Inspection·November 27, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reflected a text message sent at 10:02PM on 11/13/2025 stated, Hey, I don't know any update but I wanted to let you know that [Resident #1] was on the floor when I walked on [Resident #1's hallway] and the staff took forever to even help him up [Visitor D] walked up to them a second time and snapped on them. The return message from SC LVN on 11/13/2025 at 11:28PM stated, Wow. In an interview with MAINT DIR on 11/25/2025 at 11:10AM, she stated that on 11/13/2025 she observed Resident #1 on the floor in his room. She denied any other witnesses at the scene. She stated that she was unsure how long he had been on the floor. She stated that she informed 2-3 nurses at the nurses station, but they took, too long, about 5 minutes, to respond to the fall. She stated that Resident #1 stated he was on the floor for about an hour, but that she observed him in his wheelchair going down the hallway about ten minutes prior to that. She stated that she informed SC LVN about the fall for Resident #1 and the delay in nursing response. She did not recall which nurses were notified. She stated that was the only phone number that she had for the facility administration. She denied observing any other delays in care or concerning behaviors from nursing before or after this episode. In an interview with the ADON on 11/25/2025 at 10:51AM, she stated that the expectation for resident falls was that nursing assess the resident immediately. She stated that staff should not leave them alone after observing a resident on the floor. She state that nursing should perform vital signs, physical assessment, neurological assessment, and observe for any pain or signs of fracture. She stated that if there was an injury, staff should keep them there and call EMS (emergency medical services). She stated that if nursing was not responding immediately to fall and a resident was injured, they may not receive the medical care they need. She stated that she attends morning meetings and did not recall an incident or grievance of a fall where it was reported that staff did not respond immediately to the fall. Attempted a telephone interview with CNA J on 11/25/2025 at 12:43PM., a voicemail was not able to be left. Text message was sent to request a call back at that time. In a telephone interview with SC LVN on 11/25/2025 at 1:10PM, she stated that she was not in the facility in the evening on 11/13/2025. She denied receiving a call regarding a fall on that night or being found on the ground by staff. She stated that, depending on the circumstances, if a resident was found on the ground that she would consider it a fall and perform a physical assessment of the resident and get x-rays if there was concern for injury. She stated that nursing should report falls to the DON, RP, MD, and complete an incident report. She stated that Resident #1 likes to sleep on the ground. She stated that it was care planned. She stated that she had not observed the behavior, but she knew from conversations with staff that he does get on the ground. She stated that he requires assistance to transfer from the wheelchair, but she believed he could get up on his own from the ground, 9 times out of 10. She stated that if Resident #1 stated that he fell, that staff should treat it as a fall. She stated that when a fall was reported, that nursing should stop what they are doing and attend to the person right away. She stated that if a nurse was in the middle of a treatment or in another emergency situation, they should ask another nurse to assist the resident until they are able to get there. She stated that if nursing was not responding to resident falls right away that the resident could have a lot happen, including blood pressure changes, bleeding or other things that could prolong the healing process if there was an injury. In an interview with LVN B on 12/25/2025 at 12:49PM, she stated that she worked the day shift on 11/13/2025. She denied recalling a fall that day for Resident #1, but then stated that there was a day where the resident, put himself on the floor, and the MAINT DIR and an unknown visitor reported to nursing that Resident #1 was on the floor. She initially stated that one night nurse was passing medications and one was on a hallway. She stated that there was no call light on at the time. She gave multiple accounts of the locations and responses of LVN C and LVN H, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 2 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who were the two nurses working the night shift on 11/13/2025. In version #1, she stated that the nurse passing medications finished her medication pass and went down the hallway after she was done. In version #2, she stated that the nurse passing medications was already closing her narcotic drawer and walking down the hallway while the second nurse was in the bathroom. She stated that it could not have been a minute after the reported fall, the nurse doing the medications was already walking down the hallway to respond to Resident #1. In version #3, she stated that the second nurse was exiting the bathroom while the nurse was closing the narcotic drawer and they both responded to the fall before she could have responded to the report from the nurses station. She stated that when the MAINT DIR and the visitor reported the resident was on the floor, she told the MAINT DIR that Resident #1 will, sit on the floor, and the other nurse stated that she would be right there. She did not indicate which LVN working that evening was the one passing medications. She stated that Resident #1 was care planned for a, change in plane. She stated that if Resident #1 stated that he put himself on the floor, that she would not treat it as a fall. She stated that he does it often, and she was not sure if she had documented every instance in which he was found on the floor and stated that it was not a fall on her shift. She stated she could not recall how often he exhibits that behavior. She stated that she did not respond to the fall because she had given report and was preparing to leave the facility. She did not report any direct interaction between nursing and the visitor. She stated that the impact to a resident of nursing not responding to a reported fall, is that they could have a fracture or a bleed that may cause more damage during that time or potentially lead to death. In a telephone interview with LVN C on 11/25/2025 at 5:22PM, she stated that she worked