Health inspection·June 10, 2023

F 0609 BP:99/56 HR 65 RR 15 o2 97RA T: 98.9. this nurse called EMS to transport res to Hospital A . Level of Harm - Minimal harm or potential for actual harm Record review of CR #229's Progress Notes dated [DATE] at 4:57 a.m. entered by Agency Nurse, read in part, .Res observed on floor in room, in front of sink, away from bed . Residents Affected - Few Record review of CR #229's Patient Record-Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .DISPO: pending evals, likely return to nursing home. Patient is critically ill at risk for at least one organ failure. I spend 45 mins of critical care time . Record review of CR #229's Patient Record Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .[NAME]: #Acute traumatic subdural hemorrhage, on admission. #Acute traumatic IPH . Interview on [DATE] at 10:27 a.m. with RN A, revealed she came into work and LVN A told her CR #229 got out of bed and fell. She said during the day he stayed in his wheelchair and at night he was in the bed. She said CR #229 has not been at the facility since his fall. She said she is not sure how long CR #229 was at the facility. She said he was supposed to turn on his call light when he needed help, but he is non complaint. She said he would sometimes try to walk on his own and staff would tell him that he had to use his wheelchair. She said there are three nurses that works station one. Interview on [DATE] at 10:41a.m. with CNA D, revealed she came into work the next morning and was told CR #229 got up to go to the restroom and fell. She said she never allowed him to go to the restroom by himself. She said she did not allow him to do things on his own. She said she has been working at the facility for a year. She said there are two CNAs on each hall. Interview on [DATE] at 12:10p.m., with the Administrator, revealed he did not self-report the incident because it was not staff related . He said CR #229 was able to explain what happened to staff. He said it was an agency nurse that was working the night of the incident. He said CR #229 had a fall once before on [DATE]. He said CR #229 was discharged to the hospital. Follow-up interview on [DATE] at 2:18 p.m. with the Administrator, revealed he was in challenging times. He said he had challenges with staffing. He said some of the staff do not care. He said, trying to get staff to adhere to facility rules were overwhelming. He said he was going off the information regarding CR #229 that was given to him by some of the staff. He said he was told CR #229 was able to gesture what happened and he assumed CR #229 fell in the restroom. He said he was not sure as to why the initial fall assessment was not done. He said he does not know when they received the information that CR #229 was deceased . He said he never documented the updates on residents that they followed up on. He said they have not documented what was discussed in the morning meetings, especially when it had been documented that they discharged a resident. He said CR #229 died at the hospital. He said they do not go back in to document that kind information. He said he has never done that at any facility he had worked at. He said if a resident died outside of the facility, staff will be notified by word of mouth. He said they [facility] would have to call to receive that kind of information. He said the facility does not receive a death certificate on a resident. He said the family would call and provide information about the resident. He said the only way someone at the facility would know about a deceased resident was by asking. He said he acknowledges that there was conflicting information. Interview on [DATE] at 2:27p.m. with Marketing Admissions, revealed when she found out the information about CR #229 passing away, she informed the staff, the Administrator, and the DON. She said someone from the hospital called and gave her the information that CR #229 passed away. She said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 2 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 had called three times to do a follow up. She said there was nothing clinical reported to her by the hospital about CR #229 . She said they told her CR #229's family was by his bedside, and he was stable. She said she received clinical documentation via the Care Port system that was a referral system. She said when she visited CR #229 at the hospital, he was fine. She said she did not see the family at the hospital. She said there was no documentation regarding the phone call that she received. She said she called the hospital on [DATE] and they called her back at 8:30a.m. and informed her that CR #229 was deceased . She said she was nonclinical, and she did not put information into the PCC. Record Review of the facility's policy titled Prevention and Reporting Resident Abuse and Neglect, undated, read in part, .The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged abuse and neglect. This facility has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment. The Director and the Administrator will designate a person to complete an Investigative Report to: Notify Texas Department of Human Services according to state law as required by state; state specific guidelines for reporting will be followed . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 3 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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, interview, and record review, the facility failed to ensure allegations of abuse and neglect were thoroughly investigated and reported results of the investigation to the state agency within 5 working days of the incident for 1 of 7 residents (CR #229) reviewed for investigate, prevent, and correct alleged violation, in that: Residents Affected - Few The facility did not complete an investigation report regarding CR #229. This failure placed residents at risk of injury, harm, and leaving him susceptible to repeated abuse/neglect and injury of unknown origin. Findings included: Record review of CR #229's face sheet revealed he was a [AGE] year-old male who was admitted on [DATE]. His diagnosis included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety (intense excessive, and persistent worry and fear about everyday situations), and cerebrovascular disease (includes stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms, and vascular malformations). Record review of CR #229's Comprehensive MDS dated [DATE] revealed CR #229 had a BIMs score of 6 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of CR #229's Progress Notes dated [DATE] at 04:39 a.m. entered by Agency Nurse, read in part, .CNA reported to this nurse that during rounds, res was observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. Res is unable to tell nurse what happened. Res has a wound to left temporal region. Res able to move all extremities x4 without pain. Res BP:99/56 HR 65 RR 15 o2 97RA T: 98.9. this nurse called EMS to transport res to Hospital A . Record review of CR #229's Progress Notes dated [DATE] at 4:57 a.m. entered by Agency Nurse, read in part, .Res observed on floor in room, in front of sink, away from bed . Record review of CR #229's Patient Record-Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .DISPO: pending evals, likely return to nursing home. Patient is critically ill at risk for at least one organ failure. I spend 45 mins of critical care time . Record review of CR #229's Patient Record Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .[NAME]: #Acute traumatic subdural hemorrhage, on admission. #Acute traumatic IPH . Interview on [DATE] at 10:27a.m., with RN A, she said during shift report LVN A told her CR #229 got out of bed and fell. She said CR #229 has not been at the facility since he fall. Interview on [DATE] at 10:30a.m. with CNA F said she used to assist CR #229 with everything. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 4 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said she would transfer him to the chair and assist him to the bathroom. She said his balance was unsteady. She said the resident would tell her he didn't need any help. She said she wasn't present when the resident fell. She said his behavior was always good towards her. She said this was the first incident of him falling. Interview on [DATE] at 10:41a.m., with CNA D said she came into work the next morning and was told CR #229 got up to go to the restroom and he fell. Interview on [DATE] at 12:10p.m. the Administrator said he did not complete a self-report or an investigation because the incident because it was not staff related . He said CR #229 was able to explain what happened to staff. He said CR #229 had a fall once before on [DATE]. He said CR #229 was discharged to the hospital. Follow-up interview on [DATE] at 2:18p.m., the Administrator said he said regarding CR #229, he was going off the information that was given to him by some of the staff. He said he was told CR #229 was able to gesture what happened and he assumed he fell in the restroom. He said he does not know when they received the information that CR #229 was deceased . He said he never documented the updates on residents that they follow up on. He said they have not documented what is discussed in the morning meetings, especially when it has been documented that they discharged a resident. He said CR #229 died at the hospital. He said they do not go back in to document that kind information. He said he has never done that at any facility he has worked at. He said if a resident dies outside of the facility, staff will be notified by word of mouth. He said they will have to call to receive that kind of information. He said the facility does not receive a death certificate on a resident. He said the family will call and give information about the resident. He said the only way someone at the facility would know about a deceased resident is by asking. He said he acknowledges that there was conflicting information. Interview on [DATE] at 2:27p.m., with Marketing Admissions, she said someone from the hospital called on [DATE] and gave her the information that the CR #229 passed away. She said after she found out, she informed the Administrator and the DON that CR #229 passed away. Interview on [DATE] at 2:40 p.m. with the DON, said CR #229 was gone from the facility when she arrived to work that morning. She said she was told he had fallen, and staff noticed he was injured, and they sent him out to Hospital A. She said staff did not know how or where he hit his head . She said they wanted to get CR #229 assessed. She said she did not report the incident because he was discharged to the Hospital A, and no one witnessed the incident. Record Review of the facility's policy titled Prevention and Reporting Resident Abuse and Neglect, (revision date not listed) read in part . The Director and the Administrator will designate a person to complete an Investigative Report to: Notify Texas Department of Human Services according to state law as required by state; state specific guidelines for reporting will be followed. The Administrator and Director of Nursing are responsible for investigation and reporting: Investigation of all alleged violations will be done under the direction of the DON and/or Administrator. This may utilize a Complaint Form, initial Investigation for Possible Abuse Violations form, or other written documentation. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 5 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's assessment was completed within 7 and 14 days, and electronically transmit encoded, accurate, and complete MDS data to the CMS System for a subset of items upon a resident's transfer, reentry, discharge, and death for 1 of 3 discharged residents (CR #33) reviewed for encoding and transmitting resident assessments, in that: Residents Affected - Few - The Facility failed to complete and transmit a discharge MDS for CR #33. This failure could place discharged residents at risk of not having a proper discharge and not receiving services post discharge. Findings include: Record review of CR# 33's admission record dated [DATE] revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged home on [DATE]. He had a diagnoses of repeated falls and tracheostomy status (a surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing). Record review of CR #33's admission MDS assessment dated [DATE], revealed he had a BIMS of 13 of 15 which indicated he was cognitively intact. He required supervision to limited assistance with 1 person with most ADLs (Activities of Daily Living). Record review of CR #33's EMR on [DATE] revealed: he had no discharge MDS on record. Record review of CR #33's Assessment History- MDS Assessment Snapshot , revealed there was no discharge MDS on record. Record review of CR #33's Physician Discharge summary dated [DATE], revealed he was discharged home with home health care. Interview on [DATE] at 11:40am. with the MDS Coordinator A, she said that there were no discharge assessments found in the facilities EMR system for CR #33. She said she was responsible for completing the discharge MDS assessments and had not completed one for CR #33. She added that she missed this in the system. Record review of facility provided CMS's RAI Version 3.0 Manual, Chapter 5: Submission and Correction of The MDS Assessment revised 11/2019 revealed:5.1 Transmitting MDS data- All Medicare and/or Medicaid-certified nursing facilities or agents of those facilities must transmit required MDS data records to CMS. 5.2 Timeliness Criteria- completion timing . For all other comprehensive MDS assessments, Annual assessment updates . The completion may be no later than 14 days from the ARD. Upon a resident's entry, discharge to community, discharge to another facility or discharge deceased , a subset of items but be completed within 7 days of the Event Date. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 6 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan for each resident, consistent with the resident rights for 1 of 5 residents (Resident #70) reviewed for develop and implement comprehensive care plan, in that: - The facility failed to address the smoking status in Resident #70's care plan. This failure could place residents at risk for receiving decreased quality of care and or not receiving the appropriate required care and services to meet their individual needs. The findings include: Record review of the facility admission record dated 5/17/2023 revealed Resident #70 was admitted on [DATE]. Resident #70 was a 64-year- old male. Resident #70 had diagnoses that included Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems) and pneumonia (an infection that affects one or both lungs). Record review of Resident #70's admission Minimum Data Set Assessment (MDS) dated [DATE] revealed that Resident #70 had a BIM (Brief Interview for Mental Status) score of 13 out of 15, cognition was intact. Resident #70 required supervision with ADL's (Activities of Daily Living). Record review of the smoker list, no date provided revealed that Resident #70 was a smoker at the facility. Interview on 5/19/2023 at 11:22 a.m. with the DON (Director of Nursing), revealed that Resident #70's comprehensive care plan was not completed for smoking. She said she had the responsibility to make sure this was done along with the MDS Coordinator. She said that Resident #70 had the potential to have an unsafe smoking environment without the comprehensive care plan to address smoking. She said that she was the only one who missed it. She completed Resident # 70's smoking assessment and confirmed adding smoking to his comprehensive care plan on 5/16/2023. Record review of the revised Comprehensive Care Plan dated and created on 5/16/2023 read in part . Resident #70 has been advised of the facility smoking policy. Resident #70 requires supervision with smoking . Record review of the facility policy and procedure entitled Comprehensive Care Plans, undated, read in part, . The facility will develop and implement a comprehensive person-centered care plan for each resident, to meet a resident' medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 7 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 - Immediate jeopardy to resident health or safety 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 interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 43 residents (CR #229) reviewed for free of accidents, hazards, supervision, and devices. -The facility failed to develop any interventions following CR #229's fall on [DATE]. CR #229 fell again on [DATE], suffered a traumatic head injury and died as a result of his injuries. On [DATE] at 3:09 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE] at 2:36 p.m., the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure could affect residents who require assistance with ADLs and place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings included: Record review of CR #229's face sheet revealed he was a [AGE] year-old male who was admitted on [DATE]. His diagnosis included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety (intense excessive, and persistent worry and fear about everyday situations), and cerebrovascular disease (includes stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms, and vascular malformations). Record review of CR #229's Comprehensive MDS dated [DATE] revealed CR #229 had a BIMs score of 6 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of CR #229's Record review CR #229's undated comprehensive care plan revealed the following: Fall risk: CR #229 has the potential for falls r/t unsteady gait, history of falls, and poor safety awareness with poor impulse control .Date: [DATE] .Created on: [DATE] .Revision on: [DATE]. Goal the resident will be free of falls during the next 90 days .Date initiated [DATE] .Revision on: [DATE] .Target date: [DATE]. Interventions anticipate and meet the resident's needs .Date initiated:[DATE] .Created on: [DATE] .Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter, remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes .Date initiated: [DATE] .Created on: [DATE]. Therapy for strengthening .Date initiated; [DATE] .Created on [DATE] .Revision on: [DATE]. Record review of CR #229's Progress Notes dated [DATE] at 4:39 a.m. entered by Agency Nurse, read in part, .CNA reported to this nurse that during rounds, res was observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. Res is unable to tell nurse what happened. Res has a wound to left temporal region. Res able to move all extremities x4 without pain. Res (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 8 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 BP:99/56 HR 65 RR 15 o2 97RA T: 98.9. this nurse called EMS to transport res to [Hospital A] . Level of Harm - Immediate jeopardy to resident health or safety Record review of CR #229's incident report dated [DATE] at 3:35a.m., read in part, .Nurse Description: CNA reported to this nurse that during rounds, res as observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. When asked what happened resident did gesture to the bathroom. Res has a wound to the left temporal region. Resident is able to move extremities x4 without pain. Res BP:99/56 HR 65 RR 15 o2 97RA T: 98.9. Resident Description: Asked to give more details as to what happened resident pointed to bathroom but did not say anything else. Immediate Action Taken: Res transported to Hospital A of head injury. Residents Affected - Few Record review of CR #229's Patient Record-Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .DISPO: pending evals, likely return to nursing home. Patient is critically ill at risk for at least one organ failure. I spend 45 mins of critical care time . NERO: #Acute traumatic subdural hemorrhage, on admission. #Acute traumatic IPH . Record review of CR #229's PT Evaluation & Plan of Treatment dated [DATE] at 6:47a.m., read in part, New Goal/Short Term Goals: Patient will safely ambulate on level surfaces 60 feet using RW with Min assist for task segmentation with reduced risk for falls in order to increase independence with all functional ambulation and to reduce risk for loss of balance (Target date: [DATE]). New Goal/Bed Mobility: Patient will safely perform functional transfers with Stand Assist for push up from arms of chair and for correct hand/foot placement with reduced risk for falls in order to facilitate increased (I) with functional mobility throughout facility and decreased level of assistance from caregivers (Target Date: [DATE]). New Goal/Transfers: Patient will safely ambulate on level surfaces 125 feet using RW with Stand by assist for task segmentation with reduced risk for falls in order to increase independence with all functional ambulation and to reduce risk for loss of balance (Target date [DATE]) . Interview on [DATE] at 10:27a.m., with RN A said she came into work and LVN A told her CR #229 had gotten out of bed and fell on [DATE]. She said during the day he stayed in his wheelchair, and at night he was in the bed. She said CR #229 has not been at the facility since his fall. She said she is not sure how long CR #229 was at the facility. She said he is supposed to turn on his call light when he needs help, but he is non-compliant. She said he would sometimes try to walk on his own, and staff would tell him that he had to use his wheelchair. She said there are three nurses that works station one. Interview on [DATE] at 10:30 a.m. with CNA F said she used to assist CR #229 with everything. She said she would transfer him to the chair and assist him to the bathroom. She said his balance was unsteady. She said the resident would tell her he didn't need any help. She said she was not present when the resident fell. She said his behavior was always good towards her. She said this was the first incident of him falling. Interview on [DATE] at 10:41 a.m., with CNA D said she came into work the next morning and was told CR #229 got up to go to the restroom and he fell. She said she never allowed him to go to the restroom by himself. She said she did not allow him to do things on his own. She said she has been working at the facility for a year. She said there are two CNAs on each hall. Interview on [DATE] at 12:10 p.m. the Administrator said he was told by staff that CR #229 had fallen and was able to explain what happened to staff. He said it was an agency nurse that was working the night when CR #229 fell. He said CR #229 had a fall once before on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 9 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Follow-up interview on [DATE] at 2:18p.m., the Administrator said he is in challenging times. He said he has had challenges with staffing. He said some of the staff do not care. He said, trying to get staff to adhere to his rules is overwhelming. He said regarding CR #229, he was going off the information that was given to him by some of the staff. He said he was told CR #229 was able to gesture what happened and he assumed he fell in the restroom. He said he was not sure as to why the initial fall assessment wasn't done. He said he does not know when they received the information that CR #229 was deceased . He said he never documented the updates on residents that they follow up on. He said they have not documented what is discussed in the morning meetings, especially when it has been documented that they discharged a resident. He said CR #229 died at the hospital. He said they do not go back in to document that kind information. He said he has never done that at any facility he has worked at. He said if a resident dies outside of the facility, staff will be notified by word of mouth. He said they will have to call to receive that kind of information. He said the facility does not receive a death certificate on a resident. He said the family will call and give information about the resident. He said the only way someone at the facility would know about a deceased resident is by asking. He said he acknowledges that there was conflicting information. Interview on [DATE] at 2:40 p.m. with the DON said she did not talk to CR #229 about his fall. She said CR #229 was gone from the facility when she arrived at work. She said she was notified by staff that he had fallen, and staff