Health inspection·January 11, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's accident and injury report completed by LVN G, indicated on 12/05/2022 Resident #1, sustained an injury to her right lower extremity measuring 6.0cm X 4.0cm X 0.5cm. The accident report revealed Resident #1 was in moderate pain, there was a large amount of blood, the accident occurred during transfer, first aid was administered, and Resident #1 was sent to the emergency room. The accident report revealed the injury was a large laceration with jagged edges that needed sutures. Record review of Resident #1's from 12/05/2022 nursing notes indicated the following: LVN G Wrote: This nurse called to resident's room (Resident #1). Resident received laceration to RLE (right lower extremity) 6.0cm X 4.0cm X 0.5cm. First aid performed to stop bleeding. EMS (emergency medical services) called for transfer to the local emergency room for further evaluation. NP (nurse practitioner) and family aware. Record review of a hospital exam dated 12/05/2022 indicated Resident #1 came to the emergency room after suffering a laceration to right calf area measuring 6.0cm X 3.8cm. The laceration required sutures to approximate the skin and stop the bleeding. Procedure completed and Resident #1 was sent back to the nursing facility. During interview on 01/09/2023 at 2:30 p.m., Resident #1's family stated on 12/05/2022 she was called and informed that Resident #1 was being sent to the ER because she had a skin tear to her leg. Resident #1's family stated she met Resident #1 in the ER and had more than a skin tear. She stated it was a huge laceration that required 16 sutures. She stated she stayed with Resident #1 until the sutures were completed, and the ER (emergency room) sent her back to the facility. During an interview on 01/10/2023 at 9:40 a.m., CNA B said she had worked at the facility for several years and was the full time CNA for 100 hall (the hall Resident #1 resided on). CNA B stated she remembered the incident in which Resident #1 sustained a laceration to her right lower extremity. CNA B stated that was the day the Hospice CNA F reported to her she had transferred Resident #1 by herself with no assistance. CNA B stated she remembered it because it was a huge deal that she transferred Resident #1 alone and Resident #1 was injured in the process. CNA B explained that Resident #1 was always a 2-person mechanical lift transfer. CNA B further explained that Resident #1 was too unpredictable to attempt any kind of stand pivot transfer and for the safety of the resident and the CNA she must be transferred by mechanical lift and always have 2 staff. CNA B stated, Hospice CNA F knew Resident #1 was a mechanical lift with 2 staff because Hospice CNA F had assisted her with the mechanical lift transfer of Resident #1 several times before. During an interview on 01/10/2023 at 2:00 p.m., LVN G stated she recalled the incident that occurred on 12/05/2022 with Resident #1 and Hospice CNA F. LVN #G stated she was called down to Resident 1's room and noted a large amount of blood pooled beneath her wheelchair. She noted a large laceration to Resident #1's right posterior calf area. LVN G stated, Hospice CNA F told her she was not sure how it happened but Resident #1 had to have scratched her leg on the wheelchair during transfer. Hospice CNA F stated she did transfer Resident #1 alone. LVN G stated Hospice CNA F called her supervisor and told her the laceration occurred and the facility was sending Resident #1 to the hospital. LVN G was not aware of any education or disciplinary action for Hospice CNA F. LVN G stated the care plan, as well as the CNA kiosk had the information for each resident's care needs. LVN G stated the hospice CNAs generally asked the nurse or another CNA if they were unsure of how to transfer a resident. LVN G stated Hospice CNA F had been to the building dozens of times and was the assigned hospice CNA to Resident #1. LVN G stated Hospice CNA F had transferred Resident #1 with the assistance of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 2 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 0609 herself and other staff members by mechanical lift multiple times prior to the incident. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/10/2023 at 3:00 p.m., Hospice CNA F stated she transferred Resident #1 alone at least once per week. Hospice CNA F stated on 12/05/2022 around 4:00 p.m., she transferred Resident #1 with a stand pivot transfer. (The stand pivot transfer is useful for residents who can support most of their weight by standing but are too weak to take steps to move from one place to another) She could not recall if she used a gait belt. She got ready to leave the room wheeling Resident #1 and noted a small pool of blood beneath Resident #1's wheelchair. She stated she immediately called for help, the nurse came, and first aid was administered. Hospice CNA F stated she did not have access to the facilities records to know how they had Resident #1 care planned for transfer. Hospice CNA F stated she believed hospice had Resident #1 care planned as a 1 or 2-person transfer. Hospice CNA F stated she had not reviewed the care plan. Hospice CNA F further explained she was tall and had not had any problem transferring Resident #1 alone in the past. Hospice CNA F stated she knew the facility used a mechanical lift to transfer Resident #1. She stated she felt the facility used a mechanical lift because the CNAs were short, and Resident #1 was tall, and they could not handle her. Hospice CNA F stated she had not received any further training on transfers by the facility or the hospice company, nor had she received any direction on how to communicate with the facility about the amount of care each resident required. Hospice CNA F stated she had been back in the facility and cared for other hospice resident's a dozen times since 12/05/2022. Hospice CNA F stated was told by the DON on 12/05/2022, after the incident occurred that Resident #1 was to always be a 2-person mechanical lift transfer and that hospice was to follow the facilities care plan that stated Resident #1 was a 2-person mechanical lift transfer. Residents Affected - Few Record review on of hospice plan of care with a start date of 07/18/2022 author unknown, revealed Resident #1 was always a 2-person mechanical lift transfer. Hospice provided the mechanical lift and the sling required for transfer. During an interview on 01/11/2023 at 10:15 a.m., the DON stated she did not report the laceration on Resident #1, because the hospice aide caused the injury. The DON stated she did not feel the laceration was a serious injury and did not feel it required reporting. The DON stated she had in the past reported injuries such as bruises, major skin tears, and lacerations. The DON stated the incident should have been reported now that she looked back at it because there was a component of neglect that occurred, and