with Resident #1 on the evening of 11/13/2025, she denied any recollection of a fall on that evening. She further stated that she did remember Resident #1 having a one to one observation, but denied any falls after or around the time it was completed. In a follow up interview with MAINT DIR on 11/25/2025 at 1:24PM she contradicted her original report that there was a second person with her when she observed the fall. She stated it was because she was walking with Visitor B when she heard Resident #1 calling for help. She stated that Resident #1 was positioned face down with a pillow under his head. She stated that he was asking for help to get back up and denied any injuries. She stated that Resident #1 stated that he fell while he was trying to get into bed from the wheelchair. She stated that the Resident's call light was not in reach. She stated that she and the visitor stayed at the doorway. She stated that she informed the nurses first that the resident had fallen and the nurses, were just standing there talking. She stated she walked back to Resident #1's doorway and approximately 3 minutes later, the visitor went up to the nurse's station and the nurses were still standing at the nurse's station. She stated that the visitor was upset, but she did not hear what was said to the nurses at that time. In a telephone interview with Visitor B on 11/25/2025 at 1:44PM, he stated that it was almost 7:00PM when he was walking down the hallway with the MAINT DIR and heard Resident #1 calling for help. He stated the resident was positioned face down on the floor with a pillow under his head next to the bed. He stated that the resident denied any injuries. He stated there was no visible bleeding and had his pants partially down while he was lying on the ground. He stated that when the MAINT DIR went to the nurse's station there were three nurses at the nurse's station. She stated that when she told them about the fall, they stated that they would, get to it. He stated that 15-20 minutes went by, and when no one came to assist the resident, he stated that he went to the nurse's station while the MAINT DIR stayed with the resident. He stated that when he told the nurses that Resident #1 fell, the nurses chuckled and stated that Resident #1, always falls. He stated that after he informed them of the fall, they responded by coming to assess the resident. Attempted a phone interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 3 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with LVN H, who was on staff for the evening shift on 11/13/2025, on 11/25/2025 at 2:49PM. There was no answer. Left a message requesting a call back. Attempted a phone interview with CNA K, who was on staff for the evening shift on 11/13/2025, on 11/25/2025 at 3:52 PM. There was no answer. Left a message requesting a call back. In a follow-up interview with SC LVN on 11/25/2025 at 4:42PM, she received a text message on 11/13/2025 at 10:00PM from MAINT DIR, about a fall for Resident #1 with a delay in nursing response. She stated she did not see it until the following day on 11/14/2025. She stated that she did not tell the ADMIN or any nursing administration about the message. She stated that she believed the MAINT DIR dealt with it. She stated that she was informed by the MAINT DIR that while she was walking down the hallway with a visitor, Resident #1 was found on the floor and nursing took, too long to respond to the fall. She stated that she did not know who was working that night. She stated that she believed the MAINT DIR contacted her because she was the only phone number that she had saved for the staff on her phone, because she was responsible for scheduling. She stated that she was available for call ins and denied being the administrator on call for that time period. She stated that in instances where there was an allegation that staff did not respond to resident needs, it should be investigated by the administrative staff. She stated that the Charge nurse working that night should have written an incident report and reported it to the DON. She stated that she made no attempt to ensure that the DON was made aware of the incident. She stated that she was present for the morning meeting the next day and heard no further mention of the incident with a fall for Resident #1. In an interview with the DON on 11/26/2025 at 7:48AM, she stated that she started an investigation into the fall incident reported by the surveyor on 11/25/2025. She stated that the nurse on duty for Resident #1, LVN C, came into the facility and during an interview with the DON she stated that Resident #1 was found on the floor on 11/13/2025. She stated that LVN C stated that the resident told her that he was transferring from the wheelchair to the bed and went to the floor. She stated that it should have been treated as a fall, but that she thought that LVN C was confused with the context of the difference between Resident #1 placing himself on the floor and what should be considered a fall. She stated that LVN C was written up for the incident. She stated that any resident found on the floor is to be treated as a fall. She stated that it would be considered a, change in plane and should be documented in the resident records. She stated that from her interviews with LVN C and LVN B, it was approximately 2-3 minutes from the time that the fall was first reported by the MAINT DIR to when nurses responded to Resident #1. She stated LVN C stated that she would be right there. She stated that she was told that she needed to secure the medication cart and then responded to the fall. She stated that LVN B stated that the MAINT DIR came down the hallway to report the resident was on the floor, then before the MAINT DIR could get down the hallway to Resident #1's room, the visitor was already walking down the hallway to the nurse's station and the nurses were walking toward Resident #1's room. The DON stated that she was in-servicing staff on the facility policy for abuse, neglect, and exploitation recognition and reporting and the facility policy for falls. She stated that when anyone was found on the floor in the future, staff would need to fill out written statements regarding the incident and submit them to her or place them under her door if she was not present. She stated that she would have the social worker conduct safe surveys with the residents when she arrived on 11/26/2025. She stated that she had not interviewed the MAINT DIR yet, but she planned to speak with her that day. In