Inspection·April 28, 2023

F 0610 Level of Harm - Minimal harm or potential for actual harm was rarely/never understood, so no BIMS was conducted; her cognitive skills for daily decision making were severely impaired; she wandered daily; she required limited assistance from one staff member for bed mobility and transfers; she required extensive assistance from one staff for dressing and personal hygiene; she required total assistance from one staff for toilet use and bathing; she was independently ambulatory; and she was always incontinent of bowel and bladder. Residents Affected - Few Record review of Resident #1's care plan updated on 03/29/2023 revealed the following care areas: *The resident had difficulty making self-understood due to severe cognitive loss and was unable to understand more than simple, basic, direct communication. Her speech was mumbled and mostly non-essential to conversation. The goal was for Resident's needs to be met as evidenced by resident being kept clean, dry, and odor free. The approaches were for staff to explain simple directions to task, observe for non-verbal signs of distress, turn/reposition, communicate, provide peri care, assess for pain, provide liquids/food as needed, and to anticipate needs. *The residents also experienced wandering (moves with no rational purpose, seemingly oblivious to needs or safety) A Goal was the Resident would wander safely within specified boundaries. The Approaches were to assure resident has proper fitting and appropriate foot attire; maintain a calm environment and approach to the resident; place resident in a specially designed therapeutic locked dementia unit; and remove resident from other resident's rooms and unsafe situations. Further review of Resident #1's care plan updated 03/29/2023 revealed no documentation regarding the alleged physical abuse incident with Resident #2, her injuries, or any safety plan initiated to keep her safe while Resident #2 still resided in the memory care unit after the incident on 11/26/2022. Observation and interview with Resident #1 on 04/21/2022 at 12:26 p.m. revealed she was in bed eating lunch. Resident #1 briefly looked up and smiled, but she did not respond to any questions. She continued to eat her lunch and only responded at the end of the interview and said, Bye. In an interview with the Administrator on 04/21/2023 at 12:40 p.m., he stated the facility changed management companies on 01/01/2023, so all progress notes in the computer system prior to 01/01/2023 had to be imported from the old management company's computer system. He said any notes imported from the old system would not indicate who authored the notes. He said the only way he could possibly identity the writer for each progress note would be to contact the computer program company to see of they could retrieve that information. Record review of Resident #1's Progress Notes for November 2022 and December 2022 revealed: On 11/27/2022 at 3:16 a.m., an unidentified nurse (the note indicated the writer's discipline was nursing) wrote, Resident is fine, walking around the unit as usual. She does have a small bruise on her left temple and a few scratches on her face. I have checked on her every hour through the shift and she has been sleeping well. I spoke to her family member when she called to check on her about 7 p.m. and assured her she was acting like herself, and that I was checking on her frequently and would do so the rest of the night. On 11/28/2022 at 12:40 p.m., and unidentified nurse wrote, Late documentation for 11-26-22 at 12:40 (p.m.). Resident was ambulating the halls of the unit and in the dining room. Noted that she was fine with no injuries. I had observed Resident #2's light on and he never has put his light on. So, I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 2 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 opened the door, Resident #1 was lying on the (bed) and Resident #2 was over her with his hands on top of hers. He jumped up and said WHAT. I pulled Resident #1 off the bed and took her to her room. We (no other person was identified) noted a scratch on her lip and some small scratches on both hands. Took her to the room. I did a complete exam. Her face was red and skin on her chest was red. Did not notice any other injuries at this time. She showed no pain or discomfort. She was taken to the dining area, and she was watched by staff. She acted the same as she usually does. On 11/29/2022 at 6:23 a.m., an unidentified nurse wrote, 11/28/22 6pm-6am Resident resting well in bed this shift. At the beginning of the shift resident alert and oriented x1, self, laying in bed smiling and talking with this nurse (confused conversation, resident normal). Noted scant amount of greenish/yellow bruising to left temple and left side of lower mouth . On 12/05/2022 at 10:42 a.m., the NP wrote, . Chief Complaint: Bruise to head after encounter with another resident. History of Present Illness: . It was reported by the nurse the patient was found in what seemed to be possible physical encounter from another resident in the facility. The nurse reports they did not see the physical encounter occur, but the patients were found together in a room. Resident #1 did not previously have a bruise to her head. It was reported upon finding the patient she had a new bruise after the encounter. The nurse states she reported the incident to the physician and DON . Superficial bruising of head and neck region, contusion of unspecified part of neck . Additional notes: Spoke with Medical Director. Medical Director updated NP later in the evening, CT negative . On 12/05/2022 at 3:24 p.m., the Medical Director wrote, Commented in the chart by the nurse which happened with Resident #1 and another resident, I came to see the patient. I had been called by the (Former) DON to order a CT scan for her as well which we did, however when I came to see the patient, she was at CT scan, and I could not see her. I was later called by the reports of the CT scan which were negative for any intracranial bleed or other findings consistent with a bruise on her head, she had superficial injury findings on the CT . Record review of a hand-written note by LVN A revealed, . Saturday 11/26/22 . As I was walking up the hallway, I noticed that Resident #2's light was on. I figured that was very awkward because he never put his light on. Before I opened the door, I thought about Resident #1. Because she was always going in that room. She had been in the room about a week or so before standing in front of Resident #2 while he sat on his bed. So that is when I just opened the door. I saw Resident #2 holding her (Resident #1) down on the bed. When I opened the door, he jumped off of her and I helped her to get out of the room. I put her (Resident #1) in her room and got someone to watch him (Resident #2). He was cursing, fuck you, and getting angry I took her (Resident #1). I went and got the (Former) DON. I went to her (Resident #1) room and she had a scratch on her lip and small scratch on both hands. They both still had their clothes on . After checking her all out, we took her to the dining area so someone could watch her. I called Resident #1's family member. Explained what happened, she was concerned but not angry. Just wanted to know what we were going to do. Sunday, 11/27/22. Resident #1's [family member] came in to see how Resident #1 was. She was upset that Resident #2 was not out of the building. She told me if it would be possible to press charges. I told her I did not know if that would work. They (unknown who they were) talked to Resident #2's doctor and decided to send him to ER for psych evaluation. Ambulance picked him up and I called his family member. Record review of Resident #1's radiology report dated 11/28/2022 revealed she was