it was her job to ensure it did not happen again. The DON stated not reporting incidents related to injury and neglect could lead to further injury and neglect of the residents, resulting in serious injury or possibly death. During an interview on 01/11/2023 at 10:30 a.m., the Administrator stated he was unsure how reporting the laceration incident fell through the cracks. He stated his best guess was because the incident did not include any facility staff, it only included the hospice CNA, that hospice should have educated their staff on following the care plan and safe transfers. The Administrator stated he knew the facility was responsible for resident safety no matter who was caring for them. The Administrator stated not reporting could lead to repeated and continued injury to the residents. The Administrator stated he was the abuse coordinator, and he was responsible for reporting all abuse and neglect situations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 3 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **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 and assistance devices to prevent accidents for 2 of 6 residents (Resident #1 and Resident #242) reviewed for adequate supervision. 1. The facility failed to transfer Resident #1 with a mechanical lift and 2 staff member assistance, resulting in a laceration to her right lower extremity requiring 16 sutures. 2. The facility did not ensure the brakes were engaged when Resident #242 was lifted and lowered with the Hoyer device (an assistive lift device that allows for transfer using electrical power). These failures could place residents at risk for injury, harm,or impairment. Findings included: 1. Record review of Resident #1's admission Record indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included senile degeneration of the brain (the mental loss of intellectual ability that is associated with old age), repeated falls, abnormalities in gait (when a person is unable to walk in the usual way), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should, and anxiety (Intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's MDS dated [DATE] revealed a BIMS with a score of 4, which indicated severely impaired cognition. The MDS also revealed, Resident #1, required extensive assistance with 2 staff members for transfers. Record review of Resident #1's Care Plan, completed by the DON, revealed a problem initiation on 12/05/2022 for a laceration to right lower posterior leg from a wheelchair transfer by hospice aide. The laceration measured 6.0cm X 4.0cm X 0.5cm and required 16 sutures in the emergency room. Care plan titled ADL assistance revealed Resident #1 required extensive assistance of 2 staff members for transfer. Record review of Resident #1's accident and injury report completed by LVN G, indicated on 12/05/2022 Resident #1, sustained an injury to her right lower extremity measuring 6.0cm X 4.0cm X 0.5cm. The accident report revealed Resident #1 was in moderate pain, there was a large amount of blood, the accident occurred during transfer, first aid was administered, and Resident #1 was sent to the emergency room. The accident report revealed the injury was a large laceration with jagged edges that needed sutures. Record review of Resident #1's nursing notes dated 12/05/2022 revealed the following: LVN G wrote: This nurse called to resident's room (Resident #1). Resident received laceration to RLE (right lower extremity) 6.0cm X 4.0cm X 0.5cm. First aid performed to stop bleeding. EMS (emergency medical service called for transfer to a local emergency room for further evaluation. NP (nurse practitioner) and family aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 4 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 - Actual harm Record review of a hospital exam dated 12/05/2022 indicated Resident #1 came to the emergency room after suffering a laceration to right calf area measuring 6.0cm X 3.8cm. The laceration required sutures to approximate the skin and stop the bleeding. Procedure completed and Resident #1 was sent back to the nursing facility. Residents Affected - Few During observation and interview on 01/09/2023 at 2:30 p.m., Resident #1's family stated on 12/05/2022 she was called and informed that Resident #1 was being sent to the ER because she had a skin tear to her leg. Resident #1's family stated she met Resident #1 in the ER and she had more than a skin tear. She stated it was a huge laceration that required 16 sutures. She stated she stayed with Resident #1 until the sutures were completed, and the ER (emergency room) sent her back to the facility. Resident #1 was well-groomed lying-in bed with family at bedside. During an interview on 01/10/2023 at 9:40 a.m., CNA B said she had worked at the facility for several years and was the full time CNA for 100 hall (the hall Resident #1 resided on). CNA B stated she remembered the incident in which Resident #1 sustained a laceration to her right lower extremity. CNA B stated that was the day the Hospice CNA F reported to her she had transferred Resident #1 by herself with no assistance. CNA B stated she remembered it because it was a huge deal that she transferred Resident #1 alone and Resident #1 was injured in the process. CNA B explained that Resident #1 was always a 2-person mechanical lift transfer. CNA B further explained that Resident #1 was too unpredictable to attempt any kind of stand pivot transfer and for the safety of the resident and the CNA she must be transferred by mechanical lift and always have 2 staff. CNA B stated, Hospice CNA F knew Resident #1 was a mechanical lift with 2 staff because Hospice CNA F had assisted her with the mechanical lift transfer of Resident #1 several times before. During an interview on 01/10/2023 at 2:00 p.m., LVN G stated she recalled the incident that occurred on 12/05/2022 with Resident #1 and Hospice CNA F. LVN #G stated she was called down to Resident 1's room and noted a large amount of blood pooled beneath her wheelchair. She noted a large laceration to Resident #1's right posterior calf area. LVN G stated, Hospice CNA F told her she was not sure how it happened but Resident #1 had to have scratched her leg on the wheelchair during transfer. Hospice CNA F stated she did transfer Resident #1 alone. LVN G stated Hospice CNA F called her supervisor and told her the laceration occurred and the facility was sending Resident #1 to the hospital. LVN G was not aware of any education or disciplinary action for Hospice CNA F. LVN G stated the care plan, as well as the CNA kiosk had the information for each resident's care needs. LVN G stated the hospice CNAs generally asked the nurse or another CNA if they were unsure of how to transfer a resident. LVN G stated Hospice CNA F had been to the building dozens of times and was the assigned hospice CNA to Resident #1. LVN G stated Hospice CNA F had transferred Resident #1 with the assistance of herself