Inspection·October 6, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety to diabetes starting 9/4/23. The physician orders indicated Resident #1 had an order for Lantus (a long-acting insulin to treat diabetes) 100u/ml Inject 12 unit subcutaneously two times a day for diabetes starting 9/4/23. Record review of the MAR indicated on 9/24/23 Resident #1 had a blood sugar readings of 409 at 7:00 a.m., 502 at 12:00 p.m., and 600 at 5:00 p.m. Residents Affected - Few Record review of the nursing progress notes dated 9/24/23 indicated there had not been physician notification regarding the three elevated blood sugar readings. Record review of the nursing progress note dated 9/25/23 at 3:50 a.m. written by RN A indicated she, received a phone call from the 2:00 p.m.-10:00 p.m. nurse stating that she had forgotten to tell me about [Resident #1's] p.m. blood sugar. Record review of the hospital record dated 9/25/23 indicated Resident #1 admitted to the emergency department via EMS after being found unresponsive at the facility. The hospital records indicated RN A reported Resident #1 had been found unresponsive at approximately 3:00 a.m. The hospital records indicated RN A reported Resident #1 had a blood glucose reading of HI (blood sugar reading greater than 600) and continued to have an undetectable blood glucose reading. The hospital records indicated due to the undetectable blood glucose reading the decision was made to send Resident #1 to the hospital. The hospital records indicated Resident #1 was sedated and intubated. The hospital records indicated Resident #1 had a blood glucose reading of 946. Record review of the hospital Discharge summary dated [DATE] indicated Resident #1 had diagnoses including diabetic ketoacidosis with coma related to diabetes (a process that forms toxic acids known as ketones (measure in the blood or urine and high blood sugar resulting in coma) and non-ST elevated myocardial infarction (heart attack). During an interview on 10/4/23 at 1:49 p.m., the NP said she remembered receiving a phone call at approximately 4:30 a.m. on 9/25/23 regarding Resident #1's blood sugars. The NP said she had not been previously notified of Resident #1 having an elevated blood sugar. The NP said the 10:00 p.m.- 6:00 a.m. nurse had called her and informed her the nurse who had worked 2:00 p.m.-10:00 p.m. the previous shift called the 10:00 p.m.-6:00 a.m. nurse at approximately 3:00 a.m. and told her she had forgot to let her know about Resident #1's elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse did not have current vital signs or a current blood sugar for Resident #1 when she called. The NP said the 10:00 p.m.-6:00 a.m. nurse told her she waited 1.5 hours to notify her of Resident #1's elevated blood sugars from the previous shift because she was passing medications. The NP said she gave orders for Resident #1's blood sugar to be checked. The NP said when she received the blood sugar results, she gave an order to administer insulin and recheck in one hour. The NP said when the nurse called her back after re-checking Resident #1's blood sugar an hour later, the nurse informed her Resident #1 was unresponsive. The NP said she gave an order for Resident #1 to be transported to the emergency department for evaluation. The NP said she was not informed of Resident #1's blood sugar being 946 when she arrived at the hospital. The NP said she expected the nurses to notify her of a blood sugar of 400 or greater. During an interview on 10/6/23 at 2:59 p.m., LVN C said she worked a double shift from 6:00 a.m.-10:00 p.m. on 9/24/23. LVN C said she did not notify the physician of Resident #1's elevated blood sugars because she got sidetracked. LVN C said she should have notified the physician and just did not do it. LVN C said she did not think about Resident #1's elevated blood sugars again until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 2 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few approximately 1:00 a.m. LVN C said jumped up and called the night nurse at that time. LVN C said she did not tell the nurse about Resident #1's elevated blood sugars during report due to the fact she had forgotten about it. LVN C said she called back the next morning and found out Resident #1 had been sent to the hospital. During an interview on 10/6/23 at 3:17 p.m., the DON said she expected the nurses to report any blood sugar over 400 to the physician or NP immediately. Record review of the facility's Diabetic Management policy last revised January 2023 indicated, Diabetic Management involves both preventative measures and treatment of complications .The interdisciplinary team assesses the diabetic resident/patient upon admission, validated the orders with the attending physician and initiates plan of care that may include: blood glucose monitoring as ordered .Blood glucose measurements shall be take per the physician order. Results outside of order parameters should be communicated to the physician per orders .Acute Complication Management: It is best practice to avoid hypoglycemic events in the older adult .For acute events, the clinical record shall include the following information: resident's condition indicated clinical presentation, blood glucose test levels, interventions provided, resident's response to treatment or interventions administered, and notification of the physician and any new orders . The Administrator was notified on 10/4/23 at 3:22 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 10/4/23 at 3:26 p.m. The facility's Plan of Removal was accepted on 10/5/23 at 4:48 p.m. and included: Situation: Resident # 1 was discharged to the hospital on 9-5-23 due to a change in condition. Resident was diagnosed and treated for Urinary Sepsis secondary ESBL secondary chronic indwelling foley catheter. Resident re-admitted to facility on 9-10-23 with a diagnosis of Urinary Sepsis as well as Diabetes Mellitus. Resident #1 was being treated with antibiotic therapy and completed the regimen on 9-15-23 as per physician's orders. On 9/24/23 Resident # 1 presented with abnormal blood glucose levels and on 9/25/23 Resident #1 experienced an acute change in condition. Upon identifying the change in condition, the nurse evaluated the patient's condition, notified the physician and at 4:40am nurse received new orders to administer Humalog 10units, at 5:50am the nurse re-checked the blood glucose following the administration of the insulin and the nurse notified the medical provider and received new order to send Resident #1 to the emergency department for evaluation and treatment. Outcome: Resident was admitted and treated in the hospital on 9/25/23, was noted to be at medical and cognitive baseline and has been readmitted to facility on 10/3/23. Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 3 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 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 0580 Date of completion: 10/4/23 Level of Harm - Immediate jeopardy to resident health or safety The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. Residents Affected - Few Date completed: 10/4/2023 The Director of Nursing Services/Assistant Director of Nursing conducted and education to all licensed nurses regarding the process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/23 Date to be completion: 10/4/2023 Risk Response: All residents who are diabetic may potentially be affected by the deficient practice. Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date of Completion: 10/5/2023 Director of Nursing Services/Assistant Director of Nursing Services completed a 100% audit on all residents who receive insulin. Physician orders were audited to ensure blood sugar parameters where in place as well as notifications to the MD/NP with the indicated parameters for all residents who receive insulin. Date completed: 10/4/2023 The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of diabetic management orders. The nurse will document the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date Commenced: 10/4/23 Date to be completion: 10/4/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 4 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 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 0580 Systemic Response: Level of Harm - Immediate jeopardy to resident health or safety Inservice training & re-education will be provided to all licensed nurses regarding topics: Residents Affected - Few Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff prior to assuming next shift/assignment. Inservice topics included but not limited to the following: the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia. assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. The process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. We are using the education on abuse, neglect, and exploitation as an opportunity for our team members. Date completed: 10/4/2023 10:00PM Director of Nursing / Assistant Director of Nursing will ensure all licensed nursing staff to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Director of Nursing / Assistant Director of Nursing will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date completed 10/4/2023. Director of Nursing / Assistant Director of Nursing in-serviced all C.N.As and M.As prior to assuming their next shift regarding reporting changes in residents' condition to the licensed nurse. Date of completed: 10/5/2023. All staff will be in-serviced on Abuse, Neglect and Exploitation- Prevention, Identification, Protecting and Reporting. This is used for educational purposes. Date Commenced: 10/4/2023 Date to be completion: 10/5/2023 Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. Monitoring Response (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 5 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The Director of Nursing/Assistant Director of Nursing will conduct 3 random audits per week of diabetic patients' plan of care and physician orders to validate the prescribed plan of care is being followed specifically reviewing orders for blood glucose monitoring for both labs being monitored and/or routine finger-stick blood glucose accu-checks monitoring as prescribed by the medical provider. The Director of Nursing/Assistant Director of Nursing will conduct random interviews during random shifts to ensure licensed nurses are able to identify signs and symptoms of hyper/hypoglycemia. Director of Nursing/Assistant Director of Nursing will also conduct daily reviews during the clinical start-up meeting (1-7days per week) to review new admissions, new orders for diabetic blood glucose monitoring ordered, review the 24hr report, pertinent progress notes, and SBARs (changes in condition documentation) to ensure that appropriate interventions are in place and to identify additional follow up interventions has been assigned. This plan will remain in place for the next 1-2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 1- 2 months. On 10/6/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility's Diabetic Management policy updated 10/4/23 indicated the policy had been updated to include both hyper and hypo-glycemia signs and symptoms and what to do in the event of a resident experiencing hyper or hypo-glycemia. Record review of a random selection of residents with diagnosis of diabetes who receive insulin's orders indicated orders had been updated to include blood glucose parameters and to notify the physician if the resident's blood sugar was outside of the parameters. Record review of the Ad Hoc QAPI meeting sign in sheet dated 10/4/23 indicated a QAPI meeting had been conducted regarding the above failure. Interviews with licensed nurses (LVN D, LVN E, RN F, LVN G, LVN H, and LVN J) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews the nurses were able to name signs and symptoms of hyper and hypo-glycemia, blood sugar parameters and when to notify the physician, all types of abuse, what to do in the event of witnessed of reported abuse, and documentation of clinical findings and physician notification. Interviews with CNAs (CNA K, CNA L, CNA M, CNA N, and CNA P) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews CNAs were able to identify changes in condition, when to report a change in condition, who to report a change in condition to, all types of abuse and what to do in the event of witnessed or reported abuse. On 10/6/23 at 10:39 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 6 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights for 1 of 9 (Resident #5) residents reviewed for care plans, The facility failed to ensure Resident #6's refusal of care was care planned. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings Include: 1. Record review of the face sheet dated 10/6/23 indicated Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hemiparesis and hemiplegia following a cerebral infarction (paralysis and weakness of one side following a stroke), contracture (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joint) of the right wrist, contracture of the right hand, and weakness. Record review of the MDS assessment dated [DATE] indicated Resident #5 was usually understood by others and usually understood others. The MDS indicated Resident #5 had a BIMS score of 03 and was severely cognitively impaired. The MDS indicated Resident #5 required extensive assistance with dressing, toileting, and personal hygiene. Record review of the care plan dated 8/6/23 indicated Resident #5 had a self-care deficit related to poor physical functioning. The care plan indicated interventions included bathing, dressing and grooming, and hygiene assistance times 1 person assist. Record review of the Documentation Survey Report dated August 2023 indicated Resident #5 was scheduled for showers on Tuesdays, Thursdays, and Saturdays. The Documentation Survey Report indicated Resident #5 refused her scheduled showers on 8/1/23, 8/8/23, 8/10/23, 8/12/23, 8/15/23, 8/17/23, 8/22/23, 8/26/23, and 8/29/23. Record review of the Documentation Survey Report dated September 2023 indicated Resident #5 refused her scheduled showers on 9/2/23, 9/7/23, 9/12/23, 9/14/23, and 9/21/23. During an interview on 10/6/23 at 10:35 a.m. LVN J said if a resident refused it should have been reported to the nurse. LVN J said the nurse should reapproach the resident and ask them about taking a shower. LVN J said if the resident continued to refuse the nurse should document the refusal. LVN J said if something was not documented it could not be proved it was done. LVN J said a resident who repeatedly refused their showers should have the refusal of care in their care plan. During an interview on 10/6/23 at 3:17 p.m. the DON said if a resident refused their scheduled shower the charge nurse was supposed to go ask the resident again. The DON said sometimes when the CNA askedhe resident about taking a shower the resident refuses because the resident wants their shower at a different time. The DON said the CNAs did not always make it back at a later time to provide the resident with their shower. The DON said when a resident routinely refuses their showers the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 7 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility would speak with the resident's family to get them to assist in getting the resident to take their shower. The DON said continuous refusals should be care planned. The DON said Resident #5 refused showers but would receive bed baths. The DON said a bed bath and a shower would be documented in the same place on the Documentation Survey Report. The DON said she was not sure why Resident #5's refusals had not been care planned. The DON said the nursing management was responsible for the resident care plans. The DON said the importance of care planning refusals was so staff would know exactly what was going on with a resident. Record review of the facility's Activities of Daily Living policy dated February 2017 indicated, Each resident's abilities to perform activities of daily living will not diminish unless the individual's clinical condition demonstrates that diminution was unavoidable. Activities of daily living include: personal hygiene .Residents who refuse care and treatment will be offered alternative treatment options and be advised of the negative impact of the continued refusal to accept treatment and care Record review of the facility's Care Plans policy dated February 2017 indicated, The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial need that are identified and in the comprehensive assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 8 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 3 of 9 (Resident #4, Resident #5, and Resident #6) residents reviewed for ADLs . Residents Affected - Some 1.The facility failed to provide assistance with facial hair removal for Resident #4 and Resident #5. 2. The facility failed to ensure Resident #5's fingernails were trimmed. 3. The facility failed to provide scheduled showers to Resident #6 This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings Include: 1. Record review of the face sheet dated 10/6/23 indicated Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, COPD, hemiparesis and hemiplegia following a cerebral infarction (paralysis and weakness of one side following a stroke), and hypertension (elevated blood pressure). Record review of the MDS assessment dated [DATE] indicated Resident #4 was understood by other and usually understood others. The MDS indicated Resident #4 had a BIMS score of 04 and was severely cognitively impaired. The MDS indicated Resident #4 required extensive assistance with dressing and toileting. The MDS indicated Resident #4 required total dependence for bathing. Record review of the care plan dated 8/24/23 indicated Resident #4 had a self-care deficit related to poor physical functioning. The care plan indicated interventions included bathing, dressing and grooming, and hygiene assistance times 1 person assist. During an observation and interview on 10/5/23 at 1:23 p.m. Resident #4 had thick white/grey chin hair approximately 0.5cm in length. Resident #4 said she would love to have assistance with removing her chin hair. Resident #4 said some of the staff would assist with chin hair removal and others would not. Resident #4 said she did receive her scheduled showers when she wanted them. 2. Record review of the face sheet dated 10/6/23 indicated Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hemiparesis and hemiplegia following a cerebral infarction (paralysis and weakness of one side following a stroke), contracture (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joint) of the right