Health inspection·January 26, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of physician orders reflected an order of Code Status: Full Code with starting date of [DATE] with no end date. Record review of the nursing progress note dated [DATE] written by RN A indicated that RN A found Resident #1 unresponsive at approximately 9:00 PM on [DATE]. The progress note indicated RN A assessed Resident #1 and he was without pulse or respirations. The progress note indicated RN A called the facility ADM, DON, and ADON but did not initiate CPR or call 911. The progress note indicated RN A called NP at 9:29 and was directed to call 911 due to resident Full Code status. The progress note indicated Emergency Services arrived at 9:50 PM and initiated CPR at 9:52 PM. The progress note indicated Justice of the Peace arrived at 10:20 PM and CPR was stopped at 10:27 PM and Resident #1 was pronounced deceased . During a telephone interview on [DATE] at 12:30 PM, RN A said on [DATE] she discovered Resident #1 lying in his bed and he did not respond to her voice. RN A said she assessed Resident #1, and he had no palpable pulse, no respirations, pupils were fixed, dilated, and nonreactive to light, and resident's lips and fingertips were cold to the touch. RN A said she did not start CPR because Resident #1 was already deceased . RN A said she called the facility ADM, ADON, and DON for guidance on funeral home notification but only the ADON responded, and she did not know the policy. RN A said she called NP for further guidance and NP directed her to call 911 due to Resident #1 Full Code status. RN A said the 911 operator asked her to start CPR on Resident #1, but she declined to do so because he was already gone. RN A said she was familiar with Resident #1's code status because she was responsible for updating the resident code status book nightly at midnight. RN A said she had never received any training from the facility regarding Emergency Procedures or CPR. Record Review of an in-service education form dated [DATE] included topics Code Status Guidelines and Advanced Directives and Code Blue reflected RN A was in attendance. Record review of a National CPR Foundation Provider Card indicated RN A was certified in Standard CPR / AED issued [DATE] and expiring [DATE] . During an interview on [DATE] at 1:00 PM the ADON said she remembered Resident #1 expiring. The ADON said RN A called her that night and told her Resident #1 was deceased and asked what Justice of the Peace and funeral home to notify. The ADON said if there was no preference in Resident #1's chart she was unsure and would call her back. The ADON said she assumed RN A had initiated CPR for Resident #1 due to his Full Code status and did not ask for clarification. During a telephone interview on [DATE] at 2:30 PM, NP said she first learned that Resident #1 was deceased on the morning of [DATE] when she received a message left with her answering service. She said RN A never called her on the night of [DATE] and she did not give RN A any directions or guidance. She said CPR should have been initiated immediately on a nonresponsive resident who is a full code. During an interview on [DATE] at 3:00 PM the ADM said he remembered Resident #1 expiring. The ADM said he was not at the facility but was given report regarding Resident #1's death. The ADM said he had been informed CPR was not initiated on Resident #1. The ADM said staff are expected to follow facility policy and initiate CPR for any resident who is Full Code. He said an RN may pronounce death if there are obvious signs of irreversible death . (e.g., rigor mortis, decomposition, decapitation) The ADM said the facility had begun disciplinary action with RN A for failing to follow policy when she self-terminated her employment at the facility. He said all staff receive education in Abuse, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 2 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0600 Neglect, and Exploitation on hire and the facility has frequent in-services to reinforce training. Level of Harm - Immediate jeopardy to resident health or safety During a telephone interview on [DATE] at 4:00 PM . CNA B said she worked the overnight shift on [DATE]. CNA A said she checked on Resident #1 at approximately 8:00 PM and assisted him to the restroom and he did not appear to be in distress. She said RN A was Resident #1's nurse that night. Residents Affected - Few Record review of the facility's Abuse, Neglect, and Exploitation policy last revised [DATE] indicated: .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents . Record review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation policy last revised February 2018 indicated: .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . The Administrator was notified that an Immediate Jeopardy situation was identified due to the above failure and provided with the Immediate Jeopardy template on [DATE] at 5:22 PM. A Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] 8:23 AM and included: Plan of Removal: 600: Free from Abuse & Neglect Ensure staff performed CPR for Resident #1 until emergency services arrived. Utilize the AED when Resident #1 was found unresponsive. Immediately call 911 when the resident was found unresponsive waited approximately 29 minutes until calling emergency services. 