Health inspection·February 28, 2024

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few missed MDS could affect resident care and expected the MDS coordinator to follow the RAI manual and communicate with her to ensure MDS were not missed. During an interview no 02/28/24 at 12:05 PM the DON stated she signed the MDS behind the MDS coordinator and the MDS assessment schedules were discussed in morning meeting as well as changes in resident conditions requiring a significant change MDS. She stated when Resident #36 was admitted to hospice the admission was discussed in the meeting and was not aware the MDS coordinator had not completed it. She stated if MDS were not submitted per the guidelines it could affect resident care and expected all MDS to be done according to the RAI manual. During an interview on 02/28/24 at 2:33 PM the administrator stated the MDS coordinator was responsible for completing the MDS assessments for significant change in condition. He stated the MDS coordinator was in training and the clinical reimbursement nurse was assisting but they failed to complete the MDS assessment on Resident #36. He stated if MDS were not completed it could affect resident care and expected all MDS assessments to be completed per the RAI manual. He stated the facility did not have a policy on MDS assessment completion and followed the RAI manual. Record review of the RAI version 3.0 manual dated October 2019 indicated a significant change assessment must be completed and submitted within 14 days of the assessment review date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 2 of 22 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 02/28/2024 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 - Minimal harm or potential for actual harm 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 observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision as is possible for 1 of 1 resident (Resident #5) reviewed for accidents and hazards. The facility failed to ensure that Resident #5 did not have a rechargeable vape device at bedside. The facility failed to supervise Resident #5 while using a rechargeable vape device that was affixed to a device clamped to her bedside table designed to hold it next to her face. The facility failed to ensure that Resident #5 did not use vaping device with door open, exposing other residents to secondhand exposure. This failure could place residents that vape at risk of nicotine overdose and vape related injuries. Findings include: Record review of a facility face sheet dated 2/27/24 for Resident #5 indicated that she was a [AGE] year-old female originally admitted to the facility on [DATE] and subsequently re-admitted on [DATE] with diagnosis of quadriplegia (the inability to move arms and legs). Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated that she had a BIMS score of 13, which indicated that she was cognitively intact. Section GG indicated that she had functional limitation to bilateral upper and lower extremities that interfered with daily functions or placed resident at risk of injury. Record review of a Comprehensive Care Plan revised on 1/18/24 for Resident #5 indicated that she was at risk for injury related to using a nicotine inhaler. Care plan indicated that she kept it at bedside, and staff must assist with use. Interventions included: Device connected to bedside to hold nicotine inhaler; Staff to monitor inhaler for safety; and Staff to provide assistance to resident with nicotine inhaler. Record review of a smoking assessment for Resident #5 dated 8/22/23 indicated that she used a vape and was a safe smoker. Record review of physician orders for Resident #5 indicated that she had the following order: Nicotine inhaler prn, attached to side of bed for self-administration; Special Instructions: Is not a rechargeable vaping device, with start date of 5/30/23. During an observation and interview on 2/26/24 at 10:07 am, Resident #5 was observed lying in bed. Vape device was observed next to resident duct taped to a holding device which was attached to a piece of wood and secured to her bedside table with a c-clamp. Resident stated that it was her vape and proceeded to turn her head toward device and use it in room with door open. During an observation and interview on 2/26/24 at 3:50 pm, CNA E was observed in room with Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 3 of 22 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 02/28/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few #5. CNA E positioned device closer to resident after passing ice so that resident could reach it with her mouth. CNA stated, That is her vape. Resident was observed vaping in room with door open. During an interview on 2/27/24 at 10:00 am VP of Clinical said that the vape that Resident #5 had been using on 2/26/24 was a temporary device that she was using until they could get her one that did not have to be recharged. She said that the temporary device she was using was a disposable, rechargeable device. She said that the resident was normally using a disposable, non-rechargeable device. During an observation and interview on 2/27/24 at 11:00 am, Resident #5 was observed lying in bed. No vape device observed in room at this time. She said that she had been using the same device for a while but could not remember exactly how long. She was referring to the device she was observed using on 2/26/24. She said that staff would charge it for her, but never charged it in her room. During an interview on 2/28/24 at 11:50 am the DON said that they had now removed the device from Resident #5's room and she