Health inspection·October 26, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some right elbow discomfort and right hip discomfort, RN C assisted with the neuro check, no visible injury present at this time, notify DON, NP new order x-ray of right elbow and right hip, and emergency contact . Record review of a self-report to HHSC dated 10/19/20223 by the Administrator indicated an incident occurred at the facility on 10/15/2023 with LVN B who told Resident #4 to stop acting like a fool with RN C present. Record review of a signed witness statement by RN C undated indicated, On 10/15 called to secure unit to evaluate a patient who had fallen. No injuries noted. LVN B put gait belt on resident to help him get up. He jerked away and hit his head on sink, and she informed him not to act a damn fool. Record review LVN B's punch detail, (punch by punch detail of hours worked) dated 10/1/2023-10/15/2023 indicated on 10/15/223 she worked from 6:04 AM to 6:51 PM. Record review of the personnel file for LVN B indicated she hired as a mobile support nurse with the company on 1/19/2022. An Employee Memorandum dated 10/25/2022 indicated she was suspended from a sister facility on 10/20/2022 with potential abuse towards a resident at a sister facility. Allegation of abuse towards a resident verbally and physically. LVN B was attempting to wake up an unresponsive patient in fear they were choking on medications. Allegation of abuse was made against LVN B. Corrective action the employee may take to eliminate the above problem areas: LVN B will participate in an education and training session regarding abuse definition, prevention, and reporting. If the problem persists after education is completed, further disciplinary action up to an including termination will occur. During an observation and interview 10/25/23 at 10:30 AM, Resident #4 was sitting in his wheelchair in the dining room on the secure unit. He was clean and well groomed. There was another resident that kept hollering out and Resident #4 made a face and grimaced whenever the other resident hollered. Attempted to interview Resident #4 and ask him a few questions and resident continues to sit with eyes closed and not answer. When asked if anyone had ever hurt him, he did not answer. During an interview on 10/25/23 at 11:02 AM, the Administrator said LVN B and RN C did not like each other. He said RN C started working for them in August 2023. The Administrator said he had heard something happened at another facility with LVN B. He said she was already suspended from his facility, and he did not know if the other allegation happened before or after the allegation was made at his facility. He said he figured the agency took care of it. He said she worked for the agency and cannot work anywhere else because of the abuse allegations. He said he did not hear about incident at his facility until 10/19/23. On 10/18/23 his DON was called by the Travel pool nurse manager and was told not to work LVN B anymore, but they did not know why. On 10/19/23 while the DON was trying to cover LVN B's shift she called RN C about working LVN B's shift. He said RN C asked whose shift she would be covering, and the DON said for LVN B. RN C said the one who called Resident #4 a, damn fool. The Administrator said he formally suspended LVN B on 10/19/23 because of the verbal allegation of abuse. He said she has not worked at the facility since. During a phone interview on 10/25/23 at 11:10 AM, RN C said she had worked at the facility as the RN Supervisor on the weekends since the first of August 2023. She said Resident # 4 had fallen in a bathroom on the memory care unit. She said she was called back there to assist LVN B with assessing Resident #4. She said Resident #4 was lying on the floor in the bathroom with his head under the sink. RN C began to assess Resident #4 and she decided it was ok to get him up in a chair. She said LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 2 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some B told CNA P to get her gait belt out of her bag. RN C said Resident #4 was moving around while LVN B was attempting to put gait belt on him, he jerked away and hit his head on the sink and LVN B said, stop acting like a damn fool. RN C said resident had no visible injuries. She said they notified the nurse practitioner and she ordered an x-ray of his hip. RN C said the incident slipped her mind until 10/19/23 when the DON contacted her to work on 10/20/2023 and she asked which nurse she was working for and the DON said LVN B and RN C said, oh the one that called the resident a damn fool. RN C said she should have reported the incident immediately to her DON or the abuse coordinator, which was the Administrator. During a phone interview on 10/25/2023 at 2:26 PM, the Travel Pool's Nurse Manager for the facility's company said the company had its own mobile support staffing. She said LVN B had worked for them for a year. She said LVN B was terminated on 10/25/2023. She said none of the facilities that the company owns want her working for them anymore because she had two allegations of abuse within a year. She said she had an allegation of abuse not long ago at a sister facility. She said the incident at that time, LVN B was written up, suspended and in-serviced. She said that facility would not allow her to work there anymore. She said she received a call on 10/16/2023 about an allegation of abuse with LVN B from [name of facility] and they said she could not return to their facility. During an interview on 10/26/2023 at 11:52 AM, CNA P said she had been working at the facility for about a month through an outside agency. She said on 10/15/2023 she worked in the secured unit with LVN B. She said while doing rounds on the residents she noticed Resident #4 had been gone for a while and she went to his room looking for him. She said she found Resident #4 lying on his bathroom floor. She said she called for LVN B and they went in the bathroom of Resident #4. She said LVN B told her to stay with the resident while she went to get RN C. She said LVN B came back with RN C and they went to Resident #4's room. CNA P said Resident #4 was complaining of pain and LVN B said she was going to send him out to the emergency room and RN C said not to send him. She said she was asked by RN C to get a gait belt from her bag. She said if something was said by LVN B that was demeaning, she did not hear it because she was not in the room the entire time. She said LVN B had a tone of voice that was loud, and she did not speak good English. She said some people may think LVN B was being rude to them, but she cared about the residents. During a phone interview on 10/26/23 at 12:50PM, LVN B said she was a travel nurse for the facility's corporation company. She said she traveled to different facilities within the company that needed staffing. She said she last worked on the secure [unit] on October 15, 2023 from 6am-6pm. She said she was no longer with the facility's staffing agency ; her last shift was 10/17/2023 at a sister facility in [NAME], Texas. She said the facility's corporation company terminated her today and her boss, who was the Travel Pool Nurse Manager, told her she was a high risk. LVN B said she did not do anything. She said on 10/15/23 Resident #4 fell and was on the floor in the bathroom lying on his right side. She said he was a very large guy, so CNA P went and grabbed a gait belt; the bathroom was too small for a mechanical lift. Resident #4 kept saying to help him up and she told him, be a little patient please. She said CNA P returned with a gait belt and RN C came and assessed Resident #4 and the three of them got him up in a wheelchair. LVN B said she did not recall any inappropriate words by herself or any of the CNA's. She said she left her shift after 6:00 PM on 10/15/23 and gave report to the night nurse. LVN B said she had abuse training in the past and was to report any allegation of abuse within two hours to the Administrator and if he was not available to report to the DON. During an interview on 10/26/23 at 3:00pm, the Administrator said he had been employed at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 3 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm facility since August 14, 2023. He said he was the abuse coordinator, and if he had known about the incident when it occurred, he would have completed a self-report. He said he would have immediately suspended the employees, started in-servicing staff, conducted a head-to-toe assessment along with an emotional status assessment for each resident involved. He said by incidents not being reported timely, a staff member had the ability to do it again if not reported immediately. Residents Affected - Some Record review of an Employee Memorandum dated 10/19/2023 for RN C indicated she was suspended for failure to report abuse allegations in timely manner with date of violation on 10/19/2023. Record review of a notice of termination dated 10/25/2023 for RN C indicated she was terminated for failure to report abuse/neglect in a timely manner to Abuse Coordinator. Record review of an in-service dated 10/25/2022 on abuse prevention/behavior indicated LVN B signed the in-service with presentation length of one hour. Record review of a notice of termination dated 10/25/2023 for LVN B was signed by the travel pool nurse manager. 