1. Immediate Actions Taken for Those Residents Identified: What immediate/direct action was taken for the staff involved? Action: Charge Nurse no longer works for [facility] as of [DATE]. Nurse self-termed themself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 3 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Action: Resident #1 was noted as unresponsive, CPR initiated by emergency services, Resident #1 was pronounced as deceased . Person(s) Responsible: Charge Nurse Date: [DATE] Residents Affected - Few 2. How the Facility Identified Other Possibly Affected Residents:? Action: Completed a DNR and Full Code audit:? Reviewed Physician orders, vs the face sheet, vs the care plan, vs the Out of Hospital DNR (if applicable) to ensure all are matching and correct. ? Person(s) Responsible: Regional Nurse Consultant, Director of Nursing, and/or Designee ? Date: [DATE] 8AM Action: Audit staff CPR cards to ensure proper number of certified employees present each shift. ? Person(s) Responsible: Human Resources, Administrator, and/or Designee ? Date: [DATE]? 10AM 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred:? Action: Ensured the crash cart has an updated list of full code and DNR residents. ? Person(s) Responsible: Administrator and/or Designee ? Date: [DATE] 10PM Action: ?EducationAll Nurses educated regarding Emergency Management Code Procedure Policy to include the following, in which would be the response in an emergency situation for a full code resident requiring CPR: 1. If an individual is found unresponsive, the nurse to first arrive to the resident will briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: The first responding nurse will- Instruct a staff member to activate the emergency response system (code) and call 911. The first responding nurse will- Instruct a staff member to retrieve the automatic external defibrillator. The first responding nurse will- Verify or instruct a staff member to verify the DNR or code status of the individual. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 4 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0600 Initiate the basic life support (BLS) sequence of events. Level of Harm - Immediate jeopardy to resident health or safety 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). Residents Affected - Few 3. Chest compressions: Following initial assessment, begin CPR with chest compressions. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; Allow full chest recoil after each compression; and Minimize interruptions in chest compressions. 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide 2 breaths via ambu bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. All above-mentioned staff will be educated prior to working their next shift. ? Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, &/or Designee Date: [DATE] 10AM Action: All direct care staff educated over the abuse and neglect policy. All above-mentioned staff will be educated prior to working their next shift. ? Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, &/or Designee Date: [DATE] 10AM 4. How the Corrective Actions Will be Monitored, by whom and for how long:? Action: 1 mock code drill to be performed once a shift, for each Charge Nurse shift, to ensure proper reaction and that staff are following protocols educated on above. Charge Nurses work 12-hour shifts. Person(s) Responsible: Administrator, Director of Nurses, and/or Designee Date: [DATE] 10AM QAPIAction: Ad hoc QAPI performed with Medical Director to review the IJ Template and the facility's plan to lower the immediacy. ? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 5 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0600 Person(s) Responsible: Administrator ? Level of Harm - Immediate jeopardy to resident health or safety Date: [DATE]? 10PM On [DATE] at 12:50 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Residents Affected - Few Record review of a random selection of staff CPR certifications indicated 8 of 8 staff reviewed had a current and appropriate CPR certification, sample included 3 RN, 2 LVN, 3 CNA. Record review of a random selection of resident charts indicated 15 of 15 residents reviewed had code status that matched on the face sheet and orders and had DNR's on file for residents who had chosen to be a DNR. Record review of AED/Crash Cart checklist sheet for the month of [DATE] indicated the crash cart had been checked daily. Record review of AED Competency Check Lists, DDU-100 Life Line Semi-Automatic External Defibrillator Post Tests. Record review of mock Code Blue drill sheet dated [DATE] including both overnight and day shift staff. Review of Ad Hoc QAPI meeting minutes. Attendees: ADM, DON, Medical Director, topics