up. LVN B said from the hallway when she was standing by her med cart she remembered looking up and Resident #1's room door was open and seeing Resident #1 with Resident #2's bags of personal belongings inside Resident #1's room. LVN B said at some point Resident #1 took Resident #2's items because Resident #2 is forgetful and will walk away often leaving the items unattended near the door, LVN B explained Resident #1 had a habit of taking the other resident items. LVN B said she entered Resident #1's room and explained to Resident #1 how the bag of items belonged to Resident #2 and needed to be returned, LVN B said Resident #1 told her the bag of items was hers [Resident #1] and not Resident #2, LVN B said she waited until Resident #1 released the bag and appeared to be okay and she [LVN B] received the bags of items from Resident #1 and left Resident #1 room. LVN B said whenever she stepped back onto the hallway Resident #2 happened to been standing and she [LVN B] handed Resident #2 her bag of items back and with direct eye contact instructed for Resident #2 to take the bag of items straight to her [Resident #2's] room, LVN B said Resident #2 replied okay, as if she understood and then immediately took off walking the opposite direction of her [Resident #2] room and went right back towards the directions of the exit door where Resident #2 had been standing originally with the bag of items. LVN B said since Resident #1 was in her room at that time and did not appear to be coming back out she did not believe there would be any concerns or issues. LVN B said she was in the process of getting ready to start doing her med pass and was at her med cart and she remembered Resident #1 left her [Resident #1's] room, she [LVN B] looked up from her med cart and seen Resident #1 was walking fast paced like and was headed straight towards (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 6 of 8 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 11/11/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in Resident #2 direction, LVN B said she immediately started screaming/yelling Resident #1's name repeatedly, in hopes to prevent whatever from happening, but she before she knew it, it was too late Resident #2 flying in the air, landed against the wall, bounced off the wall and finally landed onto the floor. LVN B said it was the most horrific thing she ever witnessed or imagined and was still in shock about the incident. LVN B described Resident #1 as being strong and the amount of strength Resident #1 had Resident #2 did not have a chance. LVN B said Resident #1 and Resident #2 did not have word exchange, did not have an incident or anything, LVN B said Resident #1 just walked up to Resident #2 and picked her up by both arms in one second and by the next second Resident #2 was in the air literally. LVN B said she was the only staff who witnessed the resident-to-resident physical abuse, the other staff assisted after the incident had happened. LVN B said Resident #1 had a history of being physical in 2024 with residents nothing physical she could recall in 2025 against another resident. LVN B said normally staff were able to redirect Resident #1, but Resident #1 had never done anything like that before. LVN B said post incident Resident #2, did not appear fearful of the other residents or staff. She said Resident did not stay in room or appear fearful other than Resident #2 went from long hair to shoulder length hair and possibly if asked may not recall but never brought it back up out of respect for Resident #2 and did not want to trigger anything. LVN B said after the incident she was retrained on abuse and neglect prevention, resident rights, early identification of escalating behaviors, and proper use of de-escalation techniques. She was instructed to intervene immediately, maintain resident dignity, notify supervisory staff and the physician without delay, follow the care plan, and accurately document all actions taken. During an interview on 11/07/25 at 5:50pm, The Administrator said he was the abuse coordinator and followed their abuse policy. The Administrator said following their investigation it was confirmed the abuse incident did occur and they had not had any similar issues since. He said he was the Administrator at the time of the incident. It was determined these failures resulted in Resident #2's closed head injury and a fractured lumbar vertebra on 5/13/25.Facility took the following actions to correct the noncompliance: -On 5/13/25 the morning of the altercation Resident #1 was seen by psych services and new orders were given to increase medication to control the increased behaviors and delusions. -Resident #1 the alleged perpetrator was placed on one-on-one supervision with staff place outside of her door to monitor, until the police arrived. -On 5/13/25 Local police were notified and arrived at the facility, detained and arrested Resident #1 at 9:08pm. - Resident #2's Neurological evaluation assessment was completed from 5/14/25 to 5/19/25. -On 5/14/25 Facility had in-serviced and trained staff in the following areas: Abuse and Neglect, Resident Rights, De- Escalation, and Effective Communication Methods. In-Services addressed immediate recognition and reporting of any behaviors or incidents that may place a resident at risk. Staff were in-serviced on Effective de-escalation methods, including calm verbal responses, allowing personal space, avoiding confrontation, and using redirection techniques. Resident rights, ensuring residents are treated with dignity, and staff do not use any form of intimidation or retaliation. Staff were educated on accurate and timely documentation of resident behavior, attempted interventions, and escalation to supervisory personnel. In-service emphasized following individualized care plans, including implementing interventions for residents with behavioral risks and increasing monitoring when indicated. This was verified by record review of staff in-services signature sheets and staff interviews. The in-service rosters indicated 46 employees were provided education on the topics. -On 5/14/25 Safe surveys throughout the facility were completed. The residents reported that staff were courteous, respectful, and kind, and stated they felt comfortable and safe with the care provided. The residents indicated that staff were careful when assisting or transferring them (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455485 If continuation sheet Page 7 of 8 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 11/11/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and confirmed that they were receiving the care they needed. This was verified by record review of safe survey sheets. --On 6/2/25 Resident #2 had an appointment at the trauma clinic for staples removal and refused treatment. Interviews and record reviews were conducted from 11/9/25 through 11/11/25 from 8:00 a.m. to 6:00 p.m. and included 5 LVNs, 4 CNAs, ADON, DON, and MDS Coordinator. Staff were able to explain abuse and neglect prevention, resident rights, and the facility's expectations for immediate intervention and reporting. Staff were able to explain how to identify early signs of behavioral escalation and proper use of effective and calm communication techniques and apply de-escalation strategies. Staff had knowledge to intervene immediately, maintain resident dignity, notify supervisory staff and the physician without delay, follow the care plan, and accurately document all actions taken. During observations from 11/9/25 through 11/11/25 at various times from 8:00 a.m. to 6:00 p.m. on the secured memory care unit, residents were noted to engage in calm and non-confrontational interactions. Residents appeared generally quiet, with limited verbal engagement, and interactions were primarily passive or casual in nature. Some residents were observed walking in common areas or sitting near one another without signs of agitation or distress. No instances of verbal or physical aggression were observed. Residents did not demonstrate behaviors that suggested intimidation or fear. Staff were present in the area, providing routine supervision and re-direction as needed, and were observed promptly intervening if any residents began to appear anxious or confused. Residents appeared to be appropriately monitored, and no residents displayed behaviors that posed a risk to others during the period of observation. Interactions were consistent with the cognitive and functional levels of the residents on the memory care unit. Interview with RN MDS who was the DON at the time of the incident, verified the QAPI committee implemented the following steps as part of the Post Investigation follow up, the secure unit policy and procedure was reviewed and during care plan review, IDT determined other residents with independent ambulatory ability on the secure unit may be at risk for similar behaviors of initiating or receiving physical aggression. The facility will monitor staff to ensure appropriate and care planned interventions were implemented: Department heads agreed to assist in providing increased rounding on secure unit - for 4 weeks department heads (Med Records, Staffing, Admin, DON, ADON, Housekeeping, BOM) intentionally made hourly walking rounds on the secure unit to enhance observation of ambulatory residents and provide assistance with any noted needs (snacks, hydration, distraction, re-direction is needed), QAPI Committee reviewed the incident and findings at June 2025 and July Event ID: Facility ID: 455485 If continuation sheet Page 8 of 8