Inspection·August 24, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of wound care nurse practitioner's notes for Resident #2 dated 08/08/2023 indicated: Surgical excisional debridement was performed. Treatment plan for Stage 4 sacral pressure ulcer and Stage 3 pressure ulcer: discontinue alginate calcium, add venelex, continue collagen powder and betadine, cover with composite dressing with waterproof border. Change daily and as needed for soilage. During an interview on 08/22/2023 at 1:12 p.m., LVN F said venelex was an ointment used for wounds and it would be ordered as a prescription and come from the pharmacy. During an interview on 08/22/2023 at 1:30 p.m., the DON said the process for changing the wound care orders was that the wound doctor or nurse practitioner wrote the wound note for the visit, then she (the DON) printed out the visit note and brought it to the nurse. The DON said the nurse was then supposed to put in the orders as the wound care provider ordered. The DON said she checked that the orders were input each weekday. She said she expected the orders to be put in the EMR the same day wound care was here. The DON said she, the ADON, or the MDS nurse updated the care plans with new orders. During an interview on 08/22/2023 at 1:57 p.m., LVN D said she took care of the back station on 08/08/2023. She said she discussed the venelex for Resident #2 with the NP G. LVN D said she normally transcribed the orders based on the wound care note. LVN D said she had to leave early that day and she may have not been the nurse that received the wound care printout from the DON. During an interview on 08/22/2023 at 2:20p.m., LVN E said that he did not remember getting any wound notes with orders on 8/8/2023. LVN E said it was likely the previous shift nurse that was responsible for transcribing the notes. During an interview on 08/24/2023 at 9:48 a.m., NP G said he saw Resident #2 on 08/08/2023 and ordered the venelex as an attempt to improve the healing of his Stage3 and Stage 4 sacral wounds. NP G said he expected the facility and nurses to make wound care order changes when he orders them. NP G said he was unaware the wound care orders were not transcribed or implemented. During an interview on 08/24/23 at 11:26 a.m., ADON B said she does not deal with wound care orders. The DON takes care of that. ADON B said she expected the nurse to put orders in the EMR ordered by a provider. During an interview on 08/24/23 at 11:31 a.m., ADON C said she expected the nurses to follow any wound care provider orders and enter them into the EMR. ADON C said she did not print out the wound care notes that day. ADON C said sometimes the DON asked her to do it, but she did not that day. During an interview on 08/24/23 at 11:36 a.m., the DON said she printed out the wound notes and gave them to LVN D. The DON said she expected the nurse to put the orders in the EMR as the provider ordered. She expected the nurse that rounded with the wound care provider to input the orders into the EMR as ordered. The DON said if an LVN left early and was unable to transcribe the new orders she should have communicated with the oncoming nurse. The potential for wound decline is present if the order is not changed. During an interview on 08/24/23 at 11:54 a.m., the Administrator said he expected the nurses to put in and follow orders as ordered by the provider. The Administrator said not following orders left the resident with the possibility of additional wounds or deterioration of the wounds up to death. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Review of a facility policy titled Care Plans dated 11/2020 revealed the resident care plan was used to plan and assign care for all disciplines. The resident care plan must be kept current at all times. 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: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 each resident received adequate supervision to prevent accidents for seven of seven residents (Resident #1, #3, #4, #5, #6, #7, and #8) reviewed for accidents and hazards in that: 1. The facility failed to ensure the gate in the courtyard was locked and the alarm was functioning after Resident #1 eloped. 2. The facility failed to follow their policy and monitor the alarms daily. 3. The facility failed to secure the side door on Hall 500 and there was no alarm on it. Resident #3, #4, #5, #6, #7, and #8 were in the facility at this time and were at risk of elopement. 4. The facility failed to monitor and supervise residents in the courtyard who were an elopement risk. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 08/23/23 at 03:52 PM. While the IJ was removed on 08/24/23 at 11:10 AM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place the residents at risk for serious harm, serious injury, or death. Findings included: 1. Record review of Resident #1's face sheet, dated 08/22/23, indicated she was an [AGE] year-old female, admitted on [DATE]. Her diagnoses included dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), diabetes mellitus type 2 (a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), heart failure (a condition that occurs when the heart muscle doesn't pump blood as well as it should), and repeated falls. Record review of Resident #1's annual MDS assessment, dated 07/13/23, indicated she had a BIMS score of 04, which indicated severe cognitive impairment. The MDS indicated she exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. Resident #1 required limited assistance with bed mobility, transfers, walking in room and the corridor, locomotion on and off unit, and eating. She required extensive assistance with dressing, toileting, and personal hygiene. She normally used a wheelchair as a mobility device. She required insulin injections and diuretic medications 7 of 7 days of the assessment. She used a wander/elopement alarm daily. Record review of Resident #1's physician's orders, dated 08/22/23, indicated she had this order: *May have Wanderguard bracelet. Verify placement each shift. Special instructions: left lower leg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 Every Shift. The start date was 09/15/22. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's care plan, last edited 08/07/23, indicated a problem of resident is at risk for wandering around facility with/without purpose. Interventions included: Residents Affected - Some *observe resident when out of room for wandering in/out of other rooms, wandering to unauthorized areas and provide redirection when needed. *wanderguard to ankle for safety *If wandering increases and places resident at risk for injury, or leaving facility, notify MD, RP, ADMIN, DON and assess, discuss possible need for secure unit/proper placement. *Maintenance to check all alarm functions Further record review of Resident #1's care plan, edited on 07/24/23, indicated a problem of potential for elopement resident verbalizing she needs to get out of building. She often believes she needs to leave to her her children to/from school. Interventions included: *Assess resident for use of wanderguard system, Wanderguard placed to left ankle. *Attempt to make resident feel secure/safe within facility *Re-direct if resident attempts to elope Record review of Resident #1's elopement risk assessment, completed on 07/11/23, indicated Resident #1 was at risk for elopement. The assessment indicated Resident #1 had a history of wandering. Record review of Resident #1's provider investigation report for her elopement incident indicated she told the staff after her elopement I am trying to get out of here to leave. Further review indicated Resident #1 was located at 1830 (6:30 pm) on 08/06/23, 15 minutes after RN A last saw her inside the building. 2. Record review of Resident #3's facesheet, dated 08/22/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included acute respiratory disease (a serious lung condition that causes low blood oxygen), delusional disorders (a type of mental health condition in which a person can't tell what's real from what's imagined), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Record review of Resident #3's annual MDS assessment, dated 05/18/23, indicated she had a BIMS score of 06, which indicated severe cognitive impairment. The MDS indicated she exhibited behaviors of wandering at least 4-6 of 7 days of the assessment. The MDS indicated her wandering put her at significant risk of getting to a potentially dangerous place. She required supervision assistance with bed mobility, transfers, walking in room and the corridor, and locomotion on and off unit. She required limited assistance with dressing, toileting, and personal hygiene. She did not use a mobility device such as a walker or wheelchair. She used a wander/elopement alarm daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 Record review of Resident #3's physician's orders, dated 08/23/23, indicated she had this order: Level of Harm - Immediate jeopardy to resident health or safety *May have Wanderguard bracelet. Verify placement each shift. Special instructions: left lower leg. Every Shift. The start date was 05/09/23. Residents Affected - Some Record review of resident #3's care plan, last edited on 08/18/23, indicated a problem of resident is at risk for wandering and elopement with/without purpose. Interventions included: *place in wandering book at each nurse's station, as well as in wanderguard bracelet for resident's own safety. *if resident is noted attempting to wander away from facility, attempt to redirect back to facility. Offer distraction for example food, activity, call family, and if they become agitated and continue to wander, seek assistance and continue to observe for safety until resident is back in building. * If wandering increases and places resident at risk for injury, or leaving facility, notify MD, RP, ADMIN, DON and assess, discuss possible need for secure unit/proper placement. Record review of resident #3's elopement risk assessment, dated 08/14/23, indicated Resident #3 was at risk for elopement. She exhibit behaviors of making statements she was leaving, and displayed behavior(s) that may indicate an attempt to leave. 