would be having staff go into the room at designated smoking times for 20 minutes with the door closed to allow resident to use device with supervision. She said that she was planning to discuss quitting with Resident #5, but she did not think resident would quit. She said that she now understood that it was a safety risk to allow Resident #5 to use device unsupervised and at will. She said that resident might use it too much, that other residents could be exposed by second-hand exposure and that it was also a fire hazard. During an interview on 2/28/24 at 2:09 pm, the Administrator said that going forward there would be staff supervising Resident #5 during her use of the vaping device. He said that he had assumed that it was alright since it had been care planned and documented. He said that he now knows that there are dangers with it and that the risks include explosion or fire and that he only wants the residents to be safe. Record review of FDA website accessed on 2/27/24 from the following address: https://www.fda.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-d read .In addition to exposing people to risks of tobacco-related disease and death, FDA has received reports from the public about safety problems associated with vaping products including: o Overheating, fires, and explosions; o Lung injuries; and o Seizures and other neurological symptoms . Record review of facility policy titled Vaping Policy - Residents undated read .This facility shall establish and maintain safe resident vaping practices . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 4 of 22 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 02/28/2024 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 0692 Provide enough food/fluids to maintain a resident's health. 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 residents were offered sufficient fluid intake to maintain proper hydration and health for 7 of 14 residents (Residents #6, #7, #9, #13, #30, #33, and #41) reviewed for hydration. Residents Affected - Some The facility failed to ensure Resident #6, Resident #7, Resident #9, Resident #13, Resident #30, Resident #33, and Resident #41 received adequate fluids during the 6am to 2pm shift on 2/26/24. This failure could place residents at risk for dehydration, electrolyte imbalance, and infections. Findings include: Resident #33 Record review of a facility face sheet dated 2/27/24 for Resident #33 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of dementia. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #33 indicated that he had a BIMS score of 7, which indicated that he had severely impaired cognition. Record review of a comprehensive care plan dated 8/4/23 for Resident #33 indicated that he had a history of urinary tract infection and intervention included to encourage adequate fluid intake, and offer at frequent intervals. Resident #6 Record review of a facility face sheet dated 2/28/24 for Resident #6 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of chronic obstructive pulmonary disease with acute exacerbation (a condition where a person with chronic obstructive pulmonary disease (COPD) has a sudden and severe worsening of respiratory symptoms). Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated that he had a BIMS score of 12, which indicated that he had moderate cognitive impairment. Record review of a comprehensive care plan dated 12/20/23 for Resident #6 indicated that he was at risk for dehydration with intervention to keep water at bedside within reach. During an observation on 02/26/24 at 09:43 AM, Resident #6 was observed in his room sitting up in his wheelchair. No water was observed in his pitcher, or the pitcher for his roommate, Resident # 33. Resident #7 Record review of a facility face sheet dated 2/28/24 for Resident #7 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 5 of 22 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 02/28/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with diagnosis of chronic obstructive pulmonary disease with acute exacerbation (a condition where a person with chronic obstructive pulmonary disease (COPD) has a sudden and severe worsening of respiratory symptoms). Record review of a Quarterly MDS assessment dated [DATE] for Resident #7 indicated that he had a BIMS score of 12, which indicated that he had moderate cognitive impairment. Record review of a comprehensive care plan dated 8/19/23 for Resident #7 indicated that he was at risk for dehydration with intervention to keep water at bedside within reach. During an observation and interview on 02/26/24 at 10:30 AM Resident #7 was observed sitting up in his chair. His water pitcher was empty. He said staff rarely bring him water. He simply said, sometimes they bring it and sometimes they don't. During an observation on 02/26/24 at 03:08 PM Resident #7s water pitcher was still empty. Resident #9 Record review of a facility face sheet dated 2/28/24 for Resident #9 indicated that she was a [AGE] year-old female originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of urinary tract infection. Record review of a Quarterly MDS assessment dated [DATE] for Resident #9 indicated that she had a BIMS score of 9, which indicated that she had moderately impaired cognition. Record review of a comprehensive care plan dated 8/22/23 for Resident #9 did not address fluid needs. Resident #30 Record review of a facility face sheet dated 2/28/24 for Resident #30 indicated that she was an [AGE] year-old female originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of heart failure. Record review of a Quarterly MDS assessment dated [DATE] for Resident #30 indicated that she had a BIMS score of 3, which indicated that she had severely impaired cognition. Record review of a comprehensive care plan dated 8/19/23 for Resident #30 indicated that she was at risk for dehydration with intervention to keep fluids at bedside, within reach. During an observation on 02/26/24 at 09:50 AM both water pitchers in Resident #9 and Resident #30's room were empty. During an observation and interview on 02/26/24 at 03:10 PM Resident #9 and Resident #30's water pitchers were observed still empty. Resident #13 Record review of a facility face sheet dated 2/28/24 for Resident #13 indicated that he was a [AGE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 6 of 22 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 02/28/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] for diagnosis of chronic kidney disease (progressive worsening of kidney function). Record review of a Quarterly MDS assessment dated [DATE] for Resident #13 indicated that he had a BIMS score of 11, which indicated that he had moderately impaired cognition. Residents Affected - Some Record review of a comprehensive care plan dated 11/17/23 for Resident #13 indicated that he was at risk for urinary tract infection, and intervention was to encourage resident to drink plenty of fluids. During an observation and interview on 02/26/24 at 10:18 AM Resident #13 was observed in his room lying in his bed with no water in his pitcher. He said that staff does not fill it up and he said that he normally just went and filled it himself. Resident #41 Record review of a facility face sheet dated 2/28/24 for Resident #41 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of atherosclerotic heart disease (A condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #41 indicated that he had a BIMS score of 10, which indicated that he had moderately impaired cognition. Record review of a comprehensive care plan dated 1/11/24 for Resident #41 indicated that he was at risk for nutritional deficit with intervention to encourage oral intake of food and fluids. During an observation and interview on 02/26/24 at 03:05 PM Resident #41 was observed lying in bed. There was water in his pitcher, but it was not cold, nor did it have any ice. Resident said that it had been there awhile. He said that he did not get very thirsty, but if he did, he just ignored it. During an interview on 02/26/24 at 03:12 PM CNA E said that she had just came in. She said that CNAs are responsible for passing ice and water and that she passes water as soon as she comes in. She said that CNAs should pass ice every shift and said that residents could be at risk for dehydration if they do not drink enough water. During an interview on 02/28/24 at 07:20 AM the DON said she expected her CNAs to pass ice and water at least once per shift, approximately 2 hours after the beginning of their shift. She said that the CNA had just gotten busy on Monday, 2/26/24, and did not get around to it. She said she would be in-servicing staff and monitoring to ensure that ice and water get passed as needed. She said that residents could be at risk of dehydration if they do not have access to water. During an interview on 02/28/24 at 02:09 PM the Administrator said that residents not having water was uncalled for and they had a hydration station set up before, but during all the renovations it had gotten removed. He said that as leaders, it was their responsibility to ensure the residents had water. He said that he would ensure that residents going forward had water and ice passed. He said that residents were at risk of dehydration, especially if they were unable to get water themselves and were dependent on staff for hydration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 7 of 22 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 02/28/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Record review of a facility policy titled Diets, Nutrition, and Hydration dated April 18, 2022, read .Each resident will be offered and have access to beverages between meals . and .Fluid should be available for residents between meals for additional hydration . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 8 of 22 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 02/28/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice for 1 of 9 residents (Resident #21) reviewed for oxygen usage. Residents Affected - Few The facility failed to ensure Resident #21's oxygen tubing was stored properly when not in use and discarded when contamination occurred. This deficient practice could place residents at risk of respiratory infections. Findings include: Record review of a facility face sheet dated 02/28/2024 indicated Resident #21 was a [AGE] year-old female that admitted to the facility on [DATE] for diagnosis of hypertension (high blood pressure). Record review of a care plan dated 9/29/2023 indicated Resident # 21 required oxygen therapy and to change oxygen tubing per facility policy. Record review of a physician order dated 10/02/2023 indicated Resident # 21 had an order to change oxygen tubing each Friday. Record review of a physician order dated 02/26/2023 indicated Resident # 21 had an order for oxygen at 2 liters/minute per nasal cannula for shortness of breath. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #21 had a BIMS of 01 indicating severely impaired cognition and did not receive oxygen therapy during that assessment. During an observation on 02/26/24 at 10:04 AM Resident #21's oxygen tubing was laying on the floor. During an observation on 02/27/24 at 7:27 AM Resident #21's oxygen tubing was off the floor and wrapped around concentrator handle. During an interview on 2/27/24 at 10:39 AM CNA B stated Resident #21 used oxygen at night and was not aware that the tubing was on the floor. She stated oxygen tubing should be bagged or off the floor and if tubing was on the floor the nurse should be notified to replace it. She stated if oxygen tubing was used after being on the floor it could cause an infection. During an interview on 02/27/24 at 10:49 AM LVN A stated she had been a nurse for 38 years and at the facility since July 2023. She stated oxygen tubing was changed weekly and should be checked daily each shift to ensure it was stored correctly when not in use. She stated Resident #21 wore her oxygen as needed but mostly at night. She stated if oxygen tubing was on the floor, it should not be used and should be replaced with new tubing to prevent infections. During an interview on 02/27/24 at 4:00pm the DON stated that all respiratory supplies should be bagged for protection against cross contamination. She stated the nurses should be monitoring that oxygen tubing was properly stored when not in use and if oxygen tubing was on the floor, it should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 9 of 22 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 02/28/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discarded and replaced. She stated the resident could develop an infection if oxygen tubing was used that was on the floor. She stated she expected all nursing staff to identify respiratory supplies that were not stored properly and replace them as needed. During an interview on 02/28/24 at 2:36 PM the administrator stated that the nurses were responsible for ensuring oxygen tubing was properly stored when not in use and if oxygen tubing was used that was contaminated it could cause an infection. He stated he expected all oxygen tubing was stored properly to prevent infections. Record review of a facility policy dated 9/2017 titled Oxygen Tubing and Cannula Replacement indicated, .the facility will change oxygen tubing when they become visibly contaminated and when known contamination occurs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 10 of 22 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 02/28/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 2 of 12 months (July 2023 and September 2023) reviewed for pharmacy services. The facility failed to properly inventory drugs at time of disposal on 7/7/2023 and 9/5/2023. This failure could put residents at risk for misappropriation and drug diversion. Findings include: Record review of facility drug destruction records dated February 2023 through February 2024 revealed that on July 7, 2023, the cover page was not numbered with the number of attached pages for destruction and was only signed by one witness and the consultant pharmacist; also on September 5, 2023, the cover sheet was only signed by the consultant pharmacist and contained no witness signatures. During an interview on 2/28/24 at 7:20 am the DON said that she was normally so obsessive about her paperwork and that she must not have been here those days, or she would have ensured that they were completed properly. She said that going forward she would ensure that drug destruction was done correctly because there could be a risk of drug diversion if it was not done correctly. During an interview on 2/28/24 at 2:09 pm, the Administrator said that going forward, he would plan on being a part of the drug destruction. He said that the risks included a drug diversion. During an interview on 2/28/24 at 2:49 pm, the Consultant Pharmacist said he did not realize the cover sheet had not been signed and that the witnesses were always with him during destruction. He said that he knew it was a regulation that it must contain 2 witness signatures and going forward, he would not leave the facility until the cover sheets were correctly signed. He said that there could be a risk for drug diversion if destruction was not completed per regulation. Record review of facility policy titled Discarding and Destroying Medications dated 5/2020 read .For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 11 of 22 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 02/28/2024 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 0755 d. Dispose with the solid waste (i.e., regular trash) in the presence of two witnesses. Level of Harm - Minimal harm or potential for actual harm e. Document the disposal on the medication disposition record. f. Include the signature(s) of at least two witnesses . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 12 of 22 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 02/28/2024 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 Residents Affected - Many 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 and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. DA C failed to follow the cleaning and sanitizing requirements for equipment when she dried wet plates from the dishwasher on 02/26/2024. 2. The facility failed to store foods in accordance with professional standards. 3. The facility failed to date opened items in the refrigerator. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and/or transmission-based infections. Findings include: During an observation on 02/26/24 at 9:23 AM DA C was drying plates from the dishwasher with a cloth towel. During an observation on 02/26/24 at 9:27 AM a sugar storage container did not have the lid attached and there was a scooper inside the container. During an observation on 02/26/24 at 9:30 AM the refrigerator contained an opened ready care thickened tea and water carton with no open date and each container had directions that read: may be kept up to 7 days under refrigeration. During an interview on 02/26/24 at 9:37 AM DA C stated she had started drying the dishes to keep them from being too wet when they were stored. She stated she was not aware dishes could not be dried with a cloth. She stated she had not been dating the thickened liquids because they were usually used within a few days but could see how if the liquids were not dated, they could be used past the 7 days. She stated she was not aware of a scoop in the sugar container and the cook may have left the scoop in the container. She stated if items were used past the use by date, it could cause a resident to get sick. She stated drying dishes and leaving a scoop in a container could cause cross contamination. During an interview on 02/26/24 at 9:40 AM [NAME] D stated she just came back from her days off and was not aware of the sugar container being open or having a scoop in it. She stated the container should be sealed and not have anything inside because of cross contamination. She stated that all items in the refrigerator should be dated when opened and was not aware that thickened liquids were only good for 7 days after opening. She stated that using items past the use by date could cause a resident to get sick. During an interview on 02/28/24 at 7:38 am the DM stated she was responsible for training all dietary staff and dietary staff were trained on kitchen sanitation to include air drying dishes, not leaving scoops in containers, and dating items when they were opened and to discard those items per the guidelines of that item. She stated she would begin retraining all staff because of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 13 of 22 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 02/28/2024 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 cross-contamination risk and expected all staff to follow all kitchen sanitation rules. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/28/24 at 2:43 PM the administrator stated the DM was responsible for oversight of kitchen sanitation as well as the training for the dietary staff. He stated that if sanitation measures were not followed in the kitchen, it could cause resident illness and contamination. He stated he expected all dietary staff to follow the regulations for kitchen sanitation. Residents Affected - Many Record review of a facility policy dated 4/18/2022 titled Food Safety in Receiving and Storage indicated, .Food will be received and stored by methods to minimize contamination and bacterial growth; 7. check expiration dates and use by dates to assure the dates are within acceptable parameters . Record review of a facility policy dated 10/01/2018 titled Manual Cleaning and Sanitizing of Utensils and Portable Equipment indicated, .11. air dry utensils and equipment, since wiping can re-contaminate equipment and can remove the sanitizing solution from the surfaces . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 14 of 22 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 02/28/2024 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit to CMS (Centers for Medicare & Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 quarters (Fiscal year 2023 for the fourth quarter July 1, 2023 to September 30, 2023) reviewed for administration. The facility failed to submit data for the fourth quarter of the fiscal year from July 1, 2023, to September 30, 2023, to CMS This failure could place residents at risk for personal needs not being identified and met. Findings include: Record review of the facility's Civil Rights form (3761) dated 2/5/2024 provided by the Administrator indicated a total of 51 residents and 52 staff that included: 2-Registered Nurses 5-Licensed Vocational Nurses 25-Direct Care Staff 7-Dietary Staff 6-Housekeeping and Laundry 7-All others Record review of the CMS PBJ (payroll-based journal) Staffing Data Report dated 2/21/2024 for the FY Quarter 4 2023 (July 1-September 30) indicated the facility failed to submit data for the quarter. Record review of a PBJ Submission report for Quarter 4 of 2023 by the facility dated 11/8/2023 indicated the submission had a warning that said files contained records with dates that was not within the date range of the report quarter. During a phone interview on 2/27/2024 at 1:52 PM, the HR Assistant said she was responsible for the PBJ submissions at the facility. She said she submitted the data quarterly and the 4th quarter of 2023 was submitted on 11/8/2023 for the facility. She said she was unable to submit until the last day of that quarter and the submissions were not due to CMS until 45 days after the end of that quarter. She said Simple LTC submission indicated the file was received by CMS on 11/8/2023 at 11:12 am. She said the errors on the submission report always had errors on it. During an interview on 2/28/2024 at 9:20 AM, the Administrator said the PBJ submissions were conducted in the corporate office. He said if errors were present on the PBJ submission report, there was a system in place to catch them and it would need follow up. He said going forward the information could go back to the HR director for final check and there was no risk of patient safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 15 of 22 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 02/28/2024 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of a facility policy titled Payroll-Based Journal (PBJ) undated indicated, .Payroll-Based Journal (PBJ) will be submitted