2. Record review of a face sheet for Resident #2 dated 10/26/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), generalized anxiety disorder (feel extremely worried or nervous more frequently), and schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior). He discharged to a behavioral hospital on [DATE]. Record review of 15 minute checks for Resident #2 dated 8/19/2023 indicated he started 1:1 monitoring at 6:45 pm and continued 1:1 monitoring following the incident on 8/20/2023 when he attacked Resident #5 at 8:00 am. Record review of an admission MDS assessment dated [DATE] for Resident #2 indicated he had moderate impairment in thinking with a BIMS score of 10. He had physical behavioral symptoms directed toward others that occurred 1 to 3 days (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). The behavioral symptoms put others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. He has psychiatric mood disorder that included anxiety disorder and schizophrenia. Record review of Resident #2's Significant Change MDS assessment dated [DATE] indicated that he had moderate impairment in thinking with a BIMS score of 10. He had physical behavioral symptoms directed toward others that occurred 1 to 3 days (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). The behavioral symptoms put others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. He has psychiatric mood disorder that included anxiety disorder and schizophrenia. Record review of a care plan for Resident #2 dated 8/19/2023 indicated he had cognitive/dementia with impaired decision making that included interventions to determine if decisions made by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 4 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 resident endanger the resident or others. Intervene if necessary. Level of Harm - Minimal harm or potential for actual harm Record review of a progress note for Resident #2 dated 8/20/2023 at 8:00 am by LVN H indicated, Notified per staff member that resident was observed choking his roommate. Staff immediately separated and redirected the resident of his behavior. Resident stated, I didn't know I had a roommate I thought he was a burglar that came into my room. Resident is new to this facility and had been in another facility with a different roommate. The resident was taken to an empty room with belongings. The resident is currently on 1 and 1 with staff due to behaviors. Notified DON, ADON, emergency contact and provider NP. A call was placed to EMS. EMS and police officers arrived to the facility and escorted resident to a local hospital for further eval and treatment. Residents Affected - Some Record review of a care plan for Resident #2 dated 8/20/2023 indicated Resident #2 had behavioral symptoms, and he was a threat to others related to being heard by staff smack his roommate and observed with his hands around roommate neck. Interventions included to provide 1:1. Record review of a care plan for Resident #2 dated 9/21/2023 indicated Resident #2 had behavioral symptoms with physical behavioral symptoms toward other resident with intervention to continue to provide 1:1. 3. Record review of a face sheet for Resident #5, undated, indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior), generalized anxiety disorder (feel extremely worried or nervous more frequently), generalized idiopathic epilepsy (seizures) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated he did not have any impairment in thinking with a BIMS score of 15. He did not have any behavioral symptoms that included physical or verbal toward others. He required supervision with ADLs with one person assist. He had active diagnoses of anxiety disorder and schizophrenia. Record review of a care plan for Resident #5 dated 8/18/2023 indicated he had behavioral symptoms with diagnoses of dementia and resided in the secured unit due to his wandering and poor safety awareness. Record review of a progress note dated 8/20/2023 by LVN H at 8:46 am for Resident #5 indicated, The Resident was lying in bed in a supine position. The staff member was sitting outside of the door when she heard a smack. Upon entering the patient's room staff observed the resident's roommate with his hands around said patient. Upon assessing the resident, a large red area was observed around the patient's neck. Pt was also hit on his left upper arm with no bruising observed at this time. Pt denies any pain or discomfort at this time. Notified NP, DON, and ADON regarding the incident. No new orders received. Will check on resident Q15 minutes to monitor for any delayed injuries or discomforts. During an observation and interview on 10/24/2023 at 9:43 AM, CNA D was in the secured unit and said she had been employed at the facility for a month. She said she normally worked outside of the secured unit, and it had only been a few weeks since being assigned in the secured unit. She said when she first started at the facility on 9/14/2023, she was 1:1 with Resident #2. She said the facility did not specifically tell her why he was on 1:1 with him. She said they told her to sit with him and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 5 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some follow him everywhere he went. She said when he was in his room, as long as they could see him you could be outside the door, but she said sometimes he would get aggressive that was triggered by the noises and yelling of other residents. She said he would get anxious sometimes and wanted to go outside and would go door to door trying to get out. She said he was violent sometimes, he would slam doors, threaten to knock out the windows, and would threaten to hurt other residents. She said they had a 15-minute check off to document where he was. During an observation and interview on 10/24/2023 at 9:50 AM, Hospitality aide E was in the secured unit passing out ice water and making beds for the residents. She said she had been employed at the facility for 2 weeks. She said her first day was on 10/9/2023 and she was on 1:1 with Resident #2. She said he was in a room at the end of the hall by himself in the secured unit at that time. She said when a resident was 1:1, they were to watch their every move. She said she sat outside his room in a chair and would watch and document every 15 minutes along with his location. She said sometimes the door would be closed and she would sit outside of his room. She said she provided 1:1 with him from 6 am to 6 pm. She said she only observed him that one day and then he discharged to a behavioral hospital later that day around 4-5 pm. She said he was good until about 4 pm and he started packing up his belongings and was trying to open the exit doors. She said she did not know why he was on 1:1 supervision. During an observation and interview on 10/24/2023 at 9:59 AM, Resident #5 was lying in bed awake, watching television. He was alert to person, place, and time. He said he has had a roommate before and was unable to recall when they moved out. He said they stopped people from being in the room with him because they always go on his side of the room and go through his stuff. Resident #5 said one day he was asleep, and Resident #2 came over and hit him on the shoulder and started choking him. He said there was no one in the room with them. He said staff heard him hollering and he was telling Resident #2 to get off of him and staff came into the room and got him off of him. He said the next day they moved him out. He said Resident #2 had not hit him before that day or attacked him. He said he did not notice Resident #2 being aggressive with any other residents. He said it scared him when he was hit and choked by Resident #2. He said since that incident they stopped