Inspection·October 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON said she gave Resident #28 an enema and she did not notice any feces on his bed after the procedure. The Corporate Clinical Resource Nurse said anyone that saw a mess should clean it up. She said the nurses when they made rounds or the CNAs when they went into the room should have cleaned it up. Record review of the facility policy Homelike Environment, dated as revised February 2021, revealed the following [in part]: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; e. clean bed and bath linens that are in good condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 2 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate the assessment of 1 of 3 residents (Resident #30) reviewed for the pre-admission screening and resident review (PASRR) program and PASRR assessments and evaluations. Residents Affected - Few The facility did not identify Resident #30 as having mental illness that would require a PASRR Form 1012 (a form which is used to determine whether the individuals dementia diagnosis is the primary diagnoses that would take precedence over a mental illness diagnosis), or a new PL1 form. This failure could affect residents with psychiatric diagnoses who may not be evaluated for PASRR services and place them at risk of not receiving services for care and treatment. The findings included: Review of Resident #30' Significant Change MDS assessment dated [DATE] revealed he a was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #30's diagnoses included: Manic Depression/Bipolar Disorder (a mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), heart failure, fractures and other multiple traumata, high blood pressure, and wound infection. Review of Resident #30's Physician Orders dated 10/12/2023 revealed an order of Seroquel 100 mg at bedtime (an antipsychotic medication) for bipolar disorder with an order start date of 06/23/23. Review of Significant Change MDS dated [DATE] revealed Resident #30 could usually understand others and was usually understood by others; BIMS score of 12 (moderate cognitive impairment). No mood or behavior concerns were indicated. Review of Resident #30's Care Plan dated 08/02/2023 revealed the following: Focus: The resident uses psychotropic medications Risperdal. Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Review of Resident #30's PASRR Level One Screening Forms dated 06/23/2023, (after the resident's admission into the facility) completed by the referring entity revealed Resident #30 had no diagnosis of mental illness, intellectual disability, or developmental disability. Review of Resident #30's records revealed there was not a Form 1012 (dementia/Alzheimer's) completed. An interview on 10/13/2023 at 10:30 AM, with the MDS coordinator revealed that Resident #30 should have had a yes for mental illness with his PL1 form. When asked if she completed a new PL1 form she stated she was not aware that his PL1 was documented incorrectly on admission until today. She stated she had training in PASRR and had been an MDS Nurse for 13 years at other facilities before taking this position. She said by not accurately showing the residents mental illness through PASRR, it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 3 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0645 Level of Harm - Minimal harm or potential for actual harm could cause the resident to not receive PASRR services. She stated she would do a PL1 and submit it today. A copy of the facility's policy on PASSR was requested from the MDS LVN on 10/13/23 at 10:00 AM. A copy of the policy was not provided before exit. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 4 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours for 1 of 2 residents (Resident #33) whose records were reviewed for recent admission to the facility, in that: Resident #33 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours following her admission to the facility. This failure placed the resident at risk for not receiving care and services to meet her needs and to promote her physical and mental health and well-being within her new living environment. The findings included: Review of Resident #33's Face Sheet, not dated, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: metabolic encephalopathy (health conditions affect brain function); gastro-esophageal reflux disease (stomach liquid flows back into the esophagus); Vitamin B deficiency; Bipolar disorder, current episode hypomanic (mental illness that causes extreme mood swings, high to low, that affect energy, thinking, and behavior); generalized anxiety disorder; hypothyroidism (thyroid gland does not produce enough thyroid hormone and the body slows down); essential (primary) hypertension (high blood pressure); other specified depressive episodes; urinary tract infection; Bradycardia, unspecified (slower than normal heart rate); and wedge compression fracture of second lumbar vertebra (lower spine). Review of Resident #33's electronic health record revealed care plans dated 9/25/23 which addressed the use of an assist bar for bed mobility and full code status. In an interview of 10/13/23 at 1:08 PM, the LVN-CCM stated she was responsible for the residents' comprehensive care plans and the DON did the baseline care plans for newly admitted residents. During an interview and record review on 10/13/23 at 2:12 PM, the RN Clinical Resource Nurse reviewed Resident #33's electronic health record for a baseline care plan. She stated the care plans dated 9/25/23 for assist bar for bed mobility and full code status were completed by RN J. The RN Clinical Resource Nurse stated the resident did not have a baseline care plan. She stated the baseline care plans would be indicated by care needed within 48 hours of admission. Review of the facility's policy and procedure for Care Plans - Baseline, dated as revised December 2016, revealed the following [in part]: Policy Statement A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 5 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0655 will be developed within forty-eight (48) hours of the resident's admission. Level of Harm - Minimal