wrist, contracture of the right hand, and weakness. Record review of the MDS dated [DATE] indicated Resident #5 was usually understood by others and usually understood others. The MDS indicated Resident #5 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated Resident #5 required extensive assistance with dressing, toileting, and personal hygiene. The MDS indicated Resident #4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 9 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the care plan dated 8/6/23 indicated Resident #5 had a self-care deficit related to poor physical functioning. The care plan indicated interventions included bathing, dressing and grooming, and hygiene assistance times 1 person assist. During an observation and interview on 10/5/23 at 1:29 p.m. Resident #5 had chin hair approximately 0.5cm in length. Resident #5 said she would like her chin hair removed. Resident #5 had a contracture to her right hand and fingernails to her right hand approximately 1-2cm in length above the tip of her finger. Resident #5 said she wanted staff to cut her fingernails short. 3. Record review of the face sheet dated 10/6/23 indicated Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including muscle weakness, lack of coordination, schizoaffective disorder-bipolar type (a mental illness that can affect your thoughts, mood, and behavior), and mood disorder. Record review of the MDS dated [DATE] indicated Resident #6 was understood by others and understood others. The MDS indicated Resident #6 had a BIMS score of 15 and was cognitively intact. The MDS indicated Resident #6 required supervision with dressing and toileting. The MDS indicated Resident #6 required limited assistance with personal hygiene. The MDS indicated Resident #6 required supervision with bathing. Record review of the care plan dated 9/27/23 indicated Resident #6 had a self-care or mobility deficit related to immobility or weakness. Record review of the Documentation Survey Report dated September 2023 indicated Resident #6 was scheduled for showers on Mondays, Wednesdays, and Fridays. The Documentation Survey report indicated Resident #6 did not receive a shower on 9/1/23, 9/8/23, 9/15/23, 9/18/23, 9/22/23, and 9/25/23. The Documentation Survey Report indicated Resident #6 received showers on 9/4/23, 9/6/23, 9/11/23, 9/20/23, 9/27/23, and 9/29/23. The Documentation Survey Report indicated Resident #6 refused her shower on 9/13/23. During an interview on 10/5/23 at 1:33 p.m. Resident #6 said she did not receive her scheduled showers. Resident #6 said the CNAs complained because she had long hair and it took too long to shampoo. Resident #6 said she received a shower on 10/04/23 and prior to that it had been approximately a week since she had received a shower. Resident #6 said the staff did not think about the fact the residents wanted to be clean and go to bed clean like the staff had the option to do when they got home from work. During an interview on 10/6/23 at 10:05 a.m. LVN G said CNAs were responsible for providing residents their scheduled showers. LVN G said the importance of ensuring residents received their scheduled showers was to prevent skin breakdown, urinary tract infections, and fungal rashes. During an interview on 10/6/23 at 10:35 a.m. LVN J said the CNAs were responsible for resident showers. LVN J said facial hair removal for women should have been done daily or as needed. LVN J said resident's nails should be cared for by facility policy or on shower days. LVN J said the importance of facial hair removal, nail care, and showers was dignity, hygiene, fungal infection and rash prevention, and skin integrity. During an interview on 10/6/23 at 3:17 p.m. the DON said CNAs were responsible for showers, facial hair removal, and nail care. The DON said she had issues with agency staff not providing showers to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 10 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the residents. The DON said she had received grievance regarding residents not receiving their showers. The DON said the importance for providing scheduled showers, facial hair removal, and nail care was for the residents' overall well-being and to make them feel good. During an interview on 10/6/23 at 3:35 p.m. the Administrator said the only thing about showers he really was comfortable saying was resident showers should be scheduled and provided according to the resident's preference. Record review of the facility's Activities of Daily Living policy dated February 2017 indicated, Each resident's abilities to perform activities of daily living will no diminish unless the individual's clinical condition demonstrates that diminution was unavoidable. Activities of daily living include: personal hygiene . Record review of the facility's Certified Nurse Aide Standards of Clinical Practice policy dated 3/12/19 indicated, .The CNA assists the resident in activities of daily living such as feeding, drinking, turning and positioning, ambulating, bathing, grooming, toileting, dressing, and socialization . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 11 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 (Resident #1) residents reviewed for quality of care. Residents Affected - Few 1. The facility failed to monitor Resident #1's condition following elevated blood sugar readings. 2. The facility failed to notify Resident #1's physician of elevated blood sugars resulting in her being sent to the emergency department unresponsive and with a blood sugar of 946 (normal blood sugar ranges are 70-110) 3. The facility's Diabetic Management policy failed to address high blood sugars. 4. The facility failed to include blood sugar parameters for physician notification in Resident #1's physician orders. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 3:00 p.m. on 10/4/23. While the IJ was removed on 10/6/23 at 10:39 a.m., the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could result in diabetic residents suffering injury, hospitalization, or death related elevated blood sugars Findings include: Record review of a face sheet dated 10/6/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility om 3/3/04 with diagnoses including diabetes, dementia, major depressive disorder, and hypertension (elevated blood pressure). Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS score of 09 and was moderately cognitively impaired. Record review of the care plan last updated 8/31/23 indicated Resident #1 had diabetes and was at risk for complications associated with diabetes such as frequent infections, diabetic wounds, vision impairment, and hyper\hypo-glycemia. Interventions included administer medications as recommended by the doctor, monitor labs as indicated, and promptly report abnormal labs results and significant clinical findings to the doctor. Record review of the physician orders dated 10/4/23 indicated Resident #1 had an order for Humalog (a fast-acting insulin to treat diabetes) 100u/ml inject 14 unit subcutaneously before meals related to diabetes starting 9/4/23. The physician orders indicated Resident #1 had an order for Lantus (a long-acting insulin to treat diabetes) 100u/ml Inject 12 unit subcutaneously two times a day for diabetes starting 9/4/23. Record review of the MAR indicated on 9/24/23 Resident #1 had a blood sugar readings of 409 at 7:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 12 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 a.m., 502 at 12:00 p.m., and 600 at 5:00 p.m. Level of Harm - Immediate jeopardy to resident health or safety Record review of the nursing progress notes dated 9/24/23 indicated there had not been physician notification regarding the three elevated blood sugar readings. Residents Affected - Few Record review of the nursing progress note dated 9/25/23 at 3:50 a.m. written by RN A indicated she had, received a phone call from the 2:00 p.m.-10:00 p.m. nurse stating that she had forgotten to tell me about [Resident #1's] p.m. blood sugar. I checked the resident's blood sugar and the reading was HI [blood sugar reading greater than 600] . Call placed to [the physician] and received voicemail that instructed me to text and wait for response. Awaiting response. Record review of the nursing progress dated 9/25/23 at 4:20 a.m. written by RN A indicated Spoke with [the NP]. Order received to recheck blood glucose [on Resident #1]. Blood glucose rechecked and still reads HI. 4:40 a.m. called [the NP] and new order received. 4:50 a.m. [Resident #1] was given 10units of Humalog Insulin. Record review of the nursing progress note dated 9/25/23 at 5:50 a.m. written by RN A indicated Recheck of [Resident #1's] blood glucose revealed glucometer still reading HI. Call placed to [the NP] and was instructed to send resident to hospital. EMS called and resident transferred to [hospital]. Record review of the hospital record dated 9/25/23 indicated Resident #1 admitted to the emergency department via EMS after being found unresponsive at the facility. The hospital records indicated RN A reported Resident #1 had been found unresponsive at approximately 3:00 a.m. The hospital records indicated RN A reported Resident #1 had a blood glucose reading of HI and continued to have an undetectable blood glucose reading. The hospital records indicated due to the undetectable blood glucose reading the decision was made to send Resident #1 to the hospital. The hospital records indicated Resident #1 was sedated and intubated. The hospital records indicated Resident #1 had a blood glucose reading of 946. Record review of the hospital Discharge summary dated [DATE] indicated Resident #1 had diagnoses including diabetic ketoacidosis with coma related to diabetes (a process that forms toxic acids known as ketones (measure in the blood or urine and high blood sugar resulting in coma) and non-ST elevated myocardial infarction (heart attack). During an interview on 10/4/23 at 1:45 p.m. RN B said the facility did not have standing orders to add blood sugar parameters of when to notify the physician for blood sugar readings if too high or too low. RN B said some residents did have individualized parameters in place for when to notify the physician regarding their blood sugars. RN B said blood sugar parameters of when to notify the physician were normally if the blood glucose level was less than 60 or greater than 400. RN B said if she had a resident who had a blood sugar of 400, 500, or 600 she would notify the physician. RN B said physician notification and new orders should have been documented. During an interview on 10/4/23 at 1:49 p.m. The NP said she remembered receiving a phone call at approximately 4:30 a.m. on 9/25/23 regarding Resident #1's blood sugars. The NP said she had not been previously notified of Resident #1 having an elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse had called her and informed her the nurse who had worked 2:00 p.m.-10:00 p.m. the previous shift called the 10:00 p.m.-6:00 a.m. nurse at approximately 3:00 a.m. and told her she had forgot (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 13 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to let her know about Resident #1's elevated blood sugar. The NP said the 10:00 p.m.-6:00 a.m. nurse did not have current vital signs or a current blood sugar for Resident #1 when she called. The NP said the 10:00 p.m.-6:00 a.m. nurse told her she waited 1.5 hours to notify her of Resident #1's elevated blood sugars from the previous shift because she was passing medications. The NP said she gave orders for Resident #1's blood sugar to be checked. The NP said when she received to blood sugar results she gave an order to administer insulin and recheck in one hour. The NP said when the nurse called her back after re-checking Resident #1's blood sugar an hour later the nurse informed her Resident #1 was unresponsive. The NP said she gave an order for Resident #1 to be transported to the emergency department for evaluation. The NP said she was not informed of Resident #1's blood sugar being 946 when she arrived at the hospital. The NP said she expected the nurses to notify her of a blood sugar of 400 or greater. During an interview on 10/5/23 at 12:38 p.m. RN A said she was employed at the facility since March 2023. RN A said on 9/25/23 at approximately 4:00 a.m., the nurse who worked the 2:00 p.m.