and other staff members by mechanical lift multiple times prior to the incident. During an interview on 01/10/2023 at 3:00 p.m., Hospice CNA F stated she transferred Resident #1 alone at least once per week. Hospice CNA F stated on 12/05/2022 around 4:00 p.m., she transferred Resident #1 with a stand pivot transfer. She got ready to leave the room wheeling Resident #1 and noted a small pool of blood beneath Resident #1's wheelchair. She stated she immediately called for help, the nurse came, and first aid was administered. Hospice CNA F stated she did not have access to the facilities records to know how they had Resident #1's care planned for transfer. Hospice CNA F stated she believed hospice had Resident #1 care planned as a 1-person transfer. Hospice CNA F stated she had not reviewed the facility or hospice care plan. Hospice CNA F further explained she was tall and had not had any problem transferring Resident #1 alone in the past. Hospice CNA F stated she knew the facility used a mechanical lift to transfer Resident #1. She stated she felt the facility used a mechanical lift because the CNAs were short, and Resident #1 was tall, and they could not handle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 5 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 - Actual harm her. Hospice CNA F stated she had not received any further training on transfers by the facility of the hospice company, nor had she received any direction on how to communicate with the facility about the amount of care each resident required. Hospice CNA F stated she had been back in the facility and cared for other hospice resident's a dozen times since 12/05/2022 with no further education on transfer. Residents Affected - Few Record review of hospice plan of care with a start date of 07/18/2022, revealed Resident # 1 was always a 2-person mechanical lift transfer. Hospice provided the mechanical lift and the sling required for transfer on 07/18/2022. During an interview on 01/10/2023 at 3:30 p.m., the DON revealed she was informed on 12/05/2022, that Resident #1 had sustained a laceration to her right calf during the improper transfer and was being sent to the ER for evaluation. The DON stated she reviewed the accident report and questioned Hospice CNA F. The DON stated Hospice CNA F had a horrible attitude and was loud with her when she attempted to educate her on communicating with the staff about how many people should be assisting with transfers. The DON stated she attempted to educate Hospice CNA F, but Hospice CNA F called her manager and told her the facility was demanding Resident #1's care plan be changed to 2-person mechanical lift transfer. The DON stated she told the Hospice Nurse Manager not to send the CNA back into the facility and that the facility and hospice care plans had to be the same. The DON stated she attempted to educate Hospice CNA F to ask staff, look at the hospice care plan, or look at the CNA kiosk before providing care to ensure she was giving proper safe care. The DON stated the hospice staff had to ask the facility staff for access to the facility care plan and the kiosk which contained the CNA care plan for each resident The only way for the hospice staff to know the resident's plan of care was to ask the staff to see it or look at the hospice care plan. The DON was not aware of how many times Hospice CNA F had been back to the building following the 12/05/2022 incident. No paperwork was located showing documentation of education for any CNA after the improper transfer with a laceration occurred. During an interview on 01/10/2023 at 4:40 p.m., Hospice RN manager E revealed she was called by Hospice CNA F and informed Resident #1 was being sent to the ER following an incident in which Resident #1 was injured during a transfer. Hospice RN E stated Hospice CNA F thought Resident #1 was a one-person pivot transfer and requested that Resident #1's hospice care plan be changed to reflect the 2-person mechanical lift transfer. Hospice RN manager E revealed she did not change the care plan to a 2-person mechanical transfer. She stated when she looked at it, hospice was already providing a mechanical lift and sling for the transfer of Resident #1. Hospice RN manager E stated she did not do further education with Hospice CNA F ensuring resident safety and continuity of care. Hospice RN manager E stated the hospice company educated the CNAs to always speak the nurse and CNA prior to care to ensure no changes in the resident care status had occurred. Hospice RN manager E stated the hospice CNAs were educated to follow the hospice care plan which was located in the hospice book at each nurses station. During an interview on 01/11/2023 at 10:15 a.m., the DON stated the incident from 12/05/2022 with Resident #1, could have been prevented if the Hospice CNA F had followed the plan of care set forth by the facility and transferred Resident #1 with a mechanical lift with 2 staff members present. The failure to do so resulted in a laceration to her right calf requiring 16 sutures. The DON stated she attempted to do education with Hospice CNA F, and she was not receptive to the education. The DON stated she talked to the Hospice RN E and requested Hospice CNA F not take care of Resident #1 and that all hospice care plans match facility care plans for continuity of care. The DON stated failure to provide adequate supervision for ADLs will result in injury and could result in serious injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 6 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 - Actual harm Residents Affected - Few During an interview on 01/11/2023 at 10:30 a.m., the Administrator stated He stated that hospice should have educated their staff on following the care plan and safe transfers. The Administrator stated he knew the facility was responsible for resident safety no matter who was caring for them. The Administrator stated not providing the proper supervision during care can result in serious injury and harm. The Administrator stated the facility had monthly in services and following resident care plans was discussed at least quarterly and upon hire with each staff member. 