putting residents in his room. During an observation and interview on 10/24/2023 at 10:25 AM, CNA P said she had been employed at the facility for a month through agency on 6am-6 pm shift in the secured unit. She said she had Resident #2 on 1:1 a few times. She said he had aggressive behaviors, and the noises would bother him and sometimes he would want to leave the secured unit. She said Resident #2 would jump at other residents but did not physically touch them as if he was trying to intimidate them. During an interview on 10/24/2023 at 11:15 AM, CNA A said she was agency staff who worked at the facility often. She said she witnessed the incident with Resident #2 and Resident #5. She said that day she came on from the weekend being off and was told about a new admission by nursing staff for Resident #2 who she had to provide 1:1. She said she was standing at the door with Resident #2 and Resident #5. She said someone called her name and she turned to see who called her. She said Resident #5 came to the door looking for breakfast trays and then went back into the room. She said Resident #2 was sitting on the bed. She said when she turned back around Resident #2 had his hands around Resident #5's neck and Resident #5 was trying to get loose, and Resident #2 used an open hand and slapped Resident #5 on the face. She said she was able to get the two separated with assistance. She said Resident #2 was moved to a room at the end of the hall. She said Resident #2 woke up that morning and she guessed he was confused and thought his roommate, Resident #5, had broken into his home. She said the nurse assessed Resident #5 and he did not have any bruises. She said Resident #5 was scared (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 6 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some more than anything. She said Resident #2 continued 1:1 supervision after the incident. She said 1:1 meant staff had to have eyes on him at all times to make sure nothing happened to any of the other residents. She said Resident #2 had not been at the facility long. She said Resident #2 calmed down once he was moved to another room. She said noises irritated Resident #2. She said she had to intervene once with Resident #2 who tried to get at another resident because he acted as if he was going to hurt them. She said Resident #2 was currently at a behavioral hospital. She said following the incident staff had to watch a video on behaviors and how to handle different behaviors. During an interview on 10/24/2023 at 11:55 AM, the Administrator said he started at the middle of August 2023. He said Resident #2 was not currently at the facility and was at a behavioral hospital. He said Resident #2 admitted shortly after he started at the facility. He said the resident came from another sister facility. He said he was admitted to the facility because he needed a secured unit because he was trying to exit seek. He said they decided to placed Resident #2 in the room with Resident #5 because he would be a better fit in that room and did not want to put Resident #2 in a empty room at the end of the hall by the exit doors due to his exit seeking behaviors. He said when he admitted he was ambulatory and was very strong. He said he was kicking on the doors and was placed on 1:1 monitoring at that time. He said that this was Resident #2's second time to go to a behavioral hospital. He said the first time was when he choked Resident #5 on 8/20/2023 and then after that Resident #2 tried to choke a staff member on 9/21/2023. He said Resident #2 was having behaviors on admission to the facility. He said they had him on 1:1 supervision and staff were in-serviced on 8/20/2023 about 1:1 monitoring and resident to resident altercations. He said the staff should be within arm reach when they were assigned 1:1 monitoring. He said as Resident #5 was coming back in the room, Resident #2 grabbed him and choked him. He said following the incident, both residents were separated, Resident #2 was placed in a room by himself at the end of the hall and continued 1:1 monitoring. He said staff were provided in-service education on abuse/neglect and 1:1 supervision following the incident. During an interview on 10/25/2023 9:50 AM, the DON said she had been employed at the facility since 8/29/2023. She said if a resident was on 1:1, then it was for safety, the welfare of the residents and the people around them. She said staff should be within arm reach to prevent an altercation. She said 1:1 was constant supervision with no break. She said if someone needed a break in 1:1, then they would call to ask for relief. She said there should not be any resident-to-resident contact if a resident was on 1:1 supervision. She said the incident with Resident #2 and Resident #5 should not have occurred. Attempted a phone interview with LVN H on 10/25/2023 at 11:43 AM, voicemail box said it was full and unable to leave a message. Record review of a facility policy titled Abuse Prevention Program with a revised dated of 1/9/2023 indicated, .1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. 2. Our residents have the right to be free from abuse, neglect. Reporting: 2. An alleged violation of abuse, neglect exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: (2) hours if the alleged violation involves abuse . Record review of a facility policy titled Resident to Resident Altercations with a revised date of 10/25/2023 indicated, .All altercations, including those that may represent resident to resident abuse, shall be investigated, and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. 1. Facility staff will monitor residents for aggressive/inappropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 7 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm behavior towards other residents, family members, visitors, or to the staff. 2. If two residents are involved in an altercation, the nursing staff will: a. Separate the residents, and institute measures to calm the situation up to and/or including 1:1 supervision of the offending resident . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 8 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement written policies and procedures to prohibit and prevent abuse for 2 of 10 residents (Resident #4 and Resident #5) reviewed for abuse policies. Residents Affected - Some On 10/15/2023, the facility did not protect Resident #4 from verbal abuse when LVN B told Resident #4 to stop acting like a damn fool with RN C present. LVN B was allowed to work on 10/15/2023 until her shift ended. The facility did not report the incident to the abuse coordinator until 10/19/2023. On 8/20/2023, the facility failed to protect Resident #5 from abuse when he was choked by Resident #2 who was on 1:1 monitoring on 8/20/2023. These failures could place residents at risk of abuse which could lead to further abuse and neglect of other residents. Findings include: 1.Record review of Resident #4's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia, with agitation (problem in the brain affecting memory), Psychotic disorder (loss of contact with reality), anxiety (feeling of fear, and uneasiness) schizoaffective disorder, (mental disorder). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8, which indicated resident had moderate cognitive impairment. He required limited to extensive assistance of one staff for ADL care. Record review of Resident #4's care plan dated 10/18/2023 indicated he had a history of schizoaffective disorder with psychosis, anxiety, major depressive disorder, recurrent, severe with psychosis. He receives psychotropic (for mood), anxiety and anti-depression medications. Interventions were to approach in a calm, slow manner, maintain a calm environment, introduce self and explain procedure/care to be provided, provide validation of feeling by restating concerns/feelings, encourage to focus on positive. During an observation and interview 10/25/23 at 10:30 AM, Resident #4 was sitting in his wheelchair in the dining room on the secure unit. He was clean and well groomed. There was another resident that kept hollering out and Resident #4 made a face and grimaced whenever the other resident hollered. Attempted to interview Resident #4 and ask him a few questions and resident continues to sit with eyes closed and not answer. When asked if anyone had ever hurt him, he did not answer. During an interview on 10/25/23 at 11:02 AM, the Administrator said LVN B and RN C did not like each other. He said RN C started working for them in August 2023. The Administrator said he