-10:00 p.m. shift on 9/24/23 called and informed her she had forgot to tell her Resident #1's blood sugar was high. RN A said she immediately went to take Resident #1's blood sugar and it only read high. RN A said she called the physician and when he did not answer she waited approximately 30 minutes and then called the on-call for the administration. RN A she spoke RN B who was on-call for administrative call and was told to call the NP. RN A she called the NP and was told to administer 10u of Humalog and recheck in 1 hour RN A said Resident #1 was not very responsive when she administered the Humalog. After re-checking the blood sugar and it was still HI, she reported to NP, and called 911. She said Resident #1 was semi-conscious when she left for the hospital. RN A said she was unsure whether the facility had standing parameters of when to notify a physician regarding blood sugars. RN A said the physician or NP should have been notified if the glucometer read HI when checking a blood sugar. RN A said a glucometer reading of HI was usually over 600. RN A said she would probably notify the physician of a blood sugar reading of 400 or 500. During an interview on 10/6/23 at 2:59 p.m. LVN C worked a double shift from 6:00 a.m.-10:00 p.m. on 9/24/23. LVN C said she did not notify the physician of Resident #1's elevated blood sugars because she got sidetracked. LVN C said she should have notified the physician and just did not do it. LVN C said she did not think about Resident #1's elevated blood sugars again until approximately 1:00 a.m. LVN C said jumped up and called the night nurse at that time. LVN C said she did not tell the nurse about Resident #1's elevated blood sugars during report due to the fact she had forgotten about it. LVN C said she called back the next morning and found out Resident #1 had been sent to the hospital. During an interview on 10/6/23 at 3:17 p.m. the DON said she expected the nurses to report any blood sugar over 400 to the physician or NP immediately. Record review of the undated EvenCare G2 Blood Glucose Monitoring System's Healthcare Professional Operator's Manual indicated a reading of HI meant the patient's blood glucose was greater than 600. Record review of the facility's Diabetic Management policy last revised January 2023 indicated, Diabetic Management involves both preventative measures and treatment of complications .The interdisciplinary team assesses the diabetic resident/patient upon admission, validated the orders with the attending physician and initiates plan of care that may include: blood glucose monitoring as ordered .Blood glucose measurements shall be take per the physician order. Results outside of order parameters should be communicated to the physician per orders .Acute Complication Management: It is best practice to avoid hypoglycemic events in the older adult .For acute events, the clinical record shall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 14 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few include the following information: resident's condition indicated clinical presentation, blood glucose test levels, interventions provided, resident's response to treatment or interventions administered, and notification of the physician and any new orders . The Administrator was notified on 10/4/23 at 3:22 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 10/4/23 at 3:26 p.m. The facility's Plan of Removal was accepted on 10/5/23 at 4:48 p.m. and included: Situation: Resident # 1 was discharged to the hospital on 9-5-23 due to a change in condition. Resident #1 was diagnosed and treated for Urinary Sepsis secondary ESBL secondary chronic indwelling foley catheter. Resident re-admitted to facility on 9-10-23 with a diagnosis of Urinary Sepsis as well as Diabetes Mellitus. Resident #1 was being treated with antibiotic therapy and completed the regimen on 9-15-23 as per physician's orders. On 9/24/23 Resident # 1 presented with abnormal blood glucose levels and on 9/25/23 Resident #1 experienced an acute change in condition. Upon identifying the change in condition, the nurse evaluated the patient's condition, notified the physician and at 4:40am nurse received new orders to administer Humalog 10units, at 5:50am the nurse re-checked the blood glucose following the administration of the insulin and the nurse notified the medical provider and received new order to send Resident #1 to the emergency department for evaluation and treatment. Outcome: Resident was admitted and treated in the hospital on 9/25/23, was noted to be at medical and cognitive baseline and has been readmitted to facility on 10/3/23. Regional Nurse Consultant re-educated the Director of Nursing / Assistant Director of Nursing regarding the expected management of a diabetic patient, assessing/evaluating and responding to the urgent needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, observing and monitoring a resident's condition, evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/23. Date of completion: 10/4/23 The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses regarding the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia, assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. Date completed: 10/4/2023. The Director of Nursing Services/Assistant Director of Nursing conducted education to all licensed nurses regarding the process for observing and monitoring a resident's condition, proceed with an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 15 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medical record (SBAR/progress note) as well as complete and document notifications of the change in status to the MD/PCP and resident/resident's representative accordingly. Date commenced: 10/4/2023. Residents Affected - Few Date to be completion: 10/4/2023. Risk Response: All residents who are diabetic may potentially be affected by the deficient practice. Administrator and Director of Nursing and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date to be completed: 10/5/2023. Director of Nursing Services/Assistant Director of Nursing Services completed a 100% audit on all residents who receive insulin. Physician orders were audited to ensure blood sugar parameters where in place as well as notifications to the MD/NP with the indicated parameters for all residents who receive insulin. Date completed: 10/4/2023. The Director of Nursing / Assistant Director of Nursing/Licensed Nurse will review all diabetic patients' current plan of care with the attending MD/NP to ensure that the appropriate orders are in place per MD/NP's prescribed plan of care and confirm accuracy of diabetic management orders. The nurse will document the MD/NP's orders should any new or changes in the plan of care be provided by the prescriber. Date completed: 10/4/2023. Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Director of Nursing / Assistant Director of Nursing conducted retraining for all licensed nursing staff prior to assuming next shift/assignment. Inservice topics included but not limited to the following: the expected management of a diabetic patient, how to respond to signs and symptoms of hyper/hypoglycemia. assessing/evaluating and responding to the needs of the diabetic patient based on presenting symptoms of hyper and hypoglycemia, reviewing and validating the plan of care with regards to blood glucose monitoring, sliding scale insulin orders routinely and/or as needed, prescriber's plan of care and management of the diabetic resident and following physician's orders/recommendations. The process for observing and monitoring a resident's condition, proceed with an assessment / evaluation of the resident's status, reporting changes in condition to the physician, obtaining physician's orders, following physician's recommendations/orders, documenting clinical findings and orders within the medial record (SBAR/progress note) as well as complete and document notifications of the change in status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 16 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 to the MD/PCP and resident/resident's representative accordingly. Level of Harm - Immediate jeopardy to resident health or safety Date completed: 10/4/2023. 10:00PM Residents Affected - Few Director of Nursing / Assistant Director of Nursing will ensure all licensed nursing staff to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. Director of Nursing / Assistant Director of Nursing will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Date completed: 10/4/2023. Director of Nursing / Assistant Director of Nursing in-serviced all C.N.As, and M.As prior to assuming their next shift regarding reporting changes in residents' condition to the licensed nurse. Date completed: 10/5/2023 All staff will be in-serviced on Abuse, Neglect and Exploitation, Prevention, Identification, Protecting and Reporting. This is for educational purposes for our employees. Date Commenced: 10/4/2023 Date to be completion: 10/5/2023 Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. Monitoring Response for the plan of correction. The Director of Nursing/Assistant Director of Nursing will conduct 3 random audits per week of diabetic patients' plan of care and physician orders to validate the prescribed plan of care is being followed specifically reviewing orders for blood glucose monitoring for both labs being monitored and/or routine finger-stick blood glucose accu-checks monitoring as prescribed by the medical provider. The Director of Nursing/Assistant Director of Nursing will conduct random interviews during random shifts to ensure licensed nurses are able to identify signs and symptoms of hyper/hypoglycemia. Director of Nursing/Assistant Director of Nursing will also conduct daily reviews during the clinical start-up meeting (1-7days per week) to review new admissions, new orders for diabetic blood glucose monitoring ordered, review the 24hr report, pertinent progress notes, and SBARs (changes in condition documentation) to ensure that appropriate interventions are in place and to identify additional follow up interventions has been assigned. This plan will remain in place for the next 1-2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 1- 2 months. On 10/6/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 17 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 remove the Immediate Jeopardy (IJ) by: Level of Harm - Immediate jeopardy to resident health or safety Record review of the facility's Diabetic Management policy updated 10/4/23 indicated the policy had been updated to include both hyper and hypo-glycemia signs and symptoms and what to do in the event of a resident experiencing hyper or hypo-glycemia. Residents Affected - Few Record review of a random selection of residents with diagnosis of diabetes who receive insulin's orders indicated orders had been updated to include blood glucose parameters and to notify the physician if the resident's blood sugar was outside of the parameters. Record review of Resident #1's physician orders for insulin indicated she had insulin orders starting 10/4/23 which included diabetic parameters to notify the physician for blood sugar readings of less than 60 or greater than 400. Record review of the Ad Hoc QAPI meeting sign in sheet dated 10/4/23 indicated a QAPI meeting had been conducted regarding the above failure. Interviews with licensed nurses (LVN D, LVN E, RN F, LVN G, LVN H, and LVN J) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews the nurses were able to name signs and symptoms of hyper and hypo-glycemia, blood sugar parameters and when to notify the physician, all types of abuse, what to do in the event of witnessed of reported abuse, and documentation of clinical findings and physician notification. Interviews with CNAs (CNA K, CNA L, CNA M, CNA N, and CNA P) on 10/6/23 between 9:17 a.m. and 10:35 a.m. were performed. During these interviews CNAs were able to identify changes in condition, when to report a change in condition, who to report a change in condition to, all types of abuse and what to do in the event of witnessed or reported abuse. On 10/6/23 at 10:39 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 18 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 2 of 4 (Resident #2 and Resident #3) residents reviewed for quality of care. 1. The facility failed to ensure Resident #2's tube feeding formula was labeled clearly with the correct formula. 2. The facility failed to ensure Resident #2's tube feeding water flush was labeled with the date and time it was started. 