an interview with the RNC on 11/26/2025 at 10:05AM, she stated that the administration had preformed an Ad Hoc QAPI (when necessary Quality Assurance and Performance Improvement) meeting regarding Resident #1 and an action plan was started for the fall that was not reported to administration. She stated that she did not think there was any evidence of neglect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 4 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from staff. She stated that the resident was assessed by nursing at the time of the incident, but it was not documented. She stated that it was a documentation error, and they did not feel like it was neglect. She stated that it would not have been something that was brought to the attention of the DON and the ADMIN on the night of 11/13/2025, as there was no injury to the resident. She stated that the investigation revealed that Resident #1 placed himself on the floor as they previously thought. She stated that staff was in-serviced that when a resident is found on the floor that it should be treated and documented as a fall. She stated that when Resident #1 was interviewed by the administrative staff on the night of 11/25/2025, that he stated he slipped from the wheelchair. She stated that an incident report was created with the investigation findings related to the fall on 11/13/2025. She stated that the MAINT DIR was involved and interviewed that on the morning of 11/26/2025. She stated that she was informed that she and person with her found him on the floor in his room but had not witnessed the fall. She stated that she had no knowledge of a report that nursing did not respond when they were notified of the fall. She stated that it was her expectation that nursing should come and assess the resident as soon as they are notified of a fall. She stated that if it is safe to get the resident up after assessing them, then they should assist the resident up. She stated that an incident report should be completed for the fall and the physician and RP should be notified. She stated that because there was no injury involved in Resident #1's fall on 11/13/2025, the notification to the MD and DON do not need to occur right away, as they would be made aware on the risk management report the following morning. She stated that therapy would also be informed of the fall during that meeting also and they would know to screen the resident after the fall. She stated that staff should be implementing interventions after falls to address the root cause to prevent future falls. She stated that she had not read the witness statements at that time. She stated that safe surveys were done with residents that morning with no reports of abuse or neglect. She stated that she questioned Resident #1's ability to be alone outside when she arrived on site. She stated that she was told that staff monitor Resident #1 while he is outside, but she did not know how frequently they were able to monitor him. She stated that because he does not have the code to the door, the staff were aware when he went outside, because he set off the alarm. She stated that she suggested that staff walk with him if he is going outside. She stated that they did new BIMS (Basic Interview for Mental Status) for Resident #1 and he was scored as a 9 (moderately impaired cognition) on 11/26/2025. She stated that the ADMIN felt like it might be higher but Resident #1 is not answering the questions correctly. Review of facility policy for Falls-Clinical Protocol reflected, Assessment and Recognition1. As part of the initial assessment, the physician will help Identify Individuals with a history of falls and risk factors for subsequent falling.a. Staff will ask the resident and the caregiver or family about a history of falling.b. The staff and physician should document in the medical record a history of one or more recent falls (for example, within 90 days).c. While many falls are isolated individual Incidents, a significant proportion occur among a few residents/patients. Those individuals may have a treatable medical disorder or functional disturbance as the underlying cause.2. In addition, the nurse shall assess and document/report the following:a. Vital signs;b. Recent injury, especially fracture or head Injury;c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.;d. Change in cognition or level of consciousness;e. Neurological status;f. Pain;g. Frequency and number of falls since last physician visit;h. Precipitating factors, details on how fall occurred;i. All current medications, especially those associated with dizziness or lethargy; andj. All active diagnose.3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk.a. Risk factors for subsequent falling include (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 5 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, and illnesses affecting the central nervous system and blood pressure.4. The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications associated with Increased falling risk) and the risk for significant complications of falls (for example, increased fracture risk In someone with osteoporosis or Increased risk of bleeding in someone taking an anticoagulant).a. Falls often have medical causes; they are not just a nursing Issue.3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Review of facility policy for Falls and Fall Risk, Managing reflected, Policy heading Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and ImplementationDefinition According to the MDS, a fall is defined as:Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Challenging a resident's balance and training him/her to recover from loss of balance is an intentional therapeutic intervention. The losses of balance that occur during supervised therapeutic interventions are not considered a fall.Resident-Centered Approaches to Managing Falls and Fall Risk1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once).5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. Event ID: Facility ID: 675101 If continuation sheet Page 6 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 - Few 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 observations, interviews, and record reviews, the facility failed to ensure that resident environment remained as free from accident hazards as is possible, by not providing adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for falls. The facility failed to provide adequate supervision to Resident #1, who has frequent falls and severe cognitive impairment, and was allowed to wander outside with no supervision near a busy highway with a speed limit of 45 mph and through restricted construction areas with uneven pavement.This failure resulted in an Immediate Jeopardy (IJ) situation on 11/26/2025. While the IJ was removed on 11/27/2025, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm with an isolated scope and severity. 