Health inspection·October 27, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with Resident #29 to discuss with her about therapy services and screen her if resident wanted therapy services. She stated she thought Resident #29 had a standard wheelchair and would go look for it. She stated Resident #29 had a 75 degree contracture of both lower extremities on her last screening. Follow-up interview on 10/26/22 at 9:19 AM with DOR revealed after speaking with Resident #29 and seeing her contractures of lower extremities again she realized Resident #29 did not have a wheelchair to get up out of bed to sit in due to her contractures of her lower extremities. She stated Resident #29's bilateral knee contractures made it unsafe for Resident #29 to be placed in a standard wheelchair. She further stated Resident #29 would need a specialized wheelchair to be able to be placed in to get out of bed. She stated she would have to contact a specialized wheelchair company. She stated they would need to do an evaluation of her to find an appropriate wheelchair or broda chair for her specialized needs. She stated she would talk with facility administration about seeing what options were available for Resident #29. She stated Resident #29 was two degrees more contracture in her knees than previous evaluation. Interview on 10/26/22 at 10:47 AM revealed DOR stated facility had ordered a rental geri-chair for Resident #29 to be able to get in when and if she wanted to get out of bed in it. She stated once it is at facility she will ensure Resident #29 had it available for it to be used by Resident #29. Review of Resident #29's therapy screen dated 10/26/22 completed by DOR reflected Resident #29 to be evaluated for physical therapy today. Resident #29 to be screened for wheelchair assessment and was total care. It reflected Resident #29 had bilateral knee rom 77 degrees. Interview on 10/26/22 at 2:41 PM with CNA G revealed Resident #29 was transferred via hoyer lift for showers when resident would let staff shower her. CNA G stated Resident #29 stayed in her bed except for showers. She stated she had not seen Resident #29 in a wheelchair and was not aware of Resident #29 having any type of specialized chair to sit in to be able to get up. Interview on 10/27/22 at 2:00 PM with CNA E revealed Resident #29 was only transferred out of bed with a hoyer lift to be showered and put in shower chair. CNA E refused to get up and did not have a wheelchair or any type of chair to sit in. Interview on 10/27/22 at 2:02 PM with CNA F revealed Resident #29 did not have a wheelchair or any type of chair to sit in. She stated only time Resident #29 is out of bed is when she is showered and allows the CNAs to shower her. Interview on 10/27/22 at 10:38 AM with LVN C revealed Resident #29 did not have a wheelchair or any type of chair to sit in. She stated Resident #29 refused to get out of bed and refused showers at times. Review of Resident #29's order confirmation dated 10/26/22 reflected facility ordered Resident #29 a geri-geri chair. Review of Assistive Devices and Equipment revised January 2020 reflected the facility maintains and supervises the use of assistive devices and equipment for residents .1. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include (but are not limited to): .c. Mobility devices (wheelchairs, walkers and canes) .6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. Appropriateness for resident condition - the resident is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 2 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. b. Personal fit - the equipment or device is used according to its intended purpose and is measured to fit the resident's size and weight . Review of facility's policy Accommodation of Needs revised March 2021 reflected .assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being .The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. Event ID: Facility ID: 455970 If continuation sheet Page 3 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to notify the resident's physician when there was a significant change in the physical status for one (Resident #7) of 16 residents reviewed for notification of change in condition. LVN H failed to notify the physician of Resident #7'significant weight loss on 09/06/22. Resident #7's physician was not informed of significant weight loss until 10/04/22. The failure could place residents at risk for further decline in health status. Findings included: Review of Resident #7's admission MDS assessment dated [DATE] reflected Resident #7 was admitted on [DATE] to the facility and had a weight of 89 pounds. Review of Resident #7's quarterly MDS assessment dated [DATE] reflected Resident #7 was an [AGE] year-old female with diagnoses of hypertension( high blood