Health inspection·October 19, 2023

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 10/18/23 at 1:43 PM revealed Resident #11's lying in bed and was receiving oxygen via nasal cannula. Observed oxygen concentrator next to his bed and oxygen concentrator was set between 3 and 4L. Resident #11 denied any distress at this time. Interview on 10/18/23 at 1:43 PM with LVN A revealed she had been employed for a week. She stated was the nurse assigned to Resident #11. She stated she could not recall if Resident #11 was on continues oxygen. She stated she does check Resident #11 O2 in the morning. She stated she could not recall how many liters Resident #11 oxygen should be set on. She stated for the week she had been employed she had not adjusted Resident #11 oxygen concentrator. LVN A and Surveyor reviewed Resident #11 physician orders and LVN A stated resident had an order for two liters. LVN A stated the nurses were responsible for setting the oxygen rate on the concentrators. She stated if the resident was receiving more than what was ordered the risk to the resident could be respiratory issues. Interview and observation on 10/18/23 at 2:23 PM, ADON revealed Resident #11's had an order for oxygen to be set at 2 liters. Observed ADON enter Resident #11's room and stated resident's oxygen concentrator was set to 3.5 liters, and she turned it to 2 liters. She stated the resident should be on 2 liters, not 3.5 liters. The ADON asked Resident #11 if he had adjusted the oxygen concentrator and resident stated he had not touched it. The ADON stated the nurses were responsible to ensure residents who were receiving oxygen therapy were receiving the correct amount. She stated her expectations were for her nurses to follow physician orders . She stated it was her responsibility and the DON to ensure staff are following physician orders. She stated risk of not following physician orders could cause nose bleeds. Interview on 10/19/23 at 11:13 AM, the DON revealed her expectation was for her nurses to know and to check the oxygen concentrator to ensure the correct amount was being administered. She stated she was notified by the ADON that Resident #11 was not receiving the correct amount of oxygen. The DON stated she held her nurses accountable for doing their job correctly. She stated the risk of not providing the correct amount of oxygen was that it could cause brain damage or respiratory distress. Record review of the facility's Oxygen Administration policy, dated September 2017, reflected the following: .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 2 of 8 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 675374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Irving 619 N Britain Rd Irving, TX 75061 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 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was not five percent (5%) or greater for one staff (LVN A) which resulted in a 14.29% medication error rate after 28 opportunities with 4 errors for one of four residents (Resident #22) reviewed for medications. Residents Affected - Few 1. The facility failed to ensure LVN A administered all the crushed medication in the medication cups without leaving residue for Resident #22. 2. LVN A failed to follow the physician orders for flushing Resident #22's gastrostomy tube with 5-10 mL of water between medication when she administered medication. These failures could put residents at risk for not receiving the correct dose of medication and getting intended therapy. Findings included: Review of Resident #22's Quarterly MDS assessment dated [DATE], revealed the resident was a [AGE] year-old female, admitted to the facility on [DATE]. Resident #22 had diagnoses which included adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol) and nontraumatic subdural hemorrhage is a kind of intracranial hemorrhage, which is the bleeding in the area between the brain and the skull). Resident #22 had a BIMS status score of 99 indicating cognition was severely impaired. Review of Resident #22's October 2023 MAR revealed physician orders to administer medications via gtube (a tube inserted through the wall of the abdomen directly into the stomach). Flush tube with 5-10mL of water between medication administration. Review of Resident #22's August physician orders revealed the following medications were prescribed: - Multivitamin with Minerals (supplements), - Loratadine 10mgs (used to treat allergies), - Memantine 10mgs (used to treat memory loss which is one of the main symptoms of dementia), - Zinc 50mgs (use help immune system and metabolism functions), - Baclofen 10 mg (muscle relaxant), - Miralax 17 gm (laxative that provides relief from occasional constipation), - Senna 8.6 mg (laxative), and - Calcium carbonate -vitamin d3m 600-10mcg (400 unit) (used to prevent or treat low blood calcium levels in people who do not get enough calcium from their diets.) to be crushed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 3 of 8 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 675374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Irving 619 N Britain Rd Irving, TX 75061 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 0759 Observation on 10/18/23 beginning at 8:55 AM revealed LVN A crushed the following medications to administer to Resident #22 via g-tube in separate medication cups: Level of Harm - Minimal harm or potential for actual harm - Baclofen 10 mg, Residents Affected - Few - Multi-Vitamin with minerals 1 tablet, - MiraLAX 17 gm, -Zinc 50mgs, -Memantine 10mgs, -Loratadine 10mgs, - Senna 8.6 mg, and - Calcium with Vitamin D (calcium carbonate-vitamin d3) 600-10mcg (400 unit). LVN A was observed mixing medications with 5 ml water in each cup with crushed medication. She administered each of these eight medications via g-tube flushing the g-tube between each medication administration with 30 ml of water. Four cups