Inspection·September 25, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 9/4/25 indicated Resident #1's right leg amputation site had a 100% epithelial ((a wound in final stages of healing) with serosanguineous (a thin, watery discharge that is a mixture of pale yellow, clear liquid and blood) drainage. The progress not indicated Resident #1 had an order to cleanse the surgical site with wound cleanser, apply xeroform, and cover with dry dressing 3 times a week and as needed. Record review of a picture dated 9/4/25 indicated Resident #1's surgical amputation site was well approximated with minor bruising. Record review of the Wound Care NP's progress note dated 9/11/25 indicated Resident #1's right leg amputation site had a 100% epithelial ((a wound in final stages of healing) with serosanguineous (a thin, watery discharge that is a mixture of pale yellow, clear liquid and blood) drainage. The progress not indicated Resident #1 had an order to cleanse the surgical site with wound cleanser, apply xeroform, and cover with dry dressing every other day and as needed. Record review of a picture dated 9/11/25 indicated Resident #1's surgical wound site was well approximated with redness up the leg from the site to the knee. Record review of the Wound Care NP's progress note dated 9/18/25 indicated Resident #1's right leg amputation site had a 100% epithelial ((a wound in final stages of healing) with serosanguineous (a thin, watery discharge that is a mixture of pale yellow, clear liquid and blood) drainage. The progress not indicated Resident #1 had an order to cleanse the surgical site with wound cleanser, apply xeroform, and cover with dry dressing every other day and as needed. Record review of a picture dated 9/18/25 indicated Resident #1's surgical wound site was well approximated with eschar (thick, black, adherent crust of dead tissue) in several different areas near the surgical incision. Record review of the Vascular Surgery NP's progress note dated 9/19/25 indicated Resident #1 had an order for Clindamycin (Cleocin) 300mg three times a day for 10 days with diagnosis of right below the knee amputation. During an interview on 9/23/25 at 12:35 p.m. the DON said she did not know why wound care on Resident #1 was not performed or documented. The DON said the wound care was being done and just because it was not documented, or the orders were not put in does not mean it was not being performed. The DON said the importance of ensuring wound care was performed as ordered was patient care. The DON said she was unsure whether not following the wound care orders would have contributed to Resident #1's wound deterioration due to his other comorbidities including being a smoker, diabetes, hypertension, and peripheral vascular disease. The DON said the negative effect of not performing the ordered wound care or starting the antibiotic on Resident #1 would be the infection to his wound growing. During an interview attempt on 9/23/25 at 2:13 p.m. in the hospital Resident #1 was sleeping. During an interview on 9/23/25 at 2:15 p.m. the Hospital Nurse said Resident #1 was admitted for a non-healing surgical wound following a below the knee amputation and infection to the surgical wound. The Hospital Nurse said Resident #1 was given the option to have a surgical revision performed on his BKA to remove the infection to his wound or to have an AKA performed. The Hospital Nurse said Resident #1 had chosen to move forward with and AKA and it was scheduled for 9/24/25. The Hospital Nurse said per the hospital physician's progress note Resident #1 reported he had been seen by the wound care doctor on 9/18/25 at the facility and was told his wound looked good. The Hospital Nurse said per the hospital physician's progress note Resident #1 said he had a follow-up with his surgeon on 9/19/25 and was informed his wound did not look good and was infected. During an interview attempt on 9/24/25 at 10:28 a.m. the surveyor left a message with office staff for the Vascular Surgery NP with no return phone call received. During an interview on 9/24/25 at 11:00 a.m. LVN A said she had performed wound care on Resident #1 (unknown date). LVN A said the wound care she had performed was wrapping the surgical site with a bandage. LVN A said wrapping the surgical site with a bandage was the only order for wound care for Resident #1. 