discussed included IJ templates and Plan of Removal. Review of In-service Education Form titled Abuse, Neglect, and Misappropriation (Other Occurrences That Are Reportable to HHSC/DADS) dated [DATE] 14 staff members of varying departments attended including nursing, human resources, and housekeeping. Observed mock code blue drill performed on [DATE] at 12:30 PM. During an interview on [DATE] at 9:20 AM, the DON said nurses and direct care certified in CPR had been in-serviced on CPR and AED use, she had run mock code blue (unresponsive resident) drills with both overnight and day shift staff, and they had a QAPI (Quality Assurance and Performance Improvement) meeting where the topics of emergency procedures and CPR were discussed. She said all staff has received additional in-service training in Abuse, Neglect, and Misappropriation. During an interview on [DATE] at 9:25 AM. the Administrator said the facility had audited all resident code statuses and verified all were correct in code status binder, audited crash cart check-off, audited direct care staff CPR cards, conducted training with nurses and direct care staff regarding emergency procedures, AED, CPR, and Abuse and Neglect training. He said the facility also ran mock code blue drills with both overnight and day shift staff. He said not all staff had been trained due to being unavailable but those who have not been would not be allowed to work until completing training. He said he held an ad hoc QAPI meeting with ADON and Medical Director to review IJ templates and discuss plan of removal. Staff interviewed on [DATE] between 10:30 AM and 12:30 PM (CNA B, CNA C, LVN D, CNA E, CNA F, RN G, CNA H, LVN J, CNA K, LVN L) were able to name where to find the code status for a resident. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 6 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete interviewed said they should call for help and initiate CPR immediately for an unresponsive resident who is Full Code and not breathing normally. CPR certified staff were able to verbalize correct usage for AED. Staff interviewed were able to define neglect and who to report witnessed incidents to. ADM was notified of IJ removal on [DATE] at 12:50 PM. While the IJ was removed on [DATE] , the facility remained out of compliance at no actual harm with potential for more than minimal 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. Event ID: Facility ID: 675408 If continuation sheet Page 7 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 (Resident #1) residents reviewed for CPR. The facility failed to ensure staff performed CPR on [DATE] for Resident #1 who was identified as a full code . CPR was not initiated prior to emergency services arrival. The facility failed to ensure staff utilized the AED on [DATE] when Resident #1 was found unresponsive. The facility failed to follow their policy and procedure for Emergency Procedure - Cardiopulmonary Resuscitation. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:50 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal 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 place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings include: 1. Record review of an undated facesheet indicated Resident #1 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (movement disorder of the nervous system that worsens over time), hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated). Record review of MDS dated [DATE] indicated Resident #1 was rarely understood by others and rarely understood others. The MDS indicated Resident #1 BIMS was not conducted due to resident being rarely/never understood. The MDS did not indicate Resident #1 had a DNR advanced directive in place. Record review of the care plan last revised [DATE] indicated Resident #1's code as .[resident] is a Full Code. He wishes to be resuscitated if he should stop breathing. Record review of the physician orders reflected order of Code Status: Full Code with starting date of [DATE] with no end date. Record review of the nursing progress note dated [DATE] written by RN A indicated that RN A found Resident #1 unresponsive at approximately 9:00 PM on [DATE] . The progress note indicated RN A assessed Resident #1 and he was without pulse or respirations. The progress note indicated RN A called the facility ADM, DON, and ADON but did not initiate CPR or call 911. The progress note indicated RN A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 8 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few called the facility NP at 9:29 and was directed to call 911 due to resident Full Code status. The progress note indicated Emergency Services arrived at 9:50 PM and initiated CPR at 9:52 PM. The progress note indicated Justice of the Peace arrived at 10:20 PM and CPR was stopped at 10:27 PM and Resident #1 was pronounced deceased . During a telephone interview on [DATE] at 12:30 PM, RN A said on [DATE] she discovered Resident #1 lying in his bed and he did not respond to her voice. RN A said she