Inspection·April 4, 2024

F 0550 02/23/2024 Created By: DON Level of Harm - Minimal harm or potential for actual harm Problem Start date 11/28/2023: Elopement attempt: Resident was on the smoking porch with other residents and a staff member. Staff turned around to talk to another resident and when she turned back around and saw resident jumping over the fence. Staff went to door and yelled for assistance and went back to the fence to look for resident. She saw the resident round the side of the building. 2 CNA's left out door 4 staff door and turned right running to the resident. When the 2 CNA's got between halls 2 and 3 they saw the resident in between our parking lot and the apartment buildings parking lot. Resident remained in the line of sight for the remainder of the event . Resident was out of sight while he was rounding the building for approximately 30 seconds. From start to finish the event was approximately 5 minutes before the resident was back in the building. Edited: 02/16/2024 Edited By: LVN A Residents Affected - Few Goal: Resident will not have the opportunity for another elopement attempt. Edited: 02/16/2024, Edited By: LVN A Approach: Resident already resides on secure unit however did have smoking privilege's previously. Smoking privileges revoked indefinitely. Edited: 02/16/2024 Edited By: LVN A Record review of Resident #1's Safe Smoking Assessment with a completion date of 03/05/2024 revealed: Resident safe to smoke supervised. During an interview on 04/03/2024 at 1:10 PM CNA C stated they took Resident #1's smoking privileges away because the facility was afraid Resident #1 would try to run off again. During an interview on 04/03/2024 at 1:30 PM, the DON stated after thinking more about suspending Resident #1's smoking privileges she could see where it could possibly a violation of resident rights. The DON stated the care plan did read punitive but that was not the intentions. The DON stated the idea was not to punish Resident #1, but for the safety of resident #1 . The DON stated she was fearful that Resident #1 could have been harmed by trying to run off or climbing the fence. The DON stated the facility had not attempted any other measures, they just stopped the smoking. The DON stated the resident did not have any safety concerns related to smoking, she did not know if they would be able to prevent him running off. The DON stated they did not try to have one on one while smoking, or allowing him to smoke in the secure courtyard. During an interview on 04/04/2024 at 10:30 AM, Resident #1's family member stated her only concern with the facility was that they took Resident #1's smoking privileges away and that was the only thing that he still enjoyed. Resident # 1's family member stated she understood they had to punish him for trying to run off but even without smoking he still ran away from the facility. Resident #1's family member stated Resident #1 was able to smoke safely, the facility was concerned he would try to run off. Resident #1's family member did not understand why they did not allow him to smoke in the secure courtyard, because he was able to smoke there when she visited. Resident # 1's family member stated she did not have a problem sending Resident #1 cigarettes. During an interview on 04/04/2024 at 12:40 PM Resident #1 stated he would like to be able to smoke again. Record review of facility policy titled, Resident Rights dated August 2009 revealed: Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455744 If continuation sheet Page 2 of 8 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 455744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401 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 0550 make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455744 If continuation sheet Page 3 of 8 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 455744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401 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 comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 2 (Resident # 1) residents reviewed for care plan completion. The facility failed to ensure Resident #1 had a comprehensive care plan with measurable objective and person-centered interventions specific to smoking safety and elopement. This failure could place residents at risk for not receiving appropriate supervision. Findings included: Record review of Resident #1's face sheet dated 04/04/2024 revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Age-related cognitive decline, Nicotine dependence, Unsteadiness of feet, high blood pressure, Major Depressive disorder, and anxiety. Review of Resident #1's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns Resident #1 had a BIMS score of 5 (sever cognitive impairment). Record review of Resident #1's Comprehensive Care Plan last revised on 02/23/2024 revealed: Problem start date 02/23/2024: Resident #1 had an elopement 2/22/2024 at 4: 10 pm. He was found in the park adjacent to the facility with 7 minutes of report. Resident had been seen 10 minutes prior to report of resident being missing. When asked why he did it he stated I am a vet tech and a diesel mechanic. I am middle aged and do not belong in a nursing home. Created: 02/23/2024 Created By: DON. Goal Resident #1 will have no further elopement attempts. Created: 02/23/2024 Created By: DON. Approach: Full body RN assessment completed, Moved to the other side of the hall with a closed courtyard, Placed on A side of room by the door, Window audits and head count to be done BID x 7 days, QD x 14 days, 5x/week during IDT/friends with [NAME] rounds, 1: 1 with maintenance, Elopement in-service, Abuse/Neglect in-service, Elopement drill with all shifts, Questioned all staff for the unit if he has ever messed with the windows before: No Created: 02/23/2024 Created By: DON Problem Start date 11/28/2023: Elopement attempt: Resident was on the smoking porch with other residents and a staff member. Staff turned around to talk to another resident and when she turned back around and saw resident jumping over the fence. Staff went to door and yelled for assistance and went back to the fence to look for resident. She saw the resident round the side of the building. 