were noted to have medication residue remaining in the cups. Interview with LVN A on 10/18/23 at 9:35 AM revealed she was aware for good results she was supposed to stir the medication well and administer the whole dose to the resident, but she did not do that. She stated she tried as much as she could to administer the whole dose, but residuals were left in the cups. She stated she was supposed to give all the contents in the cup for Resident #22 to get the full dose of those medications. She stated failure to administer the full doses to Resident #22 would lead to Resident #22 not getting the therapy needed. She stated she had been trained on g-tube medication administration. LVN A stated she was flushing with 30 mL between each medication because she did not check the orders, but she was aware she was supposed to check orders with each medication administration. She stated failure to check the orders for the flushes can lead to fluid overload on Residnet#22. LVN A stated she was having difficulties going through the MARs/TARs since she was new nurse, but she stated she had been trained on how to navigate. Interview with the DON on 10/18/23 at 10:07 AM revealed her expectation was that nurses should try to give as much as possible of all the content in the medication cups. The DON also stated LVN A was supposed to follow the physician orders on flushes between the medications because failure could cause fluid overrode on Resident #22. She stated she had done training on medication administration through g-tubes with all nurses. She stated failure to administer the full dose could lead to Resident #2 not getting the right therapy, and the medications would not be effective. Record review of facility's General Guidelines for Administering Medication through an Enteral Tube policy and procedure, revised August 2022, reflected the following: .23. Dilute the crushed or split medication with 15-30 mL water (or prescribed amount). If administering more than one medication, flush with 15 mL (or prescribed amount) water between (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 4 of 8 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 675374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Irving 619 N Britain Rd Irving, TX 75061 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 0759 medications. The policy did not address cups are rinsed to get all the medications Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 5 of 8 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 675374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Irving 619 N Britain Rd Irving, TX 75061 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 1 (Resident #7) of 12 residents and labeled in accordance with currently accepted professional principles for two (front hall medication cart and back hall medication cart) of two medication carts reviewed for labeling and storage. 1. Resident #7's had eye drops stored at the resident's nightstand and not locked in a lock box or secured in the medication cart or medication room. 2. The facility failed to ensure insulin vials were dated after they were opened. The failure could place residents at risk of unauthorized access to medications or receiving medications that were ineffective. Findings included: 1. Record review of Resident #7's face sheet revealed the resident was a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included vascular dementia (problems with reasoning, memory) and essential hypertension (high blood pressure) Record review of Resident #7's quarterly MDS dated [DATE] revealed BIMS was 0 indicating resident is rarely/never understood. It also revealed resident required assistance with 1 or more staff assistance for ADL care. Further review of the resident MDS indicated the resident's vision was impaired. Record review of Resident#7's care plan dated [DATE], revealed Resident is experiencing self-care deficits related to advance age and weakness and diagnosis. Resident #7 requires extensive assistance with ADLs. The care plan did not address self-administration of medications. Observation and interview on [DATE] at 10:45 AM revealed Resident #7 in his room sitting on his wheelchair. Observed Resident #7 to have Combigan (brimonidine tartrate/ timolol maleate ophthalmic solution 0.2%/0.5%) eye drops with an expiration date of 10/22 on his nightstand. Resident #7 stated he had always had his eye drops in his room. When asked further questions Resident #7 stopped responding to questions asked. Interview and observation on [DATE] at 1:48 PM with MA B revealed she was the medication aid for Resident #7. She stated she did not have any residents who can self-administered medications which included eye drops. MA B observed Resident #7's eye drop medications on the resident's nightstand . She stated she had already provided Resident #7 with his medications this morning and did not observe the eye drops on resident's nightstand. MA B stated she was not aware the resident had them. She stated resident did not have an order for this eye drops. MA B stated Resident #7's family had a history of providing the resident with medications without notifying the staff. She stated the risk of leaving medication unattended was that another resident might take the medications or the resident over medicating. 