Inspection·February 6, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm she needs help. When asked if the Resident #14 was not able to yell for help what possibly could happen, CMA A stated the resident could try to get up and fall. During an observation on 02/06/2025 at 8:35 AM, Resident #14 was lying in her bed, observation of call light on resident's bed at the foot of the bed out of reach of resident. Residents Affected - Few During an interview on 02/06/2025 at 8:45 AM CNA C stated that all staff were responsible for iensuring call lights were in reach. The possible negative outcome for not having it in reach of the resident would be that residents could get hurt. During an interview on 02/06/2025 at 8:50 AM, the ADM and the DON were in the ADM's office, the ADM stated Resident #14 couldn't use the regular call light so she hollers for help., When asked if Resident #14 could use the pad style call light, the ADM said she could use that type. The DON stated the facility had that type of call light and said she would change out Resident #14's regular call light to the pad type call light. The ADM did not have a negative outcome for not having a call light in reach. During an interview on 02/06/2025 at 9:32 AM with Resident #14's family member, the family member stated Resident #14 can and will use the call light if it was near her. The family member said the call light that the facility should be using was the pad type call light to accommodate Resident #14's lack of movement in her hands. Record Review of Accommodations of Needs Policy dated March 2021 reflected the following: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and or achieving safe independent function, dignity, and wellbeing. The resident's individual needs and preferences including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 2 of 24 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 02/06/2025 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 16 residents (Resident #19) reviewed for right to receive written notification in that: The facility did not provide evidence that Resident #19 was given a written notice of a room change before the resident was moved. This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment. Findings included: Record review of Resident #19's face sheet dated 2/5/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to acute kidney failure, heat failure, major depressive disorder, and weakness. Record review of Resident #19's Quarterly MDS dated [DATE] revealed resident had a BIMS score of 15 out of 15 indicating cognition was intact. Record review of Resident #19's care plan dated 12/16/2024 revealed resident had a problem with psychosocial wellbeing with approach to allow resident to participate in daily care and decision making. Record review of Resident #19's progress notes dated 01/30/2025 revealed resident was moved to another room on 1/30/2025, no information of how the resident was notified of the moved. Interview on 02/04/2025 at 9:31 AM, Resident #19 stated she was moved to a different room because the staff told her the room, she was in was a Medicare room and she needed to be changed to a Medicaid room. Resident #19 said she didn't understand what the staff meant and didn't realize she could say she didn't want to move. Resident #19 said she didn't like the room she was in because in her old room she could see out the window and in her new room she cannot. Resident #19 said she was never given any type of written notice about moving rooms. Resident #19 said she was told verbally when she was moved. Interview on 02/05/2025 the DON said she was new and that she was told that the resident had to move rooms because of payment reason so she had the resident moved. The DON said she did not give Resident #19 anything in writing about the move. The DON stated that a possible negative outcome for moving a resident without consent would be it wouldn't be good for their wellbeing. Interview on 02/05/25 at 9:00 AM, the ADM said she only gave verbal notice to Resident #19 about the move. The ADM said that they were going to do some remodeling in that room and that was why she was moved, it wasn't because of the any type of billing. The ADM said the resident should have been given a notice in writing as to why she was moving. Interview on 02/06/2025 at 11:09 AM, the SW said she did not assess the resident's wellbeing before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 3 of 24 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 02/06/2025 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident was moved, the SW was unsure if that was protocol to do so. The SW stated that moving a resident without consent or notification could be viewed as punishment by the resident. Record Review of the Resident Rights policy dated February 2021 reflected the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Self Determination. Be informed of and participate in his or her care planning and treatment. Refuse a transfer from distinct part within the institution. Record Review of Policy Statement Room Change/Roommate Assignment dated June 25, 2024 When a resident is being moved at the request of facility staff, the resident, family, or resident representative must receive an explanation in writing of why the move is required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 4 of 24 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 02/06/2025 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. Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment was provided for 1 of 16 resident (Resident # 19) and 1 of 1 facility observed for environment 1. Hall 2 and Hall 4 had residue on the floor causing it to feel sticky while walking. 2. Hall 2 had a roach walking across the floor. 