Health inspection·August 14, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Lt eye. Upon assessment of resident, she was observed with discoloration to under Lt eye coming up around eye and small [NAME] to Lt eyebrow. Writer spoke to CNA A morning of 08/03/2023 who stated resident had band aid over eyebrow at start of shift morning 08/02/2023. CNA B also stated it was noted 08/02/2023 at beginning of shift. Writer reported findings to DON morning 08/03/2023. Record Review of additional progress notes for R#1's, and assessments on 08/04/2023, had no additional mention of R#1's injuries. During an observation and interview on 08/04/2023 at 5:45PM, R#1 was in a wheelchair, sitting at a dining room table, being assisted to eat by staff. R#1 was observed to have dark purple discoloration with light green on the left eye, in the eye-ball socket area. Attempted interview with R#1, but R#1 was non-verbal to the questions asked. During an interview on 08/04/02023 at 5:16PM, the Administrator stated injury of unknown origin, especially bruises are reportable injury to state. The administrator stated every morning the ADONs and DON, will discuss events that transpired during the previous 24hr. day before, during their morning clinical meeting. The Administrator stated during the morning meetings, any incident and accidents will also be discussed during the morning clinical meeting. with the 24hrs. The Administrator stated if an event transpired during the weekend, the event will be discussed during Monday morning meeting. The Administrator stated he was not aware of event regarding R#1 and would report the incident to state. The Administrator stated he needed to be notified of any injury small or large, to begin an investigation to determine how the injury happened, not just guess. The Administrator stated he was not made aware of any scratch, or bruise for R#1 from 08/02/2023-08/04/2023. The Administrator stated, had the DON known about R#1's injury, the DON should have begun internal investigation to rule out abuse, and should have instructed managerial staff to continue the investigation, while the DON was off. The Administrator stated no definitive answer as to why the internal investigation had not been done. The Administrator verbalized his dismay for his staff not reporting and investigating R#1's injury. During an interview on 08/04/2023 at 6:04pm, ADON A stated any time an unexplainable injury was observed, the charge nurse will notify the DON and fill out incident report. The ADON A stated if there was a large or small bruise or injury of unknown origin, there needs to be an incident report and the physician needs to be notified to attain recommendations. ADON A stated bruises are reportable to state. ADON A stated an investigation will begin by the DON to ensure the safety of resident and to rule out abuse. ADON A stated she was aware of the event with R#1, but does not know what transpired, and was not given directions to continue any investigation regarding R#1's bruise. ADON A stated she did not know if the DON had begun the internal investigation for R#1. ADON A stated the event with R#1 was not discussed at morning meeting on 08/03/2023. ADON A stated if the DON could not definitively state what happened, it should be investigated, and reported to state. During an interview on 08/04/2023 at 6:18PM ADON B stated she was in the room on 08/03/2023 at 8:30-8:45AM when the charge nurse notified the DON that she had noticed discoloration on R#1's left eye. ADON B stated, the charge nurse notified the DON, there was no documentation nor progress note on R#1's injury. ADON B stated she heard the charge nurse notify the DON, that LVN A had stated in report that R#1 had some slight red discoloration and upon the charge nurse's observation, there was dark purple bruising to R#1's left eye. ADON B stated the DON told the LVN B that she would investigate the injury and get with LVN A. ADON B stated during the morning meeting on 08/03/2023, the topic of R#1's bruising was not brought up and stated the bruising topic should have been discussed due to the injury's unknown origin. ADON B stated she was not given any direction to continue any internal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455697 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Corpus Christi 202 Fortune Dr Corpus Christi, TX 78405 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 investigations. ADON B stated both nurses LVN A and charge nurse should have filled out an incident report. ADON B stated she conducted an in-service regarding abuse/neglect and reporting criteria given about a month ago to all clinical staff. The ADON B stated the DON should have followed up on R#1's injury and should have begun an internal investigation to rule out abuse, especially due to not knowing of definitive origin of R#1's injury and should have been reported to state. ADON B stated when she was looking at R#1's electronic medical record , no was not incident report for R#1. During an interview on 08/04/2023 at 6:55pm, LVN A stated she went into work on 08/01/2023 6:00AM6:00PM, no redness or bruising were observed through her shift. On 08/02/2023 LVN A again went to work from 6:00AM- 6:00PM shift. LVN A stated that she was in R#1's room when two CNAs were getting R#1 up. LVN A stated she was notified while in R#1's room, that R#1 had red discoloration to left eye. LVN A stated she assessed the left eye and observed red discoloration on eye but did not feel a cause for concern. LVN A stated R#1 will at times curl hand near her left eye and utilized her previous experience with R#1 to determine the cause of the red discoloration was R#1 rubbing her left eye. LVN A stated there was no bruising on either of R#1's eyes or nose. LVN A allowed the CNAs to place R#1 in wheelchair and take to the dining area for