2. The facility failed to ensure that nursing staff responded to an unwitnessed fall for Resident #1, and when notified by staff member dismissed the fall as a behavior. The fall was not documented by staff, reported to the DON, physician, or resident representative (RP). This failure could place residents at risk for serious injury, fracture, or death. Findings included: Record review of Resident #1's Facesheet dated 11/25/2025 reflected a [AGE] year-old, male admitted to the facility on [DATE]. Diagnoses included: Repeated falls, Impulse disorder, Cerebral Infarction, muscle weakness, unspecified lack of coordination, bipolar disorder, and chronic kidney disease requiring dialysis. Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 7 (severe cognitive impairment), He is partial to moderate assist when moving from sitting to standing and for all transfers. Review of Resident #1 care plan dated 11/25/2025 reflected a Problem area stating as follows: Problem Start Date: 11/15/2023 Category: Falls [Resident #1] has impaired balance during transfers, he is at risk for falls. [Resident #1] likes to self transfer and put himself on the floor at times. [Resident #1] likes to sleep on the floor. [Resident #1] will lean forward to pick up items from floor. [Resident #1] states he likes to lie on the floor 1/12/24 on floor----2/19 fall, 11/17/2024 fall, unwitnessed fall 1-11-2025 no injuries. 3/31/2025 unwitnessed fall x3 no injuries. 4/05/25 unwitnessed fall in restroom no injuries.4/20/25 witnessed fall in room with transfer 7/01/25 Edited: 10/15/2025 Edited By: LVN C. Problem Start Date: 04/25/2024 Category: Behavioral Symptoms [Resident #1] has taken himself outside the front door for fresh air, sunshine exposure and to just sit and watch traffic as well as rolls self around building for exercise Edited: 08/18/2025 Edited By: LVN C. Falls noted on Care Plan are dated 1/12/24, 2/19/24, 11/17/24, 1/11/25, 3/31/2025, 4/05/25, 4/20/25, 7/01/25 and 10/14/2025. Further review revealed there are no interventions related to the type or frequency of staff supervision outside during the day. Record review of Resident #1's progress notes from 9/26/2025 to 11/26/2025 revealed no documentation of a fall or reports of delay in care on 11/13/2025. There was no evidence that notifications were made to the physician, RP, or the Administrative staff. Record review of Resident #1's incident reports from 9/25/2025 to 11/25/2025 revealed no documentation of a fall or reports of delay in care on 11/13/2025. There was no evidence that notifications were made to the physician, RP, or the Administrative staff. Review of Resident #1 Fall risk assessment on 11/7/2025 reflected, History of falls (past 3 months): 3 or more falls in past 3 months . Resident is chairbound / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 1-2 present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. 1. In an interview with CNA A on 11/25/2025 at 4:10PM she stated that Resident #1 was outside the facility doing laps around the building on his own. She stated that he would let himself out of the building. She stated that when he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 7 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 - Few pushed the doors open it would set off the alarm and the staff would know that he was going outside. She led surveyor to the resident and stated that he was allowed to self-propel outside around the building without supervision or assistance. She left the surveyor and resident outside after observing him in that area. Observation of Resident #1 on 11/25/2025 at 4:15PM revealed he was alone outside the facility on the left side of the building, self-propelling in his wheelchair passed a section of broken caution tape. There was a strip of pavement approximately a foot wide, missing with exposed dirt and rocks that was below the level of the pavement. The broken, yellow caution tape was in front of the first strip of missing pavement. In front of Resident #1 was another strip of missing pavement that was below the level of the pavement. He was observed pushing himself over the second area without assistance or supervision from staff. There was caution tape on one side of the breaks in pavement only. The facility was directly adjacent to a busy, 4 lane highway with a paved, uneven driveway leading to the road. In an interview with Resident #1 on 11/25/2025 at 4:15PM, he stated that he was not able to remember how long he had lived at the facility. He stated that he could move himself safely outside alone. He stated that he had previous falls but could not recall when. He stated that he recalled falling on his face twice in the past and one of the times was outside the facility. He stated that he did not remember how long it took for someone to help him. He stated that he did recall falling on a Thursday night a few weeks prior and that it took about 30 minutes for the nurses to arrive. He stated that he fell on his knees while trying to walk and the nurse found him. He denied injuries with any of his falls. Interview with ADMIN and ADON on 11/25/2025 at 4:27PM, both stated that they were aware that Resident #1 was known to let himself out of the facility and self-propel around the building, unsupervised. They stated that he was care planned to be allowed to do so during the day. The ADMIN stated that staff check on him while he was outside every hour or two. She stated there are hazards outside the building from recent plumbing work. She stated the work started a week or two prior to this week. She stated that there was caution tape around the hazard. She stated that he has a history of unwitnessed falls outside. She stated there was no injury to his falls. She stated that to prevent future falls outside the staff told him to stay in the front area away from the caution tape. She stated that she did not know his current BIMS score, but that he was intact enough to follow staff instructions. She stated that the potential risk of allowing him to propel himself outside without supervision or assistance was that he could fall in the areas where the pavement was