3. Resident #19's room was not homelike with her personal items stacked up against the wall, gnats flying around resident's face. 4. Gnats flying around in the conference room. 5. Phone outlet in the unlocked conference room was hanging out of the wall and wires attached. These failures could affect residents by placing them in an uncomfortable and unsanitary environment. Findings include: In an observation on 02/24/2025 at 8:27 AM, Conference room located on hall 5 was unlocked and the phone outlet was hanging out of the wall, wires attached. In an interview and observation on 02/04/2025 at 9:31 AM, Resident #19 was in her room, the room was cluttered with her personal items in bags and piled up against the wall. Resident #19 stated that she cannot put the items up herself and stated she did not like the clutter in her room., Resident #19 said she moved into the room on January 30, 2025, and her personal items have been piled up since then. In an observation on 02/05/2025 at 7:04 AM, shoes were sticking to floor while walking. In an observation on 02/05/2025 at 8:27 AM several gnats were flying around in the conference room. In an observation on 02/05/2025 at 9:40 AM, A roach was observed crawling across the hall on Hall 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 5 of 24 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 02/06/2025 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 In an observation on 02/05/2025 at 9:41 AM, this surveyor was walking on Hall 2 and her feet were sticking to the floor. The floor appeared to have a type of residue causing the floor to feel sticky. In an interview and observation on 02/05/2025 at 9:45 AM, Resident #19 was in her room, the room was cluttered with her personal items in bags and piled up against the wall. 2 to 3 Gnats were flying around Resident, Resident #19 stated that the gnats were bothering her. In an interview on 02/05/2025 at 10:00 AM, CMA A stated the negative outcome for having a cluttered environment would that it could affect the resident's wellbeing. In an interview and observation on 02/05/2025 at 10:30 AM, the DON stated that the nursing staff and all staff were responsible for ensuring items were put up in resident's room. The DON stated they had a contract with a pest control company and facility was treated monthly and the last treatment was in January. The DON showed surveyor the pest control book where they keep track of any pest sightings and treatments. The negative outcome would be to have clutter around in a room would the room would not feel homelike for the resident. In an interview and observation on 02/05/2025 at 10:43 AM, CMA B stated that it was all staff's responsibility to ensure residents had a homelike environment and that a possible negative outcome for having a dirty environment would be that it could cause the residents to get depressed. In an interview on 02/06/2025 at 8:50 AM, the ADM stated it was not normal for rooms to be cluttered and that it was the nurses responsibility to ensure items were put up in the room. The negative outcome for having a dirty environment would be that that it was not homelike for the residents. In an observation on 02/06/2025 at 9:30 AM, Resident #19 was in her room, the room was cluttered with her personal items in bags and piled up against the wall. In an interview on 02/06/2025 at 10:33 AM, the MS stated it was his responsibility to ensure the residents had a clean homelike environment. The MS stated they had a contract with Pest Control but because residents bring their personal items in the facility roaches can come with their items. The MS also stated it was his responsibility to ensure any residue on floors need to be cleaned but staff need to let him know if any issues of such were going on. The MS said that negative outcome for not having homelike clean environment would that it may not feel like home. Record Review of the grievances from the past three months revealed on 12/28/2024 a grievance was filed due to a roach was observed on a bedside table in their room. Record review of the Homelike Environment policy dated February 2021 reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongs to the extent possible. Staff provides person-centered care that emphasized the resident's comfort, independence and personal needs and preferences. The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment and personalized furniture and room arrangements, clean bed and linens that are in good condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 6 of 24 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 02/06/2025 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment for 1 of 16 (Resident #43) reviewed for care plans. This facility failed to implement the comprehensive care plan for Resident #43, resulting in ineffective communication. This failure could place residents at risk of not receiving the care needed to live at their highest practicable level of health and mental well-being. Findings included: Record review of Resident #43's clinical face sheet, dated 02/06/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS score of 08 indicating moderate cognitive impairment with a diagnosis of, but not limited to, Cerebral infarction (stroke) Aphasia (inability to speak) following cerebral infarction, Dysphasia (difficulty swallowing)following cerebral infarction, Muscle wasting and atrophy, not elsewhere classified, Unsteadiness on feet, lack of coordination, Type 2 diabetes mellitus with unspecified complications, Gastrostomy status, Gastro-esophageal reflux disease without esophagitis, Cellulitis of left finger, Pain, Constipation, disorders of bile acid and cholesterol metabolism, Anxiety disorder, Insomnia, chronic pain, hypertension The face sheet also stated that Resident #43 speaks Mandarin. Record review of Resident #43's MDS dated [DATE] revealed in section A1110-Language A) Resident's preferred language is Mandarin and B) stated that Resident #43 will need/want an interpreter to communicate with doctor or health care staff. Section B-hearing, Speech, and Vision revealed that Resident #43 has unclear speech, and is sometimes understood and usually understands others. In