assessed Resident #1, and he had no palpable pulse, no respirations, pupils were fixed, dilated, and nonreactive to light, and resident's lips and fingertips were cold to the touch. RN A said she did not start CPR because Resident #1 was already deceased . RN A said she called the facility ADM, ADON, and DON for guidance on funeral home notification but only the ADON responded, and she did not know the policy. RN A said she called NP for further guidance and NP directed her to call 911 due to Resident #1 Full Code status. RN A said the 911 operator asked her to start CPR on Resident #1, but she declined to do so because he was already gone. RN A said she was familiar with Resident #1's code status because she was responsible for updating the resident code status book nightly at midnight. RN A said she had never received any training from the facility regarding Emergency Procedures or CPR. Record Review of an in-service education form dated [DATE] included topics Code Status Guidelines and Advanced Directives and Code Blue reflected RN A was in attendance. Record review of a National CPR Foundation Provider Card indicated RN A was certified in Standard CPR / AED issued [DATE] and expiring [DATE]. During an interview on [DATE] at 1:00 PM the ADON said she remembered Resident #1 expiring. The ADON said RN A called her that night and told her Resident #1 was deceased and asked what Justice of the Peace and funeral home to notify. The ADON said she assumed RN A had initiated CPR for Resident #1 due to his Full Code status and did not clarify. During a telephone interview on [DATE] at 2:30 PM, She said RN A never called her on the night of [DATE] and she did not give RN A any directions or guidance. The NP said CPR should have been initiated immediately on a nonresponsive resident who is full code. During an interview on [DATE] at 3:00 PM the ADM said he remembered Resident #1 expiring. The ADM said he was not at the facility but was given report regarding Resident #1's death. The ADM said he had been informed CPR was not initiated on Resident #1. The ADM said staff are expected to follow facility policy and initiate CPR for any resident who is Full Code unless there are obvious signs of irreversible death. During a telephone interview on [DATE] at 4:00 PM. CNA B said she worked the overnight shift on [DATE]. CNA A said she checked on Resident #1 at approximately 8:00 PM and assisted him to the restroom and he did not appear to be in distress. She said RN A was Resident #1's nurse that night. Record review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation policy last revised February 2018 indicated: .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 9 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0678 Level of Harm - Immediate jeopardy to resident health or safety It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . Residents Affected - Few The Administrator was notified that an Immediate Jeopardy situation was identified due to the above failure and provided with the Immediate Jeopardy template on [DATE] at 5:22 PM. A Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] 8:23 AM and included: Plan of Removal: 678: Cardio-Pulmonary Resuscitation (CPR)? The facility failed to: Ensure staff performed CPR for Resident #1 until emergency services arrived. Utilize the AED when Resident #1 was found unresponsive. Immediately call 911 when the resident was found unresponsive - waited approximately 29 minutes until calling emergency services. Follow their policy and procedures to immediately initiate CPR. 1. Immediate Actions Taken for Those Residents Identified:? What immediate/direct action was taken for the staff involved? Action: Charge Nurse no longer works for [facility] as of [DATE]. Nurse self-termed themself. Action: Resident #1 was noted as unresponsive, CPR initiated by emergency services, Resident #1 was pronounced as deceased . Person(s) Responsible: Charge Nurse Date: [DATE] 2. How the Facility Identified Other Possibly Affected Residents:? Action: Completed a DNR and Full Code audit:? Reviewed Physician orders, vs the face sheet, vs the care plan, vs the Out of Hospital DNR (if applicable) to ensure all are matching and correct. ? Person(s) Responsible: Regional Nurse Consultant, Director of Nursing, and/or Designee ? Date: [DATE] 8AM Action: Audit staff CPR cards to ensure proper number of certified employees present each shift. ? Person(s) Responsible: Human Resources, Administrator, and/or Designee ? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 10 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0678 Date: [DATE]? 