harm or potential for actual harm 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate needs . Residents Affected - Few 3. The baseline care plan will be used until staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 4. The resident and their representative will be provided a summary of the baseline care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 6 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 1 resident (Resident #28) reviewed for quality of care, in that: Residents Affected - Few The facility failed to ensure Resident #28 received an enema for a complaint of constipation when requested. This failure could place residents at risk of unmet care needs and constipation. The findings included: Review of Resident #28's face sheet, dated 10/28/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE] with a latest return on 01/25/2023. Diagnoses included acute on chronic diastolic congestive heart failure (impairment of the heart's blood pumping function) and constipation (a bowel dysfunction that makes bowel movements infrequent or hard to pass). Review of Resident #28's Quarterly MDS Assessment, dated 07/12/2023, revealed the resident had a BIMS score of 10 out of 15 (moderate cognitive impairment). In an interview on 10/12/23 at 11:24 AM, Resident #28 came up to this writer and stated he needed an enema right away as half of it was sticking out. He was walking with legs spread apart and said he was uncomfortable. He said he told LVN B, but she said she was too busy. In an interview on 10/12/23 at 11:25 AM, the DON was walking in the hallway and was informed about the situation. The DON went up to LVN B who was sitting at nurse's station working on the computer and asked about it. The DON said she would give the resident an enema and asked Resident #28 to go to his room. In a follow-up interview on 10/12/23 at 1:32 PM, the DON said LVN B was putting in orders and that was why she had performed the enema for Resident #28. The DON was asked if putting in orders took precedence over patient care. She stated, No, LVN B is new, and she will get it. She said a potential outcome of this failure would be the resident could become constipated and have an impaction. In an interview on 10/12/23 at 1:35 PM, LVN B said she told Resident #28 she was in the middle of something and would do it when she got done. When asked if she thought that Resident #28 was in pain or distressed, LVN B stated, I don't really know him that much. When asked if what she was doing on the computer took precedence over patient care, she stated, I just needed to check his orders. In an interview on 10/12/23 at 1:37 PM, Resident #28 stated he had been asking LVN B for an enema for 30 minutes. He stated, I think when someone is hurting really bad, the nurse needs to get off the computer and help. He said the DON gave him an enema and he was feeling better. Resident #28 denied being in pain and said he had constipation occasionally. In an interview on 10/12/23 at 3:41 PM, LVN I said she was familiar with Resident #28 and he was known to have occasional issues with constipation. She said the resident had an order for an enema (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 7 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0684 when needed. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy for Dignity, dated as last revised February 2021, revealed the following [in part]: Residents Affected - Few Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: b. promptly responding to a resident's request for toileting assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 8 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #13) whose records were reviewed for quality of care. 1. The facility failed to ensure a physician-ordered wander guard was in place for Resident #13. 2. The facility failed to prevent Resident #13 from leaving the facility unaccompanied on 10/05/23. This failure resulted in Immediate Jeopardy on 9/30/23. The noncompliance was determined to be past noncompliance (PNC). The noncompliance began on 9/30/23 at 6:37 PM and ended on 10/06/23. The facility had implemented the actions that corrected the noncompliance before the surveyor's entrance into the facility on [DATE]. The facility's failure placed residents at risk for harm and injury from an incident of elopement. The findings included: Review of Resident #13's Face Sheet, not dated, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: dementia with other behavioral disturbance; other depressive episodes; restlessness and agitation; anxiety disorder; schizoaffective disorder (mental disorder with abnormal thought processes with symptoms of schizophrenia characterized by psychosis and bipolar disorder characterized by mood swings ranging from high to low). Review of Resident #13's Significant Change in Condition MDS Assessment, dated 9/27/23 revealed the resident was assessed as having a BIMS score of 1 out of 15 (severe cognitive impairment); verbal behavioral symptoms 1-3 days during the past 7-day review period; and wandering behavior 1-3 days during the past 7-day review period. Review of Resident #13's comprehensive care plan, dated as initiated 6/24/22 revealed it addressed the resident's risk for elopement. A documented intervention was added 9/28/23 for wander guard in place to be checked every shift. Review of Resident #13's Physician orders revealed the following: 6/24/22 - Wander Guard: Check placement every shift to left leg. 3/29/23 - Wander Guard: Apply to Resident for safety related to wandering and/or elopement seeking. Change bracelet per manufacturer's guidelines. Review of Resident #13's Quarterly Elopement evaluation, dated 7/31/23, revealed documentation the resident was ambulatory, cognitively impaired, had a history of wandering, and an elopement care plan was initiated. Review of the Nursing Progress Note, dated 9/30/23 at 11:03 AM, revealed Resident #13 sat down by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 9 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the nurse's cart, stated she could not breathe, and grabbed her chest. The nurse assessed her oxygen saturation level to be at 60% and an