section C-Cognitive patterns under C0200 the repetition of three words revealed that Resident #43 could repeat 3 words after first attempt. Record review of Resident #43's Care Plan dated 12/30/2024 revealed the following: Communication: [Resident #43] primary language is Mandarin and has expressive aphasia r/t late effects of CVA. Goal: Will be able to communicate his/her wants, needs. Approach: -Ask simple yes/no questions and allow adequate time to respond, communication board as needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 7 of 24 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 02/06/2025 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 -Do not pretend to understand, request clarification when needed Level of Harm - Minimal harm or potential for actual harm -Speak directly to resident in clear voice facing him/her -ST referral Residents Affected - Few During an observation on 02/04/25 at 08:52 AM revealed Resident #43 lying in bed on his back with covers pulled up to chest. Resident #43 was unable to answer any questions that were asked of him. During an interview on 02/05/25 at 01:20 PM the MDS nurse revealed that the SW performs the BIMS for residents. and that Resident #43 should be using a translator to communicate. During an interview on 02/05/25 at 01:22 PM the SW stated that Resident #43 used SW's Google translate APP to communicate to Resident #43. The SW stated that Resident #43 speaks back to the phone, and it will translate what he says from Mandarin to English. The surveyor asked SW if she could demonstrate how she communicates with Resident #43 using her phone. During an observation on 02/05/25 at 01:26 PM revealed demonstration with Resident #43 and SW using her google translate. The SW fumbled quite a bit and had to find the languages to be translated in the APP. The process of communicating with Resident #43 took approximately 25minutes. Resident #43 never spoke to the phone head shaking and thumbs up was his only form of communication. There was no communication board utilized during this demonstration. During an interview on 02/06/25 at 08:44 AM LVN G who was responsible for the care of Resident #43 for the day was asked if a translator was utilized during his care, and LVN G stated that it was not due to the resident answering questions with shaking his head or give a thumbs up to respond to questions because he does not speak. LVN G was asked how the resident understood her when the language that he speak was Mandarin/Chinese? LVN G stated that he gives a thumbs up and shakes his head yes or no. LVN G stated that a negative outcome for not utilizing translation services were that Resident #43 wouldn't understand what they were asking. During an interview on 02/06/25 at 09:30 AM CNA L said Resident #43 does not have a communication board. CNA L stated that there has been no education on communication with this resident. CNA L stated that a negative outcome for not being able to communicate with this resident was something could go wrong. During an interview on 02/06/25 at 09:41 AM CNA I stated that Resident #43 does not have a communication board and has not received any education on communication services for Resident #43. During an interview on 02/06/25 at 11:48 AM DON stated that a negative outcome for not being able to communicate with Resident #43 would be that he was not able to communicate his needs. Record review of facility provided policy titled, Care Plans, Comprehensive Person-Centered, revised December 2020 revealed the following: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 8 of 24 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 02/06/2025 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 resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan are provided by qualified persons, are culturally-competent and trauma-informed. Level of Harm - Minimal harm or potential for actual harm .7. The care planning process will: Residents Affected - Few a. Facilitate resident and/or representative involvement; b. include an assessment of the resident's strengths and needs; and c. Incorporate the resident's personal and cultural preferences in developing the goals of care. .8. The comprehensive, person-centered care plan will: . . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . . j. Reflect the resident's expressed wishes regarding care and treatment goals; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 9 of 24 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 02/06/2025 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 1 (Resident #43) of 16 residents reviewed for activities of daily living. Residents Affected - Few The facility failed to work with Resident #43 on using his communication device to communicate effectively. This failure could place residents with communication deficits in danger of being unable to communicate and thereby experiencing a decrease in quality of life. Findings included: Record review of Resident #43's clinical face sheet, dated 02/06/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS score of 08 indicating moderate cognitive impairment with a diagnosis of, but not limited to, Cerebral infarction (stroke) Aphasia (inability to speak) following cerebral infarction, Dysphasia (difficulty swallowing)following cerebral infarction, Muscle wasting and atrophy, not elsewhere classified, Unsteadiness on feet, lack of coordination, Type 2 diabetes mellitus with unspecified complications, Gastrostomy status, Gastro-esophageal reflux disease without esophagitis, Cellulitis of left finger, Pain, Constipation, disorders of bile acid and cholesterol metabolism, Anxiety disorder, Insomnia, chronic pain, hypertension. The face sheet also states that Resident #43 speaks Mandarin. Record review of Resident #43's MDS dated [DATE] revealed in section A1110-Language A) Resident's preferred language is Mandarin and B) stated that Resident #43 will need/want an interpreter to communicate with doctor or health care