pressure) and dementia (impaired ability to remember, think or make decisions with activities of daily living). Her weight was 107 lbs. Resident #7 was total dependence with ADLs of bed mobility, dressing, toileting and hygiene. She required supervision with set up help with eating. Review of Resident #7's comprehensive care plan last revised 08/06/22 reflected Resident #7 was at risk for weight loss related to dementia. Current body weight under 100 pounds. Interventions included to Notify MD and family of significant weight change. The care plan was not updated for significant weight loss. Review of Resident #7's weights reflected the following weights put in by nurses: 06/07/22 105 lbs 07/12/22 103.6 lbs 08/02/22 110.2 lbs 09/06/22 90 lbs input in system by LVN H 10/14/22: 98 lbs Review of Dietary note dated 09/26/22 completed by Consultant Dietitian reflected weight loss assessment with weight changes of -18.3% x 30 days, 14.3% x 90 days, -2.3% x 180 days. Po intake good avg 75% per nurse note. Recommendations of fortified meal plan. Review of Nurse notes for September to October 2022 about weight loss reflected the following: 10/04/22 Nurse note by LVN I d/t (due to) recent noted weight loss new order per md medication Remeron 15 mg 1 tab q hs (at bedtime) to help with appetite. Order placed in system resident notified of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 4 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0580 new medication. Level of Harm - Minimal harm or potential for actual harm Interview on 10/27/22 at 8:52 AM with Consultant Dietitian revealed she came out to facility once a month and reviewed weights. She stated she would have been made aware of Resident #7's significant weight loss when she came to facility on 09/26/22 and reviewed resident's weights. Residents Affected - Few Observation on 10/27/22 at 10:05 AM revealed CNA E weighed Resident #7 in her wheelchair and scale showed 134.4 lbs. Interview with CNA E revealed she had weighed Resident #7 with her wheelchair cushion which was 35.4 lbs. She stated to get Resident #7's weight you subtract the weight of the wheelchair. She stated the weight of Resident #7 was 98 lbs. CNA E stated she weighed Resident #7 for the last couple of months. Interview on 10/27/22 at 10:18 AM with Resident #7's physician stated he would have ordered Resident #7 Remeron as an appetite stimulant when notified of significant weight loss. He stated when he ordered Resident #7's Remeron medication on 10/04/22 that would have been the time he was notified of the significant weight loss. He expected nurse to notify him immediately of significant weight loss of a resident so he could put resident on Remeron medication or other interventions. He stated Remeron medications takes about 2-3 weeks to get into resident system before it starts assisting resident to increase appetite. He stated he a delay in notification of significant weight loss would put a delay in interventions like Remeron medication being added. Surveyor attempted to interview LVN H via telephone on 10/27/22 at 11:18 AM but was unable to reach LVN H. Interview on 10/27/22 at 12:05 pm with ADON revealed Resident #7's physician should have been notified of significant weight loss when triggered on 09/06/22 by the nurse. She stated by notifying the physician orders and interventions can be put in place to address the weight loss. She stated the previous DON updated the acute care plans for significant weight loss. She stated Resident #7 could have been placed on Remeron medication sooner if notified when significant weight loss occurred. She stated physician notification should be documented in the nurse's note about resident's significant weight loss. Review of facility's policy Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol reflected The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 5 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for three (CNAs E, G and D) of six employees reviewed for abuse and neglect. Residents Affected - Some The facility failed to conduct criminal background checks for CNAs E, G and D. These failures could place residents at risk for abuse and receiving care from unemployable staff. Findings included: Review of facility's policy Abuse Prevention Program revised June 2021 reflected the facility conducted employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees. For purposes of this policy 'direct access employee' means any individual who has access to a resident or patient of a Long Term Care (LTC) Center or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the Center or provider, as determined by the State. Under Screening in the policy reflected the following: 1. The personnel/Human Services Director, or other designee, will conduct background checks, reference checks and criminal conviction checking (including fingerprinting as may be required by state law) on all potential employees and contract personnel who meet the criteria for direct access employee, as stated above. 