2. Record review of the face sheet dated 9/24/25 indicated Resident #2 was an [AGE] year-old (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675320 If continuation sheet Page 2 of 9 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 675320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bradburn 520 Bradburn Rd Grand Saline, TX 75140 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 - Some female re-admitted to the facility on [DATE] with diagnoses including fracture of the upper and lower end of the right fibula (thin outer bone of the lower leg that runs from the knee to the ankle), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), osteoarthritis, hypertension, and diabetes. Record review of the MDS dated [DATE] indicated Resident #2 understood others and was understood by other. The MDS indicated Resident #2 had a BIMS score of 09 and was moderately cognitively impaired. The MDS indicated Resident #2 did not have any ulcers, wounds, or skin problems. Record review of the care plan last revised 7/15/25 indicated Resident #2 was at risk for impaired skin integrity. Record review of the physician orders which include active, completed, and discontinued order dated 9/24/25 indicated Resident #2 had an order to cleanse wound with wound cleanse, apply xeroform, and cover with dry dressing ordered 9/20/25 and with an unknown discontinue date. The physician orders indicated Resident #2 had an order to cleanse the right later low leg wound (wound #1) with wound cleanser, apply xeroform, and cover with a dry dressing starting 9/25/25. The physician orders indicated Resident #2 had an order to clean the right lower leg wound (wound #2) with wound cleanser, apply medical honey and calcium alginate, and cover with a dry dressing starting 9/25/25. The physician orders indicated Resident #2 had an order for Doxycycline (an antibiotic used to treat infections) 100mg twice a day for 10 days for wound infection. Record review of the Wound Care NP's progress note dated 9/11/25 indicated Resident #2 had a closed surgical wound to her right lower leg with 40% granulation (pink or red tissue that forms in the [NAME] stages of wound healing) and 60% scab. The Wound Care NP's progress note indicated Resident #2 had an order to cleanse the surgical wound with wound cleanser, apply xeroform, and cover with border dressing daily and as needed. Record review of the Wound Care NP's progress note dated 9/18/25 indicated Resident #2 had two surgical wounds to the right lower leg. The progress note indicated the wound to the right lateral lower leg (wound #1) had 80% granulation and 20% slough (non-viable, dead tissue)/ The progress note indicated Resident #2 had an order for wound #1 to cleanse the surgical wound with wound cleanser, apply xeroform, and cover with border dressing daily and as needed. The progress note indicated the wound to the right lower leg (wound #2) had 20% granulation, 40% slough, and 40% scab. The progress note indicated Resident #2 had an order for wound #2 to cleanse surgical wound with cleanser, apply medical honey and calcium alginate, and cover with a dry bordered dressing daily and as needed. During an interview on 9/24/25 at 9:45 am the DON said she did not know why Resident #2's wound care orders for 9/11/25 were not implemented until 9/20/25 or why Resident #2's wound orders for 9/18/25 were not implemented. The DON said the importance of ensuring wound care orders were implemented was patient care. The DON said the antibiotic order for Resident #2's wound was requested by the facility for prophylaxis due to her wound being open and fear of the wound becoming infected. The DON said she had not been able to access the wound care provider's progress notes until last week. The DON said she had emailed the wound care provider on 9/4/25 regarding not being able to access the progress notes and the wound care provider was supposed to have the issue resolved. The DON said the issue was not resolved until last week. During an interview on 9/24/25 at 11:30 a.m. Resident #2 said her surgical wound was doing well and healing nicely. Resident #2 said the facility had reached out to the community consultant regarding her wounds. Resident #2 said the community consultant had ordered her an antibiotic due to part of the wound not healing like the other part. Resident #2 said her surgical wound was not infected. During an interview on 9/24/25 at 12:13 p.m. the Wound Care NP said she was not aware her wound care orders on Resident #1 were not being followed. The Wound Care NP said she had seen him 3 times in the facility. The Wound Care NP said on the initial visit she gave orders to cleanse the wound with wound cleanser, apply Xeroform, and cover with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675320 If continuation sheet Page 3 of 9 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 675320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bradburn 520 Bradburn Rd Grand Saline, TX 75140 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 - Some rolled gauze. The Wound Care NP said on her 2 subsequent visits Resident #1 did have Xeroform in place. The Wound Care NP said when she rounded with the nurses she gave her treatment plan verbally