had heard something happened at another facility with LVN B. He said she was already suspended, and he did not know if it happened before or after allegation was made at his facility. He said he figured they took care of it. He said she worked agency and cannot work anywhere else because of the abuse allegations. He said he did not hear about incident at his facility until 10/19/23. On 10/18/23 his DON was called by the Travel pool nurse manager and told not to work LVN B anymore, but they did not know (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 9 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some why. On 10/19/23 while the DON was trying to cover LVN B's shift she called RN C about working LVN B's shift. He said RN C asked whose shift she would be covering, and the DON said for LVN B. RN C then responded to the DON and said the one who called Resident #4 a damn fool. The Administrator said he formally suspended LVN B on 10/19/23. He said she has not worked at the facility since. During a phone interview on 10/25/23 at 11:10 AM, RN C said she had worked at the facility as the RN Supervisor on the weekends since the first of August 2023. She said resident # 4 had fallen in a bathroom on the memory care unit on 10/15/2023. She said she was called back there to assist LVN B with assessing Resident #4. She said Resident #4 was lying on the floor in the bathroom with his head under the sink. RN C began to assess Resident #4 and she decided it was ok to get him up in a chair. She said LVN B told CNA P to get her gait belt out of her bag. RN C said Resident #4 was moving around while LVN B was attempting to put gait belt on him he jerked away and hit his head on the sink and LVN B said, stop acting like a damn fool. RN C said resident had no visible injuries. She said they notified the nurse practitioner and she ordered an x-ray of his hip. RN C said the incident slipped her mind until 10/19/23 when the DON contacted her to work on 10/20/2023 and she asked which nurse she was working for and the DON said LVN B and RN C said, oh the one that called the resident a damn fool. RN C said she was not sure if Resident #4 heard LVN B or not when LVN B made the statement, but RN C said she should have reported the incident immediately to her DON or the abuse coordinator, which was the Administrator. During a phone interview on 10/25/2023 at 2:26 PM, the Travel Pool Nurse Manager for the facility's company said the company had its own mobile support staffing. She said LVN B had worked for the company for a year and traveled to facilities in the area and was not assigned a specific facility to work at. She said the mobile support staffing traveled to facilities that needed assistance with staffing. She said LVN B was terminated on 10/25/2023. She said none of the facilities that the company owned wanted her working for them anymore because she had two allegations of abuse within a year. She said the most recent was from [name of facility]. She said she had an allegation of abuse not long ago at a sister facility. She said LVN B had an allegation of verbal and physical abuse at a sister facility. She said the incident at that time, LVN B was written up, suspended and in-serviced. She said that facility would not allow her to work there anymore. She said she received a call on 10/16/2023 about an allegation of abuse with LVN B from [name of facility] and they said she could not return to their facility. During an interview on 10/26/2023 at 11:52 AM, CNA P said she had been working at the facility for about a month through an outside agency. She said on 10/15/2023 she worked in the secured unit with LVN B. She said while doing rounds on the residents she noticed Resident #4 had been gone for a while and she went to his room looking for him. She said she found Resident #4 lying on his bathroom floor. She said she called for LVN B and they went in the bathroom of Resident #4. She said LVN B told her to stay with the resident while she went to get RN C. She said LVN B came back with RN C, and they went to Resident #4's room. CNA P said Resident #4 was complaining of pain and LVN B said she was going to send him out to the emergency room and RN C said not to send him. She said she was asked by RN C to get a gait belt from her bag. She said if something was said by LVN B that was demeaning, she did not hear it because she was not in the room the entire time. She said LVN B had a tone of voice that was loud, and she did not speak good English. She said some people may think LVN B was being rude to them, but she cared about the residents. During a phone interview on 10/26/23 at 12:50PM, LVN B said she was a travel nurse for the facility's corporation company. She said she traveled to different facilities within the company that needed staffing. She said she last worked on the secure unit at [name of facility] on October 15, 2023, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 10 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some from 6am-6pm. She said she was no longer with the company anymore; her last shift was 10/17/2023, at a sister facility in [NAME], Texas. She said the facility's corporation company terminated her today and her boss who was the Travel Pool Nurse Manager told her she was a high risk. LVN B said she did not do anything. She said on 10/15/23 Resident #4 fell and was on the floor in the bathroom lying on his right side. She said he was a very large guy, so CNA P went and grabbed a gait belt; the bathroom was too small for a mechanical lift. Resident #4 kept saying to help him up and she told him, to be a little patient please. She said CNA P returned with a gait belt and RN Supervisor (RN C) came and assessed Resident #4 and the three of them got him up in a wheelchair. LVN B said she did not recall any inappropriate words by herself or any of the CNA's. She said she left her shift after 6:00 PM on 10/15/23 and gave report to the night nurse. LVN B said she had abuse training in the past and was to report any allegation of abuse within two hours to the Administrator and if he was not available to report to the DON. During an interview on 10/26/23 at 3:00pm, the Administrator said he had been employed at the facility since August 14, 2023 and was the abuse coordinator. He said if he had known about the incident when it occurred, he would have completed a self-report, suspended the employees, started in-servicing staff, conducted a head-to-toe assessment along with an emotional status assessment for each resident involved. He said by incidents not being reported timely, a staff member had the ability to do it again if not reported immediately. He said staff received in-service training monthly on abuse/neglect and had a test on abuse/neglect 9/26/2023 that included reporting and prevention. Record review of an Employee Memorandum dated 10/19/2023 for RN C indicated she was suspended for failure to report abuse allegations in timely manner with date of violation on 10/19/2023. Record review of a notice of termination dated 10/25/2023 for RN C indicated she was terminated for failure to report abuse/neglect in a timely manner to Abuse Coordinator. Record review of a notice of termination dated 10/25/2023 for LVN B was signed by the travel pool nurse manager. 2. Record review of a face sheet for Resident #2 dated 10/26/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), generalized anxiety disorder (feel extremely worried or nervous more frequently), and schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior). He discharged to a behavioral hospital on [DATE]. Record review of an admission MDS assessment dated [DATE] for Resident #2 indicated he had moderate impairment in thinking with a BIMS score of 10. He had physical behavioral symptoms directed toward others that occurred 1 to 3 days (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). The behavioral symptoms put others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. He has psychiatric mood disorder that included anxiety disorder and schizophrenia. Record review of Resident #2's Significant Change MDS assessment dated [DATE] indicated that he had moderate impairment in thinking with a BIMS score of 10. He had physical behavioral symptoms directed toward others that occurred 1 to 3 days (hitting, kicking, pushing, scratching, grabbing, abusing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 11 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some others sexually) and verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). The behavioral symptoms put