noticed he was injured, and was sent to Hospital A. She said staff didn't know how or where he hit his head. She said they wanted to get CR #229 assessed. She said she did not report the incident because he was discharged to the Hospital A, and no one witnessed the incident. Interview on [DATE] at 12:50 p.m. with RN A, said she worked with CR #229 for the short time he was at the facility. She said she provided day to day care for him. She said CR #229 had to be redirected a lot because he wanted to be self-sufficient. She said on her shift, he did well with staying in his wheelchair. She said the night the CR #229 had the fall; she came into work and LVN A reported it to her. She said she is not sure if it was LVN A who gave her the report. She said staff told her that CR #229 got up in the middle of the night and was found on the floor in front of the sink. She said she was told he was bleeding from his head, and they sent him out for evaluation. She said she cannot remember if there was anything put in place prior to the second fall. She said CR #229 had a low bed. She said if he asked for assistance to the bathroom, they would help him, but he would not ask for assistance. She said he thought he could do everything on his own, but he couldn't anymore. She said she checked on him a lot. She said he was able to get up and go to the restroom by himself, but he had an unsteady gait. She said CR #229 did not need two persons assist. She said he only needed one person assists to go to the bathroom. She said when she would assist him to the restroom, she would take his wheelchair and put in the bathroom doorway. She said she helped him pivot and put him on the stool. She said if something was put in place for CR #229, he could carry out that plan. She said sometimes his cognition would be better than it would at other times. She said he was able to communicate his needs to her. She said she would ask CR #229 if he was in pain and needed assistance to the bathroom and he would answer her appropriately. She said she was surprised he had a BIMs score of 06. Interview on [DATE] at 1:27 p.m. with MDS Coordinator A, said she has been the MDS nurse at the facility for 21 years. She said she is responsible for doing the MDS assessments, LTC's, MI's, and she also does PASSAR's for the residents. She said the DON and the ADON are responsible for the care plans and care plan meetings. She said whatever triggers are from the MDS, they are added to the care plan. She said on the MDS assessment if it says limited assistance for toilet use, it means that resident needs assistance to go to the bathroom. She said extensive assistance means he needs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 10 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 - Immediate jeopardy to resident health or safety Residents Affected - Few someone to help him all the time. She said she knows that CR #229 used his walker, and he would say different words or wrote them down. She said he could articulate his words. She said limited toilet use means moderate assist which means someone might need to watch him but not assist or they can help clean him. She said it is a difference when it comes to extensive assistance and limited assistance. She said if there is a care plan that says limited assistance and a MDS that says extensive assistance in a certain care area, it is a problem because it can affect the proper guidance or care that is needed for the resident. She said she cannot answer why the MDS assessment does not match the care plan. She said CR #229 was not on a toileting program. She said CR #229 was able to move around, and he was able to go leave his bed and go to the bathroom. She said when she did the MDS assessment for CR #229, he seemed to need extensive assistance. She said on [DATE], she said did not do the intervention process on the care plan because she does not create the care plans. She said the nurses and the ADON are responsible for completing the fall risk assessments. Interview on [DATE] at 1:51 p.m. with the ADON, said is the Interim Assistant DON, till they find someone permanently. She said she checks the resident's admission assessments, and she does what is needed at the facility. She said she also review the resident's orders. She said she has also written care plans. She said she looks at the resident's diagnosis and their assessments, and their history. She said she does not receive information from the MDS on how to write the care plan. She said she has spoken to CR #229 when she needed to get consent on a vaccine. She said she called his family member for that information as well. She said MDS assessments are done quarterly or if there was a significant change. She said the MDS, and the care plan should correlate. She said she is responsible for the baseline care plan. She said the baseline care plan is done upon admission, which is what she had assessed on the resident. She said the comprehensive care plan is more detailed and is pulls more data on the resident. She said the importance of the care plan is so staff can establish a plan of care for the resident. She said the importance of an MDS assessment is to show what service is needed for the resident. She said CR #229 was able to move around on his own. She said he went to the restroom on his own. She said when she went to ask him about a vaccine, he was coming out of the restroom with his wheelchair. She said on [DATE], she was told he had a fall and was bleeding from his head and was sent to the hospital. She said she was aware that CR #229 had fall on [DATE] as well. She said he was able to understand what was being care planned. She said CR #229 could use the call light and moving the bed up and down. Interview on [DATE] at 2:15 p.m., with the DON, said she is responsible for everything. She said she oversees the nursing department. She said she is responsible for the comprehensive care plan. She said she has been the DON since [DATE] and was the interim during February of 2022. She said the care plan comes from the trigger assessment that was on the MDS. She said the MDS assessment can trigger certain problems a resident has, and their diagnosis and she would create the care plan. She said CR #229 was alert and oriented. She said he could speak, but it was not that clear. She said he was also able to write. She said he could walk but it was a scary walk. She said he was able to tell you when he needed to go to the bathroom. She said a BIM's score of 06 means it is a low score and that the person is not cognitively inclined. She said staff would tell CR #229 to call for assistance and to use the call light when he needed to use the restroom, but he would go on his own. She said extensive assistance means the staff is doing the work 75 percent of the time. She said limited assistance means the resident is doing 75 percent of the work. She said it would not be an issue if the MDS and the care plan had something different. She said if she goes into a resident's room and they can make their needs known, she will document what they can relate to, and that would be it was resident centered. She said CR #229 was not always verbal, but he can write things down. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 11 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 - Immediate jeopardy to resident health or safety She said what she was told by LVN D, was that CR #229 was on the ground, and he had a head injury. She said she told her to see if CR #229 could write it down. She said she was not sure if CR #229 ever wrote anything down. She said CR #229 could walk and staff would sometimes help him. She said the MDS extensive assistance, and two-person assist doesn't really mean that is what he needs. When the DON was asked to explain what she meant by her last statement, she said she did not know how to explain what she meant. Residents Affected - Few Interview on [DATE] at 2:35 p.m., with the Administrator, said he has been the administrator at the facility for 31 years. He said he is a hands-on administrator, and he goes to resident council meetings when asked. He said the residents and the resident's family members has his personal phone number. He said his first interaction with CR #229 was when he first came to him and introduced himself. He said the second time was after his first fall. He said the first fall that occurred on [DATE] was not investigated and it was not reported to the state. He said it was a fall without injury, so he did not feel there was a reason to report it. He said he does not know why there wasn't an intervention completed. He said he has told staff to be more cautious about the residents having falls. He said there was a morning meeting about CR #229's fall. He said if there was a fall in the facility, they would have a follow up in a morning meeting. He said if a resident has a fall and there is no updated assessment, or a prevention put in place, a resident can have another fall with an injury. He said it is not a problem to have a care plan that is different from the MDS. He said when he first met CR #229, he was not total assist. He said CR #229 showed no difference in how he moved after he fell on [DATE]. He said he was the same on [DATE]. He said he was able to do things on his own. He said does not help with the MDS assessments. He said if a resident has a fall, an assessment should be updated. He said the care plan should be updated as well. He said the care plan should reflect the needs of the resident, so staff would know how to care for the resident. He said he did not receive CR #229's death certificate. He said medical records could ask for it, but they do not automatically receive that information. He said when CR #229 had his second fall on [DATE], he was told he had a fall and had a gash. He said they called the doctor, and CR #229 was sent out to the hospital. He said he does not know how long after CR #229 left the facility, that he expired. Telephone Interview on [DATE] at 10:07 a.m., with LVN D, said when CNA G was doing rounds, she let her know she observed CR #229 on the floor. She said when she went into the room, his bed was in a low position. She said he was near the bathroom. She said it looked like he hit his head. She said he was on his back, and it looked like he was trying to get up. She said CNA G got another nurse to help. She said she cannot remember the nurse's name who came to help her with CR #229. She said she called 911. She said she tried to ask CR #229 what happened and what he was doing, and she said he was pointing towards the bathroom and couldn't really speak. She said he used a communication board to communicate daily. She said she did not have much communication with him during the night. She said CR #229 had a roommate as well. She said he could walk on his own, unsteadily. She said she CR #229 did not always try to get up through the night to use the restroom. She said he always made gestures and never really spoke to her. She said she does not remember if she worked with him in the past. She said the night CR #229 had fall on [DATE], he did not say he was in pain. She said when she assessed him, he had a laceration on his head. She said CR #229 was not moaning. She said the bathroom is no more than 10 feet away from his bed. She said she did a risk management report. She said she does not recall if she did a change of condition report. She said she contacted the on-call service (physician) for the facility. She said she left a voice mail for whomever was listed under his contacts. She said when CR #229 went to the hospital, she called the DON. She said she did not think the fall was suspicious. She said the facility made sure she included a witness statement inside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 12 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 the risk assessment. She said it is in the risk management portion. Level of Harm - Immediate jeopardy to resident health or safety Interview on [DATE] at 10:52 a.m., with family member, said she was told by the facility that CR #229 accident happened in the middle of the night. She said they told her he fell, and he had to go to the hospital. She said they told her he had a gash on his head, and he was conscious. She said she did not hear from the facility once her brother arrived at Hospital A because they l took over. She said she went by the facility to pick up CR #229's belongings and she was able to retrieve everything except his necklace and hearing aid. She said CR #229 passed away on [DATE]. She said at the hospital, they did a full body MRI on CR #229, and it showed that the gash was more than 5 inches. She said it went straight up from his head to his eyebrow. She said the MRI also showed a brain bleed. She said CR #229 seemed disoriented and was acting up and being erratic and trying to get out of his bed. She said CR #229 was transferred on a Sunday from Hospital A, to a specialized trauma hospital. She said once she arrived at the main hospital, CR #229 couldn't open his eyes or do anything. She said she flew out again on [DATE] and his lungs started to fail. She said her mom was in rehab and she took her out of rehab because she is the legal guardian of CR #229. She said her mom talked to the brain surgeon, but he could not say if CR #229 would wake up again. She said CR #229 was on a breathing machine and was not breathing on his own. She said he was intubated. She said CR #229 death certificate said the cause of death was blunt force trauma to the brain and a hematoma in the brain. She said when she went to the facility on [DATE] to pick up CR #229 things, staff told her the night her brother fell, he was using a walker. She said she was not notified by staff when he fell on [DATE]. Residents Affected - Few Interview on [DATE] at 11:44 a.m. with PT A said, CR #229 was evaluated for physical therapy on [DATE] and for occupational therapy on [DATE] as well as speech therapy. He said he was not evaluated upon admission on [DATE] because he was a Hospital C resident and they do not come into the facility with approvals for therapy, which means if he came to the facility on the [DATE] he would be evaluated the following week. He said he submitted documentation to Hospital C on a Monday. He said CR #229 never participated in therapy. He said he is not sure why he wasn't evaluated after the first week. He said CR #229 might not have been feeling well. He said it was reported to the therapy department on [DATE] about a resident with a recent fall during transfers. He said he evaluates a resident, depending on when they fall, if they don't normally fall, and he will screen and evaluate a resident and recommend therapy. He said residents that fall and don't move around a lot will be screened. He said CR #229 was using a rolling walker. He said he had been evaluated for the safety of the walker. Followed-up interview on [DATE] at 1:18 p.m., with the DON and the Administrator. The DON said, the root cause was that CR #229 was impulsive and was not asking for help as suggested. She said she discussed the IDT fall in the morning meetings. She said she removed some of the things that was in the room and straightened up the clutter. The Administrator said he did not document the clutter, that he just rearranged the clutter. The DON said staff assigned to therapy evaluated CR #229 on using a rolling walker and determined if it was safe to be used or not. She said she knew right away if it was safe or not. She said she is not sure if anyone took the walker away. The Administrator said he could not force CR #229 to not use the walker because that would be taking away his rights. He said when they asked him not to get up, CR #299 would listen. Followed-up interview on [DATE] at 1:25 p.m., with the Administrator, said CR #229 was able to verbalize the things he needed. He said when he received CR #229's medical record, he did not think to report it. He said he thought CR #229 was coming back to the facility. He said he had a conversation with staff from Hospital C, and he never thought the blame would be put on him regarding CR #229. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 13 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Followed-up interview on [DATE] at 2:11 p.m., with the DON said, MDS Coordinator A, social services, activity services, and the dietary manager assist with completing the MDS assessment. She said section G of the MDS assessment is completed by the MDS Coordinator A. She said she and MDS Coordinator A, used to be responsible for the comprehensive care plan. She said she was responsible for the comprehensive care plan while CR #229 was present at the facility. She said MDS Coordinator A was responsible for the admission MDS assessment. She said she cannot speak on the discrepancy of the care plan and the MDS assessment because she did not see it as a big discrepancy. She said she did not check to see if there was a discrepancy because she did not see what the surveyors were seeing. She said she did the care plan based on what staff was telling her and not what was documented. She said she did not realize that certain care areas regarding CR #229 was not documented. She said CR #229 could ambulate because he could move. She said if he had a significant change, she has 14 days to update the assessment. She said she did not think the fall could have been prevented. She said he was put bed in the low position. She said CR #229 wanted to be independent. She said she would not do an SBAR or MDS assessment, only a fall risk assessment. She said no one told her that CR #229 had a walker the night he fell, on [DATE]. She said the walker was in his room and she cannot take the walker away. She said a Hospital C resident does not come into the facility with orders for rehab. She said something must happen for a Hospital C resident to receive rehab. She said it is difficult for a Hospital C resident to receive rehab. She said there are some residents who come on admission with rehab orders. She said it does not always happen. She said the facility will have to push for it, not Hospital C. Interview on [DATE] at 12:09 p.m., with the Medical Director, said he has been sharing his responsibility with Physician B. He said at the nursing facility, the meetings are usually once a month. He said he often attends the meetings virtually. He said he goes to the meetings in person when the issues are more complex. He will go over the issues with MDS Coordinator A, and the Administrator. He said in the meetings if there was an unwitnessed fall or a serious injury occurred, it will be discussed well before QAPI comes up. He said if a major fall happened that caused a brain bleed, it would be something that you would immediately report to the state. He said regardless of if the resident could communicate or not, it will still need to be reported to the state. Interview on [DATE] at 12:38 p.m., with Physician B said she was only at the facility once a week. She said her last day working at the nursing facility was on [DATE]. She said when she was working at the facility, she participated in QAPI once a month. She said she attended in person, and they discussed falls, who fell and followed up on plans after the falls. She said she will look at CR #229's medical history, and what happened with the fall. She said she would ask questions about medication before making a [NAME] to report an incident to the state. She said if the resident is deemed by therapy not safe to use different devices to keep them safe and they still want to use them, she said it is their right and they cannot hold a resident down or retrain them. She said if a resident takes a walker even after he's been redirected it will put them in an interesting position. She said some residents have tried to hit her and other staff members. Record Review of the facility's policy titled Fall and Post-Fall Management, undated, read in part, . Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for the resident as well as staff safety. Identify residents at risk for falls during ADL execution by resident individually or with staff assistance. Initiate preventative approaches. Provide appropriate strategies and interventions directed to resident, environmental factors, and staff. Provide learning opportunities. Monitor and evaluate resident outcome . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 14 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 - Immediate jeopardy to resident health or safety This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:09 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 3:10 PM. The following Plan of Removal was submitted and accepted on [DATE] at 1:29 PM. Plan of Removal Residents Affected - Few [DATE] Submission #3 Immediate action: Other residents affected: o Forty-three (43) current facility residents have been identified and assessed by the DON, ADON, MDS Coordinator and Rehab Director as having the potential to be affected by the deficient practice on [DATE]. o The DON, ADON, MDS Coordinator and Rehab Director will review the Plans of Care and Kardex of the 43 residents at risk for falls to ensure universal fall precautions, appropriate and adequate assistive devices and interventions are in place to prevent unnecessary falls and accidents to be completed on [DATE]. The DON, ADON, MDS Coordinator and Rehab Director will investigate all new falls and ensure interventions are in placed within 24 hours during the daily Stand-Up meeting utilizing the Post Huddle Fall Worksheet. The Administrator will monitor the IDT Team to ensure all falls are appropriately investigated and correct interventions are updated and in place to prevent falls. o The DON and Nurse Managers will in-service Direct Care Staff regarding universal fall precautions, the Kardex system and the importance of residents having appropriate and adequate assistive devices, fall interventions and needed assistance with transfer and toileting. In-services began on [DATE] and will be completed with current Direct Care Staff on [DATE]. All other nursing staff not currently on shift or on leave will be in-serviced upon return to work prior to providing care. Facilities Plan to Ensure Compliance: o A Quality Assurance and Performance Improvement meeting was held on [DATE] with the Medical Director, Administrator, DON, ADON, Rehab Director, and MDS Coordinator to review the allegations surrounding

F689 tag and the plan moving forward related to the IJ Plan of Removal. It was determined by the committee that the DON, ADON, Rehab Director and MDS Coordinator will review fall policy(s), implementation of fall interventions within 24 hours, assessment of high fall risk residents in regards to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 15 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete inappropriate durable medical equipment usage and provide a care plan meeting with the resident and/or responsible party to discuss unsafe practices and resolution, such as removal of equipment, upon admission and as needed. o Facility process on how to access the Kardex in Point Click Care - In-services performed by DON and ADON began on [DATE] and will be completed with current nursing staff by [DATE]. All other nursing staff not currently on shift will be in-serviced and a post- test administered by [DATE]. All new hires will receive training on the same topics during new employee orientation and prior to providing care. Agency staff will also receive training on the same topics at start of their shift prior to providing care. A posttest will be provided for understanding and competency. If in-house and agency staff members don't achieve 100%, they will be re-ed[TRUNCATED] Event ID: Facility ID: 455613 If continuation sheet Page 16 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of fifteen residents (Resident #27 ) who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, in that: -The facility did not have the supplies available to replace the Gastrostomy Tube for Resident #27 for at least 5 days and used an indwelling urinary Foley catheter for at least 5 days, instead of an actual gastrostomy tube. -The facility did not have appropriate physician orders for Resident #27's medications to be administered through the