breakfast and then back to bed. LVN A stated she checked and monitored the red discolored eye area throughout her shift on 08/02/2023 and did not fill out an incident report due to her previous experience with R#1 rubbing her eyes. LVN A stated she did not notify the DON nor Administrator about eye discoloration, due to her previous experience with R#1 self-inflicted red discoloration on left eye by scratching and rubbing eyes. LVN A stated she notified the incoming LVN B on 08/02/2023 at 6:00PM to keep an eye on red eye discoloration. LVN A stated when she left work on 08/02/2023 at 6:00PM R#1's left eye had slight red discoloration but nothing big like a black eye. LVN A stated she felt she acted and advocated appropriately for R#1. LVN A was asked if she witnessed R#1 rubbing and scratching her eye during her shift, to which she replied no and was asked how she then definitively ruled out abuse, given that she did not witness R#1 scratching her eyes, LVN A gave no definitive answer. LVN A stated she was last in-serviced about abuse and neglect early August 2023. During an interview on 08/11/2023 at 12:53PM the DON stated the expectation of the facility, when dealing with injuries was for the charge nurse to be notified, and for the charge nurse to assess the resident, file an incident report, notify family, doctor and according to injury will report according to the HHSC Guidelines. The DON stated on Thursday 8/3/2023 around 8:30AM in the morning, the night charge nurse notified the DON that she needed to speak with her. The DON stated the charge nurse told her that R#1 had a bruise to her left eye, and that nobody had done anything about it. The DON stated she had not heard anything about R#1's injury and stated she would investigate. The DON stated the injury was not brought up in morning clinical meeting because no incident report was done, no risk management report/incident report was done, and because she did not know extent of bruise. The DON stated on 08/03/2023 she observed R#1 to which she saw R#1 with light purple discoloration on left eye. The DON stated she interviewed LVN A on 08/03/2023, and was told by LVN A, that R#1 had self-inflicted injury with her hands. The DON stated R#1 had tendency to rub her eyes and rest her hands by face. The DON stated upon interviewing LVN A, LVN A stated she saw red discoloration during her 6:00AM- 6:00PM shift on 08/02/2023 but did not see a cause for concern or need for incident report. The DON stated, on 08/03/2023 she told LVN A to complete an incident report and dismissed because she knew R#1 rubbed her eyes. The DON stated she was off on 08/04/2023. The DON continued by stating she started her investigation on 08/03/2023, and assessed for safety hazards, spoke to all clinical staff, and on 08/05/2023 CNA A stated while she was changing R#1, CNA A observed R#1 rubbing her eye with hand on face, and when she turned R#1 back to supine position (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455697 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Corpus Christi 202 Fortune Dr Corpus Christi, TX 78405 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 a little bit of blood was visualized. The DON stated, the CNA A stated she reported the injury to LVN A, and that LVN A forgot to do an incident report. The DON was asked how she ruled out abuse, the DON stated she did recall discussing R#1's injury in the clinical morning meeting on 08/03/2023 and notified the ADONs to continue the internal investigation while she was off on 08/04/2023. The DON stated she continued her investigation on Saturday 08/05/2023 as well as conducted an in-service regarding documenting/abuse/neglect on the same day. The DON stated has attempted to rectify situation by writing a formal write up for LVN A. During an interview on 08/11/2023 at 5:17 PM, CNA A stated on 08/01/2023 she went to R#1's room to perform perineal care on R#1 and when she turned R#1 to her left side, she visualized R#1 scratching her eye with her nails. CNA A stated when she turned R#1 back to supine position, she saw that R#1 had blood on the left eyebrow. The CNA A stated she notified LVN A of R#1's bloody eyebrow while LVN A was in the hallway, to which LVN A went into R#1's room and cleaned up R#1's eyebrow, then instructed CNA A to assist R#1 to wheelchair. The CNA A stated R#1's face just had a little bleeding in eyebrow and that was it. The CNA A stated the DON did not ask about the incident until 08/05/2023. The CNA A stated she attended in-service regarding documenting/abuse/neglect on 08/05/2023. Attempted interview with LVN B and was told she was not available for interview. Record review of facility's Documenting/Abuse/Neglect dated, 08/04/2023, did not have LVN A in attendance, but did have CNA A in attendance. Record review of facility's incident/accident reports on 08/04/2023, no report documented for R#1. Record review of facility's Accident and Incident-Investigating and Reporting Policy revised July 2020 stated, 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included in the Risk Management report; a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g. bruise, fall, nausea, etc.); c. Where the accident or incident took place; d. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455697 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Corpus Christi 202 Fortune Dr Corpus Christi, TX 78405 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 The name(s) of witnesses and their account of the accident or incident Level of Harm - Minimal harm or potential for actual harm Record review of facility's Charting and Documentation Policy revised July 2017 stated, 1. Residents Affected - Few All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be report by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455697 If continuation sheet Page 5 of 5