Health inspection·July 25, 2023

F 0657 10-325mg, with the directions to give to Resident #1 every four (4) hours PRN for pain. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Progress Note, dated 06/20/2023, revealed LVN A had observed Resident #1 had increased episodes of forgetfulness and increased sleeping. The record review revealed Resident #1 reported to LVN A pain and soreness all over. The record review revealed LVN A documented Resident #1 was observed with slurred speech at times. Record review revealed LVN A notified Resident #1's doctor of new change in condition and a new order was received to transfer Resident #1 to emergency room by ambulance on 06/20/2023 for evaluation. Resident #1 was admitted into the hospital from the ER. Residents Affected - Some Record review of Resident #1's Progress Note, dated 06/27/2023, revealed Nurse B had observed Resident #1 when she arrived back at the facility from the hospital with a new diagnosis of hyponatremia (low sodium level in your blood). Record review of Resident #1's doctor order, dated 06/27/2023, revealed Resident #1 was directed to drink a vanilla Boost with her meals. Record review of Resident #1's Care Plan, dated 05/09/2023, revealed Resident #1's Care Plan had not been updated to include the episode of slurred speech, hospitalization, or new diagnosis of hyponatremia. Record review of Resident #3's Face Sheet, dated 07/25/2023, revealed Resident #3 was an [AGE] year-old-male who was admitted to the facility on [DATE]. The record revealed Resident #3 had a recently returned to the nursing facility 06/02/2023, after readmission from an inpatient hospital stay. The record revealed his diagnoses included Hypokalemia (low potassium levels in the blood), chronic (persisting) kidney disease (condition which kidneys are damaged and cannon filer blood as well as they should), Stage 3 (mild to moderate damage), Hemiplegia (paralysis of one side of the body), unspecified affecting left side, Heart failure, Nontraumatic intracerebral hemorrhage (bleeding in the brain), Cerebral infarction (occurs as a result of disruptive blood flow to brain due to problems with the blood vessels that supply it), and Chronic (persisting) obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #3's five (5) day MDS assessment, dated 06/07/2023, revealed Resident #3 had a BIM score of 08, which indicated moderate cognitive impairment. Record review of Resident #3's functional status revealed Resident #3 required extensive assistance with two (2) or more staff assist in the areas of bed mobility, transfers, dressing, and personal hygiene. During an interview on 07/25/2023 at 10:59 a.m., Resident #3 said he had been in the hospital approximately a month prior due to his stomach hurting. Resident #3 said the staff had to cut up his food since he returned from the hospital, and he was not too happy about it because Resident #3 said he had always been independent. Record review of Resident #3's Progress Notes, dated 05/30/2023 at 11:29 a.m., revealed Nurse B was informed by Resident #3 had vomited twice during the overnight shift and continued to vomit during the morning. Record review revealed Nurse B described the vomit as dark brown and Resident #3's stomach as distended and very hard in her documentation. Nurse B documented Resident #3's doctor was contacted and had ordered Resident #3 to be sent to the ER. Record review of the progress notes revealed Nurse B recorded on 05/30/2023 at 3:25 p.m., Resident #3's family member had contacted the facility and revealed Resident #3 had been admitted to the hospital for further tests. Record review of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675001 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 675001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448 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 - Some Progress Notes revealed there was no other entry that pertained to the incident documented in the progress notes after the date of 05/30/2023. Record review of Resident #3's Physician Progress Note, dated 06/02/2023, revealed Resident #3 was assessed with an upper GI bleed, as the doctor had been informed Resident #3 had coffee ground emesis (vomit) in a patient with underlying Barrett's esophagus (a condition in which the pink lining of the swallowing tube connects the mouth to the stomach [esophagus] becomes damaged by acid reflux, which causes the lining to thicken and become red). Record review of Resident #3's Hospital Discharge Report, dated 06/02/2023, revealed Resident #3's primary discharge diagnosis was upper GI bleed. Record review of Resident #3's Diet Order, dated 06/02/2023, revealed Resident #3 was prescribed a new diet by the doctor who discharged Resident #3 from the hospital. Record review revealed Resident #3's diet was changed to a Dysphagia Level III diet (diet to include bite-sized pieces of moist food with near-normal texture, and avoid hard, sticky, or crunchy foods) effective 06/02/2023. Record review of Resident #3's admission Diet Order, dated 05/18/2023, revealed Resident #3 was ordered a Regular Diet when he was admitted to the nursing facility on 05/18/2023. Record review of Resident #3's Care Plan, dated 05/18/2023, revealed the Care Plan had not been updated to include Resident #3 had been in the hospital and diagnosed with an Upper GI Bleed or received new diet orders as a result. Record review of Resident #4's Face Sheet, dated 07/25/2023, revealed Resident #4 was an [AGE] year-old-male who was admitted to the facility on [DATE]. The record revealed Resident #4 had a recently returned to the nursing facility 07/10/2023, after readmission from an inpatient hospital stay. The record revealed his diagnoses included Sepsis (body's extreme response to an infection), unspecified organism (Primary), Pneumonia (an infection that affects one or both lungs), unspecified organism, Metabolic encephalopathy (problem in the brain caused by a chemical imbalance caused by an illness or organ not working as well as they should), resistance to penicillin, other streptococcus (bacteria that causes infection) as the cause of diseases classified elsewhere, and other staphylococcus (bacteria that causes infection) as the cause of