oxygen mask was applied. The resident's vital signs were taken with a blood pressure noted at 88/49 and a heart rate of 124. A call was made to 911 for an ambulance and Resident #13 was transported via ambulance to the hospital emergency room. Resident #13's family member was notified. Review of the Nursing Progress Note, dated 9/30/23 at 6:37 PM, revealed Resident #13 returned to the facility via ambulance and was taken via stretcher to her room and placed in bed. No new orders were received. The resident ate the evening meal in the dining room and consumed 100% of the meal. No discomfort was noted. Vital signs were within normal limits and the resident continued to be monitored closely. Review of the Nursing Progress Note, dated 10/05/23 at 9:11 AM, revealed Dietary Aide A called LVN C and told her Resident #13 was down the street. The nurse documented she went outside and the resident was in the street. The dietary aide assisted Resident #13 into his car and brought her to the facility. Resident #13 walked into the facility with LVN C. The nurse documented the resident was assessed from head to toe and no open areas or bruises were noted. A wander guard was applied to her right wrist. The resident denied feeling any pain. Review of the Social Services Progress Note, dated 10/05/23 at 4:24 PM, revealed Resident #13's family member was notified regarding the resident being identified walking about a block from the facility. The note documented the family member asked what had occurred and she was informed the wander guard had been removed when Resident #13 went to the hospital. The family member was informed that all doors leading to the outside had been checked to ensure the locking mechanism worked correctly and a wander guard had been placed on Resident #13 to prevent any future elopement. Review of Resident 13's Medication Administration Records, dated October 2023, revealed they included a visual check of the resident every 2 hours related to wandering and/or exit seeking. The times listed were 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. Each time frame was initialed by the nurse on duty. Review of the Incident Investigation Summary report, dated 10/05/23, revealed Resident #13 did not have a wander guard on at the time of the incident, due to the wander guard being removed prior to being sent to the hospital. The wander guard was not replaced upon her return to the facility and the wander guard checks had not been done. The report documented the incident was reported to the State agency on 10/05/2023 at 12:22 PM. The report documented a staff in-service training was conducted to reiterate that wander guard checks needed to be performed, and the facility's policies for Missing Resident and Wandering and Elopements were reviewed with the staff. The report documented the wander guard was in place and was being checked multiple times daily and an alternate placement was being sought for Resident #13 (in a facility with a secured unit). Review of the Event Report for Elopement, dated 10/05/23, revealed Resident #13 was found off the property on the street. The resident was assessed with no injuries sustained. The resident wandered with no rational purpose and attempted to open doors, and elopement attempts in the past had been unsuccessful. Resident #13 had dementia. The immediate intervention of a door alarm wander guard band was applied and the band was effective and started alerting when the resident went near a door to the outside. The report evaluation notes revealed the wander guard was in place and checked multiple times daily and an attempt was being made to find an alternate placement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 10 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Observation on 10/12/23 at 10:54 AM revealed Resident #13 was ambulating in the [NAME] Hall and walked to the end of the hallway and looked out the glass window to the right side of the exit door. She was not wearing shoes. A wander guard security band was on her right wrist. In an interview on 10/10/23 at 1:59 PM, the Administrator revealed Resident #13 had been sent to the emergency room after being agitated and falling. She was brought back to the facility. The Administrator stated Resident #13's wander guard band was cut off from her ankle before she was transferred to the hospital, because the wander guards were lost when residents were at the hospital. Another wander guard band was not applied following her return from the hospital. The Administrator stated about one week after her return, Resident #13 eloped from the facility and was seen at a street corner intersection by a dietary aide . She stated he was in his car and Resident #13 got in the car and was brought back. The Administrator stated it was unknown how Resident #13 left the building. She stated the resident was not observed exiting, but a door must have been left ajar. Resident #13 left during the mid-morning. She was assessed by the ADON and no injury was noted. The Administrator stated Resident #13 had dementia and was not oriented at all. The Administrator stated, She likes to walk. In an interview on 10/13/23 at 12:53 PM, LVN C, the [NAME] Hall charge nurse, stated she was on duty the morning of 10/05/23 when Resident #13 left the facility unattended. She stated it was during the morning medication pass between 8:30 AM and 9:30 AM. LVN C stated her brother (Dietary Aide A) worked in the facility kitchen and worked a split shift. She stated Dietary Aide A had just clocked out and left after the breakfast meal service, and he called her and told her Resident #13 was outside on the street. He was able to get her into his car and brought her back. LVN C stated she was waiting and met Resident #13 and Dietary Aide A outside in front of the building and assisted the resident back into the building. She stated Resident #13 was wearing socks, but no shoes. LVN C stated she did a head-to-toe assessment on Resident #13 and did not find any evidence of injury. She stated the resident had not fallen outside. LVN C stated Resident #13 did not have a wander guard security band on at that time, and one was applied to her wrist that