taken to a local acute care hospital for a CT scan without intravenous contrast on 11/28/2022 for assault/trauma to the head. Findings included age-related atrophy and was negative for acute findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 3 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 Resident #2 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with unspecified focal traumatic brain injury with loss of consciousness (a traumatic injury to the brain that occurs in a single location), altered mental status (a change in metal function), restlessness and agitation, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), brief psychotic disorder (sudden onset of psychotic behavior that lasts less than one month followed by complete remission with possible future relapses), recurrent depressive disorder (at least two depressive episodes), and oppositional defiant disorder (a frequent and ongoing pattern of anger, irritability, arguing, and defiance). Resident #2 resided in the facility's locked memory care unit until 11/28/2022. Residents Affected - Few Record review of Resident #2's MDS dated [DATE] revealed he was able to make himself understood and he understood other; he had a BIMS score of 5 (severe cognitive impairment); he exhibited verbal behavioral symptoms directed towards others 1 to 3 days but did not exhibit physical behavioral symptoms directed toward others; he wandered 1 to 3 days; he required supervision and set-up help only for all activities of daily living; he was independently ambulatory; and he was always continent of bowel and bladder. Record review of Resident #2's care plan updated on 03/13/2023 revealed the following care areas: *The resident was not at ease in joining other residents in activities. A Goal was for the Resident to express satisfaction with activity involvement. The approaches were 1:1 visitation and interview the resident to determine reason for feelings of uneasiness. *The resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety) resident use to reside on locked dementia unit. On 11/28/2022 moved off locked unit with wander guard placed. A Goal was for the resident to wander safely within specified boundaries. Approaches were to have a wander guard placed with check per facility policy; 11/28/2022 moved outside locked unit with wander guard placed with to continue to assess resident; Assure resident has proper fitting and appropriate foot attire; Avoid over-stimulation [noise, crowding, other physically aggressive resident]; and Maintain calm environment and approach to the resident). *Resident was at risk for adverse consequence due to receiving antipsychotic medication of Seroquel routine, as well as PRN use of Olanzapine (Zyprexa- an antipsychotic) and Haldol (an antipsychotic) A goal was for the resident to not exhibit signs of drug related side effects or adverse drug reaction. The Approaches were: Assess if resident's behavioral symptoms present a danger to the resident and/or others; Intervene as needed; Attempt a gradual dose reduction [if not contraindicated]; and Quantitatively and objectively document the resident's behavior. *Resident has a memory/recall problem due to traumatic brain injury with deficit to date/time and shot term loss A goal was the resident will not sustain serious injury due to memory/recall deficit. The approaches were to ensure proper footwear, ensure resident's areas are free of hazards, and Redirect resident when entering unsafe areas. *Resident has verbal behavioral symptoms directed toward other (threatening others, yelling at others, cursing at others, inappropriate verbal comments both sexual and racial) due to diagnosis of brain injury with psychosis. A goal was the resident will not threaten, scream at, or curse at other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 4 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 residents, visitors, and/or staff while being redirected from inappropriate verbal comments. The Approaches were to Administer medications as ordered; Monitor and record effectiveness; Report adverse side effects; Avoid over-stimulation; Avoid power struggles with residents; Convey and attitude of acceptance toward the resident; Maintain a calm environment and approach to the resident; Obtain a psych consult/psychosocial therapy; Refocus conversation when resident becomes verbally abusive; Set expectations and limits for resident; When resident becomes verbally abusive, stop and try the task later; and Do not force the resident to do task. Further review of Resident #2's care plan revealed no documentation of his physical aggression on 11/26/2022 and no interventions regarding his physical aggression. Observation and interview of Resident #2 on 04/19/2023 at 12:40 p.m. revealed he was independently ambulatory. Resident #2 spoke every word very loud and aggressively. He answered several questions and then he began to yell curse words and appeared to be agitated. The interview was terminated at that time. No questions were asked regarding the abuse incident with Resident #2. Record review of Resident #2's Progress Notes for October 2022 and November 2022 revealed the following: On 10/26/2022 at 5:42 p.m., an unidentified nurse wrote, Resident very agitated this am, using verbally abusive language toward staff for trying to redirect him telling him to allow staff to finish serving all the residents before he wants to drink 5 or more cups of coffee before they finish serving and there are times for no apparent reason he uses verbally abusive language (towards) staff, residents, also uses inappropriate language with staff, asking a staff (would) they marry (him) and when she responded no, he asked if he could have sex with her, staff is very uncomfortable with resident, telephone contact with his family members informing them of his behavior, also informed them of a new order for Haldol Q 12 hours PRN (this order was changed to Haldol every 12 hours on 11/17/2022). Have their permission for staff to medicate him if needed with Haldol . On 10/27/2022 at 10:43 a.m., an unidentified nurse wrote, Resident had aggressive behavior this am for no apparent reason, after telling resident here is his medication, he started using abusive language, after taking his medication, he slammed the water cup on my cart spilling water on the cart and the floor, then started asking what you gonna do? As he walked away from the cart, he continued to use abusive language and threatening behavior towards other residents and staff. Other residents started coming out of their rooms telling him to stop. He then started calling them names and cursing at them, also walking towards them in a threatening way. Resident is out of control, unable to redirect him or calm him down. Seems to have a lot of anger. He later went into his room and slammed the door. (Former) DON made aware of resident's behavior. Will continue to monitor resident behavior and follow up as needed. On 11/10/2022 at 1:05 p.m., an unidentified nurse wrote, Resident was very angry and upset at everyone this am for no apparent reason. Yelling out very loudly and rude toward other residents and staff. Using very abusive, foul Language, slamming the door to his room several times. On one occasion, he grabbed the arm of one of the residents for no apparent reason and staff had to intervene . On 11/18/2022 at 2:05 p.m., an unidentified nurse wrote, Resident became upset when one of the female residents' family members was taking her out to smoke on an unscheduled smoke break, and he (Resident #2) wanted to go. When told that smoke break was at 4:00 p.m., started stating he wanted to go now. Not going now caused him to start calling staff and other residents bitches and niggers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 5 