2.Record review of the Resident #242's physician order report indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including, epilepsy (a brain disorder that causes recurring, unprovoked seizures), Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and muscle spasm. Record review of the active physician order dated 1/6/23 indicated Resident #242 was to have fall precautions in place. Record review of the care plan reviewed by the facility on 1/10/22 indicated Resident #242's environment would be monitored to decrease risk for falls. During an observation on 1/10/23 at 11:40 a.m., CNA H had positioned the Hoyer net under Resident #242 in her wheelchair. CNA H left the room and returned with LVN G to complete the transfer. CNA H moved the mechanical lift into place in front of the wheelchair. CNA H then lowered the device (brought the cradle into appropriate position to secure the mechanical lift net). LVN G and CNA H secured the mechanical lift net to the cradle. CNA H did not lock the brakes of the mechanical lift. CNA H raised Resident #242 up in the mechanical lift. CNA H and LVN G moved the lift and positioned Resident #242 over her bed. CNA H, without locking the brakes, lowered Resident #242 onto her bed. During an interview on 1/10/23 at 11:49 a.m., CNA H said she should have locked the brakes before she lifted or lowered Resident #242. CNA H said she did not lock the brakes because she forgot. CNA H said it was important to lock the brakes of the mechanical lift before a resident was lifted or lowered because the lift could move which might cause the resident to bang into something or fall. During an interview on 1/10/23 at 11:50 a.m., LVN K said staff should always make sure the brakes are applied on the mechanical lift before a resident was lifted/lowered. LVN K said leaving the brakes unlocked while a resident was lifted/lowered could cause the lift to jerk or slide, which could startle the resident. LVN K elaborated, the Resident could fall out of the lift or the lift could fall over with the Resident in the lift. During an interview on 1/11/23 at 10:36 a.m., LVN G said she did not realize CNA H had not locked the brakes of the mechanical lift before lifting/lowering Resident #242 yesterday (1/10/22). LVN G said it was very important to lock the brakes of the mechanical lift before a resident was lifted/lowered because the resident could fall out or the lift could tip over. During an interview on 1/11/23 at 1:45 p.m., the DON said she expected staff to ensure brakes were applied on the mechanical lift before a resident was lifted/lowered. The DON said she expected staff to ensure brakes were applied on the device (bed or chair) the Resident was lifted from, the device the Resident was lowered to (bed or chair) and the mechanical lift brakes were locked before lifting or lowering the Resident. She said these safety mechanisms (locking the brakes) were in place to prevent injury. The DON said failure to ensure the brakes were locked on the mechanical lift device could have resulted in significant injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 7 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 - Actual harm Residents Affected - Few During an interview on 1/11/23 at 2:06 p.m., the Administrator said staff should have locked the brakes on the Mechanical lift before lifting/lowering Resident #242. The Administrator said he expected staff to utilize all approaches to safety. Record review of an undated policy entitled Accidents and Supervision revealed, Avoidable Accident means that an accident occurred because the facility failed to: * identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or * Evaluate and analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; and/or * Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice to eliminate the risk, if possible, and, if not, reduce the risk of an accident; and/or * Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. Record review of the undated facility policy titled, General Safety Policy stated, In general, all employees will maintain a safe environment and report any issues immediately. Procedure: 1. Employees will report all unsafe or potentially hazardous acts or conditions to the supervisor immediately. Supervisors/managers will be responsible for implementing protocol to resolve the unsafe or potentially hazardous condition immediately .8. Any incident (e.g., any unusual occurrence that is not consistent with routine facility activity) must be reported immediately. Reporting incidents will assist in providing a safe and secure environment for residents, visitors, and employees. An Incident Report form must be completed within one hour of the occurrence and submitted to your supervisor as soon as possible after completing the report form. 9. The supervisor must investigate the incident report immediately. After the investigation is complete, the supervisor will complete a follow-up report, attach it to the original incident report and submit both reports to the DON before the end of the shift. 10. If the incident involves an employee or resident injury, first aid and subsequent medical evaluation as needed will be provided first. The incident reports will reflect the delay in submitting the report to the DON. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 8 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 7 of 14 residents reviewed for palatable food. (Residents #9, Resident #17, Resident #21, Resident #25, Resident #29, Resident #32, and Resident #141) Residents Affected - Some The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #9, Resident #17, Resident #21, Resident #25, Resident #29, Resident #32, and Resident #141 who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: Record review of a grievance form dated 09/22/22 indicated during a resident group meeting there was a dietary concern of Residents said the cookies are hard. Please change to cupcakes or softer cookies. Record review of a grievance form for Resident #143 dated 10/03/22 indicated, Oatmeal cold, not enough eggs for breakfast. Record review of a grievance form for Resident #37 dated 11/01/22 indicated, Food is cold by the time it gets to resident's room. Coffee has been cold. States she can't dissolve creamer due to temp of beverage. Record review of Resident Council Minutes dated 09/22/22 indicated, Dietary - less cookies - to hard. Record review of Resident Council Minutes dated 10/27/22 indicated, Dietary - less cookies - to hard .food in dining room sitting for 10 - 20 min to be handed out. Record review of Resident Council Minutes dated 11/23/22 indicated the Dietary Manager was in attendance. The minutes indicated, .food in dining room sitting for 10 - 20 min to be served. 1. Record review of the face sheet dated 1/11/23 revealed Resident #9 was [AGE] years old and admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung disease), anxiety disorder, and osteoporosis (a condition in which bones become weak and brittle). Record review of a quarterly MDS dated [DATE] revealed Resident #9 had a BIMS of 12, which indicated moderate cognitive impairment. Resident #9 required supervision to limited assistance with ADLs. Record review of a care plan dated 11/14/22 indicated Resident #9 received IV therapy for vitamin deficiencies. The care plan indicated Resident #9 was at risk for alteration in nutrition related to his obesity with an intervention to follow weight loss goals: encourage more fruits and veggies. During an interview on 01/09/23 at 9:27 a.m., Resident #9 said the food was cold. He said sometimes the food did not taste good . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 9 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of the face sheet dated 01/11/23 revealed Resident #17 was [AGE] years old and admitted on [DATE] with diagnoses including chronic kidney disease, dementia, and iron deficiency anemia (a condition of too little iron in the body). Record review of a quarterly MDS dated [DATE] revealed Resident #17 had a BIMS of 13, which indicated Resident #17 was cognitively intact. She required supervision for eating. Record review of a care plan dated 12/06/22 indicated Resident #17 received IV therapy for vitamin deficiencies. During an interview and observation on 01/09/23 at 9:25 a.m., Resident #17 said to an aide, you don't have to serve me soup with every meal. The resident said her meals were often cold. 3. Record review of the face sheet dated 01/11/23 revealed Resident #21 was [AGE] years old and admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung disease), malignant neoplasm of the colon (colon cancer), and anxiety disorder. Record review of a quarterly MDS dated [DATE] revealed Resident #21 had a BIMS of 11, which indicated moderate cognitive impairment. Resident #21 required supervision only with ADLs. Record review of a care plan dated 11/08/22 indicated Resident #21 received IV therapy for vitamin deficiencies. During an interview on 01/09/23 at 9:49 a.m., Resident #21 said the food was usually cold. 4. Record review of the face sheet dated 01/11/22 revealed Resident #25 was [AGE] years old and admitted on [DATE] with diagnoses including vitamin D deficiency, urinary tract infection, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). Record review of a quarterly MDS dated [DATE] revealed Resident #25 had a BIMS of 9, which indicated moderate cognitive impairment. Resident #25 required supervision only with ADLs. Record review of a care plan dated 08/09/22 indicated Resident #25 received IV therapy for vitamin deficiencies. During an interview on 01/09/23 at 9:46 a.m., Resident #25 said the food was not always good. She said the food was cold and just did not taste good. 5. Record review of the face sheet dated 01/11/22 revealed Resident #29 was [AGE] years old and admitted on [DATE] with diagnoses including Hypertension (high blood pressure), anemia (a condition in which the blood does not have enough healthy blood cells), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). Record review of a quarterly MDS dated [DATE] revealed Resident #29 had a BIMS of 12, which indicated moderate cognitive impairment. Resident #29 required supervision only with ADLs. Record review of a care plan dated 10/19/22 indicated Resident #29 received IV therapy for vitamin deficiencies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 10 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm During an interview on 01/09/23 at 9:17 a.m., Resident #29 said the food could be better. He said the food just does not taste good. 6. Record review of the face sheet dated 01/11/22 revealed Resident #32 was [AGE] years old and admitted on [DATE] with diagnoses including weakness, history of falling, and urinary tract infection. Residents Affected - Some Record review of a quarterly MDS dated [DATE] revealed Resident #32 had a BIMS of 10, which indicated moderate cognitive impairment. Resident #29 required supervision to limited assistance with ADLs. Record review of a care plan dated 01/08/2023 indicated Resident #32 received IV therapy for acute/chronic infections. During an interview on 01/09/23 at 9:20 a.m., Resident #32 said the food tasted horrible and was usually cold. 7. Record review of the face sheet dated 01/11/22 revealed Resident #141 was [AGE] years old and admitted on [DATE] with diagnoses including acute postprocedural pain, heart disease, and hypertension (high blood pressure). Record review of an electronic medical record for Resident #141 and accessed on 01/11/22 indicated there was not a completed MDS. Record review of a care plan for Resident #141 dated 12/30/22 indicated, .Nutritional status .Resident will not have a weight gain or loss of 5% in one month . During an interview on 01/09/23 at 2:35 p.m., Resident #141 said he was admitted for rehabilitation after back surgery. He said the food was cold and did not taste good. He said, it could use improvement. During an observation and interview on 01/10/23 at 12:30 p.m., a lunch tray was sampled by the Dietary Manager and four surveyors. The tray consisted of Ham, cornbread dressing, and green beans. There was no dessert served. The ham was room temperature. The cornbread dressing was warm, did not taste good, and left a bad after taste. The cornbread dressing had a gummy and thick texture. The green beans were cold and not seasoned. The green beans tasted like they were just poured out of the can. The Dietary Manager said the ham was not warm and she said the green beans were bland. She said she did not like cornbread dressing and could not say if it tasted bad. She said she did not know she was supposed to provide the surveyors a dessert. During an interview on 01/11/23 at 10:49 a.m., CNA B said she had heard a lot of food complaints from residents. She said residents told her the food was good and sometimes the food was not good. She said residents told her the meat was tough and the portions were too small. She said any time a resident complained she took the tray back to the kitchen and offered the resident an alternative. She said there was always an alternative. She said she reported resident complaints directly to the Dietary Manager. During an interview on 01/11/23 at 10:56 a.m., CNA D said she had only worked at the facility for a week. She said residents had complained to her about the food being cold. She said this was on a day when they were running behind. She said she reported the cold food to the kitchen staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 11 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 01/11/23 at 11:06 a.m., the Dietary Manager said she had heard the food tasted bad . She said the food was cooked according to the recipes. She said she visited with each resident and completed a food preference form with them. She said she heard food complaints from residents and the aides. She said she tried to make rounds twice a week to discuss food issues with the residents. She said the kitchen did offer alternatives if a resident did not like the food. She said cold food could cause bacteria to grow and make a resident sick. She said she wanted the residents to be happy with their food. A Food Palpability policy was requested at this time from the Dietary Manager. During an interview on 01/11/23 at 11:20 a.m., the Administrator said the facility did not have a food palatability policy. During an interview on 01/11/23 at 11:58 a.m., CNA C said residents had complained to her about the food being cold and that the food did not taste good. She said when the food was cold, she reheated the food for the resident. She said she reported the complaints to whoever was