quarterly per the Centers for Medicare and Medicaid (CMS) guidelines. At the end of each quarter, as defined by CMS, staffing hours will be collected from the Company's time keeping/payroll system along with any contracted hours and submitted in the required format defined by CMS. The CMS Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual will be referenced and used to ensure accurate submission . Event ID: Facility ID: 675217 If continuation sheet Page 16 of 22 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 02/28/2024 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 Based on observation, interview and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: Residents Affected - Many The facility did not ensure the gas stove was in working order. Two of six gas stove burners (rear middle and font middle) did not light automatically, when the knob was turned, the pilot light on the burners would not stay lit and both burners had carbon buildup. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings include: During an observation on 02/26/24 at 9:40 AM the gas stove had six burners and two burners located in the middle had excess carbon buildup. The burners would not light automatically and the pilot light would not stay lit. During an interview on 2/26/24 at 9:41 [NAME] D stated she did not use the 2 burners in the middle because they often would not light. She stated she was not sure who cleaned the burners, and the dietary manager was aware the burners did not work. She stated that the burners not working correctly could be a fire hazard. During an interview on 02/27/24 at 1:01 PM the maintenance director stated the kitchen staff were responsible for cleaning the stove burners and he cleaned them if needed. He stated he was aware of the burners not lighting last week and had called a plumber; however the plumber had not gotten back with him until today. He stated if the stove was not maintained it could possibly cause a fire. During an interview on 2/28/24 at 7:38 am the DM stated that she and the other kitchen staff were responsible for maintaining the stove and keeping it clean. She stated if the burners were not working, or the carbon build up was excessive then she would tell the maintenance director. She stated he was aware of the burners not working and had called a plumber. She stated if the stove was not working correctly, it could be a fire hazard. During an interview on 02/28/24 at 2:47 PM the administrator stated the dietary staff were responsible for everyday cleaning of the stove and the maintenance director was responsible for maintaining the equipment from carbon buildup and ensuring the equipment was working fully. He stated if equipment was not maintained it could cause an adverse event or be a fire hazard. He stated he expected all essential equipment to be maintained in proper working order. Record review of a facility policy dated 10/01/2018 titled Range and Grill indicated, .the facility will maintain the range in a clean manner to minimize the risk of food hazard; 2. scrape off burned particles and grease . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 17 of 22 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 02/28/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 16 residents (Resident #24 and Resident # 36) reviewed for call lights. Residents Affected - Few The facility failed to ensure Resident #24's emergency call button in the bathroom had a pull cord. The facility failed to ensure Resident #36's call light was within reach while in bed. These failures could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings include: 1. Record review of a face sheet for Resident #24 dated 2/28/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people), bipolar (extreme mood swings) and BPH (enlarge prostate gland that causes difficulty with urinating). Record review of a quarterly MDS assessment for Resident #24 dated 12/20/23 indicated he had severe impairment in thinking with a BIMS score of 4. He was always continent of bowel and bladder. Record review of a care plan for Resident #24 dated 9/22/23 indicated he had occasional incontinence of bladder and bowel related to BPH with interventions to provide limited to extensive assistance for toileting. At times he was independent with toileting: transfers self to toilet and cleans self. He was at risk for falls due to his poor safety awareness with interventions to always keep call light in reach. During an observation and interview on 2/26/2024 at 9:44 AM the bathroom call button in Resident #24's room did not have a pull string. The call button was attached to the wall in the bathroom by the grab bar. Resident #24 was in the room but was very hard of hearing with confusion noted. He could not answer any questions asked. During an observation and interview on 2/28/2024 at 8:35 AM, CNA H said she had been employed at the facility for 4 months and was assigned to work on hall 1 with Resident #24. She said Resident #24 used the bathroom in the room at times and other times he would forget and have accidents. She looked in the bathroom of Resident #24 and said she had never noticed the call button in the bathroom did not have a string attached and was not sure if it needed a string or not. She said if Resident #24 had a fall in the bathroom, he could push the button that was on the wall. She said if he fell, the resident would not be able to reach the call button and he could potentially be on the floor for about 2 hours because she made rounds every 2 hours. During an observation and interview on 2/28/2024 at 8:40 AM, LVN J said Resident #24 used his bathroom in the room sometimes. LVN J looked in the bathroom of Resident#24 and said she had never noticed that the call button in the bathroom did not have a pull string. She said Resident #24 would not be able to call for help if he had a fall. She said the Maintenance Manager was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 18 of 22 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 02/28/2024 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 0919 ensuring the call buttons had pull strings. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/28/2024 at 11:58 AM, the Maintenance Manager said he had been employed at the facility since September 2022. He said all of the bathrooms in the facility should have a call button with a pull string. He said he was not aware that the call button in Resident #24's room did not have a pull string. He said he was responsible for installing the call buttons and making sure they had the pull strings. He said staff were supposed to write in the maintenance book for repairs or issues and he was on call daily for the facility. He said he checked the maintenance logbook daily that was kept at the nurse station. He said if a resident fell in a bathroom that did not have a pull string, they could be lying on the floor for a while. Residents Affected - Few Record review of the maintenance request book dated 3/31/2023-2/12/2024 indicated no requests for the room where Resident #24 resided for a call light string to be installed in the bathroom. During an interview on 2/28/2024 at 2:06 PM, the Administrator said the Maintenance Manager was responsible for the call lights in the facility. He said it was brought to his attention this morning about the call light in Resident #24's bathroom and it was placed. He said going forward, staff must go through rooms to ensure things are in order twice a week such as toilet, fixtures, and lights. He said a resident could not be attended to in a timely manner and was at risk for injury if they did not have a pull string for the call button. 2. Record review of a facility face sheet dated 02/28/2024 indicated Resident #36 was a [AGE] year-old female that readmitted to the facility on [DATE] with diagnosis of cerebral infarction (impaired blood flow to the brain). Record review of quarterly MDS assessment dated [DATE] indicated Resident #36 had a BIMS of 02 indicating severe cognitive impairment and required maximum assistance with activities of daily living. Record review of a comprehensive care plan dated 02/02/2024 indicated Resident #36 was incontinent of bowel and bladder and was high risk for falls and to keep call light within reach. During an observation on 02/26/24 at 2:57 PM Resident # 36's call light was located on the floor at foot of bed next to the wall. During an observation on 02/26/24 at 3:57 PM Resident # 36's call light was on the floor at the foot of the bed next to the wall. During an observation on 02/27/24 at 7:34 AM Resident # 36's call light was at the foot of the bed. During an observation on 02/27/24 at 10:38 AM Resident # 36's call light was within reach. During an interview on 02/27/24 at 10:39 AM CNA B stated she had been a CNA for ten years and employed at the facility a few weeks. She stated the CNA's were responsible for ensuring call lights were in reach and should be checked every time the resident was checked. She stated she thought she had placed Resident #36's call light within reach when she gave care but must have forgotten. She stated if a resident could not reach the call light care could be delayed or injury could happen. During an interview on 02/27/24 at 10:49 AM LVN A stated she had been a nurse for 38 years and call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 19 of 22 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 02/28/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lights should be checked by all staff when caring for the resident. She stated she had not noticed Resident #36's call light on the floor and must have overlooked it. She stated if a resident could not reach their call light it could cause a delay in care or injury. During an interview on 02/28/24 at 12:02 PM the DON stated that all call lights should be checked by the nurse and aides during resident care. She stated all staff have received training on call light placement and planned to restart rounds by management staff. She stated if call lights were not accessible it could cause delay in resident care and expected that all residents call lights were within reach. During an interview on 02/28/24 at 2:40 PM the administrator stated call lights were the responsible of all staff, but direct care staff should be ensuring the light was in place when providing direct care. He stated if call lights were not accessible it could cause a delay in resident care and expected all call lights were within reach. Record review of a facility policy dated September 21, 2022 titled Answering the Call Light indicated, .The purpose of this policy procedure is to respond to the resident's requests and needs. 3. Explain to the resident that a call system is also located in his/her bathroom. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 20 of 22 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 02/28/2024 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 0926 Have policies on smoking. 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 follow their own established vaping policy for 1 of 1 resident (Resident #5) reviewed for vaping. Residents Affected - Few 1.The facility failed to follow the policy on vaping by allowing Resident #5 to have a rechargeable vape device at bedside. 