Inspection·January 24, 2024

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 01/24/2024 at 11:48 a.m., the Administrator stated she was aware that a private space should be available for resident council meeting per the facility's Resident Council Policy. The Administrator stated that the Activity Director was responsible for conducting and providing a safe location for the residents who participate in the monthly Resident Council Meetings to have their meetings. The Administrator stated that the monthly Resident Council Meetings had been held in the Dining Room since her employment with the facility. She stated that she had spoken with the previous Administrator about privacy for residents during the Resident Council Meetings. The Administrator stated that she and the Activity Director decided to block off the 4 open hallways to the Dining Room to prevent anyone from entering the Dining Hall during the Resident Council Meetings. She stated that the Resident Council Meetings were held in between the residents' Smoke Breaks to ensure privacy for the residents during their meeting. The Administrator stated that herself and the Activity Director were currently in the process of clearing out an Administrative Office for the monthly Resident Council Meetings for privacy. The Administrator stated that there were at least 20-30 residents who participated in the monthly Resident Council Meetings and that the Dining Room was the only space available at the facility to accommodate the members of the Resident Council. The Administrator stated that she did not feel that there were any risks or harm done to the residents who attended the monthly Resident Council Meetings due to the meeting being held in the rear of the Dining Room. The Administrator reported that there had not been any complaints from the residents in Resident Council regarding privacy issues with the location of the meetings being held in the Dining Room. Observation on 01/22/2024 at 12:47 p.m. revealed a posting on the wall in the main hallway dated 01/01/2024 that reflected, Resident Council Meeting will be held on 01/30/2024 @ 1:30 PM in Main Dining Room! Observation on 01/23/2023 at 10 a.m., revealed a posting on the exterior door of the Activity Director's Office dated 01/23/2024 that reflected, Resident Council Meeting in Progress please DO NOT disturb! Observation on 01/23/2024 at 11 am. of the Dining Hall of the facility revealed there were 4 open doorways that did not have doors. The observation revealed that the ADON's Office was located inside the Dining Hall and the door was open and staff were present inside the office. The observation revealed that there was a kitchen window that was open and kitchen staff were speaking with residents at the window. Record review of the facility's policy titled Resident Council last revised on 02/2021, indicated The facility supports residents ' rights to organize and participate in the resident council . 3. The resident council group is provided with space, privacy and support to conduct meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 2 of 12 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 1 (room [ROOM NUMBER]) of 12 resident rooms, 1 (400 hall shower room) of 6 shower rooms, and 1 (400 Hall) of 4 halls reviewed for environment. The facility failed to ensure the ceiling in room [ROOM NUMBER] was free from a hole in the tile, a drooping tile with water stains and dust surrounding the air vent, and a hole in the wall beneath his window. The facility failed to ensure the walls, floor, and bathroom fixtures were clean and in good repair in the 400 Hall shower room. The facility failed to ensure the ceiling remained free from water leaking onto the hallway floors. These failures could place residents at risk of a diminished quality of life due to an unsafe and unmaintained environment. Findings included: An observation and interview on 1/22/24 at 10:15 AM in room [ROOM NUMBER] revealed Resident #57 complained about the condition of his room. He pointed out a hole in the ceiling tile in the corner of his room which was observed to be approximately 4 inches x 3 inches. Resident #57 pointed out the air vent above his bed and stated he felt like it was a health hazard. The air vent was surrounded by dust , and the ceiling tile, in which it was situated, was drooping and had a large water stain. Resident #57 denied observing any water leaking from the area. A hole was observed in the wall beneath Resident #57's window near the floor. The hole was approximately six inches long and four inches wide. A confidential resident interview revealed the resident was not comfortable taking showers in the 400 Hall shower room because there was black stuff all around the tiles and cracked tiles everywhere with black stuff on them. The resident stated they preferred bed baths because of the condition of the shower room. The resident stated they had complained about it before, but nothing was ever done. The resident stated the staff knew because they were in there giving the showers every day. The resident was unable to say when or to whom they complained. An observation on 1/22/24 at 11:20 AM in the 400 hallway revealed there was water leaking from the ceiling near a sprinkler head close to room [ROOM NUMBER] and dripping onto the floor. There were folding wet floor signs situated around the puddle on the floor. An observation of the 400 Hall shower room on 1/22/24 at 12:35 revealed the shower stall on the left had brown/yellow stains around several tiles in center of stall. There was a broken and partially missing tile with a jagged edge near the right side of floor at the base of the wall. There were black stains in the grout between the tiles on the floor and wall which were heavier along the back