at bedside, had a conference with the DON prior to leaving, and sent her progress notes to the facility. The Wound Care NP said she was aware of the facility not being able to access her progress notes electronically and had sent them over manually. The Wound Care NP said due to Resident #1 vascular issues not receiving proper wound care would not have contributed to the deterioration of his wound. The Wound Care NP said it was possible that not receiving proper wound care led to Resident #1's surgical wound infection. The Wound Care NP said she was not aware her wound care orders on Resident #2 had not been followed or implemented until 9/20/25. The Wound Care NP said Resident #2's wound care orders could have led to the deterioration of her wounds. The Wound Care NP said she did not order an antibiotic for Resident #2, but the primary care team may have. The Wound Care NP said she could not determine whether Resident #2's wound was infected but that there was redness surrounding the wound with minimal serous (thin, watery pale yellow, clear liquid) drainage. The Wound Care NP said she expected the facility to follow the orders she gave for wound care. The Wound Care NP the goal of wound care was to reduce the chances of infection, prevent deterioration of wounds, and to heal wounds. During an interview on 9/24/25 at 1:04 p.m. the NP said she had ordered an antibiotic for Resident #2 due to wound infection. The NP said the facility had sent her a picture of Resident #2's wound and due to the redness and slough the wound appeared infected leading her to ordering an antibiotic. The NP said not implementing the proper wound care as ordered by the Wound Care NP possibly led to the infection in Resident #2's wound. Record review of the facility's Wound Care policy revised October 2010 indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure.The following information should be recorded in the resident's medical record: 1. The date wound care was given, 2, The initials of the individual performing the wound care. 3. Any change in the resident's condition. The Administrator was notified on 9/24/25 at 2:37 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/24/25 at 2:46 p.m. The facility's Plan of Removal was accepted on 9/25/25 at 9:13 a.m. and included: Plan of RemovalAction: Director of Nursing and Assistant Director of Nursing have been educated by the Regional Nurse Consultant on: 1. Notification of MD and resident responsible party of Change of condition, specifically notification of any new or deteriorated wounds.2. Transcribing physician ordersPerson(s) Responsible: Regional Nurse ConsultantDate/Time: 09/24/25Action: Licensed Nurses have been educated by the Director of Nursing on: 1. Notification of MD and resident responsible party of Change of condition, specifically notification of any new or deteriorated wounds.2. Transcribing physician ordersLicensed nurses and newly hired licensed nurses will be educated prior to working their next scheduled shift. Person(s) Responsible: Director of NursingDate/Time: 09/24/25 Action: DON/ADON will review all current wounds during Standards of Care meeting and ensure:a. Wound assessments are completed weekly.b. Care plans are completed and updated with new interventions.c. Orders from Wound practitioners are transcribed correctly.d. MD is notified of any new or deteriorating wounds.e. Wound log is updated. Person(s) Responsible: Director of NursingDate/Time: 09/24/25 On 9/25/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of 6 of 9 residents currently receiving wound care confirmed all wound care orders were entered in each residents' physician orders and on each resident, TARs as ordered by the wound care provider as of 9/25/25. Record review of the facility's wound log dated 9/25/25 indicated all wound orders and wound assessments were up to date. During an observation on 9/25/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675320 If continuation sheet Page 4 of 9 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 675320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bradburn 520 Bradburn Rd Grand Saline, TX 75140 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete at 9:15 am Observed LVN A perform wound care on Resident #2. LVN A provided privacy before starting and explained procedure to Resident #2. LVN A performed appropriate hand hygiene and glove changes during the wound care. LVN A performed wound care per the most current orders from the Wound Care NP using aseptic technique. There was no concern with the wound care performed. Record review of in-services dated 9/23/25 indicated 4 LVNs had been in-serviced regarding weekly skin and wound assessments, notifying the physician or NP regarding wound deterioration, ensuring all residents with wounds had