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 Behavior was aggressive at times walking up to staff with his finger in a gesture of the FU sign. At that time, staff walked away, and he continued with the name calling and gesture with the finger. He went to his room and slammed the door so hard it set off the defibrillator box on side of the wall. He walked towards one of the staff who was walking away from him asking her what was the matter, you are scared . Resident is getting very aggressive at times, out of control. Unable to redirect/even talk to him when he is in a rage . Staff and other residents are very uncomfortable when resident is around. His behavior is unpredictable . On 11/21/2022 at 7:31 a.m., an unidentified nurse wrote, 11/20/2022 6P - 6A Approximately 7:53 p.m. this nurse knocked on Resident closed room door, announced, nursing, and entered the room. Observed resident sitting on the side of his bed with female dementia resident facing him and standing directly in front of him. This nurse reached for female resident's hand and directed her towards me. This resident became very loud, hostile, and verbally aggressive towards this nurse and yelled, WHAT! WHAT! WHAT! He stood up from the bed and continued to approach this nurse and resident. This nurse stood in front of female resident. Handed evening medications to this resident (Haldol, Seroquel, Depakote). Resident snatched medicine cup from this nurse, took medications by mouth and tossed medication cup at me. The cup fell onto the floor. As this nurse redirected female resident further down the hallway, resident aggression continues to escalate. This resident continues loud, hostile behavior following behind this (nurse) shouting, WHAT! WHAT! You can't talk? Resident began pacing hallway. Resident returned to his room and slammed the door so hard that the AED alarm sounded off. 7:57 p.m. This resident walked to day room where a male dementia resident is sitting in Geri chair talking to self and asking for help. This resident becomes confrontational/hostile/verbally aggressive and began cursing/yelling loudly at male resident. Redirection and verbal cues non effective and resident continued behavior for approximately 1 minute . On 11/26/2022 at 2:30 p.m., an unidentified nurse wrote, Was coming up the hall from taking dirty linen to the linen basket when I observed this residents light on which is very unusual. As I got to the door, I thought of Resident #1, that liked to go into that room. I rushed and opened the door, and I observed this resident bending over the top of Resident #1. He (Resident #2) just jumped away from her, both of them still had there. I removed Resident #1 from the room. Resident #2 no pain no injuries no adverse effects. On 11/26/2022 at 5:14 p.m., and unidentified nurse wrote, Notified Resident #2's family member of incident that occurred today. Informed family member that resident would be sent out to behavioral health facility as soon as a room becomes available . On 11/27/2022 at 3:11 a.m., an unidentified nurse wrote, Resident paced the halls for a while after I came on shift, then went to his room. I gave him his night medications at 8:30 p.m., with an extra dose of Haloperidol per provider orders. He did verbally abuse the CNA staff as he wanted to go out for a cigarette and when told no, he told them FU several times and went to his room and slammed the door. He has not come out of room the rest of the night so far and I did a bed check, and he was asleep. On 11/27/2022 at 12:16 p.m., an unidentified nurse wrote, Attempt to contact Resident #1's family member to request that she take resident to ER for behavioral issues, no answer, message left. On 11/27/2022 at 1:35 p.m., an unidentified nurse wrote, Spoke with (Former) DON, per Resident #2's doctor and Medical Director, send to ED evaluation for sexual, physical, and verbally aggressive behaviors. Notified to transport and staff member will accompany. LVN A notified of current status and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 6 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 orders for transfer, she will notify resident's family member. Level of Harm - Minimal harm or potential for actual harm On 11/27/2022 at 3:00 p.m., an unidentified nurse wrote, EMS arrived, resident cursing staff and EMS but cooperative with getting on stretcher for transport. Clinical records given to EMS by LVN A. Residents Affected - Few On 11/28/2022 at 2:56 p.m., an unidentified nurse wrote, Resident was evaluated at a behavioral health facility and ER provider, and they wanted to send him back. (Former) DON contacted the family member to come sit with him due to his aggressive behavior and the incident that he cannot be left unattended. Resident #2 was brought back by BCPD at 1:00 a.m. I fed him, gave him his nighttime medications and he went to bed. His family member arrived about 1:45 a.m., she is sitting with him at this time (there was no documentation to show what time the family member left the facility), he has yet to fall asleep. On 11/28/2022 at 5:08 p.m., an unidentified nurse wrote, Plans to move resident to 500 hall with wander guard, attempt to notify family member with message left on voicemail. Record review of Provider Investigation Report dated 12/05/2022 and signed by the Administrator revealed the following: Incident Category: Injury of unknown origin . Unknown Injury. Incident Date: 11/28/2022. Time: 8:30 a.m. Individual(s)/Resident(s) Involved, Including Alleged Victim(s) or Alleged Aggressor(s): Resident #1. Alleged Perpetrator(s): N/A. Did investigation reveal the presence of a witness? No. Description of the Allegation: On 11/28/2022 Resident #1 was noted to have bruising to the left side of head and left side of lower mouth. Assessment: 11/28/2022 at 8:30 a.m. Description of Assessment: Resident was assessed by charge nurse, no other injuries noted, no signs or symptoms of pain, no signs or symptoms of distress, no other adverse effects. Provider Response: Facility notified physician, responsible party, and ombudsman. Resident sent to local acute care hospital for CT scan, results were negative. Investigation Summary: Resident #1 was unable to state or recall what caused the bruises to the left side of the head and the lower mouth. Resident #1 had a history of wandering throughout the facility and is able to transfer herself without assistance . Staff was in serviced on abuse and neglect. Based on the evidence gathered, the facility unfounded any abuse or neglect caused the bruising. Further review of the investigation report revealed there was no documentation of the incident between Resident #1 and Resident #2 on 11/26/2022 and no documentation of a possible perpetrator or witness. In a telephone interview with LVN A on 04/19/2023 at 11:50 a.m., she said she did not work at the facility anymore. She said when she did work at the facility, she was mostly stationed in the locked memory care unit. She said she did feel intimidated by the Administrator because of how he talked to her and because of the way he wanted her to document an incident when he did not like the way she wrote what she saw. She said Resident #2 was placed in the locked unit because they (she did not say who they were) were scared he would walk off. LVN A said Resident #2's room was the first room on the hall. She said she was going to provide care for the resident in the second room on the hall when she noticed Resident #2 had his light on. She said she thought this was strange because Resident #2 never used his light. She said she knocked on the closed door once and caught Resident #2 standing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 7 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 over Resident #1 with his hands around her wrists (above Resident #1's head) on the bed and she (Resident #1) was struggling and tried to fight Resident #2 off. She said Resident #1 was laying on the side of Resident #2's bed with her feet on the floor. She said she grabbed Resident #1 and took her out of Resident #2's room. She said she asked an aide to go get the Former DON. LVN A said Resident #1 wandered, so she probably went into Resident #2's room. She said after the incident, Resident #2 kept walking back and forth constantly watching Resident #1 for a day and a half. LVN A said she made sure to watch Resident #1 at all times. LVN A said Resident #2 was infatuated by Resident #1 because she was very attractive for her age (she did not provide any other statements to substantiate this). She said Resident #1's family member told them (she did not say who them was) they better get Resident #2 off the unit. She said Resident #2 was taken out for evaluation, then brought back to the unit. LVN A said days later, Resident #1's family member wanted her taken to the hospital to assess the bruise over her eye. LVN A said Resident #1's hands and wrists were red. LVN A said she wrote everything she saw in her progress notes and called the residents' families. She said in her notes, she wrote both residents were clothed. LVN A said had she not intervened, she felt like the incident would have gone further into a sexual abuse incident. LVN A said days after the incident (she could not recall the exact date), the Administrator called her into the Former DON's office to talk about the incident. She said the Administrator, the Former DON, and ADON B were present during this conversation. LVN A said she demonstrated to the Administrator how Resident #2 had Resident #1's wrists pinned down to the bed. She said the Administrator told her he needed her to document the incident another way because she made it sound too sexual. LVN A said she told them (everyone in the room) she wrote what she saw. LVN A said she was intimidated by the Administrator and ADON B into changing her statement and she began to cry. LVN A said the Former DON kept telling the Administrator that she (LVN A) had written what she saw. LVN A said the Administrator stood over her and instructed her on what words to remove and replace. LVN A said the Former DON was so upset that she walked out of the room. LVN A said she was crying so hard that the Administrator told her she could leave and ADON B would complete the note for her. LVN A said she saw it as a sexual incident when she walked into the room. She said the Former DON told her to make sure to write that they were both fully clothed, he was over her with hands bound to the bed, and that she was struggling to get up. She said the Administrator and ADON B wanted her to take out that they were fully clothed. LVN A said neither Resident #1 nor Resident #2 were talking when she walked into the room. She said she thought the call light was on because it may have fallen to the floor during the struggle (while Resident #1 struggled to get Resident #2 off of her). She said Resident #1 was found in Resident #2's room with him several days before the incident, so she thought of Resident #1 when she saw Resident #2's (call) light on. LVN A stated because of the incident, she felt like her license (nursing license) was not safe at the facility, so she had to resign. In an interview with ADON B on 04/19/2023 at 12:50 p.m., she stated Resident #2 had traumatic brain injury from a motor vehicle accident. She said Resident #2 talked rough all the time, but he had never been aggressive. She said Resident #2 had never shown an interest in any females in building. She said Resident #2 was moved out of the locked unit because it was too restrictive and there was not enough room for him to walk around. ADON B said she recalled they had a wanderer, Resident #1, who was very mobile and went into Resident #2's room. ADON B said she could not recall what was said other than Resident #1 was not wearing a bra, and she was not sure why that was said. ADON B said she thought the progress note regarding the incident said Resident #2 was over Resident #1, not on her. ADON B said the nurses did an assessment and they were trying to send Resident #2 out to a psychiatric center, but nobody wanted to accept him with a brain injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 8 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 She said Resident #2's family member would not take responsibility or go to the facility. ADON B said they never found anything during their internal investigation, but they did separate him from the locked unit because of the incident. She said she could not recall who the person was who observed the incident, but in their mind, they thought the incident was sexual. ADON B said if you looked at the facts, they did not read in a sexual way. ADON B said she did not think the reporter was asked to change anything in their report. She said the reporter may have missed some documentation in the incident report and was coached, but not asked to change anything. ADON B said maybe the reporter forgot a section of the report because there are several steps to filling out the report. ADON B said she did not think the reporter made an allegation of sexual abuse. She said did not recall if Resident #1 went to the hospital and there were no injuries that she could recall. In an interview with the Administrator on 04/19/2023 at 1:30 p.m., he stated shortly after he started in November 2022, Resident #1 was found in Resident #2's room. He said Resident #1 had previously wandered into Resident #2's room before. The Administrator said somebody walked in and found Resident #2 laying over Resident #1 with her on the bed. He said both residents were clothed, and no touching was witnessed. He said Resident #1 had bruising to her fingertips, but she was unable to recall what happened. He said Resident #1 also had bruises to the left side of her head and lower mouth. The Administrator said he called the incident in to state. He said there was nothing sexual about the incident and his investigation was unsubstantiated. He said Resident #1 had unknown injuries, so reported the incident as injury of unknown origin. He said they moved Resident #2 off the unit after that and he had been fine since then. The Administrator said nobody observed Resident #2 touching Resident #1, he was just standing over her. The Administrator said Resident #2's name was not mentioned in the self-report because nobody reported seeing him pinning Resident #1 down to the bed and they could not say her injuries were caused by Resident #2. The Administrator said perhaps[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 9 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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 be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 11 residents (Resident #1 and Resident #2) reviewed for administration. Residents Affected - Few The Administrator, who was the facility's abuse coordinator and was responsible for investigating and reporting abuse incidents, failed to thoroughly investigate and accurately report an allegation of resident-to-resident abuse in the facility's locked memory care unit when Resident #1 sustained bruises and scratches to her face and fingers and redness to her hands, wrists, and chest after Resident #2 was found standing over her on his bed and pinning her wrists down to the bed and reported the incident to HHSC as an injury of unknown origin with no witnesses or perpetrator. The Administrator failed to ensure Resident #1's and Resident #2's care plans were evaluated/revised and interventions were implemented to ensure residents were safe after an alleged resident-to-resident abuse incident occurred on 11/26/2022. The facility's