temporary indwelling urinary Foley catheter, while it was being used as a gastrostomy tube. The failure could place residents with gastrostomy tubes at risk for developing significant complications, including infections, aspiration, hospitalizations, or death. Findings included: Record review on 5/19/23 at 9:08 a.m. of Resident #27's admission Record dated 5/19/23 revealed she was a [AGE] year old female who admitted to the facility on [DATE] had some of the following diagnoses: gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), dysphagia (difficulty or discomfort in swallowing), agnosia (inability to interpret sensations and hence to recognize things, typically as a result of brain damage), flaccid hemiplegia affecting right dominant side (severe or complete loss of motor function on one side of the body), Type II diabetes mellitus, (chronic condition that affects the way the body processes blood sugar and moderate protein calorie malnutrition. Record review on 5/16/23 at 9:22 a.m. of Resident #27's admission MDS dated [DATE] revealed she had a BIMS score of 2 indicating she was severely cognitively impaired and was totally dependent on at least one staff member for eating. She was coded as having an active diagnosis of malnutrition and gastrostomy status. She was also coded as receiving 51% or more of her total calories from a tube feeding. Record review of Resident #27's physician order summary dated May 2023 revealed no orders for enteral (state of being fed through a tube) feedings to be administered through a temporary/short-term Foley catheter being used as her gastrostomy site, Record review of Resident #27's physician order summary dated May 2023 revealed no orders for medications to be administered through the temporary/short-term Foley catheter being used as her gastrostomy site. Record review on 5/18/23 at 2:12 p.m. of Resident #27's progress notes dated 5/8/23 and created by LVN A, revealed the following entry: gtube is noted to be clogged at this time. (sic)unable to flush or unclog at this time. (sic)gtube replaced by (employee initials) LVN with 16 F foley with 5 cc balloon. 5 cc of residual returned; placement verified per auscultation. No s/s of acute distress noted at this time. Gtube site care provided at this time. Stoma (artificial opening made into a hollow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 17 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few organ, especially one on the surface of the body leading to the gut), remain clean, dry, and free of s/s of infection at this time. There was no documentation that Resident #27's physician had been notified. There was no SBAR or change of condition report. There was no incident or accident report regarding Resident #27's gastrostomy tube becoming clogged and or dislodged. Record review of Resident #27's progress notes on 5/18/23 at 2:44 p.m. that were dated 5/13/23 and created by LVN C, revealed the following entry: CNA notified this nurse that resident had vomited. Upon entering resident's room large amount of coffee ground emesis noted on resident gown. TF was stopped and resident's head was elevated to a 90-degree angle. Resident has two more episodes of emesis while this nurse was in the room. VS-BP145/86 P 105 T 97.9 R 20. DON made aware. Pager called for NP A and RP contacted with no answer and voicemail not set up to leave message. EMS A contacted to transport resident to ER. Repeated attempts to contact LVN C during the investigation on 5/17/23, 5/18/23 and 5/19/23 went unanswered through exit. Record review of Resident #27's progress notes on 5/18/23 at 3:33 p.m. that were dated 5/14/23 and created by RN A read in part, .Late entry, Received a phone call from a physician (on 5/13/23) with Hospital A with question regarding resident's feeding tube, a Foley catheter had been inserted because there was not a gastrostomy tube, in the correct size, available. Resident was sent to hospital for vomiting, possibly coffee ground emesis per the report from the nurse who sent her to the ER, writer checked placement by auscultation and gastric aspiration the day before she went to the hospital and results indicated it was safe to use . Record review of Resident #27's hospital records on 5/18/23 at 4:08 p.m. that were dated 5/14/23 read in part, .discharge diagnoses: coffee ground emesis, PEG tube malfunction, pneumonia, constipation, protein-calorie malnutrition, moderate . Interview with LVN A on 5/17/23 at 2:08 p.m., she said that she was the author of the progress note dated 5/8/23. She said that Resident #27's gastrostomy tube became clogged, and she could not get it to function on her shift. She then said that the gastrostomy tube became dislodged. When asked if she received a physician order to change the gastrostomy tube, she said that she was uncomfortable changing the tube after it became dislodged and asked LVN B to assist her in replacing it. She said that LVN B changed the tube by inserting a 16 french foley catheter because the facility did not have Resident #27's size for the gastrostomy tube replacement catheter. LVN A said that after LVN B changed the tubing, Resident #27's gastrostomy site began working and functioning properly again. LVN A said that she was able to restart Resident #27's enteral feeding, medications and hydration at that time as previously ordered. When asked if she notified the physician, LVN A said she could not remember. LVN A said it should have been documented that Resident #27's physician had been notified but she could not recall if she had notified the physician. LVN A said that she did not remember if she was ever able to reach Resident #27's physician for any orders. LVN A said that she did not know why she did not complete an SBAR/change of condition or incident report for Resident #27. She acknowledged that a resident's G-tube becoming dislodged was a change in condition. She said she could not recall if she had been trained on gastrostomy tube care. Interview with RN A on 5/17/23 at 2:33 p.m., she said she cared for Resident #27 when she had the temporary/short-term Foley catheter used as a gastrostomy tube. She said because the site functioned properly, she used it for medications and feedings. RN A said it was not uncommon to temporarily use an indwelling urinary catheter tubing in lieu of actual gastrostomy tubing, until the actual gastrostomy tubing became available. She said she had been told via report from other nursing staff that Resident #27's actual gastrostomy tubing was on back order and would be arriving any day. When she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 18 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed the facility policy, she said she did not know what temporary or short-term timeframes specifically meant. When asked if she felt like 5 days was too long a period to use temporary tubing, RN A said that it was working and she did not question it. RN A said she was not sure if she had been trained by the facility on gastrostomy tubes. RN A said that she did not think that using the Foley catheter as a gastrostomy tube, for 5 days, was an issue because she thought everyone (DON, MD, RP), knew about it already. She stated she did not notify Resident #27's physician or NP because she thought it had already been done. Observation of Resident #27 on 5/18/23 during medication administration on 5/18/23 at 8:41am. The administration was performed by RN A and Resident #27 tolerated well. Observation of Resident #27's gastrostomy tube tubing intact that was patent and functioned properly throughout the medication administration. There was no drainage around the site and no signs or symptoms of infection. There were no additional surgical sites or bandages observed, indicating, the gastrostomy tubing was replaced in the hospital, using Resident #27's existing gastrostomy tube site. Resident #27 was non-verbal but waved her hand and nodded her head in affirmation that she was doing well and had no pain or concerns with the site. Interview with LVN B on 5/18/23 at 9:41 a.m., she said that she was called to Resident #27's bedside on 5/8/23 