orders in place, and ensuring all treatment orders showed up on each resident's TAR. Staff interviewed (LVN A, LVN B, and LVN C) on 9/25/25 between 9:10 a.m. and 10:03 a.m. said they had been in-serviced regarding the importance of weekly skin and wound assessments, ensuring all wounds had a treatment order in the EMR and that the treatment order was on the resident's TAR, obtaining treatment orders for new residents or residents with new wounds, and reporting changes in condition including wound deterioration. During an interview on 9/25/25 at 10:09 a.m. the DON and ADON said they would be monitoring the residents' plan of care to ensure any new orders including wound care orders were entered. The DON and ADON said they would be reviewing wound care orders against the Wound Care NP's progress notes to ensure accuracy. The DON and ADON said they would be checking the EMR to ensure all residents had weekly skin assessments performed. On 9/25/25 at 10:18 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as patterned and a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 675320 If continuation sheet Page 5 of 9 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 675320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bradburn 520 Bradburn Rd Grand Saline, TX 75140 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 9 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure Resident #1's antibiotic (Cleocin) was started on 9/19/25 when ordered from the Vascular Surgery NP instead waiting 2 days until 9/21/25 to initiate the antibiotic. The facility failed to ensure the nurses had access to the Pyxis (a machine used to safely and efficiently dispense medications) to obtain available medication such as antibiotics while waiting for pharmacy to deliver medications. The facility failed to ensure Resident #1's antibiotic was initial dosed when delivered from the pharmacy on 9/20/25 instead initiating the antibiotic on 9/21/25 and Resident #1 required hospitalization due to infection on 9/22/25. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:20 p.m. on 9/24/25. While the IJ was removed on 9/25/25, the facility remained out of compliance with a scope identified as isolated and a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents with an order for an antibiotic at risk for spread of infection leading to hospitalization, need for intravenous antibiotics, or sepsis (a life-threatening complication of infection). Findings Include:1. Record review of the face sheet dated 9/23/25 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including orthopedic aftercare following surgical amputation (surgical procedure where a body part, such as a limb, finger, or toe is removed), right below the knee amputation, diabetes, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and hypertension (elevated blood pressure). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 15 and was cognitively intact. The MDS indicated Resident #1 had a surgical wound. Record review of the care plan initiated on 9/16/25 indicated Resident #1 had a recent right below the knee amputation and was at risk for phantom pain (a painful perception an individual experiences relating to a limb or organ that is not physically part of their body), increase in disturbed self-image, increase in depression, and increase in need for assistance with ADLs. The care plan indicated Resident #1 had interventions in place including wound care/dressing changed to be performed to the stump/amputation area per physician orders. Record review of the physician orders which include active, completed, and discontinued order dated 9/23/25 indicated Resident #1 had an order for Cleocin ((Clindamycin) an antibiotic to treat infection) 150mg 2 capsules 3 times a day related to acquired absence of right leg below the knee. Record review of the MAR dated September 2025 indicated Resident #1 did not receive his Cleocin 300mg on 9/20/25 at 8:00 a.m. or 12:00 p.m. due to medication not being available. The MAR indicated Resident #1 received his Cleocin 300mg on 9/20/25 at 4:00 p.m. The MAR indicated Resident #1 did not received his Cleocin 300mg on 9/21/25 at 8:00 a.m. or 12:00 p.m. due to medication not being available. The MAR indicated Resident #1 received his Cleocin 300mg on 9/21/25 at 4:00 p.m. Record review of the Pyxis Inventory Sheet dated 5/5/25 indicated the Pyxis had Clindamycin 150mg capsules with 20 capsules available for dispensing. Record review of the Pharmacy Packing slip dated 9/19/25 and signed by unknown facility staff on 9/20/25 indicated Resident #1's Clindamycin 150mg capsules had been delivered to the facility. Record review of the Nursing Progress Note dated 9/19/25 at 4:08 p.m. written by LVN A indicated, [Resident #1] returned from the doctor's office with new