2. For any individual applying for a position as a Certified Nurse Assistant, the state nurse aide registry search will be conducted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. Review of CNA E's personnel file revealed her hire date was 01/05/21. There was no Criminal background in her file. Review of CNA G's personnel file revealed her hire date was 12/01/21. There was no Criminal background in her file. Review of CNA D's personnel file revealed her hire date was 10/10/22. There was no Criminal background in her file. The facility conducted criminal background checks for CNA D, CNA E and CNA G on 10/27/22. All three of the employees were employable and had no bars to employment. Interview on 10/27/22 at 2:30 PM with Alternate Administrator revealed Human Resources Manager left recently and they were unable to locate the criminal backgrounds for CNA D, CNA E and CNA G. She stated they had to re-run them to ensure staff were employable and had no bars to employment. She stated the criminal backgrounds should be conducted prior to being hired and annually per facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 6 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to review and revise the person centered care plan after each assessment for one (Resident #7) of 16 residents reviewed for care plans. The facility failed to address Resident #7's significant weight loss in her care plan. This failure could place residents at risk for decreased quality of care and not having their needs met. Findings included: Review of Resident #7's admission MDS assessment dated [DATE] reflected Resident #7 was admitted on [DATE] to the facility and had a weight of 89 pounds. Review of Resident #7's quarterly MDS assessment dated [DATE] reflected Resident #7 was an [AGE] year-old female with diagnoses of hypertension ( high blood pressure) and dementia ( impaired ability to think, remember and make decisions related to activity of daily living). Her weight was 107 lbs. Resident #7 was total dependence with ADLs of bed mobility, dressing, toileting and hygiene. She required supervision with set up help with eating. Review of Resident #7's comprehensive care plan last revised 08/06/22 reflected Resident #7 was at risk for weight loss related to dementia. Current body weight under 100 pounds. Interventions included to Notify MD and family of significant weight change. The care plan was not updated for significant weight loss. Review of Resident #7's weights reflected the following weights put in by nurses: 06/07/22 105 lbs 07/12/22 103.6 lbs 08/02/22 110.2 lbs 09/06/22 90 lbs input in system by LVN H 10/14/22: 98 lbs Review of Dietary note dated 09/26/22 completed by Consultant Dietitian reflected weight loss assessment with weight changes of -18.3% x 30 days, 14.3% x 90 days, -2.3% x 180 days. Po intake good avg 75% per nurse note. Recommendations of fortified meal plan. Review of Nurse notes for September to October 2022 about weight loss reflected the following: 10/04/22 Nurse note by LVN I d/t (due to) recent noted weight loss new order per md medication Remeron 15 mg 1 tab q hs (at bedtime) to help with appetite. Order placed in system resident notified of new medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 7 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/27/22 at 8:52 AM with Consultant Dietitian revealed she came out to facility once a month and reviewed weights. She stated she would have been made aware of Resident #7's significant weight loss when she came to facility on 09/26/22 and reviewed resident's weights. Observation on 10/27/22 at 10:05 AM revealed CNA E weighed Resident #7 in her wheelchair and scale showed 134.4 lbs. Interview with CNA E revealed she had weighed Resident #7 with her wheelchair cushion which was 35.4 lbs. She stated to get Resident #7's weight you subtract the weight of the wheelchair. She stated the weight of Resident #7 was 98 lbs. CNA E stated she weighed Resident #7 for the last couple of months. Surveyor attempted to interview LVN H via telephone on 10/27/22 at 11:18 AM but was unable to reach LVN H. Interview on 10/27/22 at 10:35 AM with MDS Coordinator revealed the previous DON updated the acute care plans for residents including significant weight loss. She stated the previous DON gave her notice abruptly last week. She stated Resident #7's care plan should have been updated for the significant weight loss. Interview on 10/27/22 at 12:05 pm with ADON revealed Resident #7 did have a significant weight loss back in September after reviewing dietary note for Resident #7. She stated the previous DON updated the acute care plans including significant weight loss. Review of facility's policy Care Plans, Comprehensive Person-centered revised December 2020 reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .13. Assessments of residents are on-going and care plans are revised as information about the residents and the residents' condition change .15. The Interdisciplinary team must review and update the care plan: a. When there has been a significant change in the resident's condition . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 8 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to maintain acceptable of parameters of body weights for one of 16 residents (Resident #7) reviewed for weights. Residents Affected - Few The facility failed to maintain the weight of Resident #7 with a significant weight loss on 09/06/22. This failure could place residents at risk for weight loss. Findings include: Record review of Resident #7's admission MDS assessment, dated 01/04/22, reflected Resident #7 was admitted to the facility on [DATE] and had a weight of 89 pounds. Record review of Resident #7's quarterly MDS assessment, dated 07/14/22, reflected Resident #7 was an [AGE] year-old female with diagnoses which included hypertension and dementia. Her weight was 107 lbs. Resident #7 was total dependence with ADLs of bed mobility, dressing, toileting and hygiene. She required supervision with set up help with eating. Record review of Resident #7's comprehensive care plan, last revised 08/06/22, reflected Resident #7 was at risk for weight loss related to dementia. Her current body weight was under 100 pounds. Interventions included to Notify MD and family of significant weight change. The care plan was not updated for significant weight loss. Record review of Resident #7's weights reflected the following: -On 06/07/22 her weight was 105 lbs. -On 07/12/22 her weight was 103.6 lbs. -On 08/02/22 her weight was 110.2 lbs. -On 09/06/22 her weight was 90 lbs. entered by LVN H -On10/14/22 her weight was 98 lbs. Record review of Resident #7's Dietary note, dated 09/26/22, completed by the Consultant Dietitian, reflected a weight loss assessment with weight changes of -18.3% x 30 days, 14.3% x 90 days, -2.3% x 180 days. PO intake good avg 75% per nurse note. Recommendations of fortified meal plan. Record review of Resident #7's nurses notes for September 2022 to October 2022 about weight loss reflected the following: On 10/04/22 Nurse note entered by LVN I revealed d/t (due to) recent noted weight loss new order per MD medication Remeron 15 mg 1 tab q hs (at bedtime) to help with appetite. Order placed in system resident notified of new medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 9 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/27/22 at 8:52 AM with the Consultant Dietitian revealed she went to the facility once a month and reviewed weights. She stated she would have been made aware of Resident #7's significant weight loss when she went to the facility on [DATE] and reviewed the resident's weights. Observation and interview on 10/27/22 at 10:05 AM revealed CNA E weighed Resident #7 in her wheelchair and scale which showed the residents weight as 134.4 lbs. CNA E stated she weighed Resident #7 with her wheelchair cushion which was 35.4 lbs. She stated to get Resident #7's weight you subtract the weight of the wheelchair. She stated the weight of Resident #7 was 98 lbs. CNA E stated she weighed Resident #7 for the last couple of months. Interview on 10/27/22 at 10:18 AM with Resident #7's physician revealed he would have ordered Resident #7 Remeron as an appetite stimulant when notified of significant weight loss. He stated when he ordered Resident #7's Remeron medication on 10/04/22 that would have been the time he was notified of the significant weight loss. He expected nurses to notify him immediately of significant weight loss of a resident so he could put the resident on Remeron medication or other interventions. He stated Remeron medications took about 2-3 weeks to get into the resident's system before it started assisting the resident to increase appetite. He stated a delay in notification of significant weight loss would put a delay in interventions like Remeron medication being added. Attempted interview with LVN H via telephone on 10/27/22 at 11:18 AM was unsuccessful. Interview on 10/27/22 at 12:05 PM with the ADON revealed Resident #7's physician should have been notified of the significant weight loss when it triggered on 09/06/22 by the nurse. She stated by notifying the physician, orders and interventions could be put in place to address the weight loss. She stated the previous DON updated the acute care plans for significant weight loss. She stated