10AM Level of Harm - Immediate jeopardy to resident health or safety 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred:? Action: Ensured the crash cart has an updated list of full code and DNR residents. ? Residents Affected - Few Person(s) Responsible: Administrator and/or Designee ? Date: [DATE] 10PM Action: ?EducationAll Nurses educated regarding Emergency Management Code Procedure Policy to include the following, in which would be the response in an emergency situation for a full code resident requiring CPR: 1. If an individual is found unresponsive, the nurse to first arrive to the resident will briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: The first responding nurse will- Instruct a staff member to activate the emergency response system (code) and call 911. The first responding nurse will- Instruct a staff member to retrieve the automatic external defibrillator. The first responding nurse will- Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: Following initial assessment, begin CPR with chest compressions. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; Allow full chest recoil after each compression; and Minimize interruptions in chest compressions. 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide 2 breaths via ambu bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. All above-mentioned staff will be educated prior to working their next shift. ? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 11 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0678 Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, &/or Designee Level of Harm - Immediate jeopardy to resident health or safety Date: [DATE] 10AM Residents Affected - Few Action: 1 mock code drill to be performed once a shift, for each Charge Nurse shift, to ensure proper reaction and that staff are following protocols educated on above. Charge Nurses work 12-hour shifts. 4. How the Corrective Actions Will be Monitored, by whom and for how long:? - Person(s) Responsible: Administrator, Director of Nurses, and/or Designee Date: [DATE] 10AM QAPIAction: Ad hoc QAPI performed with Medical Director to review the IJ Template and the facility's plan to lower the immediacy. ? Person(s) Responsible: Administrator ? Date: [DATE] 10PM On [DATE] at 12:50 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random selection of staff CPR certifications indicated 8 of 8 staff reviewed had a current and appropriate CPR certification, sample included 3 RN, 2 LVN, 3 CNA. Record review of a random selection of resident charts indicated 15 of 15 residents reviewed had code status that matched on the face sheet and orders and had DNR's on file for residents who had chosen to be a DNR. Record review of AED/Crash Cart checklist sheet for the month of [DATE]. Record review of AED Competency Check Lists, DDU-100 Life Line Semi-Automatic External Defibrillator Post Tests. Record review of mock Code Blue drill sheet dated [DATE] including both overnight and day shift staff. Review of Ad Hoc QAPI meeting minutes. Attendees: ADM, DON, Medical Director, topics discussed included IJ templates and Plan of Removal. Review of In-service Education Form titled Abuse, Neglect, and Misappropriation (Other Occurrences That Are Reportable to HHSC/DADS dated [DATE] Observed mock code blue drill performed on [DATE] at 12:30 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 12 of 13 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 675408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Overton 1110 Hwy 135 S Overton, TX 75684 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Staff interviewed on [DATE] between 10:30 AM and 12:30 PM (CNA B, CNA C, LVN D, CNA E, CNA F, RN G, CNA H, LVN J, CNA K, LVN L) were able to name where to find the code status for a resident. Staff interviewed said they should call for help and initiate CPR immediately for an unresponsive resident who is Full Code and not breathing normally. CPR certified staff were able to verbalize correct usage for AED. Staff interviewed were able to define neglect and who to report witnessed incidents to. During an interview on [DATE] at 9:20 AM, the DON said nurses and direct care certified in CPR had been in-serviced on CPR and AED use, she had run mock code blue (unresponsive resident) drills with both overnight and day shift staff, and they had a QAPI (Quality Assurance and Performance Improvement) meeting where the topics of emergency procedures and CPR were discussed. During an interview on [DATE] at 9:25 AM. the Administrator said the facility had audited all resident code statuses and verified all were correct in code status binder, audited crash cart check-off, audited direct care staff CPR cards, conducted training with nurses and direct care staff regarding emergency procedures, AED, CPR, and Abuse and Neglect training. He said the facility also ran mock code blue drills with both overnight and day shift staff. He said not all staff had been trained due to being unavailable but those who have not been would not be allowed to work until completing training. He said he held an ad hoc QAPI meeting with ADON and Medical Director to review IJ templates and discuss plan of removal. ADM was notified of IJ removal on [DATE] at 12:50 PM. While the IJ was removed on [DATE] , the facility remained out of compliance at no actual harm with potential for more than minimal 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 13 of 13