wall. There was grout missing along the base of the wall between the left and right stalls. Observation of the right stall revealed multiple missing and broken tiles all along the base of the walls, and a black substance was noted within the cracks. There was a long, thin, brown stain extending from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 3 of 12 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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 end of handrail down onto tiles approximately 12 inch long. The stain was thick and appeared to be a dried adhesive. There were eight screw holes and brown stains on wall near water faucet handle. There was black staining in grout between the wall tiles. Observation in the bathroom, located within the shower room, revealed two large bins covered with lids, one containing trash and the other soiled linens. There was a very foul odor in the room. There were 2 adjacent metal inset toilet paper holders in the wall by the toilet. The holders were completely covered in black and brown rust. When rubbed, a black gritty substance was left on the finger and sprinkled to the ground. One clean brief and two rolls of toilet paper were observed on the toilet tank; one was wrapped and the other open and partially used. An interview with the Maintenance Director on 1/22/24 at 12:44 PM revealed he was aware there were issues with the ceiling tiles in room [ROOM NUMBER]. He stated he had been replacing ceiling tiles and had recently run out of them. He stated more had been ordered and were due to arrive on 1/23/24. He stated he was not aware of the hole in the wall and depended on staff to log those types of issues in the maintenance logbook located at the nurses' station. The Maintenance Director stated the leak in the ceiling had just started that morning and he thought it was due to the rain. He stated he was waiting for the rain to end so that he could fully investigate it. He stated he was not aware of any issues with the roof or sprinkler system. When asked about the condition of the 400 Hall shower room, the Maintenance Director stated he was aware of the issues with the floor tile and was trying to replace them as he could. An observation on 1/23/24 at 6:50 AM in the 400 hallway revealed the area where the ceiling was dripping was no longer wet. The ceiling tile was discolored in the area affected by the leak. An interview with the Administrator on 1/23/24 at 3:58 PM revealed she stated she was aware there were issues with facility maintenance. She stated she and the Maintenance Director walked the building with regional leadership the previous week. The Administrator stated they had a list of rooms to be addressed and included things like paint touch-up. The Administrator stated they became aware of issues based on staff reporting and used of the maintenance logbook. She stated she had reminded staff to use the logbook at the nurses' station because they would try to catch the Maintenance Director in the halls and just tell him which made it difficult for him to keep up with all the requests. The Administrator stated they were also trying to get new furniture for the residents, and it was a priority for her. She stated the residents told her they really wanted updated furniture and theirs were getting old and required a lot of upkeep. The Administrator stated the facility department heads conducted weekly Angel rounds in resident rooms. She explained they checked on the residents, how were they doing, whether call lights were functioning and in reach, whether they had water in reach, and whether rooms were tidy and in good condition. She stated any issues should be documented on the Angel forms as well as in the maintenance logbook. The Administrator stated she was aware of the issues with the tile in the 400 Hall shower room and they were hoping to get it resolved soon. She stated she was previously unaware of the Shower room [ROOM NUMBER] hall, aware there were some tile issues, hoping to get resolved soon. She stated she was previously not aware of the ceiling issues in room [ROOM NUMBER] until she was told by the Maintenance Director. She stated they were expecting additional ceiling tiles soon. The Administrator stated she knew about the ceiling leak on 1/22/24 and the Maintenance Director had the leak stopped before he left for the day. It was checked again that morning and no further leaking was found. In a telephone interview on 1/23/24 at 10:35 PM, LVN G stated he typically worked the 300 and 400 halls. He stated any maintenance issues would be called to the Maintenance Director and Administrator if it was an emergency or otherwise noted in the maintenance logbook. He stated whoever identified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 4 of 12 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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 the issue should be the one to report it. LVN G stated he was unaware of any issues in the shower rooms as he never utilized it on the night shift. He denied noticing any issues in room [ROOM NUMBER]. An interview and observation on 1/24/24 at 7:25 AM with ADON B revealed any maintenance issues observed should be reported to the Administrator and the Maintenance Director. She stated CNAs and nurses should report any issues they find and could use the maintenance logbook as well. While observing the condition of the 400 Hall shower room, ADON B stated she was not previously aware of the issue as she had not been in that shower room. She stated residents should be able to use the bathroom located within the shower room. When asked about the risk to residents using that shower room, ADON B stated, .this is their home, it probably wouldn't feel good. An observation and interview on 1/24/24 