working in the kitchen. During an interview on 01/11/23 at 1:20 p.m., the Administrator said he learned of food complaints from the reports from the Resident Council monthly meetings and he got direct feedback in the dining room from the residents. He said he discussed complaints he heard with the Dietary Manager on how to resolve the complaints. He said he was in the kitchen every morning. He said the delivery time of the trays from the kitchen to the floor could have caused the food to be cold. He said he had a cook that was very adept at seasoning food. He said he was having him train the other cooks. He said he needed to make sure the cooks were hearing what the residents were saying about the taste of the food. He said cold food or food that did not taste good could negatively affect the residents with their satisfaction and could affect their weight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 12 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Residents Affected - Many The facility failed to ensure [NAME] A wore her mask over her nose and mouth in the kitchen. The facility failed to ensure [NAME] A secured all hair in a hairnet. The facility failed to discard food past its best use by date. This these failures placed residents at risk of food-borne illness. Findings included: During an initial tour observation in the kitchen on 01/09/23 starting at 9:00 AM revealed [NAME] A wore a baseball cap without a hairnet. Observation of [NAME] A revealed she failed to secure her hair in the front, the back, and on the side of her face and head; [NAME] A was observed with her mask below her nose and mouth. [NAME] A was observed with loose hair on the back of her clothes. During an observation inside of the kitchen dry food storage on 01/09/23 at 9:25 AM revealed that 5 bags of hamburger buns were past their best use by date of 1/5/23. During an observation of the kitchen on 1/10/23 at 8:10 AM revealed [NAME] A failed to secure her hair in the front, the back, and on the side of her face and head; [NAME] A was observed with her mask below her nose and mouth. During an interview on 1/11/23 at 9:45 AM with the Dietary Manager, she stated that staff are required to wear hairnets while in the kitchen. She stated that staff have been in-serviced on the use of hairnets by herself. She stated that she had the last in service on the use of hairnets on 11/2/22. She stated that the in-service states that baseball caps are acceptable in place of a standard hairnet. She stated that the purpose of wearing a hairnet is was to keep hair out of the food and to prevent contamination. She stated that it depends on hair length if wearing a baseball cap is the same as using a hairnet. She stated that for example, her hair length would require a hairnet because she hads longer hair. She stated that the hairnet is was supposed to secure hair by ensuring that all of the hair is was under the net and any loose hair will be caught by the net. She stated that it is was possible that [NAME] A's hair was sticking out of the hairnet, but she did not notice. She stated that a resident could get sick if a staff members hair was in the food of a resident. She stated that staff are required to wear masks while in the kitchen. She stated that she did not perform the in-service on mask usage, but she and her staff have all received training on mask use in the facility. She stated that a resident could get sick if they were exposed to a staff that was not wearing their mask properly. She stated that wearing a mask on your chin with your mouth and nose exposed is not proper use of a mask. She stated that her staff do not serve food that is past its best use by date. She stated that her staff and her throw away food when its past its best use by date. She stated that they keep a log that is was supposed to be checked daily that shows the staff checked and removed any food past its best use by date. She stated that a resident could have a food borne illness if they eat food that is spoiled or past its best use by date. She stated that it is the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 13 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm responsibility of staff and herself to ensure that there is no food in the kitchen that is past its best use by date, hairnets are worn properly, and masks are worn properly. During an interview on 1/11/23 at 10:30 AM with the Administrator he stated that he expected staff to adhere to policies regarding preventing foodborne illness and proper use of wearing protective equipment . Residents Affected - Many Attempted to interview [NAME] A by telephone on 1/11/22 at 11:30 AM. Voicemail box was not setup therefore a message was not left. Record review of a facility food handling policy titled Food Storage . To ensure that al food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP (Hazard Analysis Critical Control Point) guidelines. Record review of an in-service completed by the Dietary Manager on 11/2/2022 . Hair and beard nets are to be always worn inside the kitchen!! If your hair is short enough to fit under a cap without hanging out, you may also wear a cap. Shows that [NAME] A signed her name as she read the in-service material. Record review of Daily expired food inspection check off . Log shows that foods were checked for expiration on the following dates: 1/1/23 through 1/11/23. Log shows that the kitchen storage was checked for expired food daily. Record review of a facility face mask policy titled Signage for use of specific PPE (Personal Protective Equipment) dated 1/11/23 and 10/14/2022 revealed . Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infectious status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 14 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all patient care equipment was in safe operating condition for 4 (Resident # 91, #14, #32 and #31) of 16 residents reviewed for safe operating patient care equipment. Residents Affected - Some The facility failed to ensure the beds of Residents # 91, #14, #32 and #31 would lock in position when the bed was raised at an appropriate level to provide care. This failure could place Residents at risk of injury. Findings included: 1.Record review of the physician order summary report dated 1/11/23 indicated Resident # 91 was [AGE] years old admitted to the facility on [DATE] with diagnoses including aphasia (a disorder that results from damage to portions of the brain that are responsible for language), stroke, pulmonary edema (an abnormal buildup of fluid in the lungs), muscle wasting and atrophy (weakening, shrinking, and loss of muscle caused by disease), and heart failure. Record review of Resident #91's care plan dated 1/5/23 indicated her environment would be monitored to decrease the risk for falls. During an observation on 1/10/23 at 11:10 a.m., CNA H and MA M provided incontinent care to Resident #91. CNA H and MA M raised and moved the right