others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. He has psychiatric mood disorder that included anxiety disorder and schizophrenia. Record review of a care plan for Resident #2 dated 8/19/2023 indicated he had cognitive/dementia with impaired decision making that included interventions to determine if decisions made by the resident endanger the resident or others. Intervene if necessary. Record review of 15 minute checks for Resident #2 dated 8/19/2023 to 10/9/2023 indicated staff documented where Resident #2 was and what he was doing. Record review of a progress note for Resident #2 dated 8/20/2023 at 8:00 am by LVN H indicated, Notified per staff member that resident was observed choking his roommate. Staff immediately separated and redirected the resident of his behavior. Resident stated, I didn't know I had a roommate I thought he was a burglar that came into my room. Resident is new to this facility and had been in another facility with a different roommate. The resident was taken to an empty room with belongings. The resident is currently on 1 and 1 with staff due to behaviors. Notified DON, ADON, emergency contact and provider NP. A call was placed to EMS. EMS and police officers arrived to the facility and escorted resident to a local hospital for further eval and treatment. Record review of a care plan for Resident #2 dated 8/20/2023 indicated Resident #2 had behavioral symptoms, and he was a threat to others related to being heard by staff smack his roommate and observed with his hands around roommate neck. Interventions included to provide 1:1. Record review of a care plan for Resident #2 dated 9/21/2023 indicated Resident #2 had behavioral symptoms with physical behavioral symptoms toward other resident with intervention to continue to provide 1:1. 3. Record review of a face sheet for Resident #5 undated indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior), generalized anxiety disorder (feel extremely worried or nervous more frequently), generalized idiopathic epilepsy (seizures) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated he did not have any impairment in thinking with a BIMS score of 15. He did not have any behavioral symptoms that included physical or verbal toward others. He required supervision with ADLs with one person assist. He had active diagnoses of anxiety disorder and schizophrenia. Record review of a care plan for Resident #5 dated 8/18/2023 indicated he had behavioral symptoms with diagnoses of dementia and resided in the secured unit due to his wandering and poor safety awareness. Record review of a progress note dated 8/20/2023 by LVN H at 8:46 am for Resident #5 indicated, The Resident was lying in bed in a supine position. The staff member was sitting outside of the door when she heard a smack. Upon entering the patient's room staff observed the resident's roommate with his hands around said patient. Upon assessing the resident, a large red area was observed around the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 12 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some patient's neck. Pt was also hit on his left upper arm with no bruising observed at this time. Pt denies any pain or discomfort at this time. Notified NP, DON, and ADON regarding the incident. No new orders received. Will check on resident Q15 minutes to monitor for any delayed injuries or discomforts. During an observation and interview on 10/24/2023 at 9:43 AM, CNA D was in the secured unit and said she had been employed at the facility for a month. She said she normally worked outside of the secured unit, and it had only been a few weeks since being assigned in the secured unit. She said when she first started at the facility, she was 1:1 with Resident #2. She said the facility did not specifically tell her why he was on 1:1 with him. She said they told her to sit with him and follow him everywhere he went. She said when he was in his room, as long as they could see him you could be outside the door, but she said sometimes he would get aggressive that was triggered by the noises and yelling of other residents. She said he would get anxious sometimes and wanted to go outside and would go door to door trying to get out. She said he was violent sometimes, he would slam doors, threaten to knock out the windows, and would threaten to hurt other residents. She said they had a 15-minute check off to document where he was. During an observation and interview on 10/24/2023 at 9:50 AM, Hospitality aide E was in the secured unit passing out ice water and making beds for the residents. She said she had been employed at the facility for 2 weeks. She said her first day she was on 10/9/2023 and she provided 1:1 with Resident #2. She said he was in a room at the end of the hall by himself in the secured unit at that time. She said when a resident was 1:1, they were to watch their every move, she said she sat outside his room in a chair and would watch and document every 15 minutes along with his location. She said sometimes the door would be closed and she would sit outside of his room. She said she provided 1:1 with him from 6 am to 6 pm. She said she only observed him that one day and then he discharged to a behavioral hospital later that day around 4-5 pm. She said he was good until about 4 pm and he started packing up his belongings and was trying to open the exit doors. She said she did not know why he was on 1:1 supervision. During an observation and interview on 10/24/2023 at 9:59 AM, Resident #5 was lying in bed awake, watching television. He was alert to person, place, and time. He said he has had a roommate before and was unable to recall when they moved out. He said they stopped people from being in the room with him because they always go on his side of the room and go through his stuff. Resident #5 said one day he was asleep, and Resident #2 came over and hit him on the shoulder and started choking him. He said there was no one in the room with them. He said staff heard him hollering and he was telling Resident #2 to get off of him and staff came into the room and got him off of him. He said the next day they moved him out. He said Resident #2 had not hit him before that day or attacked him. He said he did not notice Resident #2 being aggressive with any other residents. He said it scared him when he was hit and choked by Resident #2. He said since that incident they stopped putting residents in his room. During an observation and interview on 10/24/2023 at 10:25 AM, CNA P said she had been employed at the facility for a month through agency on 6am-6 pm shift in the secured unit. She said she had Resident #2 on 1:1 a few times. She said he had aggressive behaviors, and the noises would bother him and sometimes would want to leave the secured unit. She said Resident #2 would jump at other residents but did not physically touch them as if he was trying to intimidate them. During an interview on 10/24/2023 at 11:15 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 13 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some , CNA A said she was agency staff who worked at the facility often. She said she witnessed the incident with Resident #2 and Resident #5. She said that day she came on from the weekend being off and was told about a new admission by nursing staff for Resident #2 who she had to provide 1:1. She said she was standing at the door with Resident #2 and Resident #5. She said someone called her name and she turned to see who called her. She said Resident #5 came to the door looking for breakfast trays and then went back into the room. She said Resident #2 was sitting on the bed. She said when she turned back around Resident #2 had his hands around Resident #5's neck and Resident #5 was trying to get loose, and Resident #2 used an open hand and slapped Resident #5 on the face. She said she was able to get the two separated with assistance. She said Resident #2 was moved to a room at the end of the hall. She said Resident #2 woke up that morning and she guessed he was confused and thought his roommate Resident #5 had broken into his home. She said the nurse assessed Resident #5 and he did not have any bruises. She said Resident #5 was scared more than anything. She said Resident #2 continued 1:1 supervision after the incident and staff had to have eyes on him at all times to make sure nothing happened to any of the other residents. She said Resident #2 had not been at the facility long. She said Resident #2 calmed down once he was moved to another room. She said noises irritated Resident #2. She said she had