orders. Cleocin 300mg by mouth three times a day for 10 days. Record review of the Administration Progress Note (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675320 If continuation sheet Page 6 of 9 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 675320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bradburn 520 Bradburn Rd Grand Saline, TX 75140 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 - Immediate jeopardy to resident health or safety Residents Affected - Few dated 9/20/25 at 7:07 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/20/25 at 11:38 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/21/25 at 7:25 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/21/25 at 11:48 a.m. written by MA D indicated the facility was waiting on Resident #1's Cleocin 150mg to be delivered from the pharmacy. Record review of the Administration Progress Note dated 9/21/25 at 2:15 p.m. written by LVN indicated Resident #1's Cleocin was initial dosed per orders. During an interview on 9/23/25 at 12:35 p.m. the DON said she could not say why Resident #1's Clindamycin was not started for 2 days when it was available in the Pyxis. The DON said the importance of ensuring antibiotics and other medications were started timely especially when available in the Pyxis was patient care. The DON said the negative effect of not performing the ordered wound care or starting the antibiotic on Resident #1 would be the infection to his wound growing. During an interview attempt in the hospital on 9/23/25 at 2:13 p.m. Resident #1 was sleeping. During an interview on 9/23/25 at 2:15 p.m. the Hospital Nurse said Resident #1 was admitted for a non-healing surgical wound following a BKA and infection to the surgical wound. The Hospital Nurse said he was unsure whether wound cultures had been collected but that blood cultures had been collected and were still pending. The Hospital Nurse said Resident #1 was given the option to have a surgical revision performed on his BKA to remove the infection to his wound or to have an AKA performed. The Hospital Nurse said Resident #1 had chosen to move forward with and AKA and it was scheduled for 9/24/25. The Hospital Nurse said Resident #1 was receiving Zosyn (an antibiotic to treat infections) via IV for the infection to his surgical wound. The Hospital Nurse said to his understanding Resident #1's surgeon had order antibiotics for the wound infection and the facility had not administered the antibiotics. During an interview on 9/24/25 at 8:25 a.m. the Regional Nurse said they had checked the Pyxis reports, and it indicated Clindamycin had not been removed from the Pyxis for Resident #1 on 9/19/25, 9/20/25, or 9/21/25. During an interview on 9/24/25 at 10:08 a.m. MA D said she had worked 6:00 a.m.-10:00 p.m. on 9/20/25 and 9/21/25. MA D said Resident #1's Clindamycin did not arrive at the facility until 9/21/25. MA D said there had been some kind of issue with medication being placed in the correct resident cubbies. MA D said neither of the nurses working the weekend had access to the Pyxis. MA D said Resident #1 did not receive his antibiotic on 9/20/25 and only received the evening dose on 9/21/25 when she found the medication in his cubby. MA D said Resident #1's Clindamycin was not previously in his cubby when she looked for it. MA D said the facility's EMR system will not allow them to go correct an error in marking a medication as given that was not given. MA D said she had accidentally marked that Resident #1's evening dose of Clindamycin was given on 9/20/25, but it had not been. During an interview attempt on 9/24/25 at 10:28 a.m. the surveyor left a message with office staff for the Vascular Surgery NP with no return phone call received. During an interview on 9/24/25 at 11:00 a.m. LVN A said Resident #1's Clindamycin was started on 9/21/25 for his evening dose. LVN A said on 9/21/25 during her shift 6:00 a.m-6:00 p.m. the medication had not come in from the pharmacy and she did not have access to the Pyxis. LVN A said she was new to the facility and management was aware she did not have access to the Pyxis. LVN A said Resident #1's Clindamycin had actually been delivered on 9/20/25 but was not put on the medication cart. LVN A said she found the medication after he had missed his morning and noon doses in his cubby. LVN A said the importance of ensuring antibiotics were started in a timely manner was to prevent the worsening of an infection. Record review of the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675320 If continuation sheet Page 7 of 9 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 675320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bradburn 520 Bradburn Rd Grand Saline, TX 75140 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Administering Medication policy revised April 2019 indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame. The Administrator was notified on 9/24/25 at 2:37 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/24/25 at 2:46 p.m. The facility's Plan of Removal was accepted on 9/24/25 at 8:01 p.m. and included: Action: The Director of Nursing immediately set up access for all licensed nurses to access the Pyxis systemPerson(s) Responsible: Director of NursingDate/Time: 09/24/25 Action: Director of Nursing and Assistant Director of Nursing have been educated by the Regional Nurse Consultant on: 1. New employee (licensed nurses) set up and access to the Pyxis on hire prior to start of first shift. 