day. LVN C stated no one saw Resident #13 leave the building. She stated the resident may have followed someone out the door. LVN C stated Resident #13 could move pretty fast. LVN C stated Resident #13 had not had any prior incidents of elopement or leaving the facility unattended prior to the incident on the morning of 10/05/23. In an interview on 10/13/23 at 1:10 PM, the DON stated the staff were having the morning meeting when Resident #13 left the faciity on [DATE]. She stated no one saw her leave the facility. During an interview and observation on 10/13/23 at 3:25 PM, the Maintenance Director stated he thought he knew which door Resident #13 left from on 10/05/23. He led the way to the East Hall sunroom door that led to the patio at the front end of the building. There was a sign on fluorescent green laminated paper on the inside of the door leading to the patio: For the safety of our Wandering Residents please ensure the door closes completely. The Maintenance Director stated the sign was already posted on the door when he started working in the facility one year ago. He stated the door was locked and the lock was released using the keypad code on the wall to the side of the door. He stated the door had a self-closure device and the door would close and latch when opened wide enough to reach the catch point where the door was pulled back to the frame and closed securely, latched and locked. The Maintenance Director demonstrated the opening of the door and stated if the door was only opened a foot for someone to slide out, the door did not pull back tightly and close securely and latch. He stated Resident #13 wandered and checked all the doors. He stated she probably saw the door was open about an inch and pushed it open and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 11 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some left. He stated residents seated in the front lobby entrance reportedly saw her walking outside the front of the building. Resident #13 was brought back into the facility by the charge nurse. He stated the staff morning meeting was held in the conference room and staff may not have noticed Resident #13 walking outside. In an interview on 10/13/23 at 4:35 PM, Dietary Aide A stated he was leaving the facility following the breakfast meal service on Thursday 10/05/23. He stated when he pulled his car onto the street he saw a lady walking on the street. He stated he thought it looked like Resident #13, so he drove around the block and came back. He stated it was Resident #13, so he stopped the car and called LVN C. He stated she came out of the building and told him to get Resident #13 into his car and bring her back. Dietary Aide A stated he talked with Resident #13, she got in the car, and he brought her back. He stated LVN C was waiting outside the front of the building and helped bring Resident #13 back inside. He stated Resident #13 was wearing socks but no shoes. He stated she did not fall. Telephone interview with Resident #13's family member on 10/27/23 at 3:13 PM revealed the resident had not had any prior incidents of elopement from the facility since her admission to the facility during December 2020. The incident on 10/05/23 had been the resident's first time to leave the facility unattended. Review of the facility's policy and procedure for Wandering and Elopements, dated as revised 9/01/2023, revealed the following [in part]: Policy Statement The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Immediate Jeopardy at Past Non-compliance was called on 10/27/23 at 7:41 PM and the Administrator was provided the IJ Template. The facility completed the following corrective actions to address the non-compliance after the incident occurred and prior to the surveyors entering the facility: Review of the staff in-service attendance record, dated 10/06/23, revealed the Administrator provided an in-service lecture regarding wander guards and the facility policy for Wandering and Elopements. The time of the inservice was not documented on the attendance record. Review of the facility Wander Guard binder notebook revealed information regarding the scanning device used to check the wander guard band for function. The book included a copy of Resident #13's Face Sheet, a Wander Risk Information form with Resident #13's picture, and the Consent for Use of Wander Guard form signed by her family member on 12/11/2020. Resident #13 was the only resident identified by the facility as being at risk for wandering and had information in the Wander Guard binder notebook. Review of Resident #13's Medication Administration Record, dated October 2023, revealed a Wander Guard Function Test was to be completed one time daily on the 6 AM - 2 PM shift and was initialed by the day shift nurses as being completed 10/05/23 - 10/27/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 12 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the Maintenance Director's weekly Logbook Documentation forms for October 2023 revealed test operation of doors and locks were completed daily Monday through Friday for the east doors, front entrance door, and west doors and pass was documented for each date. He provided the completed weekly logs dated from October 2022 to the present. Observations of Resident #13 on 10/26/23 at 4:33 PM while in bed and on 10/27/23 at 12:36 PM while walking in the middle hallway near the dining room revealed the wander guard security band was in place on her right wrist. Observations of all the facility doors were conducted during a round with the facility Maintenance Director on 10/26/23 between 4:16 PM and 4:50 PM. All hall exit doors alarmed and released within 15 seconds. The front door was the only door with an alarm that would activate by a wander guard security band. All doors were securely closed and locked. Interviews with the LVN charge nurse, the medication aide, and the certified nurse aide working on Resident #13's hall, who were on duty for the evening shift on 10/26/23 revealed visual checks of the resident were conducted every 2 hours. The LVN and medication aide stated the resident's wander guard band was tested for proper functioning one time daily