at 7:35 AM with CNA H revealed the 400 Hall shower room still had black areas within the grout and cracked tiles. Two large bins were observed in the bathroom and an open bag of soiled linen was observed on the floor of the bathroom. There was a strong foul odor in the room. CNA H stated she seldom had residents who used the bathroom in the shower room because she had them go in their rooms before they went for a shower. She stated the linens were probably placed on the floor because there was no room left in the bins. She stated the bins were placed there during meal times so they were not in the hall while trays were passed. CNA H stated maintenance issues should be reported directly to the Maintenance Director or entered into the logbook. She denied reporting the shower room issues herself and stated she thought he already knew. A large rubber mat was observed on the floor of one of the shower stalls. CNA H denied hearing residents complain about the room and stated the broken tiles did not pose a risk because she moved the mat under the resident while showering and laid towels on the floor for them after their shower. CNA H stated she was not aware of any issues in room [ROOM NUMBER]. An interview with CNA I on 1/24/24 at 7:45 AM revealed she was aware of the issues in the 400 hall shower room and stated it had been like that for a long time. She stated maintenance issues should be entered in the maintenance logbook, but she knew it had been reported before. She stated she felt like if the black substance on the wall was mildew, it would be a health hazard. CNA I was not aware of the issues in room [ROOM NUMBER]. An interview with the Administrator and ADON A and observation of the 400 hall shower room on 1/24/24 at 8:00 AM revealed the facility's housekeeping supervisor stopped working at the facility on 1/19/24. The Administrator stated she was currently responsible for housekeeping services and they had interviews lined up for the position. The Administrator stated she was aware of the issues and had been talking to leadership about it and working on a plan. ADON A stated the bathroom was functional. When pointing out the thick rust on the toilet paper holders, ADON A stated she had been unaware of the issue. ADON A stated she did not think the broken tiled posed a safety risk as they were along the sides of the stalls and she was unsure of any health risks associated with the black substance within the cracks and on the grout. When asked whether they felt there were any psychosocial impacts to the residents, the Administrator and ADON A stated they had received no complaints from the residents. The Administrator stated they were working on upgrades but the process took time. During an observation and interview on 1/24/24 at 11:25 AM, Housekeeping Staff J stated she had been working at the facility since September 2024. She stated was aware of the issues in the 400 Hall shower room and had previously discussed it with her supervisor but could not recall when they spoke. She stated they had tried a different cleaner on lack areas between the tiles, but it was no good. While observing the rusted toilet paper holder, Housekeeping Staff J stated she had tried to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 5 of 12 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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 sanitize it but it was rusted out. The surveyor lightly rubbed the surface with a paper towel and black sediment was observed falling to the ground. When asked how something like that could be sanitized, Housekeeping Staff J stated she would speak to the Maintenance Director about it. Record review of the facility's maintenance logbook entries dated 11/9/23 through 1/22/24 revealed there were no entries related to the issues within room [ROOM NUMBER]. The following entries were related to the 400 Hall shower room: 11/18/23: 400 shower rm toilet will not fill up. 12/6/23: 400 hall shower water running FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 6 of 12 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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 - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 6 Residents ( #10, #40, #6, #31,#25 and #51) out of 6 reviewed for care plan. The Minimum Data Set Coordinator did not update Resident #10, Resident#40, Resident#31, Resident#5 and Resident #51 care plan to reflect the personal refrigerator in the resident's room. This failure could place the 6 residents at risk for unmet care needs. Findings included: Record review of Resident #51 care plan dated 08/01/23 revealed no care plan for personal refrigerator in Resident room. Record review of Resident # 6 care plan dated 11/28/23 revealed, no care plan for personal refrigerator in Resident room. Record review of Resident # 31 care plan dated 07/18/23 revealed, no care plan for personal refrigerator in Resident room. Record review of Resident # 40 care plan dated 05/04/23 revealed, no care plan for personal refrigerator in Resident room. Record review of Resident #25 care plan dated 05/04/23 revealed, no care plan for personal refrigerator in Resident room. Record review of Resident #10 care plan dated 08/10/23 revealed, no care plan for personal refrigerator in Resident room. During an interview on 01/24/24 at 1:00 PM, the Minimum Data Set Coordinator stated she did not know the care plan for residents with a personal refrigerator needed to be updated to reflect that the assessment was completed until she reviewed the policy on 01/23/24. Record review of facility's policy for foods brought by Family/Visitors dated 09/11/23 revealed: 2. Care plan updated to reflect assessment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 7 of 12 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to