administration requested LVN A to remove language from LVN's witness statement referencing any sexual contact between Resident #2 and Resident #1 during an incident that occurred on 11/26/2022 causing an inaccurate facility document and delayed interventions to prevent Resident #2 from further occurrences. These failures placed residents involved in abuse incidents at risk of continued abuse, further injury, pain, and physical and emotional distress. Findings include: Resident #1 Record review of Resident #1's face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with dementia (a group of thinking and social symptoms that interfere with daily functioning), psychotic disturbance (severe mental disorder that causes abnormal thinking and perceptions), anxiety (intense, excessive, and persistent worry and fear about everyday situations), protein-calorie malnutrition (the state of inadequate intake of food), abnormal weight loss, and mild cognitive impairment (an early stage of memory loss or other cognitive ability loss). Resident #1 resided in the facility's locked memory care unit. Record review of Resident #1's MDS dated [DATE] revealed she was sometimes able to express ideas and wants (ability was limited to making concrete requests); she rarely/never understood others; she was rarely/never understood, so no BIMS was conducted; her cognitive skills for daily decision making were severely impaired; she wandered daily; she required limited assistance from one staff member for bed mobility and transfers; she required extensive assistance from one staff for dressing and personal hygiene; she required total assistance from one staff for toilet use and bathing; she was independently ambulatory; and she was always incontinent of bowel and bladder. Record review of Resident #1's care plan updated on 03/29/2023 revealed the following care areas: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 10 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few *The resident had difficulty making self-understood due to severe cognitive loss and was unable to understand more than simple, basic, direct communication. Her speech was mumbled and mostly non-essential to conversation. The goal was for Resident's needs to be met as evidenced by resident being kept clean, dry, and odor free. The approaches were for staff to explain simple directions to task, observe for non-verbal signs of distress, turn/reposition, communicate, provide peri care, assess for pain, provide liquids/food as needed, and to anticipate needs. *The residents also experienced wandering (moves with no rational purpose, seemingly oblivious to needs or safety) A Goal was the Resident would wander safely within specified boundaries. The Approaches were to assure resident has proper fitting and appropriate foot attire; maintain a calm environment and approach to the resident; place resident in a specially designed therapeutic locked dementia unit; and remove resident from other resident's rooms and unsafe situations. Further review of Resident #1's care plan revealed no documentation regarding the alleged physical abuse incident with Resident #2, her injuries, or any safety plan initiated to keep her safe while Resident #2 still resided in the memory care unit after the incident on 11/26/2022. Observation and interview with Resident #1 on 04/21/2022 at 12:26 p.m. revealed she was in bed eating lunch. Resident #1 briefly looked up and smiled, but she did not respond to any questions. She continued to eat her lunch and only responded at the end of the interview and said, Bye. In an interview with the Administrator on 04/21/2023 at 12:40 p.m., he stated the facility changed management companies on 01/01/2023, so all progress notes in the computer system prior to 01/01/2023 had to be imported from the old management company's computer system. He said any notes imported from the old system would not indicate who the writer was. He said the only way he could possibly identity the writer for each progress note would be to contact the computer program company to see of they could retrieve that information. Record review of Resident #1's Progress Notes for November 2022 and December 2022 revealed: On 11/27/2022 at 3:16 a.m., an unidentified nurse (the note indicated the writer's discipline was nursing) wrote, Resident is fine, walking around the unit as usual. She does have a small bruise on her left temple and a few scratches on her face. I have checked on her every hour through the shift and she has been sleeping well. I spoke to her family member when she called to check on her about 7 p.m. and assured her she was acting like herself, and that I was checking on her frequently and would do so the rest of the night. On 11/28/2022 at 12:40 p.m., and unidentified nurse wrote, Late documentation for 11-26-22 at 12:40 (p.m.). Resident was ambulating the halls of the unit and in the dining room. Noted that she was fine with no injuries. I had observed Resident #2's light on and he never has put his light on. So, I opened the door, Resident #1 was lying on the (bed) and Resident #2 was over her with his hands on top of hers. He jumped up and said WHAT. I pulled Resident #1 off the bed and took her to her room. We (no other person was identified) noted a scratch on her lip and some small scratches on both hands. Took her to the room. I did a complete exam. Her face was red and skin on her chest was red. Did not notice any other injuries at this time. She showed no pain or discomfort. She was taken to the dining area, and she was watched by staff. She acted the same as she usually does. On 11/29/2022 at 6:23 a.m., an unidentified nurse wrote, 11/28/22 6pm-6am Resident resting well in bed this shift. At the beginning of the shift resident alert and oriented x1, self, lying in bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 11 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few smiling and talking with this nurse (confused conversation, resident normal). Noted scant amount of greenish/yellow bruising to left temple and left side of lower mouth . On 12/05/2022 at 10:42 a.m., the NP wrote, . Chief Complaint: Bruise to head after encounter with another resident. History of Present Illness: . It was reported by the nurse the patient was found in what seemed to be possible physical encounter from another resident in the facility. The nurse reports they did not see the physical encounter occur, but the patients were found together in a room. Resident #1 did not previously have a bruise to her head. It was reported upon finding the patient she had a new bruise after the encounter. The nurse states she reported the incident to the physician and DON . Superficial bruising of head and neck region, contusion of unspecified part of neck . Additional notes: Spoke with Medical Director. Medical Director updated NP later in the evening, CT negative . On 12/05/2022 at 3:24 p.m., the Medical Director wrote, Commented in the chart by the nurse which happened with Resident #1 and another resident, I came to see the patient. I had been called by the (Former) DON to order a CT scan for her as well which we did, however when I came to see the patient, she was at CT scan, and I could not see her. I was later called by the reports of the CT scan which were negative for any intracranial bleed or other findings consistent with a bruise on her head, she had superficial injury findings on the CT . Record review of a hand-written note by LVN A revealed, . Saturday 11/26/22 . As I was walking up the hallway, I noticed that Resident #2's light was on. I figured that was very awkward because he never put his light on. Before I opened the door, I thought about Resident #1. Because she was always going in that room. She had been in the room about a week or so before standing in front