on another shift and was documented on the medication administration record by the nurse conducting the test. The Corporate RN Clinical Resource Nurse was observed using the scanning device to check the function of Resident #13's wander guard on 10/27/23 and the resident's wander guard was functioning properly. Interview with a certified nurse aide during the day shift on 10/27/23 revealed the Administrator had given a staff in-service training on 10/06/23 and had talked about wander guards, wandering, and visual checks of Resident #13. The certified nurse aide stated the Administrator told the staff not to use the east hall door located in the front part of the building (sunroom). Interview with the Maintenance Director on 10/27/23 revealed he checked the self-closing device and adjusted it as needed for the east hall door leading from the sunroom at the front of the building. He stated he had adjusted the self-closing device several times before Resident #13's elopement from the facility. He said he checked it and adjusted it first thing after Resident #13's elopement and return to the facility on [DATE]. He was observed adjusting the self-closure device on the east hall door in the sunroom and opening the door to test the door closure on 10/27/23 at 1:53 PM. This failure resulted in Immediate Jeopardy on 9/30/23. The noncompliance was determined to be past noncompliance (PNC). The noncompliance began on 9/30/23 at 6:37 PM and ended on 10/06/23 following a staff inservice training provided by the Administrator. The facility had implemented the actions that corrected the noncompliance before the surveyor's entrance to the facility on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 13 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0694 Provide for the safe, appropriate administration of IV fluids 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 parenteral fluids were administered consistent with professional standards of practice and in accordance with physicians' orders, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 1 resident (Resident #30) reviewed for receiving parenteral (administered through a vein) fluids. Residents Affected - Few The facility failed to ensure Resident #30's midline intravenous catheter (an intravenous catheter that is suitable for long term infusion therapy) dressing to his right upper arm, was changed every 7 days as ordered by his physician. This failure could place residents at risk of complications such as infection and/or sepsis and midline catheter displacement and/or infiltration. The findings included: Review of Resident #30' Significant Change MDS assessment dated [DATE] revealed he a was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #30's diagnoses included: Manic Depression/Bipolar Disorder (a mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), heart failure, fractures and other multiple traumata, high blood pressure, and wound infection. He had a bims score of 12 (moderate cognitive impairment), Record review of Resident #30's care plan, dated 03/31/23, revealed he required IV Therapy via a midline intravenous catheter. The facility would assess the catheter site for signs and symptoms of infection, dislodgement, pain, streaking or drainage. The catheter site dressing changes were to be done as ordered by the physician. Record review of Resident #30's active physician orders, dated 10/12/23, revealed an order for Resident #30's midline dressing to the right upper extremity changed every 7 days, and as needed. There was an order to monitor the iv site every shift for signs and symptoms of infection. Record review of Resident #'30's nursing medication administration record, dated 9/27/23 to 10/13/23, revealed the dressing change for the midline was initialed by LVN A as completed on 09/27/23 and 10/4/23. An observation and interview on 10/10/23 at 9:34 AM revealed Resident #30 had a midline line IV dressing to his right upper arm that was dated 09/27/23. There was no redness or other signs or symptoms of infection to the IV site. He stated he did not know when the dressing had last been changed. In an observation on 1004/10/23 at 10:34 AM revealed the midline line dressing For Resident #30 was still dated 09/27/23. In an observation and interview on 10/10/23 at 2:00 PM observed LVN C administer the IV Antibiotic Cefazolin 2 GM IV to Resident #30. The midline dressing was dated 10/10/23 and initialed by the ADON. LVN C stated she noticed the dressing needed to be changed and told the ADON. She stated it was the RN's responsibility to change the midline dressings. She stated she did not know why the 10/4/23 dressing change was initialed as completed when she had not changed the dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 14 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 10/10/23 at 3:00 PM, the ADON stated on 10/10/23 LVN C told her that Resident #30's midline dressing on his right upper arm had not been changed since 9/27/23. She stated she knew the dressing should be changed every 7 days. She stated it was the responsibility of the charge nurse to change the midline dressing and the DON or ADON was also available to change the midline dressing if the charge nurse was busy. She stated the dressing was still dated 09/27/23 when it was, however, there was documentation on the medication administration record that the dressing had been changed on 10/4/23. She stated she did not know why It was documented as done, when the date on the dressing indicated it had not been done. She stated failing to change an IV site dressing could result in an infection in the resident. In an interview on 10/13/23 the DON stated her expectation was for a midline dressing to be changed every week. She stated she did not know why the dressing was initialed as changed by LVN C on 10/04/23, but she would find out and Inservice staff on the facility policy regarding vascular access devices. She stated it was the charge nurses responsibility to change the midline dressing. She stated LVN C can change a midline dressing and administer IV medications because she has taken IV certification training to do so. The DON stated the failure to