2. The facility failed to follow the policy on vaping by failing to supervise Resident #5 while using a rechargeable vape device that was affixed to a device clamped to her bedside table designed to hold it next to her face. 3. The facility failed to follow the policy on vaping by not ensuring that Resident #5 did not use vaping device with door open, exposing other residents to secondhand exposure. These failures could place residents at risk of unsafe vaping and injury. Findings included: Record review of a facility face sheet dated 2/27/24 for Resident #5 indicated that she was a [AGE] year-old female originally admitted to the facility on [DATE] and subsequently re-admitted on [DATE] with diagnosis of quadriplegia (the inability to move arms and legs). Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated that she had a BIMS score of 13, which indicated that she was cognitively intact. Section GG indicated that she had functional limitation to bilateral upper and lower extremities that interfered with daily functions or placed resident at risk of injury. Record review of a Comprehensive Care Plan revised on 1/18/24 for Resident #5 indicated that she was at risk for injury related to using a nicotine inhaler. Care plan indicated that she kept it at bedside, and staff must assist with use. Interventions included: Device connected to bedside to hold nicotine inhaler; Staff to monitor inhaler for safety; and Staff to provide assistance to resident with nicotine inhaler. Record review of a smoking assessment for Resident #5 dated 8/22/23 indicated that she used a vape and was a safe smoker. Record review of physician orders for Resident #5 indicated that she had the following order: Nicotine inhaler prn, attached to side of bed for self-administration; Special Instructions: Is not a rechargeable vaping device, with start date of 5/30/23. During an observation and interview on 2/26/24 at 10:07 am, Resident #5 was observed lying in bed. Vape device was observed next to resident duct taped to a holding device which was attached to a piece of wood and secured to her bedside table with a c-clamp. Resident stated that it was her vape and proceeded to turn her head toward device and use it in room with door open. During an observation and interview on 2/26/24 at 3:50 pm, CNA E was observed in room with Resident #5. CNA E positioned device closer to resident after passing ice so that resident could reach it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 21 of 22 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 02/28/2024 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 0926 with her mouth. CNA stated, That is her vape. Resident was observed vaping in room with door open. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/27/24 at 10:00 am VP of Clinical said that the vape that Resident #5 had been using on 2/26/24 was a temporary device that she was using until they could get her one that did not have to be recharged. She said that the temporary device she was using was a disposable, rechargeable device. She said that the resident was normally using a disposable, non-rechargeable device. Residents Affected - Few During an observation and interview on 2/27/24 at 11:00 am, Resident #5 was observed lying in bed. No vape device observed in room at this time. She said that she had been using the same device for a while but could not remember exactly how long. She was referring to the device she was observed using on 2/26/24. She said that staff would charge it for her, but never charged it in her room. During an interview on 2/28/24 at 11:50 am DON said that they had now removed the device from Resident #5's room and she would be having staff go into the room at designated smoking times for 20 minutes with the door closed to allow resident to use device with supervision. She said that she was planning to discuss quitting with Resident #5, but she did not think resident would quit. She said that she now understood that it was a safety risk to allow Resident #5 to use device unsupervised and at will. She said that resident might use it too much, that other residents could be exposed by second-hand exposure and that it was also a fire hazard. During an interview on 2/28/24 at 2:09 pm, Administrator said that going forward there would be staff supervising Resident #5 during her use of the vaping device. He said that he had assumed that it was OK since it had been care planned and documented. He said that he now knows that there are dangers with it and that the risks include explosion or fire and that he only wants the residents to be safe. Record review of facility policy titled Vaping Policy - Residents undated read .This facility shall establish and maintain safe resident vaping practices . and .Our facility strives to maintain a safe environment for all of their residents and at the same time respect the resident's rights, dignity, and right to self-determination. Therefore, vaping regulations are necessary to ensure that this is implemented and achieved in the facility . and .6. Vape pens and other vape paraphernalia are not permitted to be kept or stored in a resident 's room or in their possession, all vape paraphernalia will be turned into designated staff to keep for them. 7. Limited Exceptions: When ordered by a physician and determined by resident condition, and with approval of the administrator, a resident may utilize a vape pen in their room, so long as it is a private room, and the resident meets the other requirements specified above . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 22 of 22