Health inspection·July 29, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some handwritten time illegible 1 tab.Record review of Resident #1's June 2025 MAR reflected no entries of tramadol - Schedule IV (substances that have a low potential for abuse and addiction compared to Schedule III drugs, but still have the potential for abuse and dependence) tablet; 50 mg; Amount to Administer: 1 tab; oral, frequency Every 6 Hours - PRN, diagnosis - pain, start dated 10/13/2024 - Open Ended administered to Resident #1.Record review of Resident #1's July 2025 MAR reflected tramadol Schedule IV (substances that have a low potential for abuse and addiction compared to Schedule III drugs, but still have the potential for abuse and dependence) tablet; 50 mg; Amount to Administer: 1 tab; oral, frequency Every 6 Hours - PRN, diagnosis - pain, start dated 10/13/2024 - open ended administered to Resident #1 was administered on:07/28/25 time 9:29 pm for PRN reason pain; pain before administered level 4 (moderated) PRN result effective Review of Resident #2's face sheet, undated, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (usually caused by a stroke, is a condition characterized by paralysis (hemiplegia) or weakness (hemiparesis) on one side of the body), chronic obstructed pulmonary disease (a progressive lung disease that makes it difficult to breathe) and bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression).Review of Resident #2's quarterly MDS assessment, dated 06/06/25, reflected a BIMS score of 06, indicating severe cognitive impairment. Section J - Health Conditions - Resident #2 received PRN pain medications or was offered or declined.Review of Resident #2's care plan reflected problem start date 02/26/2019 and edited 07/17/25 reflected Resident #2 has complaints of chronic pain related to hemiplegia, pain site back pain, generalized pain approach date edited 07/17/25 administer PRN mediations Tylenol (Acetaminophen) and/or Tylenol #3 (Acetaminophen) PRN return to assess effectiveness.Review of Resident #2's medication orders reflected acetaminophen-codeine - Schedule III (substances with a moderate potential for abuse and dependence) tablet; 300-30 mg; Amount to Administer 1 tablet oral, Every 4 Hours - PRN, 06/03/2025 - open endedReview of Resident #2's handwritten Narcotic Drug Record for Acetaminophen/codeine 300/30 (brand: Tylenol #3) mg tablet give 1 tablet by mouth every 4 hours as needed revealed the tramadol 30 mg tablet reflected:06/11/25 time 9:00 am 1 tab.06/11/25 time 3:00 pm 1 tab.06/13/25 time 9:00 am 1 tab.06/17/25 time 8:40 pm 1 tab.06/20/25 time 7:00 pm 1 tab.06/21/25 time 8:00 am 1 tab.06/21/25 time 7:00 pm 1 tab.06/22/25 time 8:00 am 1 tab.06/22/25 time 7:00 pm 1 tab.06/23/25 time 8:00 am 1 tab.06/23/25 time 7:00 pm 1 tab.06/24/25 time 8:00 am 1 tab.06/24/25 time 8:00 pm 1 tab.06/25/25 time 8:00 am 1 tab.06/25/25 time 8:00 pm 1 tab.06/26/25 time 8:00 am 1 tab.06/26/25 time 7:00 pm 1 tab.06/27/25 time 8:00 am 1 tab.06/27/25 time 7:00 pm 1 tab.06/28/25 time 8:00 am 1 tab.06/28/25 time 7:00 pm 1 tab.06/29/25 time 8:00 am 1 tab.06/29/25 time 7:00 pm 1 tab.06/30/25 time 8:00 am 1 tab.06/30/25 time 8:00 pm 1 tab.07/01/25 time 8:00 am 1 tab.07/01/25 time 8:00 pm 1 tab.07/02/25 time 8:00 am 1 tab.07/02/25 time 8:00 pm 1 tab.07/03/25 time 8:00 am 1 tab.07/03/25 time 8:00 pm 1 tab.07/04/25 time 8:00 pm 1 tab.07/05/25 time 8:00 am 1 tab.07/06/25 time 3:00 am 1 tab.07/06/25 time 8:00 am 1 tab.07/06/25 time 7:00 pm 1 tab.07/07/25 time 8:00 am 1 tab.07/07/25 time 8:00 pm 1 tab.07/07/25 time 2:00 am 1 tab.07/08/25 time 8:00 pm 1 tab.07/09/25 time 7:00 am 1 tab.07/09/25 time 8:00 pm 1 tab.07/10/22 time 8:00 am 1 tab.07/10/22 time 7:00 pm 1 tab.07/10/22 time 11:30 pm 1 tab.07/11/22 time 8:00 am 1 tab.07/11/22 time 7:00 pm 1 tab.07/12/22 time 8:00 am 1 tab.07/12/22 time 7:00 pm 1 tab.07/13/22 time 8:00 am 1 tab.07/13/22 time 7:00 pm 1 tab.07/14/22 time 7:00 am 1 tab.07/14/22 time 7:00 pm 1 tab.07/15/22 time 7:00 am 1 tab.07/15/22 time 8:00 pm 1 tab.07/16/22 time 0800 [8:00 am] 1 tab.07/16/22 time 8p 1 tab.07/16/22 time 0800 [8:00 am] 1 tab.07/17/25 time 8:00 am 1 tab.07/17/25 time 8:00 pm 1 tab.07/18/25 time 8:00 am 1 tab.07/18/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 2 of 7 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 07/29/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some time 8:00 pm 1 tab.07/19/25 time 8:00 am 1 tab.07/19/25 time 8:00 pm 1 tab.07/20/25 time 8:00 am 1 tab.07/20/25 time 8:00 pm 1 