staff. Section B-hearing, Speech, and Vision revealed that Resident #43 has unclear speech, and is sometimes understood and usually understands others. In section C-Cognitive patterns under C0200 the repetition of three words revealed that Resident #43 could repeat 3 words after first attempt. Review of Resident #43's Care Plan dated 12/30/2024 revealed the following: Communication: [Resident #43] primary language is Mandarina and has expressive aphasia r/t late effects of CVA. Goal: Will be able to communicate his/her wants, needs. Approach: -Ask simple yes/no questions and allow adequate time to respond, communication board as needed -Do not pretend to understand, request clarification when needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 10 of 24 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 02/06/2025 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 0676 -Speak directly to resident in clear voice facing him/her Level of Harm - Minimal harm or potential for actual harm -ST referral Residents Affected - Few During an observation on 02/04/25 at 08:52 AM revealed Resident #43 lying in bed on his back with covers pulled up to chest. Resident #43 was unable to answer any questions that were asked of him. During an interview on 02/05/25 at 01:20 PM MDS nurse revealed that the SW performs the BIMS for residents. and that Resident #43 should be using a translator to communicate. During an interview on 02/05/25 at 01:22 PM SW stated that Resident #43 used SW's Google translate APP to communicate to Resident #43. SW stated that Resident #43 speaks back to the phone, and it will translate what he says from Mandarin to English. The surveyor asked SW if she could demonstrate how she communicates with Resident #43 using her phone. During an observation on 02/05/25 at 01:26 PM revealed demonstration with Resident #43 and SW using her google translate. SW fumbled quite a bit and had to find the languages to be translated in the APP. The process of communicating with Resident #43 took approximately 25minutes. Resident #43 never spoke to the phone head shaking and thumbs up was his only form of communication. There was no communication board utilized during this demonstration. During an interview on 02/06/25 at 08:44 AM LVN G who was responsible for the care of Resident #43 for the day was asked if a translator was utilized during his care, and LVN G stated that it was not due to the resident answering questions with shaking his head or give a thumbs up to respond to questions because he does not speak. LVN was asked how the resident understood her when the language that he spoke was Mandarin/Chinese? LVN stated that he gives a thumbs up and shakes his head yes or no. LVN G stated that a negative outcome for not utilizing translation services were that Resident #43 wouldn't understand what they were asking. During an interview on 02/06/25 at 09:30 AM CNA L said Resident #43 does not have a communication board. CNA L stated that there has been no education on communication with this resident. CNA L stated that a negative outcome for not being able to communicate with this resident was something could go wrong. During an interview on 02/06/25 at 09:41 AM CNA I stated that Resident #43 does not have a communication board and has not received any education on communication services for Resident #43. During an interview on 02/06/25 at 11:48 AM DON stated that a negative outcome for not being able to communicate with Resident #43 would be that he would not able to communicate his needs. Record review of facility provided policy titled, Care Plans, Comprehensive Person-Centered, revised December 2020 revealed the following: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan are provided by qualified persons, are culturally-competent and trauma-informed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 11 of 24 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 02/06/2025 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 0676 .7. The care planning process will: Level of Harm - Minimal harm or potential for actual harm a. Facilitate resident and/or representative involvement; b. include an assessment of the resident's strengths and needs; and Residents Affected - Few c. Incorporate the resident's personal and cultural preferences in developing the goals of care. .8. The comprehensive, person-centered care plan will: . . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . . j. Reflect the resident's expressed wishes regarding care and treatment goals; Record review of facility provided policy titled, Residents Rights, revised February 2021, revealed the following: Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; . Record review of facility provided policy titled, Accommodation of Needs, revised March 2021, revealed the following: Policy Interpretation and Implementation 1. The resident's individual needs and preferences are accommodated to the extent possible, . 2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. .4. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. For example: a. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 12 of 24 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 02/06/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 24 residents (Resident #25) reviewed for physician orders for treatments. Residents Affected - Few In six observations over three days, the facility failed to follow physician orders and apply Resident #25's hearing aid as ordered for Resident # 25. The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include: Record review of Resident # 25's face sheet printed 02/4/2025 revealed a [AGE] year-old female, admitted on [DATE] with the following diagnoses: moderate intellectual disabilities, cognitive communication deficit, dysphasia, weakness, and generalized anxiety disorder. Record review of Resident # 25's MDS, dated [DATE] revealed a BIMS of 11 indicating no cognitive impairment. Resident #25 required substantial/maximal assistance