Inspection·November 14, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few difficulty falling asleep or staying asleep; irritability anger or depression; difficulty concentrating; being jumpy or startled at something unexpected; inability to cope with normal stresses of daily living; inability to trust, cognitive difficulties; other. Goals for the problem included, Resident will verbalize/display feeling/disposition of safeness in the community and Trauma symptoms will not interfere with residents POC or rehabilitation. Interventions included, ask and observe the situations and interactions that create well-being, engagement and a sense of safety on the part of the resident/pt recognizing that many individuals who are long-stay residents have some level of cognitive impairment that may require additional sensitivity. A review of Resident #1's social service progress note dated 9/6/23 at 4:46 PM reflected, During IDT meeting, resident made SW aware of incident that occurred with another resident the night prior 9/5. Resident stated that he came back to facility at approximately 8:30 PM and the doors were locked .Resident stated other residents were sitting in the area and he asked them to open the door but they would not. Resident managed to get the door open. Resident stated he got into an argument with another resident sitting in the area. Resident stated other resident stood and walked toward him. Resident stated other Resident put his hands around his neck. SW asked if resident feels safe. Resident stated he did not. SW informed administrator. A review of Resident #1's progress notes on 9/5/23 reflected no documentation regarding Resident #1's allegation regarding another resident choking him nor a nursing note to indicate if the resident was assessed for injuries. A review of Resident #2's face sheet printed on 9/14/23, reflected a [AGE] year-old male admitted to the facility 2/11/23 with diagnoses including Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a group of symptoms affecting memory, thinking and social abilities) essential hypertension (high blood pressure) and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 9 indicating moderately impaired cognition. He was assessed as requiring setup or clean-up assistance or supervision with ADLs. He was assessed to have an active diagnosis of dementia. A review of Resident #2's comprehensive care plan initiated 2/11/22 reflected the problem The resident has impaired cognitive function/dementia or impaired thought process related to diagnosis. Goals included maintaining current level of cognitive function, be able to communicate basic needs and develop skills to cope with cognitive decline. Interventions included administer medications and keep the resident's routine consistent and try to provide consistent care givers to decrease confusion. A review of Resident #2's nursing progress note dated 9/5/23 at 11:33 PM reflected he was found sitting on the floor in the dining room. There was no documentation that Resident #2 was involved in an incident with another resident. During a telephone interview on 11/14/23 at 9:48 AM with the SW, she stated the ADM had been made aware of the incident the night it happened and he got statements from the staff who worked that night. She identified Resident #2 as the person Resident #1 alleged choked him. Observation and interview on 11/14/23 at 11:10 AM revealed Resident #1 was sitting in his motorized wheelchair. He stated there was an incident one evening around 8:30 PM when he came into the facility and his music was playing loud on his phone. Resident #2 cussed at him and yelled at him to turn (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455522 If continuation sheet Page 2 of 5 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 455522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Temple West 1700 Marlandwood Rd Temple, TX 76502 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few off the music. Resident #1 stated because of his quadriplegia he had trouble turning off the music. He stated, The guy got up and came at me and he put his hands on my neck . He stated he was afraid to move. He stated a nurse saw what happened but, she said he put his hands on my face. He stated he was not able to dial his phone, so the Social Worker helped him to file a complaint. Observation and interview on 11/14/23 at 11:25 AM revealed Resident #2 was sitting in a chair in his room. When asked if he had ever had any altercations with other residents at the facility, he replied, You mean other prisoners? No, I haven't had any problems. During an interview on 11/14/23 at 3:00 PM, the ADM stated he was aware of the incident where Resident #1 stated he was choked. He stated he asked for statements from the staff who worked when the event occurred. The ADM stated, We have two or three residents with personality issues, and I think this was just personality issues. He stated. One RN said he wasn't choked but the other resident touched his face. The ADM stated when a resident alleged abuse, we will investigate it immediately and ask staff for statements regardless of whether they saw it. He stated he did not report the incident to the State because the eyewitness said he was not choked. When asked if allegations of abuse needed to be reported he stated, I can't say it doesn't need to be reported. I know Resident #1 and Resident #2 had personality conflicts. It felt more personality conflict than anything else. After review of the abuse policy, the ADM verified that it was the current policy then stated, In retrospect, yes, I should have reported it. The ADM stated he did look at the video but because of the angle of the camera, he could not see above Resident #1's legs. He stated, I could see the other resident walk over to him, but I couldn't see what happened. He stated an adverse outcome of not reporting was lose trust in the system, for sure. Not get the appropriate care . During an interview on 11/14/23 at 3:17 PM, the ADON stated when an allegation of abuse was made, the first thing was to assess the resident and see if anything looked abnormal. She stated she would talk with the aide to see what they saw. She would expect to see the incident documented. She stated if behaviors were not documented in the care plan, It could trigger negative behaviors. A review of the facility's incident and accident log from 8/13/23 to 11/4/23 reflected no entry for an incident involving Resident#1 and Resident #2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455522 If continuation sheet Page 3 of 5 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 455522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Temple West 1700 Marlandwood Rd Temple, TX 76502 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation is in process for two (Residents #1 and #2) of five residents reviewed for abuse and neglect. Residents Affected - Few