by LVN A to help her with Resident #27's gastrostomy tube. LVN B said that when she got to Resident #27's bedside the gastrostomy tube was out and laying on top of Resident #27's gown. LVN B said that there was no blood or other drainage and that Resident #27's gastrostomy tube site/opening in her abdomen appeared very small to her and she was fearful it would close, as she was not familiar with, and did not regularly work with Resident #27. She said that she replaced the tube using a 16 French Foley catheter tubing because they did not have a small enough gastrostomy catheter available in the facility stock/supply. She said that both she and LVN A looked and could not find another option. LVN B said she thought LVN A had already called and or contacted Resident #27's physician and RP. LVN B said that she had been trained by facility on gastrostomy tubes including use, changes and troubleshooting issues, but could not recall when she had the training last. LVN B said she believed it was upon hire. LVN B said she did not document on Resident #27 because it was not her resident and again, she thought LVN A was documenting everything including contacting the physician and obtaining orders. Interview with DON on 5/18/23 at 1:04 p.m., she said that there was no documentation that LVN A, LVN B, LVN C or RN A had contacted Resident #27's physician. The DON said she contacted Physician A and he said he was not sure if he had been contacted and would have to check his phone records but could not confirm or deny that he had been contacted by LVN A about Resident #27's gastrostomy tube becoming clogged or dislodged. The DON said that there was no SBAR or change of condition for Resident #27 but there was a progress note. When asked if she thought a dislodged g-tube on a resident was a change in condition, she said yes. The DON said that it was not uncommon and per facility policy and procedure to utilize a Foley catheter to temporarily keep a gastrostomy tube site open and patent. The DON said she could not find any documentation of physician notification or orders from Physician A to continue to use Resident #27's short-term Foley catheter for medications and feedings. The DON said that the Foley catheter could be used short term to administer medications and or feedings. The DON said that she did not believe 5 days was long term use and said that the facility no longer completed orders for supplies and that Corporate ordered supplies. The DON said she did not know why she had not reviewed LVN A's documentation to check if the physician had been notified. The DON said she did not know why there was no documentation of an SBAR, change in resident condition or incident report for Resident #27. The DON said she had been aware of Resident #27's need for gastrostomy tube tubing. The DON said that Corporate were the ones who notified the facility that the replacement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 19 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gastrostomy tubes for Resident #27 were on back order. The DON said that she did not believe that Resident #27's hospitalization from 5/13/23 through 5/14/23 had anything to do with the use or misuse of Resident #27's temporary Foley catheter. Interview with Administrator on 5/18/23 at 1:34 p.m., he said that Corporate completed the ordering of supplies such as gastrostomy tubes, for the facilities. He said that he had no dated invoices or order slips to show as evidence for when Resident #27's gastrostomy tubing was ordered or when Corporate was notified it was on back order. He said that all residents should have the supplies they need on site and that the facility did its best to maintain the appropriate supplies for their residents. Observation on 5/18/23 at 1:44 p.m. revealed a current adequate gastrostomy tube supplies for Resident #27 and all gastrostomy tube residents for the facility. Interview with Medical Director on 5/18/23 at 2:02 p.m., he said that historically the facility has and can use a Foley catheter as temporary tubing for a gastrostomy tube. He said that they do not always send a resident to the hospital for replacement because they try to avoid unnecessary hospital transfers. He said that Resident #27 had an established gastrostomy tube for years and it was not a new gastrostomy tube site, so the Foley catheter use was not a problem. He said that he did not see an issue with the facility using a temporary Foley catheter tube for 5 days to administer Resident #27's medications and feedings. He said that he did not believe Resident #27's hospitalization on 5/13/23 was as a direct result of the Foley catheter tubing, when asked about Resident #27's hospital diagnosis of pneumonia, he said it could have been early aspiration related to her nausea and vomiting or could have been related to fluid overload. He said there was no definitive aspirate in the hospital findings and that Resident #27 could have had nausea and vomiting related to constipation. He said that staff should notify a physician with any changes in condition for a resident. Telephone interview with Resident #27's attending Physician A on 5/18/23 at 3:08 p.m., he said that he could not recall, confirm or deny if LVN A contacted him on 5/8/23 when Resident #27's gastrostomy tube became dislodged or clogged. He said that best practice was to reinsert the appropriate gastrostomy tube as soon as possible but did not feel that 5 days was too a long a period of time or would have caused Resident #27 to go to the hospital on 5/8/23. He said that he could not say what kind of orders he would have given LVN A on 5/8/23 and that he may or may not have ordered LVN A to send Resident #27 to the hospital right away. He said that he did not recall if he or his NP saw or evaluated Resident #27 during the 5 days, she had the Foley catheter used as her gastrostomy tube. He said as long as it had functioned properly, there was probably no issue with the continued use of the Foley catheter for Resident #27's medications and feedings. He said that he did not know why he had not written any orders for the use of Resident #27's medications and feeding to continue via the temporary Foley catheter. Record review of facility policy and procedure Policy: Gastrostomy Tube Replacement (G-Tube) also known as PEG tube, read in part:1. The g-tube should be replaced as soon as possible (within 4 hours) to keep the tract patent. 2. If it has been greater than 4 hours, consult your physician for further instructions regarding replacing and/or hospital transfer. 3. Tubes dislodged greater than 24 hours should not be replaced at bedside .7. A foley catheter may be used in place of g-tube for SHORT TERM Use if a g-tube is not available at time replacement is needed. When the proper g-tube arrives, the replacement should occur at this time. Record review of facility policy and procedure titled Unusual Occurrences, Guidelines for .Basic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 20 of 21 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Responsibility. Licensed Nurse .To document all unusual occurrences .Documentation Guidelines .Documentation may include: the event and any surrounding circumstances .Physical assessment. Interventions provided. Notification of the physician and responsible party . Preventative measures put in place to prevent recurrence. Document occurrence . Record review of facility policy and procedure titled: Notification to Physician, Family and others, read in part: .The facility will inform the resident, consult with the resident's physician; and consistent with his or her authority, the resident representative and document in the residents medical record .A significant change in the resident's physical status .(that is deterioration .or clinical complications), Record review of facility policy and procedure titled Change in Resident Condition, revealed the following: 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff .5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical condition or status .7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 21 of 21