to complete bathing, toileting, and lower body dressing. Resident # 25 needed partial/moderate assistance with upper body dressing, and supervision or touch assistance with eating and oral hygiene. Record review of Resident #25's Care Plan dated 11/21/24 documented Resident #25 needed the assistance of 1 to 2 staff for ADLs. She was at risk for pain, dry skin and was at risk of not having needs met due to communication issues. Record review of Resident #25's physician's orders dated 2/4/25, documented Apply right hearing aid in right ear every day in am and remove at night at bedtime. Special instructions Resident is to wear right hearing aid in right ear every am and is to be removed every pm at bedtime. Order start date was 11/17/23open ended. In an observation on 02/4/2025 at 10:40 am, Resident # 25 was sitting in a wheelchair in her room. There was no hearing aid in her right ear. In an observation on 02/4/2025 at 12:25 pm, Resident # 25 was sitting in a wheelchair in her room. There was no hearing aid in her right ear. In an observation on 02/4/2025 at 2:15 pm, Resident # 25 was sitting in a wheelchair in her room. There was no hearing aid in her right ear. In an observation and interview on 02/5/2025 at 10:00 am, Resident # 25 was sitting in a wheelchair. There was no hearing aid in her right ear. Resident #25 stated she was supposed to a hearing aid but did not know where they were. Resident # 25 stated staff did not put the hearing aid on her all the time. Resident #25 stated she had not had them on at all this week. In an observation on 02/5/2025 at 3:40 pm, Resident # 25 was sitting in a wheelchair in an activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 13 of 24 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 02/06/2025 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 0684 and there was no hearing aid in her right ear. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/6/2025 at 9:06 am, Resident #25's family member stated she visits resident at least once a month and she had never seen Resident #25 wearing a hearing aid in her right ear. Residents Affected - Few In an interview on 02/6/2025 at 9:31 am LVN F stated she usually works with Resident #25 and is well acquainted with her needs. She stated Resident #25 has an order for a hearing aid in her right ear. When asked why Resident #25 did not have the hearing aid on she stated she just had not had time to get them out of the box yet. She stated everyone on staff knows Resident #25 has a hearing aid and should be wearing them every day. She stated a negative outcome for not having the hearing aid on could be she would not be able to hear. She stated she was trained by the other nurses in the facility. In an interview on 02/6/2025 at 9:40 am, the DON stated she expected all staff follow the physicians' orders. She stated an order would be put into the charting system after it is written by a physician. The order then would be listed on the Treatment Administration Record. The DON stated an order for hearing aids would be listed on the Treatment Administration Record and the system would trigger the staff to put the hearing aids on the resident. The DON stated she expected the nursing staff to put the hearing aids on Resident #25 every day as ordered. She stated she trained the nurses to do their jobs and expects physicians' orders were followed 100 percent for all orders and all residents. She stated the consequences of not wearing the hearing aid would be poor care for the resident. In an interview on 2/6/25 at 10: 55 am, the ADM stated she could not locate any policies on Quality of Care, following physician orders or documentation of treatment administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 14 of 24 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 02/06/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning was provided consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #24) of 16 residents reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #24's oxygen was set to the 4 lpm indicated in her physician's order. This failure could place residents who receive oxygen at an increased risk for hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings Included: Record review of Resident #24's admission record dated 02/04/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute and chronic respiratory failure (failure of lungs to provide oxygen), chronic obstructive pulmonary disease with (acute) exacerbation (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), and heart failure (heart muscle fails to pump blood as it should). Record review of Resident #24's quarterly MDS completed on 10/30/24 revealed the following: Section C: Resident #24 had a BIMS score of 14 which indicated intact cognition. Section O: Resident #24 was receiving continuous oxygen at admission and while resident of the facility. Record review of Resident #24's care plan, last reviewed by DON on 01/01/25 revealed Resident #24 had shortness of breath related to pneumonia, heart failure, and chronic obstructive pulmonary disease was to receive oxygen at 4 lpm to address the issues. Record review of Resident #24's physician's orders dated 02/04/25 revealed an order for continuous oxygen at 4 lpm via NC. This order had a start date of 07/15/22. Record review of Resident #24's oxygen saturations from 01/04/25 to 02/04/25 revealed 83 entries. In 16 of the entries Resident #24 was receiving oxygen at lower rates than the 4 lpm ordered. In one of the entries Resident #24 was receiving oxygen at a higher rate than the 4 lpm ordered. During an observation and interview on 02/04/25 at 10:33 AM Resident #24 was in her room, seated in her wheelchair, receiving O2 via NC at 5 lpm. She stated she had been on O2 for over a year. When asked if she moved the dial to adjust the flow rate of the O2 she stated the nurses set the flow rate and she did not touch the dial. She stated her oxygen was supposed to be set at 3 lpm. During an observation