of Resident #2 while he sat on his bed. So that is when I just opened the door. I saw Resident #2 holding her (Resident #1) down on the bed. When I opened the door, he jumped off of her and I helped her to get out of the room. I put her (Resident #1) in her room and got someone to watch him (Resident #2). He was cursing, fuck you, and getting angry I took her (Resident #1). I wet and got the (Former) DON. I went to her (Resident #1) room and she had a scratch on her lip and small scratch on both hands. They both still had their clothes on . After checking her all out, we took her to the dining area so someone could watch her. I called Resident #1's family member. Explained what happened, she was concerned but not angry. Just wanted to know what we were going to do. Sunday, 11/27/22. Resident #1's family member came in to see how Resident #1 was. She was upset that Resident #2 was not out of the building. She told me if it would be possible to press charges. I told her I did not know if that would work. They (unknown who they were) talked to Resident #2's doctor and decided to send him to ER for psych evaluation. Ambulance picked him up and I called his family member. Record review of Resident #1's radiology report dated 11/28/2022 revealed she was taken to a local acute care hospital for CT scan without intravenous contrast on 11/28/2022 for assault/trauma to the head. Findings included age-related atrophy and was negative for acute findings. Resident #2 Record review of Resident #2's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with unspecified focal traumatic brain injury with loss of consciousness (a traumatic injury to the brain that occurs in a single location), altered mental status (a change in metal function), restlessness and agitation, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), brief psychotic disorder (sudden onset of psychotic behavior that lasts (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 12 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few less than one month followed by complete remission with possible future relapses), recurrent depressive disorder (at least two depressive episodes), and oppositional defiant disorder (a frequent and ongoing pattern of anger, irritability, arguing, and defiance). Resident #2 resided in the facility's locked memory care unit until 11/28/2022. Record review of Resident #2's MDS dated [DATE] revealed he was able to make himself understood and he understood other; he had a BIMS score of 5 (severe cognitive impairment); he exhibited verbal behavioral symptoms directed towards others 1 to 3 days but did not exhibit physical behavioral symptoms directed toward others; he wandered 1 to 3 days; he required supervision and set-up help only for all activities of daily living; he was independently ambulatory; and he was always continent of bowel and bladder. Record review of Resident #2's care plan updated on 03/13/2023 revealed the following care areas: *The resident was not at ease in joining other residents in activities. A Goal was for the Resident to express satisfaction with activity involvement. The approaches were 1:1 visitation and interview the resident to determine reason for feelings of uneasiness. *The resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety) resident use to reside on locked dementia unit. On 11/28/2022 moved off locked unit with wander guard placed. A Goal was for the resident to wander safely within specified boundaries. Approaches were to have a wander guard placed with check per facility policy; 11/28/2022 moved outside locked unit with wander guard placed with to continue to assess resident; Assure resident has proper fitting and appropriate foot attire; Avoid over-stimulation [noise, crowding, other physically aggressive resident]; and Maintain calm environment and approach to the resident). *Resident was at risk for adverse consequence due to receiving antipsychotic medication of Seroquel routine, as well as PRN use of Olanzapine (Zyprexa- an antipsychotic) and Haldol (an antipsychotic) A goal was for the resident to not exhibit signs of drug related side effects or adverse drug reaction. The Approaches were: Assess if resident's behavioral symptoms present a danger to the resident and/or others; Intervene as needed; Attempt a gradual dose reduction [if not contraindicated]; and Quantitatively and objectively document the resident's behavior. *Resident has a memory/recall problem due to traumatic brain injury with deficit to date/time and shot term loss A goal was the resident will not sustain serious injury due to memory/recall deficit. The approaches were to ensure proper footwear, ensure resident's areas are free of hazards, and Redirect resident when entering unsafe areas. *Resident has verbal behavioral symptoms directed toward other (threatening others, yelling at others, cursing at others, inappropriate verbal comments both sexual and racial) due to diagnosis of brain injury with psychosis. A goal was the resident will not threaten, scream at, or curse at other residents, visitors, and/or staff while being redirected from inappropriate verbal comments. The Approaches were to Administer medications as ordered; Monitor and record effectiveness; Report adverse side effects; Avoid over-stimulation; Avoid power struggles with residents; Convey and attitude of acceptance toward the resident; Maintain a calm environment and approach to the resident; Obtain a psych consult/psychosocial therapy; Refocus conversation when resident becomes verbally abusive; Set expectations and limits for resident; When resident becomes verbally abusive, stop and try the task later; and Do not force the resident to do task. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 13 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident #2's care plan revealed no documentation of his physical aggression on 11/26/2022 and no interventions regarding his physical aggression. Observation and interview of Resident #2 on 04/19/2023 at 12:40 p.m. revealed he was independently ambulatory. Resident #2 spoke every word very loud and aggressively. He answered several questions and then he began to yell curse words and appeared to be agitated. The interview was terminated at that time. No questions were asked regarding the abuse incident with Resident #2. Record review of Resident #2's Progress Notes for October 2022 and November 2022 revealed: On 10/26/2022 at 5:42 p.m., an unidentified nurse wrote, Resident very agitated this am, using verbally abusive language toward staff for trying to redirect him telling him to allow staff to finish serving all the residents before he wants to drink 5 or more cups of coffee before they finish serving and there are times for no apparent reason he uses verbally abusive language (towards) staff, residents, also uses inappropriate language with staff, asking a staff (would) they marry (him) and when she responded no, he asked if he could have sex with her, staff is very uncomfortable with resident, telephone contact with his family members informing them of his behavior, also informed them of a new order for Haldol Q 12 hours PRN (this order was changed to Haldol every 12 hours on 11/17/2022). Have their permission for staff to medicate him if needed with Haldol . On 10/27/2022 at 10:43 a.m., an unidentified nurse wrote, Resident had aggressive behavior this am for no apparent reason, after telling resident here is his medication, he started using abusive language, after taking his medication, he slammed the water cup on my cart spilling water on the cart and the floor, then started asking what you gonna do? As he walked away from the cart, he continued to use abusive language and threatening behavior towards other residents and staff. Other residents started coming out of their