2. Transcribing new medication orders to PCC when received3. Licensed nurse nurses will check Pyxis system upon receipt of orders and determine if medication is available for initial dose. 4. Administration of initial dose of antibiotic medications timely by the licensed nurse5. Obtaining medications from Pyxis when medication is not available in the medication cart6. If medications are not stocked in the Pyxis the nurse will notify the pharmacy via telephone and request a STAT delivery and get an ETA for delivery. The nurse will notify the Director of Nursing and the physician if antibiotic medications are not available within 2 hours for follow up orders.Person(s) Responsible: Regional Nurse ConsultantDate/Time: 09/24/25Action: Licensed Nurses have been educated by the Director of Nursing on: 1. Transcribing new medication orders to PCC when received2. Licensed nurse nurses will check Pyxis system upon receipt of orders and determine if medication is available for initial dose. 3. Administration of initial dose of antibiotic medications timely by the licensed nurse4. Obtaining medications from Pyxis when medication is not available in the medication cart5. If medications are not stocked in the Pyxis the nurse will notify the pharmacy via telephone and request a STAT delivery and get an ETA for delivery. The nurse will notify the Director of Nursing and the physician if antibiotic medications are not available within 2 hours for follow-up ordersLicensed nurses/MAs and newly hired licensed nurses/MAs will be educated prior to working their next scheduled shiftPerson(s) Responsible: Regional Nurse Consultant, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate/Time: 09/24/25 Action: The Director of Nursing, Assistant Director of Nursing will review all new orders and MARS daily during morning clinical meeting to ensure all new medication orders have been transcribed, ordered and initial doses administered in a timely manner. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date/Time: 09/24/25 On 9/25/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the audit for 5 of 9 residents with a new antibiotic order in the past 90 days indicated all residents received their initial dose of medication within 24 hours of receiving the order. Record review of an in-service dated 9/23/25 indicated 5 staff members had been in-serviced regarding accessing the Pyxis to obtain medications newly ordered, ensuring all antibiotic orders were entered into the electronic medical records, ensuring all new medications including antibiotics were initial dosed by a licensed nurse, and ensuring medications are ordered STAT if they do not come in from the pharmacy. Staff interviewed (LVN A, LVN B, LVN C, and MA D) on 9/25/25 between 9:10 a.m. and 10:03 a.m. said they had in-serviced regarding new medication orders. They said for a new medication order the nurse was to obtain the medication from the Pyxis if available, order the medication from the pharmacy and if it did not come in to call the pharmacy and make the medication a stat order, and initial dose all new medications. All nurses interviewed said they had access to the Pyxis. During an interview on 9/25/25 at 10:09 a.m. the DON said all nurses now had access to the Pyxis. The DON said any newly hired nurses would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675320 If continuation sheet Page 8 of 9 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 675320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bradburn 520 Bradburn Rd Grand Saline, TX 75140 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 - Immediate jeopardy to resident health or safety immediately receive access to the Pyxis. The DON said she and the ADON would be checking for new medication orders daily and ensure the orders if available in the Pyxis had been initial dosed and if not available in the Pyxis had been ordered stat from the pharmacy. On 9/25/25 at 10:18 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as isolated with a severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675320 If continuation sheet Page 9 of 9