change the dressing could result in an infection for Resident #30. In an interview with LVN C on 10/13/23 at 11:00 AM, she stated she did not change Resident #30's dressing on 10/04/23. She stated she did not know she initialed the medication administration record; she stated it was initialed in error. She stated the consequence of not changing a midline intravenous catheter dressing was infection. Record review of the facility's Infusion Therapy Responsibilities and Scope of Practice policy, dated effective 06/01/22, revealed [in part]: . Nursing responsibilities: knowledge of risks and complications, understanding of aseptic and sterile techniques, and maintaining equipment and infusions in such a manner as to avoid complications, performing functions and procedures that are consistent with current standards of care, facility policies and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 15 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 3 residents (Resident #27) reviewed for respiratory care, in that: Residents Affected - Few Resident #27 did not have physician's orders for oxygen administration. This facility failure could place residents who received respiratory treatments at risk for receiving incorrect or inadequate oxygen support and could result in a decline in health status. The findings included: Record review of Resident #27's face sheet, dated 10/12/2023, revealed a [AGE] year-old male with an admission date of 12/06/2022 and a latest return date of 08/29/2023. Diagnoses included: sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), chronic congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath, plural effusion (an excessive collection of fluid in the pleural cavity, the fluid-filled space that surrounds the lungs), and obstructive sleep apnea (occurs when the muscles in the back of your throat relax too much to allow normal breathing while sleeping). Record review of Resident #27's Significant Change MDS Assessment, dated 09/01/2023, revealed the resident had a BIMS score of 13 out of 15 (cognitively intact) and received oxygen therapy. Record review of Resident #27's Active Orders, printed on 10/12/2023, revealed that there were no orders for oxygen administration. Record review of Resident #27's Care Plan, dated as last reviewed on 09/01/2023, revealed the following: Problem - Resident requires oxygen therapy related to congestive heart failure, respiratory insufficiency, and obesity. Approach - Administered Oxygen as ordered. In an observation and interview on 10/10/2023 at 9:40 AM, Resident #27 was receiving oxygen via nasal cannula at 4 liters per minute. He stated he received oxygen continually. In an observation and interview on 10/11/2023 at 10:57 AM, Resident #27 was receiving oxygen via nasal cannula at 4 liters per minute. He stated again he received oxygen continually. In an observation and interview on 10/13/2023 at 10:47 AM, Resident #27 was receiving oxygen via nasal cannula at 4 liters per minute. He stated he received oxygen continually. In an interview with the DON and the Corporate Clinical Resource Nurse on 10/13/23 at 10:52 AM, the DON looked in the electric record and said there was an order for oxygen administration for Resident #27, but it was not there anymore. She did not know what happened to the order. The Corporate Clinical Resource Nurse stated a potential negative outcome of a resident having no orders for oxygen administration would be the resident would not be checked for oxygen status and could possibly go into respiratory distress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 16 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 Record review of the facility policy for Oxygen Administration, dated as revised October 2010, revealed the following [in part]: Level of Harm - Minimal harm or potential for actual harm Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Residents Affected - Few Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders of facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 17 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days per week for 2 of 3 months (April 2023 and May 2023) reviewed for RN coverage, in that: The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 8 of 61 days during April 2023 and May 2023. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. The findings included: Record review of CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 3, 2023 (April 1, 2023-June 30, 2023), run date 10/05/2023, revealed no evidence of RN coverage for 8 of 61 days during April 2023 and May 2023: 1. 04/01/2023 with no RN coverage; 2. 04/02/2023 with no RN coverage; 3. 04/15/2023 with no RN coverage; 4. 04/16/2023 with no RN coverage; 5. 04/29/2023 with no RN coverage; 6. 04/30/2023 with no RN coverage; 7. 05/06/2023 with no RN coverage; 8. 05/07/2023 with no RN coverage. In an interview on 10/12/2023 at 04:44 PM, the DON and Corporate Clinical Resource Nurse said there was not coverage for those dates. The DON said possible negative outcomes of not having RN coverage was certain assessments that RNs can only do would not get completed. They denied knowledge of any negative outcomes for the reported period of no RN coverage. A facility policy was requested on 10/12/2023 at 04:44 PM, but the facility failed to provide evidence of policies or procedures regarding utilization of RNs for 8 consecutive hours a day for 7 days per week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 18 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that meet the needs of each resident for 1 of 8 residents (Resident #8), reviewed for pharmacy services. The facility failed to accurately and timely complete documentation of controlled drug administration for 1 resident and monitoring of controlled medications stored on 1 ( [NAME] Hall) of 2 Medication carts checked for narcotic reconciliation. This failure could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes. Findings included: Record review of Resident #8's significant change MDS assessment dated [DATE], revealed Resident ID #8 was admitted to the facility on [DATE] with the following diagnoses: anxiety disorder, non-traumatic brain