on 02/04/25 at 11:24 AM Resident #24's O2 concentrator was set at 5 lpm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 15 of 24 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 02/06/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm During an observation on 02/05/25 at 10:16 AM Resident #24 was seated in her w/c receiving O2 via NC at 5 lpm. During an interview on 02/05/25 at 02:02 PM CNA J stated nurses were responsible for setting flow rates for O2. Residents Affected - Few During an observation on 02/05/25 at 02:05 PM Resident #24 was lying on her bed receiving O2 via NC at 4.5 lpm. During an observation and interview on 02/05/25 at 02:08 PM LVN D stated nurses were responsible for setting flow rates on O2. He stated nurses knew what level to set O2 flow rate by referring to physician's orders. LVN D looked on his computer and found Resident #24's order for O2 at 4 lpm. During an interview on 02/06/25 at 08:46 AM CMA stated nurses were responsible for setting oxygen flow rates. During an interview on 02/06/25 at 08:50 AM LVN F stated nurses were responsible for setting oxygen flow rates. She stated the physician's orders revealed what level to set the flow rate. LVN F stated if the O2 was set lower or higher than the order called for, it could have a negative outcome for the resident. She stated, If they got CHF (congestive heart failure) it could mess with they [sic] heart. During an interview on 02/06/25 at 08:53 AM LVN G stated nurses set O2 flow rates and know what rate to set by looking at physician's orders. She stated if O2 was set lower than the order the resident would not get the O2 they need and if it was set higher the resident would get too much (O2) yeah, it's not good. During an interview on 02/06/25 at 10:39 AM DON stated a possible negative outcome of O2 administered at lower or higher rates than ordered was, Not enough O2 if lower than ordered and too high can cause some disease processes to exacerbate. Record review of facility policy titled Medication Administration-General Guidelines and dated 06/01/22 revealed the following: . Medications are administered as prescribed in accordance with good nursing principles and practices . 2) Medications are administered in accordance with written orders of the prescriber. Record review of facility policy titled Oxygen Administration and dated 2010 revealed the following: . The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Turn on the oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 16 of 24 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 02/06/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 medication carts (Hall 200 and Hall 300) reviewed for medication storage. -Medication cart for 200 Hall had 9 medication cups with multiple medications in them for unidentified residents in top drawer of medication cart. -Medication cart for 300 Hall had Lantus Solo-star for Resident #33 with no open date. -Medication cart for 300 Hall had Insulin Aspart for Resident #61 with no open date. -Medication Triamcinolone acetonide cream was on Resident #27's bed. The facility's failures could place residents receiving medication at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included: During an observation on [DATE] at 08:45 AM revealed the medication cart for 200 Hall had 9 medication cups with multiple medications in top drawer. Medication cart was observed with CMA B. CMA B stated that she shouldn't do that and apologized. CMA B stated that the negative outcome for pre-prepping medications was it's bad. When CMA B was asked if she could possibly pick up the wrong medication cup, CMA B stated, Oh no, I would never do that. During an observation on [DATE] at 09:03 AM revealed the mediation cart for Hall 300 with LVN F contained Lantus Solo-star for Resident #33 with no open date on the pen. Medication cart also revealed Insulin Aspart for Resident #61 with no open date written on the pen. During an interview on [DATE] at 09:10 AM LVN F stated that a negative outcome for not writing the open dates on the insulin could result in a write up for her. During an interview on [DATE] at 11:06 AM DON stated that a negative outcome for having medications pre-prepped before administering medications to residents could lead to a medication error. DON stated that a negative outcome for not having open dates on medications could lead to a nurse or MA giving an expired medication. Record review of facility provided policy titled, Storage of Medications, revised [DATE], revealed the following: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 17 of 24 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 02/06/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of facility provided policy titled, Preparation and General Guidelines, dated [DATE], revealed the following: . Procedures A. Preparation .4. FIVE RIGHTS - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) When the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. .B. Administration . .4. When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 18 of 24 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 02/06/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: Residents Affected - Many A. Ensure staff did not use bare or gloved hands when serving food. B. Ensure stored food was properly labeled, dated and stored. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: An observation of the facility freezer on 2/4/25 at 8:45 am, revealed: a box of frozen cookie dough, open to air and crumbs in the bottom of the freezer. An observation of the facility cooler on 2/4/25 at 8:46 am, revealed: a box of chopped pecans, open to air and an opened package of turkey lunchmeat dated 1/30/25 and a use by date of 2/1/25. In an observation and interview on 2/4/25 at 11:20 am, the DA was observed touching kitchen surfaces with gloved hands in the kitchen. [NAME] A touched the steam table and picked up silverware rolls and placed the silverware on each tray. DA then picked up a plate and then walked to the tray of rolls on the counter and placed a roll on the tray of food. DA placed the tray on the serving cart. DA did not wash her hands or change her gloves. DA then picked up another plate of food then walked to the rolls and placed a roll on the second plate with her gloved hand. DA did not wash hands or change gloves between tasks. DA stated she just forgot and was supposed to use tongs when touching bread. DA stated not changing gloves and not using tongs could cause cross contamination and illness for the residents. An observation of the facility freezer on 2/5/25 at 10:33 am, revealed: a box of frozen cookie dough, open to air and crumbs in the bottom of the freezer. An observation of the facility cooler on 2/5/25 at 10:34 am, revealed: a box of chopped pecans, open to air and an opened package of turkey lunchmeat dated 1/30/25 and a use by date of 2/1/25. In an interview on 2/6/25 at 9:50 am, the DM stated all food items should be labeled and dated when taken out of the box. She stated all food had to have a date and a label. The DM stated foods should be labeled and dated as soon as it comes in or is taken out of the box. The DM stated foods should be thrown out by the expiration date and they just missed the lunchmeat. The DM stated tongs should always be used when serving food. The DM stated all kitchen staff know they should secure foods when storing. The DM stated she had done an in-service on all the kitchen issues with the staff, and they were aware of the kitchen policies. Record review of the policy dated 12/1/11 titled, Food Storage revealed to ensure freshness opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. All refrigerator foods are stored per state and federal guidelines. All refrigerator foods are labeled, dated and tightly sealed including leftovers using clean covered containers. All leftovers are used (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 19 of 24 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 02/06/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm within 48 hours. Items that are over 48 hours are discarded. Frozen foods are stored in moisture proof wrap or containers that are labeled and dated. Record review of the policy dated 6/1/19 titled, Food Preparation and Handling revealed prepare food with the least manual contact as possible. Residents Affected - Many Record review of the policy dated 10/1/18 titled, Employee Sanitation revealed Employees must wash hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service articles. Use gloves for one single task. When using gloves wash hands before touching or putting on new gloves. Change gloves between each food preparation task, after touching items utensils or equipment not related to task. Record review of the policy dated 12/1/11 titled, General Kitchen Sanitation revealed clean and sanitize all food preparation areas, food contact surfaces, and equipment. Keep food contact surfaces free of accumulated soil. to ensure freshness FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 20 of 24 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 02/06/2025 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 5 (LVN F, CNA I, CNA J, CNA K, and LVN G) of 5 staff reviewed for resident care Residents Affected - Some -LVN F came out of resident room fully donned in PPE. -LVN F did not clean glucometer before or after checking glucose level for Resident #61. -CNA I did not perform hand hygiene or glove change during incontinent care of Resident #31. -CNA J wore gloves from the hallway into Resident #31's room to assist with incontinent care. -CNA J did not perform HH or glove change during incontinent care of Resident #31. -CNA K did not retract foreskin for cleaning procedure indicated in catheter care for Resident #265. -CNA K did not don PPE before performing Catheter care for Resident #265. -CNA I did not perform HH or glove changes during assisting with wound care for Resident #6. -LVN G did not don PPE to administer medications via Peg tube to Resident #43. These failures could place residents at risk of cross-contamination and infections. Findings include: During an observation on 02/04/25 at 08:57 AM revealed LVN F coming out of unidentified residents' room fully garbed in PPE. Room had posting on the door for droplet precautions. LVN F never removed gloves or PPE, reached for the medication cart that was outside of the room and pulled it closer to herself in the doorway. LVN F came out of room after doffing PPE in bathroom of room. LVN F went to medication cart to get some tape to take into the Isolation room. LVN F then proceeded to grab PPE and placed gloves on, then a face mask. LVN F took a gown out of the packaging and pushed the outer packaging of the gown down into the trash on the side of the medication cart. LVN F never switched gloves before going back into the unidentified resident's room. Observation from the hallway revealed that LVN F placed tape on oxygen tubing in the residents' room with the same gloves that was used to push down the trash with. During an observation on 02/04/25 at 11:31 AM revealed a medication administration performed by LVN F. LVN F did not clean glucometer before performing glucose check for Resident #61. LVN F did not perform HH before performing finger stick for Resident #61 or wipe the skin with alcohol before sticking the Residents skin. LVN F then removed the gloves and did not perform HH and started to prep insulin to administer to Resident #61. LVN F did not perform HH before donning gloves to administer insulin to Resident #61 and LVN F did not perform HH after administering insulin to Resident #61. During an observation on 02/04/25 at 11:42 AM revealed a medication administration performed by LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 21 of 24 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 02/06/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some F. LVN F did not clean the glucometer