3. The facility failed to ensure Resident #3's tube feeding formula was labeled with the time and date it was started. These failures could place residents receiving tube feedings at risk of gastrointestinal disturbances (relating to the stomach and the intestines), and bacterial infection. Findings included: 1. Record review of the face sheet dated 10/6/23 indicated Resident #2 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), diabetes, hypertension (elevated blood pressure), and kidney failure. Record review of the MDS assessment dated [DATE] indicated Resident #2 was rarely/never understood by others and rarely/never understood others. The MDS indicated Resident #2 required extensive assistance with bed mobility, eating, dressing, toileting, and personal hygiene. The MDS indicated Resident #2 required tube feeding. Record review of the care plan last revised 9/27/23 indicated Resident #2 required a feeding tube related to difficulty swallowing. Record review of the physician orders dated 10/6/23 indicated Resident #2 had an order for enteral feed (tube feeding) every shift Jevity 1.5 @ 50 ml/hr starting 10/4/23 and every shift water flushes concurrently with feeding at 50ml/hr starting 10/4/23. During an observation on 10/4/23 at 12:55 p.m. Resident #2's flush water was not dated. Resident #2's feeding in bag was labeled with a handwritten label that read Glucerna [discontinued] Jevity 1.5 10/4/23 at 5:45 a.m. During interview and observation on 10/4/23 at 1:05 p.m. LVN R observed Resident #2's tube feeding with surveyor. LVN R said Resident #2 should be on Glucerna formula for feeding. LVN R said with the feeding formula being poured into a bag and the label reading Glucerna [discontinued] Jevity 1.5, it could not have been determined what formula was actually in the bag. LVN R said a new label should have been made if the resident was not on Glucerna and on Jevity instead. LVN R said the water flush bag should have been dated. LVN R said without the water flush bag being dated one could not determine when it was last changed. LVN R said not changing the bag routinely could have led to bacteria (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 19 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 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 0693 growth inside the bag that could enter the resident's body during the flush period of his feedings. Level of Harm - Minimal harm or potential for actual harm 2. Record review of the face sheet dated 10/6/23 indicated Resident #3 admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (stroke), hypertension, and seizures. Residents Affected - Few Record review of the care plan dated 10/6/23 indicated Resident #3 required tube feeding. Record review of the physician orders dated 10/6/23 indicated Resident #3 an order for enteral feed every shift Jevity 1.5 at 50 ml/hr. During an observation on 10/4/23 at 12:25 pm Resident #3's bottle of Jevity 1.5. was not dated or timed. During an interview on 10/6/23 at 10:35 a.m. LVN J said feeding tube formula, piston syringes, and water flushes should have been dated daily. LVN J said if the feeding tube formula, piston syringe, and water flushes were not dated you could not confirm when they were first used and bacteria growth could occur and enter the resident's body. LVN J said the labels and dates on formula should be clear. LVN J said if a label on formula read Glucerna [discontinued] Jevity 1.5, there would not be a way to determine which formula a resident was receiving. During an interview on 10/6/23 at 2:59 p.m. LVN C she worked the night of 10/3/23-10/4/23. LVN C said she was orientating a new nurse at the facility. LVN C said the nurse she was orientating was the one who hung the feeding tube formula and flushes that night. LVN C said the new nurse did not have computer credentials and they had to use her credentials to sign off tasks performed and medications given. LVN C said she did not go back to check the nurse had correctly labeled and dated feeding tube formulas, flushes, and piston syringes. During an interview on 10/6/23 at 3:17 p.m. the DON said feeding tube tubing and formula should be changed every 48 hours. The DON said feeding tube water flushes and piston syringes should have been changed every 24 hours. The DON said feeding tube formula, water flushes, and syringes should be dated with the date they were hung/changed. The DON said a feeding tube formula bag should be labeled with what type of formula was being used, the rate the formula was running at, and the date and time it was hung. The DON said if a label read Glucerna [discontinued] Jevity 1.5, it could not be determined what type of formula was in the bag. The DON said it was important to date the formula, water flush, and syringe for infection control and to ensure the formula did not spoil. The DON said the resident should be administered the formula prescribed by the physician. During an interview on 10/6/23 at 3:35 p.m. the Administrator said he was not confident in answering questions regarding feeding tubes. Record review of the facility's Enteral Nutrition policy revised 1/25/22 indicated, .Enteral feedings are typically indicated for the resident who cannot eat normally because of dysphagia [difficulty swallowing], oral or esophageal obstruction, or injury .A resident who is fed by nasogastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasopharyngeal ulcers .The nurse checks the orders for the enteral feeding, enteral flush frequency orders for pre and post meds and free water orders for enteral nutrition/hydration .If an open delivery system is used, administration sets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 20 of 21 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701 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 0693 Level of Harm - Minimal harm or potential for actual harm shall be changed every 24 hours or per manufacture's direction. If a closed delivery system is used, the administration set shall be changed every 24-36 hours dependent on the hang times .The irrigation syringe shall be changed every 24 hours and is labeled with the resident's name and date . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 21 of 21