disturbed. The ADON stated that she was unaware of his last BIMS score. She stated that she did not know if a BIMS of 7 was cognitively intact. She was unable to recall what an intact BIMS score was. In a follow up telephone interview with CNA G on 11/25/2025 at 4:35PM, she stated that Resident #1 was able to go outside alone. She stated that he had fallen from his wheelchair outside the facility in the past to her knowledge. She was not sure when the fall outside occurred. In an interview on 11/25/2025 at 4:52PM with LVN F she stated that she was the nurse assigned to Resident #1 for 11/25/2025. She stated that he was allowed to go outside unsupervised. She stated that anywhere outside was hazardous for residents. She stated that Resident #1 falls frequently inside the building and has fallen outside in the past. She stated that he was not injured in his fall outside to her knowledge. She stated that there is hazard tape near the laundry room outside and he is known to go pass the tape and do loops around the building. She stated that they observe him intermittently through the windows as he goes around the building. She stated that they check on him approximately every 10 minutes. She stated that he should probably be supervised outside with his history of falls and impaired cognition. She stated that he could hurt himself while self-propelling alone, outside and staff might not be aware for ten minutes. In an interview with the ADMIN, DON, and ADON on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 8 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 - Few 11/25/2025 at 5:34PM, they stated that they were not aware of any reports of a fall for Resident #1 on 11/13/2025 or any allegations that nursing did not respond right away to staff reports of an unwitnessed fall. They stated that Resident #1 would not be allowed out of the building, unsupervised at night. They stated that they were all on call and available every night for any reportable incidents or events and should have been informed if there was an allegation of negligence. In an interview with the DON on 11/26/2025 at 7:48AM, she stated that she started an investigation into the fall incident reported by the surveyor on 11/25/2025. She stated that the nurse on duty for Resident #1, LVN C, came into the facility and during an interview with the DON she stated that Resident #1 was found on the floor on 11/13/2025. She stated that LVN C stated that the resident told her that he was transferring from the wheelchair to the bed and went to the floor. She stated that it should have been treated as a fall, but that she thought that LVN C was confused with the context of the difference between Resident #1 placing himself on the floor and what should be considered a fall. She stated that LVN C was written up for the incident. She stated that any resident found on the floor is to be treated as a fall. She stated that it would be considered a, change in plane and should be documented in the resident records. She stated that from her interviews with LVN C and LVN B, it was approximately 2-3 minutes from the time that the fall was first reported by the MAINT DIR to when nurses responded to Resident #1. She stated LVN C stated that she would be right there. She stated that she was told that she needed to secure the medication cart and then responded to the fall. She stated that LVN B stated that the MAINT DIR came down the hallway to report the resident was on the floor, then before the MAINT DIR could get down the hallway to Resident #1's room, the visitor was already walking down the hallway to the nurse's station and the nurses were walking toward Resident #1's room. The DON stated that she was in-servicing staff on the facility policy for abuse, neglect, and exploitation recognition and reporting and the facility policy for falls. She stated that when anyone was found on the floor in the future, staff would need to fill out written statements regarding the incident and submit them to her or place them under her door if she was not present. She stated that she would have the social worker conduct safe surveys with the residents when she arrived on 11/26/2025. She stated that she had not interviewed the MAINT DIR yet, but she planned to speak with her that day. In an interview with the OT on 11/26/2025 at 8:52AM, he stated that Resident #1 is very impulsive. He stated that he self-propelled around the facility in his wheelchair. He stated that he is very difficult to redirect and cursed at staff when they attempted to interrupt him. He stated that the resident has a short frustration tolerance and refuses assistance at times. He stated that the residents did not have good safety awareness at times. He stated that he observed the resident coming in from outside a few days prior with mud covering his wheels. He stated that it was a fall risk to have mud on his wheelchair wheels, and he would not allow the OT to help him remove the mud. He stated that he knew Resident #1 had another fall the previous week, when he was found on the floor. He could not recall the day. He was not aware of a fall on 11/13/2025. He stated that the resident should be reviewed by the therapy department after all falls. He stated that he would consider it a fall if the resident was found on the floor. He stated that he knew that Resident #1 was known to deny falling at times when he was found on the floor. He stated that the therapy department's protocol for residents after a fall is to call the nurse and not to touch them until they are assessed by nursing. He stated that management and staff are all aware that Resident #1 was able to be outside unsupervised. He stated that it is unsafe for him to be alone outside, especially with the construction and areas of digging outside. He stated that the road in front of the facility is very busy. He stated that he had not known Resident #1 to attempt to go into the road. In an interview with the DOR on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 9 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 - Few 11/26/2025 at 9:14AM, she stated that Resident #1 is currently receiving physical therapy three times a week. She stated that he propels himself with his feet in a wheelchair for his mobility. She stated that he is a contact guard assist for ambulating. She stated that he has no safety awareness and is difficult to redirect. She stated that he is known to be impulsive and does not respond to staff education. She stated that he had a history of placing