3. Record review of Resident #4's face sheet, dated 08/23/23, indicated he was a [AGE] year-old male, admitted on [DATE]. His diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and anxiety (persistent and excessive worry that interferes with daily activities). Record review of Resident #4's quarterly MDS assessment, dated 08/07/23, indicated he had a BIMS score of 0, which indicated severe cognitive impairment. The MDS indicated he exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. Resident #4 required limited assistance with bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing and eating. He required extensive assistance with toileting and personal hygiene. He did not use a mobility device such as a walker or wheelchair. He required antipsychotic and diuretic medications 7 out of 7 days of the assessment. He used a wander/elopement alarm daily. Record review of Resident #4's physician's orders, dated 08/23/23, indicated he had this order: *May have wanderguard bracelet to right ankle, verify placement every shift. The start date was 02/01/23. Record review of Resident #4's care plan, last edited on 08/02/23, indicated a problem of potential for elopement, attempted to open door. Interventions included: *continue wanderguard to ankle *assess resident for use of wanderguard system, wanderguard placed to left ankle *Re-direct if resident attempts to elope (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 Record review of Resident #4's elopement risk assessment, dated 08/05/23, indicated he was at risk for elopement. He exhibited behaviors of history of wandering into unsafe areas, making statements he was leaving, and displaying behaviors that may indicate an attempt to leave. 4. Record review of Resident #5's face sheet, dated 08/23/23, indicated she was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included insomnia (common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep), schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), and Alzheimer's disease with late onset (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Record review of Resident #5's quarterly MDS, dated [DATE], indicated she did not have a BIMS score assessment because she was rarely/never understood. She exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. She required supervision assistance with walking in room and corridor, locomotion on and off unit, and eating. She required limited assistance with bed mobility and transfers. She required extensive assistance with dressing, toileting, and personal hygiene. She did not use a mobility device such as a walker or wheelchair. The MDS indicated she did not use a wander/elopement alarm. Record review of Resident #5's physician's orders, dated 08/23/23, indicated she had this order: *May have wanderguard bracelet to right ankle, verify placement every shift. The start date was 11/18/22. Record review of Resident #5's care plan, edited on 06/13/23, indicated she had a problem of potential for elopement. Interventions included: *Attempt to make resident fell secure/safe within facility *Encourage resident to verbalize feelings *re-direct if resident attempts to elope *Wanderguard system placed to right ankle Record review of Resident #5's elopement risk assessment, completed on 07/14/23, indicated she was at risk for elopement. She displayed behaviors that may indicate an attempt to leave. 5. Record review of Resident #6's face sheet, dated 08/24/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), psychotic disorder with delusions (a disorder in which people who have it cannot tell what is real from what is imagined), anxiety disorder (persistent and excessive worry that interferes with daily activities), insomnia (common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep), and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). Her assigned room was on the 500 hall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 Record review of Resident #6's annual MDS assessment, dated 07/11/23, indicated she had a BIMS score of 15, which indicated intact cognition. She exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. She required limited assistance with all activities of daily living. She normally used a walker as a mobility device. The MDS indicated she did not use a wander/elopement alarm. Record review of Resident #6's physician's orders, dated 08/24/23, indicated she had this order: Residents Affected - Some *Wanderguard bracelet. Check placement every shift. Special instructions: Rolling walker. The start date was 08/24/22. Record review of Resident #6's care plan, edited 07/17/23, indicated a problem of [Resident #6] is at risk for wandering around facility with/without purpose. Looking for her dog. Has history of leaving prior facility. Packs her belongings and makes statements about going to Tennessee. Wanderguard placed to rolling walker due to resident not keeping bracelet on wrist. Interventions included: *Observe resident when out of room for wandering in/out of other rooms, wandering to unauthorized areas and provide redirection as needed. *Wanderguard to bottom of walker for safety. Takes walker with her about facility. If wandering increases and resident is placed at risk for injury, or leaving facility, notify MD, RP, Admin, DON and assess, discuss possible need for secure unit/proper placement. *If resident is noted attempting to wander away from facility, attempt to redirect back to facility. Record review of Resident #6's elopement risk assessment, dated 07/31/23, indicated she was at risk for elopement. She exhibited behaviors of history of wandering. 