tab.07/21/25 time 8:00 am 1 tab.07/21/25 time 7:00 pm 1 tab.07/22/25 time 8:00 am 1 tab.07/22/25 time 7:00 pm 1 tab.07/23/25 time 8:00 am 1 tab.07/23/25 time 6:40 pm 1 tab.Record review of Resident #2's June 2025 MAR reflected, acetaminophen-codeine - Schedule III (substances with a moderate potential for abuse and dependence) tablet; 300-30 mg; Amount to Administer 1 tablet oral, Every 4 Hours - PRN, 06/03/2025 - Open Ended was administered on:06/08/25 time 7:16 am, for pain, pain level before administered level 5 (moderate) PRN result follow up effective06/09/25 time 8:38 pm, for pain, pain level before administered level 6 (moderate) PRN result follow up effective06/12/25 time 9:32 pm, for pain, pain level before administered level 6 (moderate) PRN result follow up effective06/19/25 8:03 am, for pain, pain level before administered level 4 (moderate) PRN result follow up effective06/19/25 5:03 pm for pain, pain level before administered level 5 (moderate) PRN result follow up effectiveRecord review of Resident #2's July 2025 MAR reflected, acetaminophen-codeine - Schedule III (substances with a moderate potential for abuse and dependence) tablet; 300-30 mg; Amount to Administer 1 tablet oral, Every 4 Hours - PRN, 06/03/2025 - Open Ended was administered on:07/10/25 11:23 pm for pain, pain level 3 (noticeable and distracting) PRN result follow up effective.Review of Resident #'3s face sheet, undated, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included sequelae of cerebral infarction (also known as stroke (occurs when blood flow to the brain is disrupted, either by a blockage or a bleed) refers to the long-term consequences or complications that arise after a stroke), moderate intellectual disabilities (individuals with an intelligence quotient between 35 and 39), and schizophrenia, unspecified (a diagnostic term used when a person experiences symptoms of schizophrenia (a chronic and severe mental health disorder that affects how a person thinks, feels, and behaves) or other psychotic disorders, but their symptoms don't fully meet the criteria for a more specific diagnosis within the schizophrenia spectrum. Review of Resident #3's quarterly MDS assessment, dated 06/06/25, reflected a BIMS score of 11, indicating moderate cognitive impairment. Section J - Health Conditions - reflected Resident #3 did not received PRN pain medications or was offered or declined.Review of Resident #3's admission care plan reflected no care plan for pain involving the administration of tramadol. Resident #3's care plan reflected problem start date - 09/13/2023 PainIbuprofen, Muscle Rub, edited: 06/12/2025 approach start date: - 09/13/2023 administer pain medications as ordered.Review of Resident #3's medication orders reflected tramadol Schedule IV (have a low potential for abuse relative to other controlled substances) tablet; 50 mg; amount to administer: 1 tablet; oral Every 6 Hours - PRN, take 1 tablet by mouth every 6 hours as needed for pain, indications: acute pain start date 06/26/2025 - Open EndedReview of Resident #3's handwritten Narcotic Drug Record for tramadol 50 mg tablet 1 tablet by mouth every 6 hours as needed revealed the tramadol 50 mg tablet reflected:06/29/25 time 11:00 1 tab06/30/25 time 10:00 1 tab.06/30/25 time 7:42 1 tab.07/10/25 time 7:45 1 tab.07/12/25 time 8:00 am 1 tab.07/12/25 time illegible 1 tab.07/21/25 time 11:00 am 1 tab.07/21/25 time 7:15 pm 1 tab.Record review of Resident #3's June 2025 MAR reflected tramadol Schedule IV (have a low potential for abuse relative to other controlled substances) tablet; 50 mg; amount to administer: 1 tablet; oral Every 6 Hours - PRN, take 1 tablet by mouth every 6 hours as needed for pain, indications: acute pain start date 06/26/2025 - Open Ended was administered on: 06/26/25 time 6:49 pm, for pain, PRN result follow up effective06/30/25 time 8:14 am, for pain, PRN result follow up effectiveRecord review of Resident #3's July 2025 MAR reflected tramadol Schedule IV (have a low potential for abuse relative to other controlled substances) tablet; 50 mg; amount to administer: 1 tablet; oral Every 6 Hours - PRN, take 1 tablet by mouth every 6 hours as needed for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 3 of 7 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 07/29/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pain, indications: acute pain start date 06/26/2025 - Open Ended was administered on: 07/01/25 time 5:46 am, for pain, PRN result follow up effective07/02/25 time 