Resident #7 could have been placed on Remeron medication sooner if the physician was notified when the significant weight loss occurred. She stated the physician notification should be documented in the nurse's note about the resident's significant weight loss. Record review of the facility's policy titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol reflected The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 10 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care consistent with professional standards of practice for one of two residents (Resident #37), reviewed for respiratory care in that: Residents Affected - Few The facility failed to ensure Resident #37s oxygen humidifier was changed out per doctor's order. This failure could place residents who received oxygen therapy at risk for nose bleeds and/or skin break down inside the residents' nostrils. Findings Included: Review of Resident #37's Face Sheet, dated 10/26/22, reflected an [AGE] year-old male with an admission date of 06/04/22. Diagnoses included congestive heart failure (chronic heart failure), chronic obstructive pulmonary disease (chronic inflammation of the lung which causes airflow problems), and hypertension ((high blood pressure). Record review of Resident #37's Physician orders entered on 6/22/22 stated monitor oxygen humidification bottle every shift. Replace or refill as required. Record Review of Resident #37's care plan reviewed on 10/26/22 did not include Resident# 37's need for oxygen or humidification. Observation and interview on 10/25/22 at 10:04 a.m. revealed in Resident #37's room, the humidifier had a date of 10/15/22 and oxygen humidification bottle was completely empty. Resident #37 stated that he told someone that the bottle needed to be changed out. He was unable to recall who he told but it might have been the day before (10/24/22). He stated that they came back and told him they were out of them completely in the building. In an interview with LVN B on 10/25/22 at 2:29 p.m. revealed that the night nurses are to change the nasal canula and humidifiers out every Sunday night. She stated the reason to change humidifier when empty is to prevent nose bleeds. In an interview with ADON on 10/26/22 at 1:51 p.m., revealed that the oxygen humidifiers to be replaced as needed (when empty). She stated that the humidifiers need to be replaced to prevent nose bleeds and skin break down in the residents' nostrils. Record review of the facility's policy, Oxygen Administration, revised October 2010, .Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 11 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to provide food that was palatable for one (10/27/22 breakfast) of one meal reviewed for food palatability. Residents Affected - Some The facility failed to serve bacon that had a palatable texture during the breakfast meal on 10/27/22. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Observations of the breakfast meal on 10/27/22 from 7:45 AM to 7:55 AM revealed the bacon was overcooked and a few slices of bacon was blackened on sides. Resident breakfast meal hall trays were served with blackened bacon on sides. Observation of breakfast test tray on 10/27/22 at 8:12 AM revealed test tray had blackened piece of bacon and hard. It tasted burnt. Confidential group interview on 10/26/22 with seven of seven residents revealed the bacon at breakfast was overcooked, hard and burnt that was served to them. Interview on 10/27/22 at 8:20 AM with Resident #5 revealed he had two pieces of bacon this morning with one of the pieces of bacon being burnt and too hard to eat. He stated he was not able to eat the second piece of bacon due to it being burnt. He stated he did not understand why they would serve bacon that was burnt and overcooked. Interview on 10/27/22 at 8:24 AM with the Dietary Manager revealed the bacon on the test tray was burnt and overcooked. She stated she would not eat this bacon and it should not have been on serving table. She stated they have to watch the food in oven closely so it does not overcook or burn food. Interview on 10/27/22 at 8:31 AM with Interim DON revealed she liked crispy bacon but it would be a food preference for residents if they like crispy bacon. She did not recall any residents getting any blackened or burnt bacon for breakfast. Interview on 10/27/22 at 8:37 AM with ADON revealed the bacon on the test tray could have gone out to residents and the bacon should not be blackened or burnt. Interview on 10/27/22 at 8:45 AM with Consultant Dietitian revealed food should be served based on resident preferences. She stated she was informed by the kitchen that the ovens run hotter so that might be why the bacon was burnt or blackened. She stated if food is too hard for residents it can make it more difficult for them to eat it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 12 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure items in walk-in refrigerator were labeled and dated. 