2. Observation on [DATE] at 1:15 PM of the front hall Medication Cart with LVN A revealed one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 6 of 8 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 675374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Irving 619 N Britain Rd Irving, TX 75061 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some insulin pen, Insulin basaglar (insulin glargine injection 100 units/mL) was opened, partially used, and not labeled with the open date. Interview on [DATE] at 1:20 PM with LVN A, who was the Charge Nurse for both front hall cart and back hall cart, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated, but she did not check that morning because the DON and ADON had checked the cart for the front hall, but she did not check the cart for back hall. LVN A revealed the risks of not putting the opening date was that a nurse would not know when the insulins expired, and the insulins might not be effective leading to residents having high blood sugar readings. She stated she was trained on labeling and dating medications, and it was all nurses' responsibility to check the carts to ensure medications and insulins were labeled and had an opening date before administering. Observation on [DATE] at 1:30 PM of the back hall Medication Cart with LVN A revealed four insulin pens, Insulin basaglar, insulin lispro, insulin Lantus and insulin Novolog opened, partially used, and not labeled with the open date. Interview on [DATE] at 1:40 PM with the ADON revealed it was her expectation that staff date the insulin pens once they pulled them from the refrigerator. She stated nurses are expected to check the carts every shift. The ADON stated she was responsible of monitoring the nurses every month. She stated she had checked the cart for front hall on [DATE] and had tasked LVN A to check the cart for back hall for open dates. She stated she had done training with LVN A on checking of the carts since she was a new nurse and the trainings were requested and not provided . She said if the staff were not putting the opening dates on the insulin pens and vials that required an open date it placed residents at risk of receiving expired medication and the medication being ineffective leading to high blood sugar levels. Interview on [DATE] at 11:04 AM with the DON revealed it was her expectation that staff date the insulin pens once they pulled them from the refrigerator. She stated if the staff were not putting the opening dates on the insulin pens and vials that required an open date it placed residents at risk of receiving expired medication, leading to high blood sugar levels. She stated it was the responsibility of the DON and ADON to monitor the carts for labeling once a week and charge nurses to check the cart Mondays and Fridays for labelling. She stated she has trained the nurses on putting the open dates on insulin after they were opened. The DON stated she did not have any residents who can self-administered medications which included eye drops. The DON stated MA B made her aware of the eye drops that were found in Resident #7 room. She stated the family had a history of bringing medications to the resident without notifying them. The DON stated they have notified and educated the family on not bringing medications to the resident. The DON stated the risk of leaving medications or eye drops in residents' rooms could cause residents to over medicate and it was unsafe. Review of the facility's Administering Medication policy, dated [DATE], reflected the following: Medications cannot be left at bedside, for resident to take later. If a resident refuses medication and/or wishes to take at later time. The individual administering the medications shall initial and circle the MAR space provided for that drug and dose. Review of the facility's Insulin Administration policy, dated [DATE], reflected: .4.check expiration date if drawing from an opened multi dose vial. If opening new vial, record expiration date, and time on the vial (follow the manufacturers recommendations for expiration after opening). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 7 of 8 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 675374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Irving 619 N Britain Rd Irving, TX 75061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for five of five residents reviewed for food and nutrition services. Residents Affected - Some The Dietary Manager failed to prepare and serve the pureed lunch meal on 10/19/23 in a manner to conserve nutrition, flavor, and palatability. The failure could place residents at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss. Findings included: Observation of the Dietary Manager making pureed lunches on 10/19/23 at 10:37 AM revealed the Dietary Manager put herbed chicken breast in the blender, added one tablespoon of chicken flavored base in the blender, one slice of white bread, and then he blended. The Dietary Manger then was observed to add three eight-ounce cups of water to the chicken and blended the mixture. The pureed herbed chicken breast appeared to have a mashed potato consistency. Interview and record review with the Dietary Manager on 10/19/23 at 11:40 AM revealed the facility had five residents, who required a pureed diet. He stated he reviewed the recipe prior to cooking the food to he had all the ingredients that were needed. Review of the recipe for the pureed herbed chicken breast revealed it did not indicate that water was supposed to be added. The Dietary Manager stated he misread the recipe. The Dietary Manger stated by adding water to the pureed food it may result in the residents not receiving all the nutrients. Observation on 10/19/23 at 12:10 PM revealed two residents in the dining area eating the puree lunch meal as prepared by the Dietary Manager with the added water. Review of the facility's recipe for Pureed Herbed Chicken Breast from the Dining RD 2023 Menu revealed the following: Ingredients: Herbed Chicken Breast, Bread, [NAME] sliced, *Water, *Base, Chicken Combine chicken base and water to make chicken broth. Place prepared chicken and bread in a washed and sanitized food processor. Gradually add broth and blend until smooth. Note: 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. Review of the facility's policy Portion Control policy, dated 10/01/18, revealed it did not address pureed meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675374 If continuation sheet Page 8 of 8