6. Record review of Resident #7's face sheet, dated 08/23/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (the loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #7's significant change in status MDS assessment, dated 08/09/23, indicated she had a BIMS score of 0, which indicated severe cognitive impairment. The assessment indicated she exhibited behaviors of wandering daily. She required supervision assistance with walking in her room, locomotion on and off unit, and eating. She required limited assistance with bed mobility, transfers, walking in corridor, dressing, toileting, and personal hygiene. She normally used a walker as a mobility device. She received an anticoagulant medication 7 of 7 days of the assessment. She used a wander/elopement alarm daily. Record review of Resident #7's physician's orders, dated 08/23/23, indicated she had this order: *May have wanderguard bracelet. Verify placement every shift to L ankle. The start date was 04/26/23. Record review of Resident #7's care plan, edited 08/11/23, indicated she had a problem of Resident #7 is at risk for wandering around the facility with/without purpose, and requires use of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 wanderguard. The interventions included: Level of Harm - Immediate jeopardy to resident health or safety *Observe resident when out of room for wandering in/out of other rooms, wandering to unauthorized areas, and provide redirection as needed. *Wander guard for safety Residents Affected - Some *If resident is noted attempting to wander away from facility, attempt to redirect back to facility. Further record review of Resident #7's care plan, edited 08/11/23, indicated a problem of potential for elopement. Interventions included: *Assess resident for use of wanderguard system. Wander guard bracelet on the left ankle. *Attempt to make resident feel secure/safe within facility. *re-direct if resident attempts to elope Record review of Resident #7's elopement risk assessment, dated 08/07/23, indicated she was at risk for elopement. She exhibited behaviors of making statements that she was leaving. 7. Record review of Resident #8's face sheet, dated 08/24/23, indicated she was an [AGE] year-old female, admitted to the facility 02/03/20. Her diagnoses included cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain, typically caused by disrupted blood supply to the brain), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and heatstroke (a condition caused by your body overheating, usually as a result of prolonged exposure to or physical exertion in high temperatures). Her assigned room was on the 500 hall. Record review of Resident #8's quarterly MDS assessment, dated 08/08/23, indicated she had a BIMS score of 0, which indicated severe cognitive impairment. The MDS indicated she exhibited behaviors of wandering 1-3 of 7 days of the assessment. She required limited assistance with locomotion off unit and eating. She required extensive assistance with bed mobility, transfers, locomotion on unit, dressing, toileting, and personal hygiene. She normally used a wheelchair as a mobility device. She used a wander/elopement alarm daily. Record review of Resident #8's physician orders, dated 08/24/23, indicated she had this order: *Wanderguard to left ankle. Verify placement every shift. The start date was 07/15/22. Record review of Resident #8's care plan, edited 08/10/23, indicated she had a problem of potential for elopement. Interventions included: *Attempt to make resident feel secure/safe within facility *Offer diversional activities such as snacks, fluids, or bingo during wandering episodes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 *Re-direct if resident attempts to elope Level of Harm - Immediate jeopardy to resident health or safety *wanderguard system applied to left ankle Record review of Resident #8's elopement risk assessment, dated 08/04/23, indicated she was at risk for elopement. She exhibited behaviors of history of wandering. Residents Affected - Some During an interview on 08/23/23 at 12:08PM, RN A said she was the front station charge nurse on the day Resident #1 eloped. She said she was not assigned to Resident #1. She said a resident at the front door signaled to her that Resident #1 was outside in the parking lot propelling herself in her wheelchair. She said she went outside and was able to redirect Resident #1 back inside. She said she assessed her and she did not see any negative findings. She said she notified the DON of the elopement and put Resident #1 on 15 minute checks. She placed a CNA 1 to 1 with her for 45 minutes. She said she notified the MD and family. She said Resident #1 did not have other events after this for the rest of her shift. Before the elopement she had seen the resident moving around all over the building about 15 minutes before the elopement. She said after this she checked all the exterior door locks and alarms. She said the gate in the courtyard was open and the alarm was not making any noise. She said she closed and secured the gate. During an interview on 08/23/23 at 12:45PM, the Administrator said the gate was not locked before the elopement. He said it was latched the same way it was then. There was a latch in the ground and a latch across the gate. He said they did it this way to allow egress in case of a fire. During an interview on 08/23/23 at 12:50PM, RN A said when she was checking the gate in the smoking area on the day of Resident #1's elopement the gate in the smoking area was open and the alarm was broken and nonfunctional. She said she did not notify the Administrator or DON that the alarm was broken. She said she did not assign someone to the gate even though she knew the alarm was nonfunctional. She did not say why she did not notify administration or assign someone to the gate when asked by this surveyor. During an observation on 08/23/23 at 12:52PM, the Director of Clinical Services said