injury, chronic obstructive pulmonary disease (a chronic lung disease in which air flow is blocked in the lungs, and bipolar disorder ( a mental condition in which the resident has alternating manic highs and depressive lows). Record review of Resident #8's active physician orders as of 10/10/23, included the following controlled drug, clonazepam (anti- anxiety agent) scheduled at 8 AM and 8 PM. Record review of the Resident #8's MAR on 10/10/23 at 11:30 AM revealed Resident #8 had received clonazepam 1mg 1 tablet by mouth at 7:20 AM. Record Review of Resident #8's Narcotic count sheet for Clonazepam 1mg on 10/10/23 at 11:30 AM revealed the documented count of the Clonazepam 1mg was 24 capsules. Observation of the medication card in the [NAME] medication cartcontaining the clonazepam 1 mg capsules revealed a total count of 23 capsules. In an interview with LVN C on 10/10/23 at 11:40 AM she revealed she had not signed out for the medication on the narcotic sheet at the time of administration. She stated that the proper procedure for administration of any narcotic is to sign out on the narcotic control count sheet for the drug immediately after administering the medication. She stated she did not know that she had failed to sign out for the drug, but she had been very busy during the morning. In an interview with Resident # 8 at 3:30 PM on 10/10/23 he stated he believed she had all of his medications that morning. An Iinterview with the DON on 10/12/23 at 3:00 PM she revealed that she expected nurses to sign for controlled medication immediately when administering them, she stated she did not know whythat LVN C had not signed for her controlled drugs when administering them. She stated failing to sign for medications immediated after administering them could result in a drug diversion or a medication error. She stated she would in-service her staff immediately on the facility's-controlled medication process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 19 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a review of the facility's Policy and Procedure, provided by the DON, on 10/10/23, dated 2003, titled Controlled Substances, documented [in part]: Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. An individual controlled substance record is made for each resident who is receiving a controlled substance. The record contains: name of the resident, name and strength of the drug, quantity received, number on hand name of physician, prescription number, name of issuing pharmacy, and date and time received. Texas State Board of Pharmacy @ pharmacy.texas.gov defines controlled drugs as: substances and certain chemicals whose use and distribution are tightly controlled because of their abuse potential or risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 20 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 - Few 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 observation, interview, and record review the facility failed to ensure that controlled drugs listed in the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse were stored in separately locked, permanently affixed compartments in 1 out of 2 facility medication rooms. There was injectable lorazepam in East Hall medication room refrigerator that was not in a separately locked, permanently affixed compartment. The facility's failure could place residents at risk for drug diversion, drug overdose, and accidental or intentional missed doses or administration to the wrong resident. The findings included: During an observation and interview on 1009/12/20230 at 11:20 AM with LVN's B and C in the East Wing medication room, a closed metal box which was unlocked and not affixed was in the refrigerator. LVN B Stated she was the charge nurse for that hallway. She stated she did not know where the key to the box was. She stated there was a vial of lorazepam intensol concentrate in the unlocked box, which was not permanently affixed to the refrigerator. The box was stored in the shelf of the portable refrigerator in the medication room. The refrigerator itself was not locked at the time. DON reported that the refrigerator should be padlocked should be locked and that the lorazepam vial should be locked inside a the locked box in the refrigerator. During an interview on 09/12/23 at 11:40 AM, the Corporate RN and the DON stated the box should be locked and permanently affixed. They stated that they did not know where the key was, but they would replace the box. The DON stated failure to lock refrigerated narcotics in a permanently affixed locked box could result in a drug diversion. She stated she was not aware the drugs were in an unlocked box. Record review of facility provided policy titled Controlled Substances, dated January 2001, revealed [in part]: Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Controlled medications are stored in the medication room in a locked container, separate from containers for any non-controlled medications. Access to controlled medications is remains locked at all times and access is recorded. The DON maintains a list of personnel who have access to medication storage areas and controlled substance containers. Keys to the controlled substance containers are kept on a single key ring separate from any other keys. The charge nurse on duty maintains the keys to the controlled substance containers. The DON maintains a backup set of keys. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 21 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 Texas State Board of Pharmacy @ pharmacy.texas.gov defines controlled drugs as: substances and certain chemicals whose use and distribution are tightly controlled because of their abuse potential or risk. 