4:35 pm, for pain PRN result follow up effective07/04/25 time 9:47 am, for pain, PRN result follow up effective07/05/25 time 5:50 am, for pain PRN result follow up effective07/05/25 time 9:18 pm for pain PRN results follow up effective07/07/25 time 9:51 pm for pain PRN results follow up effective 07/12/25 time 6:20 pm for pain PRN results follow up effective 07/13/25 time 12:49 am for pain PRN results follow up effective07/13/25 time 9:27 am for pain PRN results follow up effective07/14/25 time 2:20 am for pain PRN results follow up effective07/15/25 time 1:14 pm for pain PRN results follow up effective07/16/25 time 9:20 pm for pain PRN results follow up effective07/17/25 time 7:38 am for pain PRN results follow up effective07/17/25 time 6:37 pm for pain PRN results follow up effective07/18/25 time 4:20 am for pain PRN results follow up effective07/18/25 time 9:21 pm for pain PRN results follow up effective07/19/25 time 4:27 pm for pain PRN results follow up effective07/20/25 time 11:16 pm for pain PRN results follow up effective07/23/25 time 9:24 am for pain PRN results follow up effective07/23/25 time 7:36 pm for pain PRN results follow up effective07/24/25 time 7:33 am for pain PRN results follow up effectiveReview of Resident #4's face sheet, undated, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of lower end of right femur (the thigh bone, the longest and strongest bone in the human body) unspecified abnormalities of gait and mobility and other lack of coordination, cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes like attention, memory, and executive functions, rather than issues with speech or language production themselves).Review of Resident #4's resident assessment and care screening MDS assessment, dated 07/24/25, reflected a BIMS score of 10, indicating moderate cognitive impairment. Section J - Health Conditions - Resident #4 received PRN pain medications or was offered or declined.Review of Resident #4's admission care plan reflected problem start date 07/18/2025 pain related to right femur fracture - Tramadol approach start date - 07/18/2025 administer pain medications as orderedReview of Resident #4's medication orders reflected tramadol Schedule IV (have a low potential for abuse relative to other controlled substances) tablet; 50 mg; amount to administer: 1 tablet; oral Every 6 Hours - PRN, take 1 tablet by mouth every 6 hours as needed for pain, indications: acute pain start date 07/18/2025 - Open Ended Review of Resident #4's handwritten Narcotic Drug Record for tramadol 50 mg tablet give 1 tablet by mouth every 6 hours as needed reflected:07/22/25 time 1:00 pm 1 tab.07/24/25 time 7:10 pm 1 tab.Record review of Resident #4's July 2025 MAR reflected tramadol Schedule IV (have a low potential for abuse relative to other controlled substances) tablet; 50 mg; amount to administer: 1 tablet; oral Every 6 Hours - PRN, take 1 tablet by mouth every 6 hours as needed start date 07/18/2025 - Open Ended was administered on: 07/19/25 time 5:30 am PRN reason pain, pain level before 3 (notable pain that can be distracting) PRN result effective07/19/25 time 11:24 pm PRN reason pain, pain level before 4 (moderate) PRN result effective.Interview on 07/29/25 at 12:40 pm with Resident #1 who stated she was not getting her pain medications.Interview on 07/29/25 at 2:33 pm with Resident #1's hospice RN reflected when she visited Resident #1, Resident #1's pain was controlled and her review of Resident #1's hospice facility visits records reflected that Resident #1's pain had been controlled. Interview on 07/29/25 at 3:40 pm with Resident #2 who stated the staff at the facility treated him respectfully and he felt safe at the facility. She said he received all of his pain medication, and he did not have any concerns. Interview on 07/29/25 at 3:45 pm with Resident #3 who stated the staff treated her respectfully and she got all of her pain medications. Interview on 07/29/25 at 6:14 pm with Resident #4 who stated the staff treated her respectfully and she received all of her PRN pain medications. She stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 4 of 7 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 07/29/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff was responsive when she asked for the medication and she received it, she did not have any concerns. Interview on 07/28/25 at 5:04 pm with LVN A via phone stated she had administered PRN controlled substance medications to residents. She said the facility procedure