side of the bed away from the wall. CNA H and MA M did not lock the bed. They (CNA H and MA M) provided incontinent care and repositioned Resident #91. The bed shook/moved as Resident #91 was rolled to the left, then right and then pulled up in the bed. During an interview on 1/10/23 at 11:20 a.m., CNA H said Resident #91's bed should have been locked before she was turned and repositioned in the bed. CNA H said Resident #91 could have fallen and been injured because of the bed not being locked. During an interview on 1/10/23 at 11:23 a.m., MA M said Resident #91's bed could not be locked. She explained, the bed had feet which stood on the ground when the bed was in the lowest position. MA M said when the bed was in the lowest position the bed would not slide or shake. MA M said when the bed is raised up to an appropriate level to provide resident care, the bed legs lift, and the wheels lowered to the floor. But, she added, there were no brakes on the wheels. MA M said the bed shaking while turning the resident was dangerous. MA M said the bed should lock when raised to provide care. MA M said Resident #91 could have fallen and been injured because of the bed not being locked. During an observation on 1/10/23 at 11:24 a.m., MA M lowered Resident #91's bed into the lowest possible position. She then raised the bed approximately 12 inches. The wheels at the bottom right corner of the bed had a locking mechanism. MA M pointed to the left lower wheels and stated, see there is no brake here. The surveyor pointed out the brakes to the right lower foot of the bed. MA M and CNA H pulled the head and right side of the bed slightly away from the wall. The wheels to the left of the top of bed had a locking mechanism. The wheels on the right of the head of the bead did not have a locking mechanism. MA M and CNA H locked the bed wheels at the top left corner of the bed and attempted to lock the wheels at the bottom right of bed (the lock would not fully engage). The bed was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 15 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some moved freely to the left and right. CNA H and MA M placed the bed back against the wall and lowered the bed into the lowest possible position. During an interview on 1/10/23 at 11:26 a.m. MA M said she was not sure how long the bed had been in that condition (brakes not working). MA M said she noticed it today (1/10/23) when she assisted CNA H with incontinent care for Resident #91. MA M explained she primarily worked as a MA but assisted with CNA work when it was necessary. During an interview on 1/10/23 at 11:27 a.m., CNA H said she was an agency CNA and today (1/10/23) was her first time to work at the facility in a long time. CNA H said she was not aware the bed would not lock. During an interview on 1/10/23 at 11:50 a.m., LVN K said MA M had informed her earlier about Resident #91's bed inability to be locked. LVN K said she had not been notified prior to today (1/10/23) by any staff in reference to issues with a bed that would not lock. During an interview on 1/10/23 at 12:45 p.m., the DON said she had been notified that Resident #91's bed would not lock. The DON said she believed Resident #91's bed was a hospice bed. The DON said she would contact the Hospice agency to obtain a different bed, as the current bed was a safety issue. During an interview on 1/11/23 at 11:20 a.m., the Maintenance Director said he was responsible for ensuring the patient bed equipment was in safe working condition. The Maintenance Director explained he had worked at the facility in the past as the Maintenance Director in 2019 and 2020 but had just returned to the position in September 2022. The Maintenance Director said yesterday (1/10/23) after the issue with Resident #91's bed was discovered; he began the process of checking all resident beds in the facility. The Maintenance Director said he started a list of items that will be needed to ensure the beds lock appropriately. The Maintenance Director said there was no system in place to check bed brakes prior to yesterday (1/10/23). He explained since he started in September 2022 he has just dealt with problems as they came. The Maintenance Director said he was just putting out fires and had not yet had the time to get any systems in place. He said no facility staff had logged an issue in the maintenance request log (regarding bed brakes) since it's initiation in November 2022 and no facility staff had come to him to notify him of an issue with bed brakes. Record review of the facility maintenance request log from 11/1/22 to 1/6/23 indicated no facility staff had reported any issues with bed brakes. 2. Record review of the physician order summary report dated 1/11/23 indicated Resident #14 was [AGE] years old admitted on [DATE] and was a full code. The physician order summary report indicated her diagnoses included mild cognitive impairment, unspecified fracture of the right arm, high blood pressure, COPD (chronic obstructive pulmonary disease [group of lung diseases that make it hard to breathe and get worse over time]), muscle wasting and atrophy (weakening, shrinking, and loss of muscle caused by disease) and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #14 understood and made herself understood. The MDS indicated she had moderate cognitive impairment (BIMS of 12). The MDS indicated Resident #14 required extensive assistance with bed mobility, dressing, and personal hygiene. The MDS indicated walking, transfers, and locomotion in her wheelchair had not occurred during the 7 days look back period. The MDS indicated Resident #14 was totally dependent on staff for toileting, as well as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 16 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bathing and required two+ persons physical assistance to complete both tasks (toileting and bathing). The MDS indicated Resident #14 was always incontinent of bowel and bladder. Record review of the care plan revised on 12/26/22 indicated Resident #14 was at risk for falling related to a history of falls and weakness. The care plan interventions included, keep Resident #14's bed in the lowest position with brakes locked. The care plan also indicated Resident #14 had urinary incontinence and was to be provided incontinent care after each incontinent episode. The care plan indicated Resident #14 was limited in her ability to perform ADL's due to the fracture to her right upper extremity and was totally dependent on staff for toileting and bathing. During an observation on 1/11/23 at 11:30 a.m., Resident #14 laid in her bed. CMA H and the DON attempted to lock the brakes on Resident #14's bed. The brakes did not adequately lock, and the bed moved from side to side freely as CMA H and the DON tested the brake securement. During an interview on 1/11/23 at 11:40 a.m., CNA B said she had not noticed any issues with any resident beds. CNA B said she usually worked hall 1 and routinely provided care to Resident #14. CNA B said she raised Resident #14's bed up to provide incontinent care but never moved the bed away from the wall because she provided the care independently (without the assistance of other staff). 