The facility failed to have evidence of a thorough investigation when Resident #1 alleged Resident #2 choked him on 9/5/23. This failure could place residents at risk for abuse. Findings included: A review of Resident #1's face sheet printed on 11/14/23 reflected a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses including Quadriplegia (loss of motor function in the arms and legs), chronic pain, urinary tract infection, depression (persistent sadness and loss of interest in daily activities), and anxiety (a state of being apprehensive, nervous or distressed). A review of Resident #1's 5-day MDS assessment, dated 10/20/23, reflected a BIMS score of 15 indicating intact cognition. He was assessed as having verbal behavioral symptoms directed towards others 1 to 3 days during the assessment period. The MDS reflected he used a motorized wheelchair and a mechanical lift; he had impairment on both sides - upper and lower extremities. He is dependent on staff for all ADL care. A review of Resident #1's comprehensive care plan initiated on 8/6/20 reflected the problem, Resident has been assessed for actual trauma symptoms as manifested by: upsetting thoughts or memories against their will; upsetting dreams; bodily reactions such as fast heartbeat/stomach churning; difficulty falling asleep or staying asleep; irritability anger or depression; difficulty concentrating; being jumpy or startled at something unexpected; inability to cope with normal stresses of daily living; inability to trust, cognitive difficulties; other. Goals for the problem included, Resident will verbalize/display feeling/disposition of safeness in the community and Trauma symptoms will not interfere with residents POC or rehabilitation. Interventions included, Ask and observe the situations and interactions that create well-being, engagement and a sense of safety on the part of the resident/pt recognizing that many individuals who are long-stay residents have some level of cognitive impairment that may require additional sensitivity. A review of Resident #1's social service progress note dated 9/6/23 at 4:46 PM reflected, During IDT meeting, resident made SW aware of incident that occurred with another resident the night prior 9/5. Resident stated that he came back to facility at approximately 8:30 PM and the doors were locked .Resident stated other residents were sitting in the area and he asked them to open the door but they would not. Resident managed to get the door open. Resident stated he got into an argument with another resident sitting in the area. Resident stated other resident stood and walked toward him. Resident stated other Resident put his hands around his neck. SW asked if resident feels safe. Resident stated he did not. SW informed administrator. A review of Resident #1's progress notes reflected no documentation regarding the incident nor a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455522 If continuation sheet Page 4 of 5 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 455522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Temple West 1700 Marlandwood Rd Temple, TX 76502 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 0610 nursing note to indicate if the resident was assessed for injuries. Level of Harm - Minimal harm or potential for actual harm A review of Resident #2's face sheet printed on 9/14/23, reflected a [AGE] year-old male admitted to the facility 2/11/23 with diagnoses including Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a group of symptoms affecting memory, thinking and social abilities) essential hypertension (high blood pressure) and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Residents Affected - Few A review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 9 indicating moderately impaired cognition. He was assessed as requiring setup or clean-up assistance or supervision with ADLs. He was assessed to have an active diagnosis of dementia. A review of Resident #2's comprehensive care plan initiated 2/11/22 reflected the problem The resident has impaired cognitive function/dementia or impaired thought process related to diagnosis. Goals included maintaining current level of cognitive function, be able to communicate basic needs and develop skills to cope with cognitive decline. Interventions included administer medications and keep the resident's routine consistent and try to provide consistent care givers to decrease confusion. A review of Resident #2's nursing progress note dated 9/5/23 at 11:33 PM reflected he was found sitting on the floor in the dining room. There was no documentation that Resident #2 was involved in an incident with another resident. During a telephone interview on 11/14/23 at 9:48 AM with the SW, she stated the ADM had been made aware of the incident the night it happened and he got statements from the staff who worked that night. She identified Resident #2 as the person Resident #1 alleged choked him. During an interview on 11/14/23 at 3:00 PM, the ADM stated he was aware of the incident where Resident #1 stated he was choked. He stated he asked for statements from the staff who worked when the event occurred. The ADM stated, We have two or three residents with personality issues, and I think this was just personality issues. He stated. One RN said he wasn't choked but the other resident touched his face. The ADM stated when a resident alleged abuse, we will investigate it immediately and ask staff for statements regardless of whether they saw it. He stated he did not report the incident to the State because the eyewitness said he was not choked. When asked if allegations of abuse needed to be reported he stated, I can't say it doesn't need to be reported. I know Resident #1 and Resident #2 had personality conflicts. It felt more personality conflict than anything else. After review of the abuse policy, the ADM verified that it was the current policy then stated, In retrospect, yes, I should have reported it. The ADM stated he did look at the video but because of the angle of the camera, he could not see above Resident #1's legs. He stated, I could see the other resident walk over to him, but I couldn't see what happened. He stated an adverse outcome of not investigating was lose trust in the system, for sure. Not get the appropriate care. During an interview on 11/14/23 at 3:17 PM, the ADON stated when an allegation of abuse was made, the first thing was to assess the resident and see if anything looked abnormal. She stated she would talk with the aide to see what they saw. She would expect to see the incident documented. She stated if behaviors were not documented in the care plan, It could trigger negative behaviors. A review of the facility's incident and accident log from 8/13/23 to 11/4/23 reflected no entry for an incident involving Resident#1 and Resident #2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455522 If continuation sheet Page 5 of 5