was to sign on the individual resident Narcotic Drug Record that the medication was given then to record in the eMAR that the resident was administered the medication. She said the negative effect of medication that was administered but not documented in the eMAR was there was no documentation that it was given to the resident. She said that could be bad for the resident because you do not know how much medication the resident received. She said if a resident goes to the hospital, there was no record in the eMAR of what the resident had taken. She said everyone was responsible for making sure that medication given to the resident was documented in the eMAR and all staff have a role to plan. She said there was a computer problem that caused an interruption when documenting PRN medication in the eMAR and she let the DON know. She said the PRN eMAR documentation did get better. She said it was important to make sure the resident was not in pain, and they had received their correct medications. Interview on 07/29/25 at 4:36 pm with LVN D who stated he administered PRN controlled substance pain medications to facility residents. He said that when a controlled substance was going to be administered to a resident, the medication was signed out on the individual resident's Narcotic Drug Record, administered to the resident, then documented in the resident's eMAR that they received the medication. He said he was not properly trained in documenting PRN medications in eMAR and until a recent in-service involving documenting PRN controlled substances in the eMAR. He said he did not realize that he was making an error on the computer when documenting that the resident received their medication. He said that if it was not documented in the eMAR that a resident received their pain medication, the resident could go without their pain medication. He said it was a problem because you would not know if the medication the resident received was effective if it was not documented that they received it. He said that at times, the facility internet did not work well and there was an interruption in service that did not enable the documentation of the medication in the eMAR. He said it was the responsibility of the DON to confirm that PRN controlled substance medications given to the residents were documented as given in the eMAR. Interview on 07/28/25 at 4:33 pm with LVN B via phone stated she administered PRN pain medications to residents. She said when you administer PRN controlled substances the procedure was to sign on the individual resident's Narcotic Drug Record documenting that you gave the resident the controlled substance and to document in the eMAR that the medication was administered to the resident. She said the eMAR should match the resident's Narcotic Drug Record for that date and time. She said the negative effect of not documenting in the eMAR that the resident received the medication would be that you would not know if the resident was given the medication, and the resident could be in pain. She said the nurse was supposed to make sure she residents' get their medication. She said the ADON and DON were responsible for make sure that the medications have been correctly administered to the residents. Interview on 07/28/25 at 4:51 pm with LVN C via phone stated she had administered PRN controlled substance to facility residents. She said the facility policy is to sign out the medication on the resident's Narcotic Drug Record and then document in the eMAR that the medication was administered to the resident. She said medication administered to a resident should always be documented in the eMAR. She said the negative effect of not documenting medication administered in the eMAR would be that you don't know if the resident really got the medication, and it does not accurately reflect what medications were given to the resident. She said the resident's Narcotic Drug Record should match eMAR and it was the responsibility of the nurse to follow through and confirm that it was documented. She said there was an interruption in the internet system and at times the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 5 of 7 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 07/29/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff thought the medication was successfully documented in the eMAR, but it did not show up. She said anytime there was a glitch in the emery system she told the DON. She said it was very important to make sure that the resident