2. The facility failed to ensure the cleanliness of the fryer was maintained. These failures could place residents at risk for food-borne illness and food contamination. Findings include: 1. Observations on 10/25/22 at 9:24 AM in walk-in refrigerator revealed plastic container of fruit not dated or labeled and a plastic container of leftover food not labeled or dated. Interview on 10/25/22 at 9:28 AM with Dietary Manager revealed the plastic container of fruit was mixed fruit and is should have been dated and labeled. She stated the leftover food was meatballs and it should have been dated and labeled. She stated the dates and labels may have come off. Record review of the facility's policy titled Food Storage, dated 2018, reflected To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US food Codes .2. Refrigerators .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage . 2. Observation on 10/25/22 at 9:26 AM revealed the fryer had food stains and particles were on the front top and sides of fryer. Interview on 10/25/22 at 9:28 AM with the Dietary Manager revealed they used the fryer last Friday for fried fish and was not aware of the policy on how often it should be cleaned. Review of facility's policy General Kitchen Sanitation dated 2018 reflected all nutrition and food-service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness .2. Clean food-contact surfaces of grilles, griddles and similar cooking devices and the cavities and door seals of microwave ovens at least once a day .3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil .5. After cleaning and until use, store and handle all food-contact surfaces of equipment .in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects and other contaminants. 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record Review of the US Public Health Service, Food Code, dated 2017, retrieved on 11/03/22, reflected the following regarding Equipment, Food-Contact Surfaces and Nonfood-Contact Surfaces, equipment food-contact surfaces and utensils shall be clean to sight and touch .the nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 13 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0812 Record review of the US Public Health Service Food Code, dated 2017, retrieved 11/03/22, reflected the following regarding food labeling: Level of Harm - Minimal harm or potential for actual harm 3-602.11 Food Labels. Residents Affected - Some (A) food packaged in a food establishment, shall be labeled as specified in law, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 14 of 15 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #28) of five residents observed for infection control. Residents Affected - Few CMA A failed to sanitize the blood pressure cuff and stethoscope before, after, or between care for Resident #28. The failure could place residents at risk for infection. Findings included: Record review of Resident #28 annual face sheet, dated 10/26/22, reflected an admission date of 5/16/22. Resident #28's active diagnoses included bipolar disorder, anxiety disorder, and diabetes mellitus type 2. Observation on 10/26/22 at 9:14 a.m. revealed MA A at her medication cart outside Resident #28's room. MA A then obtained the blood pressure cuff and stethoscope and entered Resident #28's room. MA A then applied the blood pressure cuff to Resident #28's along with her stethoscope and obtained her blood pressure. MA A then removed the blood pressure cuff, placed her stethoscope around her neck, returned to her medication cart outside Resident #28's room, placed the blood pressure cuff on the medication cart, and then reviewed information on the computer. MA A then gathered Resident #28's medication and took to Resident #28. MA A failed to sanitize the blood pressure cuff before or after care of Resident #28. Interview with MA A on 10/26/22 08:15 a.m. revealed MA A stated that she did not clean blood pressure cuff or stethoscope before or after use on Resident #28. She stated, she does not clean after every resident. She stated that cleaning the equipment is for infection control purposes. Interview with ADON on 10/26/22 1:51 p.m. ADON stated that the expectation is for staff to clean the equipment after each use. She stated the reason we clean after every resident is to prevent spread of infectious disease. She was not able to give a reason that the medication aide did not do this but stated she has been re-educated since that happened. Record review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018 revealed .reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 15 of 15