2 CNA's left out door 4 staff door and turned right running to the resident. When the 2 CNAs got between halls 2 and 3 they saw the resident in between our parking lot and the apartment buildings parking lot. Resident remained in the line of sight for the remainder of the event. Resident was out of sight while he was rounding the building for approximately 30 seconds. From start to finish the event was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455744 If continuation sheet Page 4 of 8 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 455744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401 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 approximately 5 minutes before the resident was back in the building. Edited: 02/16/2024 Edited By: LVN A Level of Harm - Minimal harm or potential for actual harm Goal: Resident will not have the opportunity for another elopement attempt. Edited: 02/16/2024, Edited By: LVN A Residents Affected - Few Approach: Resident already resides on secure unit however did have smoking privileges previously. Smoking privileges revoked indefinitely. Edited: 02/16/2024 Edited By: LVN A Record review of Resident #1's Safe Smoking Assessment with a completion date of 03/05/2024 revealed: Resident safe to smoke supervised. During an interview on 04/03/2024 at 1:30 PM the DON stated the MDS Coordinator was responsible to complete care plans and the DON and ADON help to update the care plans. The DON stated care plans should have been person centered and measurable. The DON stated the goal should have been measurable and the approaches should guide staff on what the needs of residents were to be able to provide the needed care for resident and should have supported the goal. The DON stated the approaches should have incorporated different approaches and just not suspending Resident smoking, should have addressed that nicotine patches were given to the resident. The DON stated some of the approaches should not have been in the care plan because it was more about what the facility was going to do correct the issues facility wide. The DON stated Resident #1's care plan did not have measurable objectives and the interventions were not individualized. The DON stated Resident #1's care plan should have been person centered. The DON stated the effect on residents could have changed the was a resident was care for and could have prevented resident from receiving person centered care. The DON stated Affect care plans can change the way a resident cared for and may prevent a resident from receiving person centered care. The DON stated oversight led to failure of care plan not being person centered. During an interview on 04/03/2024 at 3:15 PM the ADMN stated his expectation was that care plans should have been person centered interventions and measurable objectives. The ADMN stated the MDS coordinator and the DON were responsible to ensure care plans were completed and person centered with measurable objectives. The ADMN stated a resident not having a person-centered care plan could cause residents to not have all their needs fulfilled or met. The ADMN stated that the approaches listed for Resident #1 were not person centered and were all approaches that would help the resident. The ADMN stated what led to the failure was staff were in the heat of moment after resident had eloped and initial thoughts were on to protect Resident. The ADMN stated the approach listed for Resident #1 for the elopement attempt on 11/28/2024 were not appropriate. During an interview on 04/04/2024 at 12:40 PM Resident #1 stated he would like to be able to smoke again. Record review of facility policy titled Care Plans-Comprehensive, dated September 2010, revealed: Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . Each resident's comprehensive care plan is designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; Reflect treatment goals, timetables and objectives in measurable outcomes; Identify the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455744 If continuation sheet Page 5 of 8 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 455744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401 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 FORM CMS-2567 (02/99) Previous Versions Obsolete professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and Reflect currently recognized standards of practice for problem areas and conditions .Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. Event ID: Facility ID: 455744 If continuation sheet Page 6 of 8 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 455744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 2 of 3 (Hall 3 Medication Cart and Hall 5 Medication Cart) medication carts reviewed for medication storage. The facility failed to keep each resident's drugs in their original containers/packaging. These failures could place all residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions. Findings included: During an observation on 04/02/2024 at 11:15 AM, the hall 3 medication cart had seven loose pills in the second drawer of the medication cart. The pills were loose under the blister packages of resident medications. During an interview on 04/02/2024 at 11:20 AM, LVN B identified the loose pills as one Lisinopril, one Midodrine, one Furosemide, two Keppra pills, one Zoloft and one Buspirone. LVN B stated there should not have been pills loose in the medication cart. LVN B stated this was not normally her cart and she had not had a chance to look through the cart this morning. LVN B stated that staff sometimes get in a hurry. LVN B stated staff will accidentally drop pills and will just pop another pill out of the blister pack; and then forget to go back and dispose of the pill that was dropped in the bottom of the drawer. LVN B stated the effect on residents could have been resident be delayed on receiving their medications, or pharmacy might not want to refill because too early to refill a medication. LVN B stated that all staff were responsible for ensuring their medication carts were clean, organized and free from any loose pills. During an observation on 04/02/2024 at 1:02PM, the hall 5 medication cart had 3 loose pills. The ADON stated the pills as one Atorvastatin, one Multi-vitamin and one Protonic. During an interview on 04/02/2024 at 12:49 PM, the ADON stated there should not be loose pills in the medication carts. The ADON stated every night shift was responsible for cleaning the medication carts and that every shift nurse should be cleaning medication carts themselves. The ADON stated herself and the DON randomly checked medication carts at least once per week. The ADON stated the effect on residents was that they could have run out of medications too soon, insurance will not fill medication because it was too soon. The ADON state what led to failure was staff not paying attention, dropped and just did not pick it up. During an interview on 04/03/2024 at 1:30 PM, the DON stated her expectation was that pills should not have been loose in the bottom of the medication cart. The DON stated the night shift were to check medication carts once per week and staff should be aware and be checking each shift. The DON stated herself and the ADON were responsible to monitor medication carts and check carts at least one time per week. The DON stated the effect on residents they could have run out of medication sooner than they should have and puts residents at the potential for having medication missed. The DON stated the reason for the failure was staff not aware of popping more than one pill and/or not realizing the cards had gotten nicked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455744 If continuation sheet Page 7 of 8 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 455744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401 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 0761 Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled, Storage of medications dated April 2007 revealed: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received . The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455744 If continuation sheet Page 8 of 8