they do not check on residents in the courtyard anymore. She said they used to check on them every hour as part of an old plan of corrections, but the QAPI team had decided it was no longer needed sometime before August 2023. During an interview on 08/23/23 at 12:55PM, the [NAME] President of Operations said he checked the courtyard gate and the alarm on 08/07/23. He said at that time the alarm was functional. He said the gate had two latches, one in the ground and one across the center of the gate. He said there was no lock on the gate. During an interview on 08/23/23 at 1:20PM, the DON said the gate and exterior doors were supposed to be locked. She said the maintenance man checked the gate and that the exterior doors were locked once a week. She said no one else checked the doors or gate more often than that. She said that the charge nurses were responsible for checking on any residents in the courtyard. She said there was no set frequency that they should check the courtyard for residents. She said they only had a wander guard alarm on the front door and the back door. She said there was no wanderguard on the other emergency exits at the end of the halls, or the courtyard gate. During an observation on 08/23/23 at 1:35PM, the gate to the smoker's courtyard was closed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 latched. There were two latches on the gate. There was a lower latch that attached to the right side of the gate into the ground. There was another latch that attached the two sides of the gate that was a slide bolt style of latch. The gate was not locked. There was an alarm attached to the gate that sounded inside the courtyard door in the dining room of the facility. There was no wanderguard alarm. During an observation on 08/23/23 at 1:39PM, an exterior door on the 500 hall that was accessible to residents was unlocked and not alarmed. This surveyor was able to open the door and walk outside to the side of the building. There was no gate or fence outside. During an interview on 08/23/23 at 2:18PM, the Administrator said he had taken over the gate and door lock checks because the maintenance person was busy with the renovations in the facility. He said he checked the emergency exits and the courtyard gate every week on Monday. He said he checked that 500 hall side door every week on Monday as part of his gate and door lock checks. During an observation on 08/23/23 at 4:25PM, an extra wanderguard was brought near the front door. The wanderguard alarm did not sound when the wanderguard was brought near it. The front door alarm only sounded when the door was pushed on. The door was locked and required a code to exit. During an interview on 08/23/23 at 4:30PM, the Director of Clinical Services said the front door was locked because the wanderguard alarm was not functioning. She said someone was working on it today and was unable to fix it. During an interview on 08/24/23 at 8:20AM, the Director of Clinical Services said the front door wanderguard was not working on 08/23/23 because they had an outside company come in to upgrade it. She said it was not as loud as they would like so they decided to upgrade it. They had to take the board with them on 08/23/23 to make some repairs. She said they should be back on 08/24/24 to put the board back in and it should be fully repaired. She said in the meantime the door was locked and the residents cannot get out of it. During an interview on 08/24/23 at 11:26 AM, ADON B said the potential for the unlocked 500 hall side door being open was that a resident could walk out if they were not supervised. She said there was a risk of serious injury, serious harm, or death if they got out and were not found. During an interview on 08/24/23 at 11:31AM, ADON B said the potential for the unlocked 500 hall side door being open was that a resident could have eloped, and they could have gotten hurt. She said there was a potential for serious harm or serious injury. During an interview on 08/24/23 at 11:36AM, the DON said on 08/06/23 a resident notified RN A that Resident #1 was outside propelling herself in the parking lot. RN A redirected her inside and an assessment was performed. Resident #1 did not have any negative effects from being outside. Resident #1 had no complaints. RN A had no negative findings on assessment. RN A did a perimeter check on the building and increased supervision for Resident #1. She said the potential harm to a resident related to the 500 hall side door being open was death, especially with the heat. She said there was a driveway around the facility and residents could have been run over. She said a resident could fall or get lost. She said there was potential for serious harm, or serious injury. She said if RN A noticed the alarm was broken on the courtyard gate she would have expected her to notify the DON. She said she expected the nurse to assign someone to remain at the door to ensure a resident did not leave out of it while the alarm was broken. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 During an interview on 08/24/23 at 11:54AM, the Administrator said if a resident got out of the 500 hall side door there was potential for sunburn, heat stroke, heat exhaustion, falls, or death. He said there was potential for serious harm or serious injury. He said he expected the nurse to notify the administration if the alarm was broken. He expected her to assign someone to watch the gate if the alarm was broken. Record review of the facility's Door Weekly Testing sheet indicated the hall doors and the Smoker's courtyard gate was checked on 8/21/23. Record review of the facility's policy, signal device (wanderguard) and door alarm monitoring, dated February 2020, stated: Policy: At times, the facility admits and retains residents that are confused and have the tendency to wander about the facility. If the facility is equipped with a secured unit, these residents will normally be secured on this unit. However, some facilities do not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their confusion. The facility must ensure the resident's safety while utilizing the least restrictive means available. To meet this need the facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implemented with specific approaches and goals for the wanderer. The resident's name, picture, and physical description are placed in the wander book located at the nurses' station. All staff are responsible for knowing whose name is in on the list and be able to recognize the resident and be able to intervene as necessary. Every new employee will be informed of the wandering policy at orientation. A monitoring device will placed on the resident according to the manufacturer's directions. Practice Guidelines: 1. Signal device testing: The signaling device (Wanderguard) will be tested daily . .2. Door Testing: Each monitored door should be inspected once each week by the Maintenance Supervisor and recorded on the test form. In most facilities, the monitored doors will sound several times per day. This in itself provides daily testing. a. A daily inspection should be made of the monitor to ensure that the indicator light is on and that the electrical connections are secure. Any door alarms that are not routinely operated at least once per shift should be activated at least once a day as a test . Record review of the facility's policy, safety and supervision of residents, dated June 2020, stated: .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 .Facility-Oriented approach to safety Level of Harm - Immediate jeopardy to resident health or safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. Residents Affected - Some 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI review of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization . .Systems approach to safety 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, the adjusts interventions accordingly. 2. Resident supervision is a core component is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's addressed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is change in the resident's condition . The Administrator was notified of an IJ on 08/23/23 at 3:52PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 08/24/23 at 9:15 AM and included the following: Plan of Removal Issues: 1. The facility failed to: * The facility failed to ensure the gate in the courtyard was locked and the alarm was functioning. * The facility failed to follow their policy and monitor the alarms daily. * The facility failed to secure and lock the side door on Hall 500 and there was no alarm on it. Two residents who are at risk of elopement reside on Hall 500. * (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 The facility failed to monitor and supervise residents in the courtyard who were an elopement risk. Level of Harm - Immediate jeopardy to resident health or safety Plan of Removal Residents Affected - Some Immediate actions 1. * The gate and the alarm in the courtyard were checked and functioned on 8/23/2023 at 4pm by the administrator. * All the alarms were checked to ensure proper functionality on 8/23/2023 at 4pm by the administrator. * The side door on Hall 500 was secured with an alarm on 8/23/2023 at 4pm by the administrator. * Policy was revised for Wander Guard daily checks and exit doors weekly. * Residents at risk for elopement will be monitored every hour to ensure not in courtyard unsupervised starting 8/23/2023 at 6pm. Staff will check functionality of the alarm on the gate every shift for three days, every day for 3 days, and return to weekly checks by the Administrator on 8/23/23. 2. Education (provided by DON, RNC, ADON) * The Administrator and Maintenance Director were in-serviced on monitoring door alarms and the Wander Guard system on 8/23/2023. The Wander Guard system is monitored daily, and the exit doors are monitored weekly by the Maintenance Director. This is documented on separate daily and weekly check-off systems and sheets. * All nurses were educated on monitoring and supervising residents in the courtyard who are an elopement risk every hour on 8/23/2023. All Nurses will be in-serviced prior to next working shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 3. Level of Harm - Immediate jeopardy to resident health or safety Medical Director - The Medical Director has been notified of the Immediate Jeopardy at 4pm. Residents Affected - Some QAPI Committee Review - An interim QAPI committee meeting was completed on 8/23/2023. 4. 5. Plan of removal date: 8/23/2023 The surveyor verification of the Plan of Removal from 08/24/23 was as follows: During an observation on 08/24/23 at 9:27AM, this surveyor opened the gate in the smoker's courtyard and heard the alarm sound in the dining room. The administrator silenced the FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 15 of 15