rooms telling him to stop. He then started calling them names and cursing at them, also walking towards them in a threatening way. Resident is out of control, unable to redirect him or calm him down. Seems to have a lot of anger. He later went into his room and slammed the door. (Former) DON made aware of resident's behavior. Will continue to monitor resident behavior and follow up as needed. On 11/10/2022 at 1:05 p.m., an unidentified nurse wrote, Resident was very angry and upset at everyone this am for no apparent reason. Yelling out very loudly and rude toward other residents and staff. Using very abusive, foul Language, slamming the door to his room several times. On one occasion, he grabbed the arm of one of the residents for no apparent reason and staff had to intervene . On 11/18/2022 at 2:05 p.m., an unidentified nurse wrote, Resident became upset when one of the female residents' family members was taking her out to smoke on an unscheduled smoke break, and he (Resident #2) wanted to go. When told that smoke break was at 4:00 p.m., started stating he wanted to go now. Not going now caused him to start calling staff and other residents bitches and niggers. Behavior was aggressive at times walking up to staff with his finger in a gesture of the FU sign. At that time, staff walked away, and he continued with the name calling and gesture with the finger. He went to his room and slammed the door so hard it set off the defibrillator box on side of the wall. He walked towards one of the staff who was walking away from him asking her what was the matter, you are scared . Resident is getting very aggressive at times, out of control. Unable to redirect/even talk to him when he is in a rage . Staff and other residents are very uncomfortable when resident is around. His behavior is unpredictable . On 11/21/2022 at 7:31 a.m., an unidentified nurse wrote, 11/20/2022 6P - 6A Approximately 7:53 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 14 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few this nurse knocked on Resident closed room door, announced, nursing, and entered the room. Observed resident sitting on the side of his bed with female dementia resident facing him and standing directly in front of him. This nurse reached for female resident's hand and directed her towards me. This resident became very loud, hostile, and verbally aggressive towards this nurse and yelled, WHAT! WHAT! WHAT! He stood up from the bed and continued to approach this nurse and resident. This nurse stood in front of female resident. Handed evening medications to this resident (Haldol, Seroquel, Depakote). Resident snatched medicine cup from this nurse, took medications by mouth and tossed medication cup at me. The cup fell onto the floor. As this nurse redirected female resident further down the hallway, resident aggression continues to escalate. This resident continues loud, hostile behavior following behind this (nurse) shouting, WHAT! WHAT! You can't talk? Resident began pacing hallway. Resident returned to his room and slammed the door so hard that the AED alarm sounded off. 7:57 p.m. This resident walked to day room where a male dementia resident is sitting in Geri chair talking to self and asking for help. This resident becomes confrontational/hostile/verbally aggressive and began cursing/yelling loudly at male resident. Redirection and verbal cues non effective and resident continued behavior for approximately 1 minute . On 11/26/2022 at 2:30 p.m., an unidentified nurse wrote, Was coming up the hall from taking dirty linen to the linen basket when I observed this residents light on which is very unusual. As I got to the door, I thought of Resident #1, that liked to go into that room. I rushed and opened the door, and I observed this resident bending over the top of Resident #1. He (Resident #2) just jumped away from her, both of them still had there. I removed Resident #1 from the room. Resident #2 no pain no injuries no adverse effects. On 11/26/2022 at 5:14 p.m., and unidentified nurse wrote, Notified Resident #2's family member of incident that occurred today. Informed family member that resident would be sent out to behavioral health facility as soon as a room becomes available . On 11/27/2022 at 3:11 a.m., an unidentified nurse wrote, Resident paced the halls for a while after I came on shift, then went to his room. I gave him his night medications at 8:30 p.m., with an extra dose of Haloperidol per provider orders. He did verbally abuse the CNA staff as he wanted to go out for a cigarette and when told no, he told them FU several times and went to his room and slammed the door. He has not come out of room the rest of the night so far and I did a bed check, and he was asleep. On 11/27/2022 at 12:16 p.m., an unidentified nurse wrote, Attempt to contact Resident #2's family member to request that she take resident to ER for behavioral issues, no answer, message left. On 11/27/2022 at 1:35 p.m., an unidentified nurse wrote, Spoke with (Former) DON, per Resident #2's doctor and Medical Director, send to ED evaluation for sexual, physical, and verbally aggressive behaviors. Notified to transport and staff member will accompany. LVN A notified of current status and orders for transfer, she will notify resident's family member. On 11/27/2022 at 3:00 p.m., an unidentified nurse wrote, EMS arrived, resident cursing staff and EMS but cooperative with getting on stretcher for transport. Clinical records given to EMS by LVN A. On 11/28/2022 at 2:56 p.m., an unidentified nurse wrote, Resident was evaluated at a behavioral health facility and ER provider, and they wanted to send him back. (Former) DON contacted the family member to come sit with him due to his aggressive behavior and the incident that he cannot be left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 15 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unattended. Resident #2 was brought back by BCPD at 1:00 a.m. I fed him, gave him his nighttime medications and he went to bed. His family member arrived about 1:45 a.m., she is sitting with him at this time (there was no documentation to show what time the family member left the facility), he has yet to fall asleep. On 11/28/2022 at 5:08 p.m., an unidentified nurse wrote, Plans to move resident to 500 hall with wander guard, attempt to notify family member with message left on voicemail. Record review of Provider Investigation Report dated 12/05/2022 and signed by the Administrator revealed, Incident Category: Injury of unknown origin . Unknown Injury. Incident Date: 11/28/2022. Time: 8:30 a.m. Individual(s)/Resident(s) Involved, Including Alleged Victim(s) or Alleged Aggressor(s): Resident #1. Alleged Perpetrator(s): N/A. Did investigation reveal the presence of a witness? No. Description of the Allegation: On 11/28/2022 Resident #1 was noted to have bruising to the left side of head and left side of lower mouth. Assessment: 11/28/2022 at 8:30 a.m. Description of Assessment: Resident was assessed by charge nurse, no other injuries noted, no signs or symptoms of pain, no signs or symptoms of distress, no other adverse effects. Provider Response: Facility notified physician, responsible party, and ombudsman. Resident sent to local acute care hospital for CT scan, results were negative. Investigation Summary: Resident #1 was unable to state or recall what caused the bruises to the left side of the head and the lower mouth. Resident #1 was a history of wandering throughout the facility and is able to transfer herself without assistance . Staff was in serviced on abuse and neglect. Based on the evidence gathered, the facility unfounded any abuse or neglect caused the bruising. Further review of the investigation report revealed no documentation of the incident between Resident #1 and Resident #2 on 11/26/2022 and no documentation of a possible perpetrator or witness. In a telephone interview with LVN A on 04/19/2023 at 11:50 a.m., she said she did not work at the facility anymore. She said when she did work at the facility, she was mostly stationed in the locked memory care unit. She said she did feel intimidated by the Administrator because of how he talked to her and because of the way he wanted her to document an incident when he did not like the way she wrote what she saw. She said Resident #2 was placed in the locked unit because they (she did not say who they were) were scared he would walk off. LVN A said Resident #2's room was the first room on the hall. She said she was going to provide care for the resident in the second room on the hall when she noticed Resident #2 had his light on. She said she thought this was strange because Resident #2 never used his light. She said she knocked on the closed door once and caught Resident #2 standing over Resident #1 with his hands around her wrists (above Resident #1's head) on the bed and she (Resident #1) was struggling and tried to fight Resident #2 off. She said Resident #1 was laying on the side of Resident #2's bed with her feet on the floor. She said she grabbed Resident #1 and took her out of Resident #2's room. She said she asked an aide to go get the Former DON. LVN A said Resident #1 wandered, so she probably went into Resident #2's room. She said after the incident, Resident #2 kept walking back and forth constantly watching Resident #1 for a day and a half. LVN A said she made sure to watch Resident #1 at all times. LVN A said Resident #2 was infatuated by Resident #1 because she was very attractive for her age (she did not provide any other statements to substantiate this). She said Resident #1's family member told them (she did not say who them was) they better get Resident #2 off the unit. She said Resident #2 was taken out for evaluation, then brought back to the unit. LVN A said days later, Resident #1's family member wanted her taken to the hospital to assess the bruise over her eye. LVN A said Resident #1's hands and wrists were red. LVN A said she wrote everything she saw in her progress notes and called the residents' families. She said in her notes, she wrote both residents were clothed. LVN A said had she not intervened, she felt like the incident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 16 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would have gone further into a sexual abuse incident. LVN A said days after the incident (she could not recall the exact date), the Administrator called her into the Former DON's office to talk about the incident. She said the Administrator, the Former DON, and ADON B were present during this conversation. LVN A said she demonstrated to the Administrator how Resident #2 had Resident #1's wrists pinned down to the bed. She said the Administrator told her he needed her to document the incident another way because she made it sound too sexual. LVN A said she told them (everyone in the room) she wrote what she saw. LVN A said she was intimidated by the Administrator and ADON B into changing her statement and she began to cry. LVN A said the Former DON kept telling the Administrator that she (LVN A) had written what she saw. LVN A said the Administrator stood over her and instructed her on what words to remove and replace. LVN A said the Former DON was so upset that she walked out of the room. LVN A said she was crying so hard that the Administrator told her she could leave and ADON B would complete the note for her. LVN A said she saw it as a sexual incident when she walked into the room. She said the Former DON told her to make sure to write that they were both fully clothed, he was over her with hands bound to the bed, and that she was struggling to get up. She said the Administrator and ADON B wanted her to take out that they were fully clothed. LVN A said neither Resident #1 nor Resident #2 were talking when she walked into the room. She said she thought the call light was on because it may have fallen to the floor during the struggle. She said Resident #1 was found in Resident #2's room with him several days before the incident, so she thought of Resident #1 when she saw Resident #2's light on. LVN A stated because of the incident, she felt like her license (nursing license) was not safe at the facility, so she had to resign. In an interview with ADON B on 04/19/2023 at 12:50 p.m., she stated Resident #2 had traumatic brain injury from a motor vehicle accident. She said Resident #2 talked rough all the time, but he had never been aggressive. She said Resident #2 had never shown an interest in any females in building. She said Resident #2 was moved out of the locked unit because it was too restrictive and there was not enough room for him to walk around. ADON B said she recalled they had a wanderer, Resident #1, who was very mobile and went into Resident #2's room. ADON B said she could not recall what was said other than Resident #1 was not wearing a bra, and she was not sure why that was said. ADON B said she thought the progress note regarding the incident said Resident #2 was over Resident #1, not on her. ADON B said the nurses did an assessment and they were trying to send Resident #2 out to a psychiatric center, but nobody wanted to accept him with a brain injury. She said Resident #2's family member would not take responsibility or go to the facility. ADON B said they never found anything during their internal investigation, but they did separate him from the locked unit because of the incident. She said she could not recall who the person was who observed the incident, but in their mind, they thought the incident was sexual. ADON B said if you looked at the facts, they did not read in a sexual way. ADON B said she did not think the reporter was asked to change anything in their report. She said the reporter may have missed some documentation in the incident report and was coached, but not asked to change anything. ADON B said maybe the reporter forgot a section of the report because there are several steps to filling out the report. ADON B said she did not think the reporter made an allegation of sexual abuse. She said did not recall if Resident #1 went to the hospital and there were no injuries that she could recall. In an interview with the Administrator on 04/19/2023 at 1:30 p.m., he stated suddenly recalled the incident. He said shortly after he started in November 2022, Resident #1 was found in Resident #2's room. He said Resident #1 had previously wandered into Resident #2's room before. The Administrator said somebody walked in and found Resident #2 laying over Resident #1 with her on the bed. He said both residents were clothed, and no touching was witnessed. He said Resident #1 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 17 of 18 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete bruising to her fingertips, but she was unable to recall what happened. He said Resident #1 also had bruises to the left side of her head and lower mouth. The Administrator said he called the incident in to state. He said there was nothing sexual about the incident and his investigation was unsubstantiated. He said Resident #1 had unknown injuries, so reported the incident as injury of unknown origin. He said they moved Resident #2 off the unit after that and he had been fine since then. The Administrator said nobody observed Resident #2 touching Resident #1, he was just standing over her. The Administrator said Resident #2's name was not mentioned in the self-report because nobody reported seeing him pinning Resident #1 down to the bed and they could not say her injuries were caus[TRUNCATED] Event ID: Facility ID: 455643 If continuation sheet Page 18 of 18