himself on the floor at times. She stated that he had previous falls while propelling in his wheelchair, unsupervised while outside. She stated that he was a high risk for falls. She could not recall when the last fall outside occurred, but stated that was when his wheelchair got stuck on the front wheels and he could not move himself forward on his own and fell. She stated she had educated him on sitting back in the wheelchair and he refused to do so. She stated that his current fall precautions were for staff to try to supervise him and educate him to be aware of his surroundings, especially when he is outside. Staff were not required to be outside with him. She stated there are definitely hazards outside, which included the vehicles in the parking lot, vehicles on the busy road in front of the facility, and the areas of plumbing work going on outside the facility. She stated that she did not believe that, given his history and risk factors, he should be allowed outside, unsupervised. She stated that he knows how to get out of the door and was known to let himself out of the building. She stated that it was dangerous for him to be outside by himself. She stated that there is always a chance he could go into the busy road in front of the building and the parking lot to the facility was known to be busy also. She stated that Resident #1 has been behind her truck more than once while she was attempting to back out of the parking lot, and she only saw him because of the backup camera on her truck. She stated that she educated him regarding not positioning himself behind vehicles in the parking lot and he was not compliant with that education. She stated that the risk to the resident of being alone unsupervised is that they could get run over by a car or severely hurt. She stated that unless the staff happened to witness it, no one would know if he fell or was injured outside. She stated that if it was not time for him to go to an appointment or eat a meal, the staff, really wouldn't know that something had happened to him. In a follow up interview with the RNC on 11/26/2025 at 4:40PM, she stated that she was working to update the fall risk and interventions for residents identified as fall risks in their care plans. She stated that Resident #1 was placed under one to one staff supervision until a new plan is in place to ensure that he will not leave the facility unsupervised. She stated that she had a care conference with Resident #1 and that he was agreeable to the plan for additional supervision. She stated that he told her that he would not go outside without staff, but that she was concerned that he might leave without their knowledge. She stated that there is a possibility that a family member of another resident might know him to be allowed outside unsupervised, and let him out of the doors not knowing there had been a change in his care. On 11/26/2025 at 2:58 PM the surveyor provided an Immediate Jeopardy (IJ) Template notification to the RNC, ADMIN, and DON that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety to the Administrator and a Plan of Removal was requested. 2. Record review of text message from MAINT DIR to SC LVN reflected a text message sent at 10:02PM on 11/13/2025 stated, Hey, I don't know any update but I wanted to let you know that [Resident #1] was on the floor when I walked on [Resident #1's hallway] and the staff took forever to even help him up [Visitor D] walked up to them a second time and snapped on them. The return message from SC LVN on 11/13/2025 at 11:28PM stated, Wow. In an interview with MAINT DIR on 11/25/2025 at 11:10AM, she stated that on 11/13/2025 she observed Resident #1 on the floor in his room. She denied any other witnesses at the scene. She stated that she was unsure how long he had been on the floor. She stated that she informed 2-3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 10 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 - Few nurses at the nurses station, but they took, too long, about 5 minutes, to respond to the fall. She stated that Resident #1 stated he was on the floor for about an hour, but that she observed him in his wheelchair going down the hallway about ten minutes prior to that. She stated that she informed SC LVN about the fall for Resident #1 and the delay in nursing response. She did not recall which nurses were notified. She stated that was the only phone number that she had for the facility administration. She denied observing any other delays in care or concerning behaviors from nursing before or after this episode. In an interview with the ADON on 11/25/2025 at 10:51AM, she stated that the expectation for resident falls was that nursing assess the resident immediately. She stated that staff should not leave them alone after observing a resident on the floor. She state that nursing should perform vital signs, physical assessment, neurological assessment, and observe for any pain or signs of fracture. She stated that if there was an injury, staff should keep them there and call EMS (emergency medical services). She stated that if nursing was not responding immediately to fall and a resident was injured, they may not receive the medical care they need. She stated that she attends morning meetings and did not recall an incident or grievance of a fall where it was reported that staff did not respond immediately to the fall. Attempted a telephone interview with CNA J on 11/25/2025 at 12:43PM., a voicemail was not able to be left. Text message was sent to request a call back at that time. In a telephone interview with SC LVN on 11/25/2025 at 1:10PM, she stated that she was not in the facility in the evening on 11/13/2025. She denied receiving a call regarding a fall on that night or being found on the ground by staff. She stated that, depending on the circumstances, if a resident was found on the ground that she would consider it a fall and perform a physical assessment of the resident and get x-rays if there was concern for injury. She stated that nursing should report falls to the DON, RP, MD, and complete an incident report. She stated that Resident #1 likes to sleep on the ground. She stated that it was care planned. She stated that she had not observed the behavior, but she knew from conversations with staff that he does get on the ground. She stated that he requires assistance to transfer from the wheelchair, but she believed he could get up on his own from the ground, 9 times out of 10. She stated that if Resident #1 stated that he fell, that