3. Record review of the physician order summary report dated 1/11/23 indicated Resident #32 was [AGE] years old admitted on [DATE] and was a full code. The physician order summary report indicated his diagnoses included chronic pain, dementia, weakness, history of repeated falling, lack of coordination, muscle wasting and atrophy (weakening, shrinking, and loss of muscle caused by disease), abnormalities of gait and mobility, difficulty walking, muscle weakness, high blood pressure and cerebrovascular disease (disorders in which an area of the brain is temporarily or permanently affected by ischemia or bleeding and one or more of the cerebral blood vessels are involved in the pathological process). Record review of the MDS dated [DATE] indicated Resident #32 made himself understood and understood others. The MDS indicated Resident #32 had moderately impaired cognitive function (BIMS of 10). The MDS indicated he required limited assistance with bed mobility, transfers, dressing, personal hygiene. The MDS indicated Resident #32 required supervision only with walking locomotion in his wheelchair, eating and toilet use. The MDS indicated he was occasionally incontinent of bladder and always continent of bowel. Record review of the care plan revised on 9/20/22 indicated Resident #32 was at risk for falls related to a history of falls, weakness, poor balance, and unsteadiness. The care plan interventions included keep Resident #32's call light in place at all times and encourage resident to use environmental devices (hand grips, handrails, etc.). The care plan also indicated Resident #32 was forgetful and had poor safety awareness. During an observation on 1/11/23 at 11:34 a.m., Resident #32 was sitting in his wheelchair next to his bed. Resident #32's bed was in the lowest position. CMA H and the DON raised Resident #32's bed several inches from the floor and examined the wheels. Resident #32's bed had no wheel brakes to any of the wheels. 4. Record review of the physician order summary report dated 1/11/23 indicated Resident #31 was [AGE] years old admitted to the facility on [DATE] and was a full code. The physician order summary report indicated her diagnoses included dementia, Stage 3 chronic kidney disease (a gradual loss of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 17 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 0908 Level of Harm - Minimal harm or potential for actual harm kidney function over time, Stage 3 indicating mild to moderate damage of the kidneys has occurred), high blood pressure, atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), COPD (chronic obstructive pulmonary disease [group of lung diseases that make it hard to breathe and get worse over time]), unsteadiness on feet, lack of coordination, and muscle weakness. Residents Affected - Some Record review of the MDS dated [DATE] indicated Resident #31 sometimes understood and sometimes made herself understood. The MDS indicated Resident #31 had severe cognitive impairment (BIMS of 1). The MDS indicated she required extensive assistance with bed mobility, transfers, walking, locomotion in her wheelchair, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #31 was totally dependent on staff for bathing. The MDS indicated she was occasionally incontinent of bladder and was always continent of bowel. Record review of the care plan revised on 11/25/22 indicated Resident #31 was at risk for falls due to dementia, unstable balance, no safety awareness and not using shoes. The care plan interventions included call light in place at all times and encourage resident to use environmental devices (hand grips, handrails, etc.), and increase staff supervision based on Resident #31's needs. The care plan indicated Resident #31 experienced bowel and bladder incontinence. The care plan interventions included provide incontinent care after each episode of incontinence and apply moisture barrier to skin. During an observation on 1/11/23 at 11:34 a.m., Resident #31 was ambulating on the secured unit. Resident #31's bed was in the lowest position. CNA L raised Resident #31's bed several inches from the floor and examined the wheels. CNA L attempted to lock the brakes on Resident #31's bed. The brakes did not adequately lock, and the bed moved from side to side freely as CNA L tested the brake securement. During an interview on 1/11/23 at 11:35 a.m., CNA L said she primarily worked on the secured unit and routinely took care of Resident #31. CNA L said shaking/moving of Resident #31's bed had not occurred while she (CNA L) cared for her (Resident #31) because she (CNA L) never raised the bed. CNA L explained Resident #31 regularly used the toilet and she (CNA L) assisted her. CNA L said she had witnessed no shaking of Resident #31's bed when she transferred out of the bed and said it was probably because her bed remained in the lowest position at all times. During an interview on 1/11/23 at 1:45 p.m., the DON clarified the bed Resident #91 was on, was a facility bed and was not obtained from the hospice provider. The DON said it was the Maintenance Director's responsibility to ensure Resident's beds were in safe working condition. The DON said he (the Maintenance Director) just has not had the chance to get any systems in place. The DON said he has just fixed things as he is notified by staff. She said he (the Maintenance Director) has been very busy since he started September. The DON said the brakes missing/inability to lock was a safety concern and could result in resident injury. During an interview on 1/11/23 at 2:06 p.m., the Administrator said the Maintenance Director was responsible for ensuring there was a system in place to confirm resident care equipment was in safe working condition. The Administrator said the Maintenance Director started with the facility in September (2022) and was working to get systems into place that routinely check essential equipment. The Administrator said Resident # 91's bed moving/shaking during patient care was a safety concern. Record review of the undated facility policy titled, General Safety Policy stated, In general, all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 18 of 19 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 0908 Level of Harm - Minimal harm or potential for actual harm employees will maintain a safe environment and report any issues immediately. Procedure: 1. Employees will report all unsafe or potentially hazardous acts or conditions to the supervisor immediately. Supervisors/managers will be responsible for implementing protocol to resolve the unsafe or potentially hazardous condition immediately . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 19 of 19