disease classified elsewhere. Record review of Resident #4's MDS five (5) day MDS assessment, dated 07/16/2023, revealed Resident #4 had a BIMS score of 07, which indicated severe cognitive impairment. Record review of Resident #4's functional status revealed Resident #4 required limited assistance with set up or one (1) staff assist in the areas of bed mobility, transfers, dressing, and personal hygiene. During an interview on 07/25/2023 at 2:01 p.m., Resident #4 said he had been in the hospital a few days before and he had been sick and not feeling well. Record review of Resident #4's Progress Notes, dated 05/27/2023, revealed Nurse C documented Resident #4 reported he was not feeling well, and was assessed with a crackle sound when breathing. The documentation revealed Nurse C contacted Resident #4's doctor who suggested Resident #4 be sent to out for evaluation. Resident #4 was admitted to the hospital with a diagnosis of Pneumonia on 05/27/2023. Record review of Resident #4's Progress Notes revealed the fact that Resident #4 was discharged and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675001 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 675001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448 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 - Some readmitted to the facility on [DATE] was not documented in Progress Notes. The information was obtained based on review of the progress notes. Record review of Resident #4's Hospital Discharge summary, dated [DATE], revealed Resident #4 was discharged from the hospital with a diagnosis of hypoxia and healthcare-associate (contracted when in a nursing home or hospital) pneumonia. Record review of Resident #4's Progress Notes, dated 07/03/2023, revealed Resident #4 was assessed by Nurse C, who contacted Resident #4's medical doctor, who requested Resident #4 be sent to the ER for evaluation due to hypoxia (state in which oxygen was not available in sufficient amounts at the tissue level to maintain adequate homeostasis) and to reach an oxygen level greater than 90%. Progress Note revealed Resident #4 was admitted into the hospital with diagnoses of Acute (sudden) Metabolic Encephalopathy (problem in the brain caused by a chemical imbalance caused by an illness or organ not working as well as they should), Leukocytosis, HTN (hypertension), urgency, dehydration, and UTI (urinary tract infection). Record review of Resident #4's Hospital Discharge Record, dated 07/10/2023, revealed Resident #4 was admitted to the hospital on [DATE] with sepsis and found to have gram positive bacteremia. Resident #4 presented at the ER with generalized weakness, and dark urine onset on the morning of 07/03/2023 upon awakening. Resident #4 was placed on antibiotics and monitored as an inpatient at the hospital. Record review revealed Resident #4 would be discharged back to the nursing home with new diagnoses of Sepsis, dehydration, and Acute metabolic encephalopathy. Record review of Resident #4's Progress Note, dated 07/10/2023, revealed Resident #4 returned to the facility and with sepsis and on IV antibiotics as documented by LVN D. Record review of Resident #4's Care Plan, date 07/18/2023, revealed the Care Plan for Resident #4 had not been updated to include Resident #4 had been hospitalized twice in the past two (2) months, had issues related to dehydration, and had new diagnoses of Sepsis and Acute metabolic encephalopathy. During an interview on 07/25/2023 at 1:30 p.m., the DON said Resident #1 was discharged to the ER on [DATE] for low sodium and readmitted to the facility on [DATE]. The DON said Resident #1's Care Plan should have been updated to reflect Resident #1's change in condition of slurred speech, which caused hospitalization and the new diagnosis of hyponatremia when she was readmitted to the nursing facility on 06/27/2023. The DON said the MDS Coordinator was responsible for the initial care plan and the baseline care plan was the responsibility of the admitting nurse. The DON said she was responsible to monitor all care plans to ensure plans were accurate and up to date. The DON said regarding Resident #1, she missed the change in condition/readmission information and the updated diagnosis of low sodium. During an interview on 07/25/2023 at 3:04 p.m., the ADON said she had been at the facility for 1 ½ years. The ADON said when Resident #3 had returned from the hospital and was readmitted with a new diagnosis of GI Bleed and a new diet, Resident #3's Care Plan should have been updated to reflect the new information. The ADON said the discharge orders had been discussed and changes put in place to ensure Resident #3 received the new diet order, but not updating the Care Plan did not meet her expectations. During an interview on 07/25/2023 at 3:26 p.m., the DON said she had been at the facility for seven (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675001 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 675001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448 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 - Some (7) months. The DON said the care plan issues of not being updated when Resident #1, Resident #3, and Resident #4 were readmitted after inpatient hospital stays did not meet her expectations. The DON said more training was needed with the MDS Coordinator to recognize when a care plan needed to be updated. Record review of the facility policy, Using the Care Plan, dated 08/2006, revealed changes in the resident's condition must be reported to the MDS Coordinator so that a review of resident's assessment and care plan can be made. Documentation must be consistent with the resident's care plan. Record review of the facility policy, Care Plans, Comprehensive Person-Centered, dated 12/2016, revealed the IDT must review and update the care plan when there had been a significant change in a resident's condition and when a resident had been readmitted to the facility from a hospital stay. Record review of the facility policy, Change in a Resident's Condition or Status. Dated 11/2015, revealed a significant change of condition required a review or revision to the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675001 If continuation sheet Page 5 of 5