staff should treat it as a fall. She stated that when a fall was reported, that nursing should stop what they are doing and attend to the person right away. She stated that if a nurse was in the middle of a treatment or in another emergency situation, they should ask another nurse to assist the resident until they are able to get there. She stated that if nursing was not responding to resident falls right away that the resident could have a lot happen, including blood pressure changes, bleeding or other things that could prolong the healing process if there was an injury. In an interview with LVN B on 12/25/2025 at 12:49PM, she stated that she worked the day shift on 11/13/2025. She denied recalling a fall that day for Resident #1, but then stated that there was a day where the resident, put himself on the floor, and the MAINT DIR and an unknown visitor reported to nursing that Resident #1 was on the floor. She initially stated that one night nurse was passing medications and one was on a hallway. She stated that there was no call light on at the time. She gave multiple accounts of the locations and responses of LVN C and LVN H, who were the two nurses working the night shift on 11/13/2025. In version #1, she stated that the nurse passing medications finished her medication pass and went down the hallway after she was done. In version #2, she stated that the nurse passing medications was already closing her narcotic drawer and walking down the hallway while the second nurse was in the bathroom. She stated that it could not have been a minute after the reported fall, the nurse doing the medications was already walking down the hallway to respond to Resident #1. In version #3, she stated that the second nurse was exiting the bathroom while the nurse was closing the narcotic drawer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 11 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 - Few and they both responded to the fall before she could have responded to the report from the nurses station. She stated that when the MAINT DIR and the visitor reported the resident was on the floor, she told the MAINT DIR that Resident #1 will, sit on the floor, and the other nurse stated that she would be right there. She did not indicate which LVN working that evening was the one passing medications. She stated that Resident #1 was care planned for a, change in plane. She stated that if Resident #1 stated that he put himself on the floor, that she would not treat it as a fall. She stated that he does it often, and she was not sure if she had documented every instance in which he was found on the floor and stated that it was not a fall on her shift. She stated she could not recall how often he exhibits that behavior. She stated that she did not respond to the fall because she had given report and was preparing to leave the facility. She did not report any direct interaction between nursing and the visitor. She stated that the impact to a resident of nursing not responding to a reported fall, is that they could have a fracture or a bleed that may cause more damage during that time or potentially lead to death. In a telephone interview with LVN C on 11/25/2025 at 5:22PM, she stated that she worked with Resident #1 on the evening of 11/13/2025, she denied any recollection of a fall on that evening. She further stated that she did remember Resident #1 having a one to one observation, but denied any falls after or around the time it was completed. In a follow up interview with MAINT DIR on 11/25/2025 at 1:24PM she contradicted her original report that there was a second person with her when she observed the fall. She stated it was because she was walking with Visitor B when she heard Resident #1 calling for help. She stated that Resident #1 was positioned face down with a pillow under his head. She stated that he was asking for help to get back up and denied any injuries. She stated that Resident #1 stated that he fell while he was trying to get into bed from the wheelchair. She stated that the Resident's call light was not in reach. She stated that she and the visitor stayed at the doorway. She stated that she informed the nurses first that the resident had fallen and the nurses, were just standing there talking. She stated she walked back to Resident #1's doorway and approximately 3 minutes later, the visitor went up to the nurse's station and the nurses were still standing at the nurse's station. She stated that the visitor was upset, but she did not hear what was said to the nurses at that time. In a telephone interview with Visitor B on 11/25/2025 at 1:44PM, he stated that it was almost 7:00PM when he was walking down the hallway with the MAINT DIR and heard Resident #1 calling for help. He stated the resident was positioned face down on the floor with a pillow under his head next to the bed. He stated that the resident denied any injuries. He stated there was no visible bleeding and had his pants partially down while he was lying on the ground. He stated that when the MAINT DIR went to the nurse's station there were three nurses at the nurse's station. She stated that when she told them about the fall, they stated that they would, get to it. He stated that 15-20 minutes went by, and when no one came to assist the resident, he stated that he went to the nurse's station while the MAINT DIR stayed with the resident. He stated that when he told the nurses that Resident #1 fell, the nurses chuckled and stated that Resident #1, always falls. He stated that after he informed them of the fall, they responded by coming to assess the resident. Attempted a phone interview with LVN H, who was on staff for the evening shift on 11/13/2025, on 11/25/2025 at 2:49PM. There was no answer. Left a message requesting a call back. Attempted a phone interview with CNA K, who was on staff for the evening shift on 11/13/2025, on 11/25/2025 at 3:52 PM. There was no answer. Left a message requesting a call back. In a follow-up interview with SC LVN on 11/25/2025 at 4:42PM, she received a text message on 11/13/2025 at 10:00PM from MAINT DIR, about a fall for Resident #1 with a delay in nursing response. She stated she did not see it until the following day on 11/14/2025. She stated that she did not tell the ADMIN or any nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 12 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 - Few administration about the message. She stated that she believed the MAINT DIR dealt with it. She stated that she was informed by the