conduct a performance review of nurse aides at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 3 of 3 CNAs (CNA D, CNA E, and CNA F) CNAs who worked at the facility more than a year. Residents Affected - Some The facility failed to conduct performance reviews at least every 12 months for CNA D, CNA E, and CNA F. This deficient practice could result in residents not receiving the necessary care and services due to nurse aides not receiving training based on their identified needs. Findings included: Review of the facility's personnel files revealed CNA D (hired 09/15/2014) had a performance review completed in 2016 and 2017 but no documented evidence a performance review was completed since 2017. A review of the facility's personnel files for CNA E (hired 10/02/2018) and CNA F (hired 01/24/2022) revealed no documented evidence annual performance reviews were conducted since hire. An interview on 01/23/2024 at 10:16 AM with the DON revealed she had not completed any annual performance evaluations on staff since she began working at the facility on 11/17/2023. She said they were important because they allowed staff to understand what was expected of them and to identify strengths and weaknesses in their performance. She said performance evaluations helped to identify training needs for staff to ensure they were caring for residents appropriately. An interview on 01/23/2024 at 11:43 AM with the Administrator revealed she began working at the facility on 06/01/2023 and had not completed any performance reviews since she had been at the facility. She said the reviews should be done by the nursing managers. She said the purpose was to identify training needs staff may need to improve performance and ensure adequate care for the residents. An interview on 01/24/2024 at 12:00 PM with the Human Resources Director revealed she recently began working as the Director of HR and had not completed any performance reviews. She said she was not aware annual reviews should be completed and was not sure who would be responsible to complete them. She said Corporate HR had not told her about them. She said she did not have a system in place to ensure performance reviews were completed annually. She stated CNA D did have a performance evaluation for the year 2016 and 2017 but none since that time. She said CNAs E and F had no performance evaluations in their personnel files. An interview on 01/24/2024 at 12:20 PM with CNA D revealed she had worked in the facility for eleven years. She said the Administrator did meet with staff to discuss wage increases from time to time but did not recall having an annual performance evaluation. A telephone interview on 01/24/2024 at 1:20 PM with the Corporate Compliance Officer revealed the performance evaluations were important as they helped identify training needs for staff. He said they provide an opportunity for staff to provide feedback to managers regarding what they may need to ensure they are doing their job in the best way possible. He said he used to be the Corporate HR Manager and confirmed performance evaluation were not being done in the facility. He was not able to answer why. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 8 of 12 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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 0730 An interview on 01/24/2024 at 12:45 PM with the Administrator revealed the facility did not have a policy on annual performance evaluations. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 9 of 12 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record reviews the facility failed to follow their policy regarding storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption of the food and beverages for 6 Residents ( #10, #40, #6, #31,#25 and #51) out of 6 reviewed for personal food storage. Residents Affected - Some The facility staff did not label and date Resident #10, Resident #40,Resident #6, Resident#31, Resident #25 and Resident#51 food and beverages. The facility staff did not clean out resident #10, Resident#40, Resident #6, Resident#31, Resident #5 and Resident#51 personal refrigerators on a schedule or as needed. The Minimum Data Set Coordinator did not update Resident #10, Resident#40, Resident#31, Resident#5 and Resident #51 care plan to reflect the personal refrigerator in the resident's room. The deficient practice placed six residents who had personal refrigerators at risk of food borne illness. Findings included: During an observation and interview on 01/23/24 at 9:00 AM, revealed. Resident #51 had at crumbs from cake and an open container of whipped cream that were not labeled and dated. Resident#51 had red sticky substance on the bottom part of the refrigerator. Resident#51 stated the personal refrigerator needed to be cleaned out. During an observation and interview on 01/23/24 at 9:05 AM Resident #25 had fruit, can soda and opened chips in her personal refrigerator. Residents #25 stated she had no concerns about her personal refrigeration. During an observation on 01/23/24 at 9:10 AM Resident #31 had 1 opened can of soda and 4 unopened cans of sodas. Resident #31had a brown sticky substance at the bottom of the refrigerator. During an observation on 01/23/24 at 9:08 AM Resident #6 had 5 opened can sodas and 4 unopened cans in his personal refrigerator. Resident #6 inside walls and bottom of the refrigerator was sticky with a brown substance. Resident #6 had food (unrecognizable) at the bottom of the refrigerator not labeled dated or sealed. During an observation on 01/23/24 at 9:10 AM Resident #40 had no food or beverages in his personal refrigerator. Resident #40 freezer section was sticky with an off-white substance and his refrigerator section was sticky with a white, brown