was not in pain, and they were given the correct medications. Interview on 07/28/25 at 4:15 pm with the ADON revealed she had administered PRN tramadol to Resident #3. She stated that the facility procedure for administering PRN tramadol to Resident #3 was to write on the resident's Narcotic Drug Record that the medication was administered to Resident #3 and then document the administration of the medication on MAR in the computer. The ADON said all kinds of things could happened if the tramadol was not marked as administered on the MAR. She said you could give the resident too much medication. She said the resident's Narcotic Drug Record and the MAR should match. She said that there was a computer glitch in the facility system and the documentation in residents' MARs that PRN medication was administered did not stick on the MAR. She said it was an on and off problem and she reported it to the DON. She said it was the responsibility of the nurse administering the medication to the resident to make sure that medications reflected on the Narcotic Drug Record and the residents' MAR matched. Interview on 07/28/25 at 2:31 pm with the DON who stated if a resident was administered a pain medication it was signed out on the resident Narcotic Drug Record and, when administered, entered into the eMAR documenting that the medication was administered. She said there was a problem if the PRN pain medication was not marked administered in the eMAR because you would not know how the medication was being used and if it was effective. She said when it is documented it the eMAR, there was a pain assessment if it was not documented, you are not really tracking the residents' pain. She said if medication was not charted, then it was not given. She said the charge nurse was responsible for making sure the eMAR and the resident Narcotic Drug Record matched. Interview on 07/29/25 at 6:17 pm with the Administrator who stated it was important that the resident Narcotic Drug Record matched the eMAR to make sure resident was administered the correct dosage and to monitor residents' pain. A resident might need a pain medication review the MD and if the eMAR does not accurately reflect what was administered to the resident, it would be difficult to review the pain and what pain medication would be beneficial to the resident. It was the responsibility of the charge nurse and the nursing administration to audit the medications recorded in the eMAR. She thought that part of the problem with the eMAR documentation was an internet issue, but that had been repaired. Additionally, she thought that the nurses administering the medication were missing a computer step in the eMAR that did not record that the resident received the information. Interview on 07/29/25 at 4:15 pm with the facility MD who stated he was concerned that the PRN controlled substances were not documented in the eMAR because it was an internal inconsistency and there needed to be better oversight. He said he was not concerned that the residents did not receive the PRN controlled substance pain medication because he said the DON was very good. He was concerned that if the problem was not corrected, people could find an opportunity to take advantage of the situation and corporate needed to know because they might need a better program. Review of facility policy Medication Administration - General Guidelines dated 06/01/2022 reflected the medication administration record (MAR) is always employed during medication administration.Documentation (including electronic). The individual who administers the medication dose records the administration on the residents' s MAR/eMAR directly after the medication is given. To ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medications.The resident's MAR/eMAR is initialed by the person administering the medication in the space provided under the date and on the line for that specific medication dose administration.When PRN medications are administered, the following documentation is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 6 of 7 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 07/29/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm provided:a. date and time of administration, dose, route of administration (if other than oral).b. Complaints or symptoms for which the medication was given.c. Results achieved from giving the dose and the time results were noted.d. Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455489 If continuation sheet Page 7 of 7