MAINT DIR that while she was walking down the hallway with a visitor, Resident #1 was found on the floor and nursing took, too long to respond to the fall. She stated that she did not know who was working that night. She stated that she believed the MAINT DIR contacted her because she was the only phone number that she had saved for the staff on her phone, because she was responsible for scheduling. She stated that she was available for call ins and denied being the administrator on call for that time period. She stated that in instances where there was an allegation that staff did not respond to resident needs, it should be investigated by the administrative staff. She stated that the Charge nurse working that night should have written an incident report and reported it to the DON. She stated that she made no attempt to ensure that the DON was made aware of the incident. She stated that she was present for the morning meeting the next day and heard no further mention of the incident with a fall for Resident #1. In an interview with the DON on 11/26/2025 at 7:48AM, she stated that she started an investigation into the fall incident reported by the surveyor on 11/25/2025. She stated that the nurse on duty for Resident #1, LVN C, came into the facility and during an interview with the DON she stated that Resident #1 was found on the floor on 11/13/2025. She stated that LVN C stated that the resident told her that he was transferring from the wheelchair to the bed and went to the floor. She stated that it should have been treated as a fall, but that she thought that LVN C was confused with the context of the difference between Resident #1 placing himself on the floor and what should be considered a fall. She stated that LVN C was written up for the incident. She stated that any resident found on the floor is to be treated as a fall. She stated that it would be considered a, change in plane and should be documented in the resident records. She stated that from her interviews with LVN C and LVN B, it was approximately 2-3 minutes from the time that the fall was first reported by the MAINT DIR to when nurses responded to Resident #1. She stated LVN C stated that she would be right there. She stated that she was told that she needed to secure the medication cart and then responded to the fall. She stated that LVN B stated that the MAINT DIR came down the hallway to report the resident was on the floor, then before the MAINT DIR could get down the hallway to Resident #1's room, the visitor was already walking down the hallway to the nurse's station and the nurses were walking toward Resident #1's room. The DON stated that she was in-servicing staff on the facility policy for abuse, neglect, and exploitation recognition and reporting and the facility policy for falls. She stated that when anyone was found on the floor in the future, staff would need to fill out written statements regarding the incident and submit them to her or place them under her door if she was not present. She stated that she would have the social worker conduct safe surveys with the residents when she arrived on 11/26/2025. She stated that she had not interviewed the MAINT DIR yet, but she planned to speak with her that day. In an interview with the RNC on 11/26/2025 at 10:05AM, she stated that the administration had preformed an Ad Hoc QAPI (when necessary Quality Assurance and Performance Improvement) meeting regarding Resident #1 and an action plan was started for the fall that was not reported to administration. She stated that she did not think there was any evidence of neglect from staff. She stated that the resident was assessed by nursing at the time of the incident, but it was not documented. She stated that it was a documentation error, and they did not feel like it was neglect. She stated that it would not have been something that was brought to the attention of the DON and the ADMIN on the night of 11/13/2025, as there was no injury to the resident. She stated that the investigation revealed that Resident #1 placed himself on the floor as they previously thought. She stated that staff was in-serviced that when a resident is found on the floor that it should be treated and documented as a fall. She stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 13 of 14 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete when Resident #1 was interviewed by the administrative staff on the night of 11/25/2025, that he stated he slipped from the wheelchair. She stated that an incident report was created with the investigation findings related to the fall on 11/13/2025. She stated that the MAINT DIR was involved and interviewed that on the morning of 11/26/2025. She stated that she was informed that she and person with her found him on the floor in his room but had not witnessed the fall. She stated that she had no knowledge of a report that nursing did not respond when they were notified of the fall. She stated that it was her expectation that nursing should come and assess the resident as soon as they are notified of a fall. She stated that if it is safe to get the resident up after assessing them, then they should assist the resident up. She stated that an incident report should be completed for the fall and the physician and RP should be notified. She stated that because there was no injury involved in Resident #1's fall on 11/13/2025, the notification to the MD and DON do not need to occur right away, as they would be made aware on the risk management report the following morning. She stated that therapy would also be informed of the fall during that meeting also and they would know to screen the resident after the fall. She stated that staff should be implementing interventions after falls to address the root cause to prevent future falls. She stated that she had not read the witness statements at that time. She stated that safe surveys were done with residents that morning with no reports of abuse or neglect. She stated that she questioned Resident #1's ability to be alone outside when she arrived on site. She stated that she was told that staff monitor Resident #1 while he is outside, but she did not know how frequently they were able to monitor him. She stated that because he does not have the code to the door, the staff were aware when he went outside, because he set off the alarm. She stated that she suggested that staff walk with him if he is going outside. She stated that they did new BIMS Event ID: Facility ID: 675101 If continuation sheet Page 14 of 14