before the glucose check for Resident #265. LVN F did not perform HH before donning gloves to perform finger stick. LVN F did not perform HH before donning gloves to administer insulin to Resident #265 and did not perform HH after doffing gloves after insulin administration to Resident #265. During an observation on 02/05/25 at 10:54 AM revealed incontinent care performed for Resident #31 by CNA I and CNA M. No HH was performed before starting incontinent care for Resident #31. CNA M had gloves on before entering into room and never changed gloves before starting to assist with incontinent care. CNA I used dirty gloves to place a clean brief under Resident #31 after the back side of Resident #31 had been cleaned. Protective cream was placed on Resident #31 by CNA I with the same gloves that were used to clean the Resident #31. No hand hygiene or glove change was performed between the dirty and clean aspects of incontinent care. HH was not performed after incontinent care was completed by either CNA. During an interview on 02/05/25 at 11:01 AM CNA M stated that the negative outcome for not performing hand hygiene or changing gloves could lead to an infection control issue. During an interview on 02/05/25 at 11:03 AM CNA I stated that the negative outcome for not performing HH and glove changes would be infection control. During an observation on 02/05/25 at 11:22 AM revealed catheter care was performed for Resident #265 by CNA K. CNA K did not don PPE to perform catheter care for Resident #265 who was on EBP precautions due to catheter placement. CNA K did not retract the foreskin to clean the head of the penis of Resident #265 during catheter care. CNA K did not perform HH after the care was completed. During an interview on 02/05/25 at 11:22 AM CNA K stated that she just didn't put the PPE on and did not have a response when asked about the performance of catheter care. CNA K also stated I forgot to when asked why Hand hygiene wasn't done. CNA K stated that a negative outcome would be infection control. During an observation on 02/06/25 at 9:52 AM revealed wound care for Resident #6 performed by LVN F and CNA I. CNA I was observed changing her gloves to assist LVN F twice with no hand hygiene performed in between glove changes. During an interview on 02/06/25 at 10:11 AM CNA I stated that HH was not performed because I just forgot. CNA I stated that a negative outcome would be infection control. During and observation on 02/06/25 at 10:18 AM revealed LVN G perfored medication administration via PEG-tube for Resident #43. LVN G did not don PPE due to Resident #43 being on EBP due to Peg-tube being present. During an interview on 02/06/25 at 10:38 AM LVN G stated that the reason for not utilizing PPE was I don't know, I just didn't put it on, I was nervous. LVN G stated that the negative outcome was that it could lead to the spread of infection among other residents. During an interview on 02/06/25 at 11:37 AM DON stated that a negative outcome of staff not performing hand hygiene, not utilizing PPE for Residents on EBP and other areas of care could lead to infection control issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 22 of 24 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 02/06/2025 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 Record review of facility provided policy titled Perineal Care, revised 01/20/2023, revealed the following: Level of Harm - Minimal harm or potential for actual harm .Steps in the procedure . .3. Perform hand hygiene and done gloves Residents Affected - Some .B. For a Male Resident: .3. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently clean and dry the area. 4. Retract foreskin of the uncircumcised mail. 5. Clean urethral area with a cleansing wipe using a circular motion. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. Use a new cleansing wipe, as needed. 6. Continue to clean the perineal area including the penis, scrotum, inner thighs. 7. Thoroughly clean perineal area in same order, using a new cleansing wipe as needed. 8. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. 9. Gently dry perineum following same sequence. 10. Reposition foreskin of uncircumcised male. .13. Perform hand hygiene. Record review of facility provided policy titled Obtaining a Fingerstick Glucose level, revised October 2011, revealed the following: . Equipment and Supplies . 3. Disinfected blood glucose meter(glucometer) with sterile lancet; or single-resident use spring-loaded device (e.g., Penlet) or automatic or safety type lancet; . .6. Single use alcohol swab; and 7. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed.) Steps in the Procedure .3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses .18. Clean and disinfect reusable equipment between uses according to the manufacturer's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 23 of 24 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 02/06/2025 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 instructions and current infection control standards of practice. Level of Harm - Minimal harm or potential for actual harm .20. Wash hands. Residents Affected - Some Record review of facility provided policy titled Handwashing/Hand Hygiene, revised 01/20/2023, revealed the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and implementation 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors. .5. Hand Hygiene must be performed prior to donning and after doffing gloves. 6. hand hygiene is the final step after removing a disposing of personal protective equipment. Record review of facility provided policy titled Infection Prevention and Control Program, dated July 2024 revealed the following: Policy and interpretation and implementation . .C. Standard and transmission-based precautions to be followed to prevent the spread of infections; . .F. The hand hygiene procedures to be followed by staff involved in direct resident contact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 24 of 24