substance and crumbs. During an observation on 01/23/24 at 9:30 AM Resident #10 had 4 uncovered cups with orange, brown, red, and clear liquid substance in her personal refrigerator. Resident #10 top section of refrigerator was frozen. Record review of Resident #51 care plan dated 08/01/23 revealed no care plan for personal refrigerator in Resident room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 10 of 12 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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 0813 Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 6 care plan dated 11/28/23 revealed, no care plan for personal refrigerator in Resident room. Record review of Resident # 31 care plan dated 07/18/23 revealed, no care plan for personal refrigerator in Resident room. Residents Affected - Some Record review of Resident # 40 care plan dated 05/04/23 revealed, no care plan for personal refrigerator in Resident room. Record review of Resident #25 care plan dated 05/04/23 revealed, no care plan for personal refrigerator in Resident room. Record review of Resident #10 care plan dated 08/10/23 revealed, no care plan for personal refrigerator in Resident room. During an interview on 01/23/24 at 1:45 PM, CNA D stated residents could be in danger of being sick from eating old food. During an interview on 01/23/24 at 2:00 PM, the DON stated residents could be in danger of foodborne illness. During an interview on 01/24/24 at 6:30 AM, LVN D stated, there needed to be a cleaning schedule and a person that labeled and dated the food. LVN G stated the food could be spoiled and could cause the residents to be sick. During an interview on 01/24/24 at 1:00 PM, the Minimum Data Set Coordinator stated she did not know the care plan for residents with a personal refrigerator needed to be updated to reflect that the assessment was completed until she reviewed the policy on 01/23/24. During an interview on 01/24/34 at 1:15 PM, the Administrator stated residents could get sick from expired food. Record review of facility policy called resident personal food policy (revised 09/11/23) reflected, It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors. .2) follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness .d) Foods requiring refrigeration will be received by the facility designee .to ensure proper and immediate storage including labeling and dating Record review of facility's policy for foods brought by Family/Visitors dated 09/11/23 revealed: 1. Foods requiring refrigeration will be received by the facility designee .to ensure proper and immediate storage including labeling and dating 2. Care plan updated to reflect assessment 3. Follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 11 of 12 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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 - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to 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 3 of 6 residents (Residents #32, #38, and #50) reviewed for infection control. Residents Affected - Few MA C failed to sanitize a re-useable blood pressure cuff between blood pressure checks on Residents #32, #38, and #50. This failure could place residents at risk of contracting or spreading an infection. Findings included: Observations on 01/23/24 between 07:31 AM and 7:37 AM revealed MA C taking Resident #32's blood pressure. MA C then returned to the medication cart outside the room and place the cuff on the cart. A few minutes later she returned to the same room with the same blood pressure cuff and placed it on Resident #38's arm. After taking Resident #38's blood pressure, she returned to the medication cart again and placed the cuff on the cart. MA C then moved the cart, down the hall, outside of Resident #50's room, took the cuff into the room and used it to take Resident #50's blood pressure. After that, MA C left Resident #50's room and placed the cuff on the medication cart. MA C did not sanitize the blood pressure cuff at any point while taking and recording blood pressures for these residents. In an interview on 01/23/24 07:45 AM, MA C said she did not sanitize the blood pressure cuff at any point between using it on Residents #32, #38, and #50. She said she had forgot to do so. She stated she had sanitizing wipes in her cart and should use them to clean the cuff between use on each resident. She said that was important to prevent the spread of germs and possible infection. She said she was trained in infection control practices but did not recall the last time. In an interview on 01/23/24 at 11:42 AM, the Administrator said she and the DON share the responsibility of infection preventionist and she expected staff to sanitize all equipment between use on each resident. She said staff were trained in infection control by the nursing managers and were expected to follow the policies of the facility regarding sanitizing equipment. She said if equipment was not sanitized between use, residents would be placed at risk of the spread of infection. In an interview on 01/23/24 10:16 AM, the DON said she was the infection preventionist and trained staff on infection control practices. She said all equipment should be sanitized between use on residents. She said that was necessary to prevent he possible spread of infection. She said she expected staff to follow the facility's infection control policies at all times. She said she did not recall exactly but did provide an infection control in-service in December, 2023. She said she and the ADONs also remind staff daily about infection control practices. Record review of the facility's policy titles, Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018 reflected: .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 12 of 12