to intervene once with Resident #2 who tried to get at another resident because he acted as if he was going to hurt them. She said Resident #2 was currently at a behavioral hospital. She said following the incident staff had to watch a video on behaviors and how to handle different behaviors. During an interview on 10/24/2023 at 11:55 AM, the Administrator said he started at the middle of August 2023. He said Resident #2 was not currently at the facility and was at a behavioral hospital. He said Resident #2 admitted shortly after he started at the facility. He said the resident came from another sister facility. He said he was admitted to the facility because he needed a secured unit because he was trying to exit seek. He said when he admitted he was ambulatory and was very strong. He said he was kicking on the doors and was placed on 1:1 monitoring at that time. He said that this was Resident #2's second time to go to a behavioral hospital. He said the first time was when he choked Resident #5 and then after that Resident #2 tried to choke a staff member on 9/21/2023. He said Resident #2 was having behaviors on admission to the facility. He said they had him on 1:1 supervision. He said the staff should be within arm reach when they were assigned 1:1 monitoring. He said as Resident #5 was coming back in the room, Resident #2 grabbed him and choked him. He said following the incident, both residents were separated, Resident #2 was placed in a room by himself at the end of the hall and continued 1:1 monitoring. He said staff were provided in-service education on abuse/neglect and 1:1 supervision following the incident. During an interview on 10/25/2023 9:50 AM, the DON said she had been employed at the facility since 8/29/2023. She said if a resident was on 1:1, then it was for safety, the welfare of the residents and the people around them. She said staff should be within arm reach to prevent an altercation. She said 1:1 was constant supervision with no break. She said if someone needed a break in 1:1, then they would call to ask for relief. She said there should not be any resident-to-resident contact if a resident was on 1:1 supervision. She said the incident with Resident #2 and Resident #5 should not have occurred. Record review of a facility policy titled Abuse Prevention Program with a revised dated of 1/9/2023 indicated, .1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. 2. Our residents have the right to be free from abuse, neglect. Reporting: 2. An alleged violation of abuse, neglect exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 14 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0607 reported immediately, but not later than: (2) hours if the alleged violation involves abuse . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 15 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 10 residents (Resident #4) reviewed for abuse. The facility failed to report an incident of abuse on 10/15/2023 when LVN B told Resident #4 to stop acting like a damn fool with RN C present. LVN B was allowed to finish her shift, she continued to work with Resident #4 and did not leave the facility until 6:51 pm that day. Staff did not report the incident to the Abuse Coordinator until 10/19/2023 and the Abuse Coordinator did not report the incident to HHS until 10/19/2023. This failure could place residents at risk of further abuse. Findings included: Record review of Resident #4's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia, with agitation (problem in the brain affecting memory), Psychotic disorder (loss of contact with reality), anxiety (feeling of fear, and uneasiness) schizoaffective disorder, (mental disorder). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8, which indicated resident had moderate cognitive impairment. He required limited to extensive assistance of one staff for ADL care. Record review of Resident #4 Quarterly MDS assessment dated [DATE] revealed a BIMS score of 8, which indicated resident had moderate cognitive impairment. He required limited to extensive assistance of one staff for ADL care. Record review of Resident #4's care plan dated 10/18/2023 indicated that he had a history of schizoaffective disorder with psychosis, anxiety, major depressive disorder, recurrent, severe with psychosis. He receives psychotropic medications, (drugs that affect a person's mental state) anxiety and anti-depression medications. Interventions were to approach in a calm, slow manner, maintain a calm environment, introduce self and explain procedure/care to be provided, provide validation of feeling by restating concerns/feelings, encourage to focus on positive. Record review of a progress note dated 10/15/23 at 3:08PM for Resident #4 by LVN B indicated on 10/15/2023 at 3:08 PM, .Resident #4 was found lying on his right side on the floor in his bathroom and his wheelchair was by the bedside. Resident stated, I walked to the bathroom to use the bathroom and fell on the floor, the CN, (LVN B) and unit CNA assisted the resident in getting off the floor with a gait belt and walked to his wheelchair, the resident denied hitting his head, complained of right elbow discomfort and right hip discomfort, RN C assisted with the neuro check, no visible injury (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 16 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 present at this time, notify DON, NP new order x-ray of right elbow and right hip, and emergency contact . Level of Harm - Minimal harm or potential for actual harm Record review of a self-report to HHSC dated 10/19/20223 by the Administrator indicated an incident occurred at the facility on 10/15/2023 with LVN B who told Resident #4 to stop acting like a fool with RN C present. Residents Affected - Few During an observation and interview 10/25/23 at 10:30 AM, Resident #4 was sitting in his wheelchair in the dining room on the secure unit. He was clean and well groomed. There was another resident that kept hollering out and Resident #4 made a face and grimaced whenever the other resident hollered. Attempted to interview Resident #4 and ask him a few questions and resident continues to sit with eyes closed and not answer. When asked if anyone had ever hurt him, he did not answer. During an interview on 10/25/23 at 11:02 AM, the Administrator said LVN B, and RN C, did not like each other. He said RN C, started working for them in August, the Administrator said he had heard that something happened at another facility with LVN B. He said LVN B had worked at the facility on numerous occasions covering different shifts. He said she was already suspended, and he didn't know if it happened before or after allegation was made at his facility. He said he figured they took care of it. He said she worked agency and cannot work anywhere else because she had two allegations of abuse within a year. He said he did not hear about incident at his facility until 10/19/23. On 10/16/23 his ADON was called by the [NAME] President of Clinical Operations and told, please do not accept LVN B to work in your facility, but they did not know why. On 10/19/23 while the DON was trying to cover LVN B's shift she called RN C about working LVN B's shift. He said RN C asked whose shift she would be covering, and DON said for LVN B. RN C said the one who called a Resident #4 a damn fool. Administrator said he formally suspended LVN B, on 10/19/23. He said she has not worked at the facility since. He said incidents not being reported timely, a staff member had the ability to do it again if not reported immediately to the abuse coordinator. During a phone interview on 10/25/23 at 11:10 AM RN C she said she had worked at the facility as the RN Supervisor on the weekends since the first of August 2023. She said Resident # 4 had fell in a bathroom on the memory care unit. RN C was called back there to assist LVN B with assessing Resident #4. She said Resident #4 was lying on the floor in the bathroom with his head under the sink. RN C began to assess resident #4 and she decided it was ok to get him up in a chair. She said LVN B told CNA P to go get her gait belt out of her bag. RN C said Resident #4 was moving around while LVN B was attempting to put gait belt on him. He jerked away and hit his head on the sink and LVN B said, stop acting like a damn fool. RN C said resident had no visible injuries. She said they notified the nurse practitioner, and she ordered an x-ray of his hip. RN C said the incident slipped her mind until 10/19/23 when the DON contacted her to work on 10/20/2023, she asked which nurse she was working for and the DON said LVN B and RN C said, oh the one that called the resident a damn fool. RN C said she should have reported the incident immediately to her DON or the abuse coordinator, which was the Administrator. Record review of an In-Service Education on Abuse/Neglect dated 9/1/2023 indicated RN C had training and her signature was present on the sign in sheet. Record review of an employee memorandum dated 10/19/2023 for RN C indicated she was suspended for failure to report abuse allegations in timely manner with date of violation on 10/19/2023. Record review of a notice of termination dated 10/25/2023 for RN C indicated she was terminated for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 17 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 failure to report abuse/neglect in a timely manner to Abuse Coordinator. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/26/23 at 3:00pm, the Administrator said he had been employed at the facility since August 14, 2023. He said if he had known about the incident when it occurred, he would have completed a self-report, suspended the employees, started in-servicing staff, conducted a head-to-toe assessment along with an emotional status assessment for each resident involved. He said by incidents not being reported timely, a staff member had the ability to do it again if not reported immediately. Residents Affected - Few Record review of a facility policy titled Abuse Prevention Program with a revised dated of 1/9/2023 indicated, .1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. 2. Our residents have the right to be free from abuse, neglect. Reporting: 2. An alleged violation of abuse, neglect exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: (2) hours if the alleged violation involves abuse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 18 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 adequate supervision for 1 of 6 residents (Residents #2) reviewed for accidents, hazards, and supervision in that: On 8/20/2023, the facility failed to provide adequate supervision in the secured unit with Resident #2 who was physically aggressive towards Resident #5. On 8/20/2023, the facility failed to protect Resident #5 from physical abuse perpetuated by Resident #2 who was supposed to be on 1:1 monitoring when Resident #2 choked his roommate Resident #5. This failure could place residents at risk of psychosocial harm including mental anguish, depression and becoming withdrawn. Findings include: 1. Record review of a face sheet for Resident #2 dated 10/26/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), generalized anxiety disorder (feel extremely worried or nervous more frequently), and schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior). He discharged to a behavioral hospital on [DATE]. Record review of an admission MDS assessment dated [DATE] for Resident #2 indicated he had moderate impairment in thinking with a BIMS score of 10. He had physical behavioral symptoms directed toward others that occurred 1 to 3 days (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). The behavioral symptoms put others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. He has psychiatric mood disorder that included anxiety disorder and schizophrenia. Record review of Resident #2's Significant Change MDS assessment dated [DATE] indicated that he had moderate impairment in thinking with a BIMS score of 10. He had physical behavioral symptoms directed toward others that occurred 1 to 3 days (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). The behavioral symptoms put others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. He has psychiatric mood disorder that included anxiety disorder and schizophrenia. Record review of a care plan for Resident #2 dated 8/19/2023 indicated he had cognitive/dementia with impaired decision making that included interventions to determine if decisions made by the resident endanger the resident or others. Intervene if necessary. Record review of a progress note for Resident #2 dated 8/20/2023 at 8:00 am by LVN H indicated, Notified per staff member that resident was observed choking his roommate. Staff immediately separated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 19 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and redirected the resident of his behavior. Resident stated, I didn't know I had a roommate I thought he was a burglar that came into my room. Resident is new to this facility and had been in another facility with a different roommate. The resident was taken to an empty room with belongings. The resident is currently on 1 and 1 with staff due to behaviors. Notified DON, ADON, emergency contact and provider NP. A call was placed to EMS. EMS and police officers arrived to the facility and escorted resident to a local hospital for further eval and treatment. Record review of a care plan for Resident #2 dated 8/20/2023 indicated he had behavioral symptoms, and he was a threat to others related to being heard by staff smack resident's roommate and observed with his hands around roommate neck. Interventions included to provide 1:1. Record review of a care plan for Resident #2 dated 9/21/2023 indicated behavioral symptoms with physical behavioral symptoms toward other resident with intervention to continue to provide 1:1. 2. Record review of a face sheet for Resident #5 undated indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior), generalized anxiety disorder (feel extremely worried or nervous more frequently), generalized idiopathic epilepsy (seizures) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated he did not have any impairment in thinking with a BIMS score of 15. He did not have any behavioral symptoms that included physical or verbal toward others. He required supervision with ADLs with one person assist. He had active diagnoses of anxiety disorder and schizophrenia. Record review of a progress note dated 8/20/2023 by LVN H at 8:46 am for Resident #5 indicated, The Resident was lying in bed in a supine position. The staff member was sitting outside of the door when she heard a smack. Upon entering the patient's room staff observed the resident's roommate with his hands around said patient. Upon assessing the resident, a large red area was observed around the patient's neck. Pt was also hit on his left upper arm with no bruising observed at this time. Pt denies any pain or discomfort at this time. Notified NP, DON, and ADON regarding the incident. No new orders received. Will check on resident Q15 minutes to monitor for any delayed injuries or discomforts. Record review of a care plan for Resident #5 dated 8/18/2023 indicated he had behavioral symptoms with diagnoses of dementia and resided in the secured unit due to his wandering and poor safety awareness. Record review of 15 minute checks for Resident #2 dated 8/19/2023 to 10/9/2023 indicated staff documented where Resident #2 was and what he was doing. Record review of a progress noted dated 9/21/2023 at 2:00 PM by RN C indicated, Resident #2 jumped up in effort to leave residence while placing hands around the neck of the one on one sitter. DON called to room to assist with the escalating situation. At present situation under control and awaiting to make a call to RP. Record review of a progress note dated 9/28/2023 at 11:26 AM by LVN R indicated, Resident #2 attempted to strike another resident but staff intervened and he did not succeed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 20 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 10/24/2023 at 9:43 AM, CNA D was in the secured unit and said she had been employed at the facility for a month. She said she normally worked outside of the secured unit, and it had only been a few weeks since being assigned in the secured unit. She said when she first started at the facility on 9/14/2023, she was 1:1 with Resident #2. She said the facility did not specifically tell her why he was on 1:1 with him. She said they told her to sit with him and follow him everywhere he went. She said when he was in his room, as long as they could see him you could be outside the door, but she said sometimes he would get aggressive that was triggered by the noises and yelling of other residents. She said he would get anxious sometimes and wanted to go outside and would go door to door trying to get out. She said he was violent sometimes, he would slam doors, threaten to knock out the windows, and would threaten to hurt other residents. She said they had a 15-minute check off to document where he