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: 675035 If continuation sheet Page 22 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Residents #7 and #183) reviewed for infection control practices, in that: Residents Affected - Few CNA G failed to perform proper hand hygiene before resident contact and after glove changes while providing incontinence care to Resident #7. CNA D failed to remove soiled gloves and perform hand hygiene before adjusting Resident 183's sheet to provide privacy and then reapplying a new brief. This failure could place residents at risk for the spread of infection. The findings included: Review of Resident #7's Admissions MDS assessment dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE] whose diagnoses included: high blood pressure, Heart failure and anemia (deficiency of bed blood cells). Resident #7 required extensive assistance with ADL's, and she was always incontinent of both bowel and bladder. Observation of incontinence care performed by CNA G for Resident #7 on 10/12/23 at 10:30 AM revealed CNA G performed hand hygiene and donned gloves. She removed Resident #7's brief that was soiled with urine. CNA G wiped the resident from front to back while cleaning her buttocks and anal area. There was no fecal matter present. CNA F and CNA G did not perform hand hygiene after changing gloves and before positioning Resident #7 on her backside and cleaning her Vulva and urinary meatus. CNA G changed gloves and performed hand hygiene before placing a new brief on Resident # 7. CNA's G removed her their gloves and performed hand hygiene before leaving the room. In an interview on 10/12/23 at 10:45 a.m. with CNA G, she revealed she should have washed her hands before starting care and performed hand hygiene between each glove change during care. CNA G stated she had infection control training. She said the resident could acquire an infection when she did not follow good infection control practices including washing hands after changing gloves. She stated she was nervous because she was being watched and she did not realize what she had done until after she had already made a mistake and then it was too late. Review of Resident #183's admission MDS assessment dated [DATE] revealed Resident #183 was a 93-year- old female with the following diagnoses: non traumatic brain dysfunction (injury to the brain not caused by external physical force), chronic obstructive pulmonary disease ( a group of lung diseases that block airflow and make it difficult to breath), dementia(thought process that interferes with daily function) and hyperlipidemia (high cholesterol). She required limited assistance with ADL's and was frequently incontinent of both bowel and bladder. Observation of incontinence care performed by CNA D for Resident #183 on 10/12/23 at 10:50 AM revealed CNA D performed hand hygiene and donned gloves. She removed Resident #183's brief that was soiled with urine. CNA D wiped the resident from front to back while cleaning her vulva and meatal area, she then cleaned the catheter tubing with a downward stroke using two wipes. She turned the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 23 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 Level of Harm - Minimal harm or potential for actual harm on to not her left side and cleaned the buttock area and rectum. There was no fecal matter present. CNA D failed to remove her gloves and perform hand hygiene before she adjusted Resident #183's sheet to provide privacy while she waited for waited for someone to bring her a clean brief. CNA D did not perform hand hygiene before applying the new brief. CNA's D then removed her gloves and performed hand hygiene before leaving the room. Residents Affected - Few During an interview with the DON on 10/12/23 at 3:00 PM., she revealed she was aware of the concern raised about infection control during the catheter care and peri-care observations earlier that same day. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand hygiene when entering the residents' room before beginning care, between glove changes and when completing care and leaving the room. She stated the DON, ADON and LVN's were responsible for monitoring the aides on a shift-to-shift basis, and the ADON performed proficiency exams on the aides when they began employment and annually. She stated she intended to start inservicing her staff immediately. Review of the facility's infection control policy titled, Perineal Care dated revised 1/20/23, revealed the following [in part]: Using the cleansing wipe clean perineal area, wiping front to back, separate labia and wash downward from front to back, (if the resident has an indwelling catheter gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Continue to clean the perineum from inside outward to the thighs, turn the resident to her side and clean the rectal area thoroughly and wiping from the base of the labia and extending over the buttocks. Use a different section of the cleansing wipe with each stroke by folding each section inward. Use a new cleansing wipe as needed. Reposition the bed covers. Make the resident comfortable. Perform hand hygiene FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 24 of 25 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 1 multiple bed resident room (East Hall room [ROOM NUMBER]) provided a minimum of 80 square feet of floor space per resident, in that: East hall room [ROOM NUMBER] was included in the facility's licensed capacity as a three-bed resident room and did not provide the minimum floor space required per resident. This failure could place residents at risk for restricted movement and limit the amount of resident use equipment and personal effects that could be accommodated in the room. The findings included: Review of the Bed Classifications Form 3740, signed and dated by the facility Administrator on 10/10/23, revealed resident room [ROOM NUMBER], located on the East Hall, was licensed for three beds and was categorized as Title 18 (Medicare). In an interview on 10/10/23 at 8:57 AM, the Administrator stated East Hall room [ROOM NUMBER] was a 3-bed ward and was used for therapy. She stated she wanted to continue the room size waiver that was in effect for the room. Observation on 10/13/23 at 3:20 PM, accompanied by the facility's Maintenance Director, revealed Room #E15, licensed as a 3-bed ward, was used by the therapy department and contained therapy equipment and a desk. The room floor space was measured at 221.8 square feet and equaled 73.9 square feet per person. * FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675035 If continuation sheet Page 25 of 25