was. During an observation and interview on 10/24/2023 at 9:50 AM, Hospitality aide E was in the secured unit passing out ice water and making beds for the residents. She said she had been employed at the facility for 2 weeks. She said her first day she was on 1:1 with Resident #2. She said he was in a room at the end of the hall by himself in the secured unit at that time. She said when a resident was 1:1, they were to watch their every move, she said she sat outside his room in a chair and would watch and document every 15 minutes along with his location. She said sometimes the door would be closed and she would still outside of his room. She said she provided 1:1 with him from 6 am to 6 pm. She said she only observed him that one day and then he discharged to a behavioral hospital later that day around 4-5 pm. She said he was good until about 4 pm and he started packing up his belongings and was trying to open the exit doors. She said she did not know why he was on 1:1 supervision. During an observation and interview on 10/24/2023 at 9:59 AM, in the room of Resident #5 was lying in bed awake, watching television. He was alert to person, place, and time. He said he has had a roommate before and was unable to recall when they moved out. He said they stopped people from being in the room with him because they always go on his side of the room and go through his stuff. Resident #5 said one day he was asleep, and Resident #2 came over and hit him on the shoulder and started choking him. He said there was no one in the room with them. He said staff heard him hollering and he was telling Resident #2 to get off of him and staff came into the room and got him off of him. He said the next day they moved him out. He said Resident #2 had not hit him before that day or attacked him. He said he did not notice Resident #2 being aggressive with any other residents. He said it scared him when he was hit and choked by Resident #2. He said since that incident they stopped putting residents in his room. During an observation and interview on 10/24/2023 at 10:25 AM, CNA P said she had been employed at the facility for a month through agency on 6am-6 pm shift in the secured unit. She said she had Resident #2 on 1:1 a few times. She said he had aggressive behaviors, and the noises would bother him and sometimes would want to leave the secured unit. She said Resident #2 would jump at other residents but did not physically touch them as if he was trying to intimidate them. During an interview on 10/24/2023 at 11:15 AM, CNA A said she was an agency staff who worked at the facility often. She said she witnessed the incident with Resident #2 and Resident #5 on 8/20/2023. She said that day she came on from the weekend being off and was told about a new admission by nursing staff for Resident #2 who she had to provide 1:1. She said she was standing at the door with Resident #2 and Resident #5. She said someone called her name and she turned to see who called her. She said Resident #5 came to the door looking for breakfast trays and then went back into the room. She said Resident #2 was sitting on the bed. She said when she turned back around Resident #2 had his hands around Resident #5's neck and Resident #5 was trying to get loose, and Resident #2 used an open (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 21 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hand and slapped Resident #5 on the face. She said she was able to get the two separated with assistance. She said Resident #2 was moved to a room at the end of the hall. She said Resident #2 woke up that morning and she guessed he was confused and thought his roommate Resident #5 had broken into his home. She said the nurse assessed Resident #5 and he did not have any bruises. She said Resident #5 was scared more than anything. She said Resident #2 continued 1:1 supervision after the incident and staff had to have eyes on him at all times to make sure nothing happened to any of the other residents. She said Resident #2 had not been at the facility long. She said Resident #2 calmed down once he was moved to another room. She said noises irritated Resident #2. She said she had to intervene once with Resident #2 who tried to get at another resident because he acted as if he was going to hurt them. She said Resident #2 was currently at a behavioral hospital. She said following the incident staff had to watch a video on behaviors and how to handle different behaviors. During an interview on 10/24/2023 at 11:55 AM, the Administrator said he started at the middle of August 2023. He said Resident #2 was not currently at the facility and was at a behavioral hospital. He said Resident #2 admitted shortly after he started at the facility. He said the resident came from another sister facility. He said he was admitted to the facility because he needed a secured unit because he was trying to exit seek. He said when he admitted he was ambulatory and was very strong. He said he was kicking on the doors and was placed on 1:1 monitoring at that time. He said that this was Resident #2's second time to go to a behavioral hospital. He said the first time was when he choked Resident #5 and then after that Resident #2 tried to choke a staff member on 9/21/2023. He said Resident #2 was having behaviors on admission to the facility. He said they had him on 1:1 supervision. He said the staff should be within arm reach when they were assigned 1:1 monitoring. He said as Resident #5 was coming back in the room, Resident #2 grabbed him and choked him. He said following the incident, both residents were separated, Resident #2 was placed in a room by himself at the end of the hall and continued 1:1 monitoring. He said staff were provided in-service education on abuse/neglect and 1:1 supervision following the incident. During an observation and interview on 10/25/2023 at 9:20 AM, LVN G was sitting outside of the secured unit at the nurse station. She said she was the nurse assigned to the secured unit. She said two aides were present in the unit that day and usually had 2 aides and 1 nurse assigned daily. She said Resident #2 was on 1:1 most of the time while he was a resident at the facility. She said the first night of him being in the facility, he was placed in a room with Resident #5, but she was not working on that day of the incident when Resident #2 choked Resident #5. She said 1:1 supervision was to ensure a resident would not hurt themselves or another resident. She said Resident #2 had been discharged to a behavioral hospital. She said currently there was not any resident in the secured unit that was on 1:1. She said 1:1 meant staff should be within arm reach of the resident. During an interview on 10/25/2023 9:50 AM, the DON said she had been employed at the facility since 8/29/2023. She said if a resident was on 1:1, then it was for safety, the welfare of the residents and the people around them. She said staff should be within arm reach to prevent an altercation. She said 1:1 was constant supervision with no break. She said if someone needed a break in 1:1, then they would call to ask for relief. She said there should not be any resident-to-resident contact if a resident was on 1:1 supervision. She said the incident with Resident #2 and Resident #5 should not have occurred. Attempted a phone interview with LVN H on 10/25/2023 at 11:43 AM, voicemail box says it is full and unable to leave a message. Record review of a facility policy titled Resident to Resident Altercations with a revised date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 22 of 23 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 455565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/25/2023 indicated, .All altercations, including those that may represent resident to resident abuse, shall be investigated, and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. 2. If two residents are involved in an altercation, the nursing staff will: a. Separate the residents, and institute measures to calm the situation up to and/or including 1:1 supervision of the offending resident . Record review of a facility policy titled Abuse Prevention Program with a revised dated of 1/9/2023 indicated, .1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. 2. Our residents have the right to be free from abuse, neglect. Reporting: 2. An alleged violation of abuse, neglect exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: (2) hours if the alleged violation involves abuse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455565 If continuation sheet Page 23 of 23