Health inspection·August 13, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few police department. The ADM said Resident #1 was transported to the ER for evaluation and treatment and later returned to the facility. During an interview and observation on 8/12/25 at 3:30 p.m., Resident #1 was observed in his room, lying in bed. He appeared clean and well-groomed with no offensive odors detected. His left eye was closed, and he showed no fear interacting with staff or other residents. Resident #1 said on the night of the resident-to-resident altercation he woke up to use the bathroom. Resident #1 said he was sitting on the side of his bed using a hand-held urinal when Resident #2 told him to quit shaking my dick at him. Resident #1 said he told Resident #2 to stop staring at him, finished using the urinal, and laid back down in bed. Resident #1 said Resident #2 came over to his bed and started hitting him in the face and head with an electrical cord, which he believed was from the television in the room. Resident #1 said he tried to get up from bed but fell onto the floor. Resident #1 said Resident #2 picked up the television and threw it on top of him. Resident #1 said Resident #2 removed the metal footrest from Resident #1's wheelchair and began hitting him in the legs with it. Resident #1 said Resident #2 then pulled a drawer out of the bedside table and hit him in the left side of his face/head with it. Resident #1 said he was unable to get up or defend himself and yelled for help. Resident #1 said he still has pain in his left eye and can not see out of it well. Resident #1 said he had to have surgery, and it would be a few weeks before he could see well.Record review of a witness statement dated 7/17/25 by CNA Q indicated .On July 16, 2025, around midnight I just finished rounds.I heard the ice machine drop ice then another boom then 3 more [NAME].When I got about halfway down c hall, about where the wooden phone booth is, [Resident #2] met me in the hall coming out of his room and said, He attacked me. I asked who attacked him and he said his roommate.I continued to their room where I saw [Resident #1] lying face down in the floor.he was still in his gown with a brief on and bleeding.I kneeled beside [Resident #1] and asked him if he was okay and he said No, he beat me. I started yelling for [LVN L]. [Resident #1]'s nightstand drawer was pulled out and busted up, the chest of drawers pulled out and busted up on the floor.The TV cord was laying across the back of [Resident #1]'s thighs.During an interview on 8/13/25 at 1:15 p.m., LVN L said she worked 7/16/25 and was assigned to Resident #1's hallway. She said she was working at the nurse's station when she was called to the secured men's unit. She said she entered the secured unit and saw Resident #2 walking in the hallway and directed him to go sit in the dining room away from other residents. LVN L said she went into Resident #1's room and noted him lying face down with blood on his head and a pool of blood under him. LVN L said she completed an assessment noting facial lacerations, swelling and bleeding to his left cheek and eye, and redness to his legs and abdomen. LVN L said 911 was called and resident was transported to the ER. LVN L said local police were also notified. LVN L said local police came to the facility and investigated which resulted in Resident #2 being placed under arrest for aggravated assault and transported to the ER for clearance to be transported to the county justice center.Record review of a progress note dated 7/16/25 at 2:14 a.m. by the LVN L, indicated she was called to Resident #1's room and noted him lying in front of his roommate's bed, face down. LVN L noted a large amount of blood on the floor and on his head. LVN L noted resident was slow to respond to verbal stimuli but responsive to physical stimuli. Resident #1 was noted with swelling to his left eye and left side of his head, skin tears to both arms, redness noted to upper legs and abdomen. EMS was called to transport Resident #1 to the ER for evaluation and treatment. Record review of an arrest report dated 7/16/25 at 12:09 a.m. indicated an officer was dispatched to the nursing facility in reference to an assault. The arrest report indicated the following .[Officer] began examining the room where the assault had occurred.There appeared to be a large puddle of blood next to the bed where [Resident #2] sleeps. There were also 3 broken wooden (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 2 of 7 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 08/13/2025 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 drawers from the furniture inside the room and a broken TV that was across the room from it's original location.There was blood spatter on the drawers next to the bathroom door, as well as on the floor with a blood belt buckle.Based on the evidence I observed on scene, I determined [Resident #2] was the aggressor the assault. I placed [NAME] under arrest for Aggravated Assault Causes Serious Bodily Injury. Record review of an ER admission record form dated 7/16/25 indicated Resident #1 was admitted to the ER with the chief complaint of assault victim and primary findings of rupture of globe of left eye following blunt trauma. A physical exam in the ER revealed resident had multiple small facial and scalp lacerations, significant swelling around his left eye. Imaging revealed Resident #1 had a nasal fracture, a hematoma (abnormal collection of blood) to his left cheek, and additional findings of ruptured globe of left eye which required surgical intervention. Resident #1 said his pain was well controlled with his current pain medications. Record review of an after-visit summary dated 7/17/25 from a local emergency room indicated Resident #1 was diagnosed with blunt head trauma, rupture of globe of eye, nasal bone fracture, and scalp laceration. He was discharged back to the facility. Record review of a progress note on 7/17/25 at 5:59 p.m. by LVN K indicated Resident #1 was readmitted to the facility. A head-to-toe assessment was conducted and noted Resident #1's left eye swollen shut, covered by an eye patch. Resident #1 had skin tears to his forehead, right eyebrow, and on both ears. Resident #1 had 4 staples on the left side of his head near the front of his hairline, swollen nose, swollen left cheek, swollen bottom lip with a purple bruise, and scratches to both shins. Resident #1 complained of pain at 9 on a 0-10 numerical scale. New orders were received for pain medication three times daily as needed. During an interview on 8/13/25 at 2:45 p.m., the DON said changes were made to the facilities staffing which included adding a second staff member to the secured men's and women's units. The DON said the facility is utilizing a hospitality aid who functions as a sitter and monitor. The DON said the hospitality aid's job duties include monitoring residents so the CNA can enter resident rooms and provide care without the resident's being unsupervised. The DON said administration review the schedule every weekday with Friday encompassing the weekend shift reviews. The DON said there was a monitoring log which is to be signed daily by the administrative staff who reviewed staffing. The DON said an on-call rotation was established to cover for callouts. The DON said additional corrective actions included staff education on resident-to-resident altercations, staffing requirements, de-escalation techniques and managing aggressive behaviors, weekly random abuse/neglect interviews with staff and residents. The DON said all residents on the men's secure unit were given safe surveys and skin assessments were conducted on residents who could not respond to interview questions to identify potential abuse. The DON said residents with similar behaviors were also reviewed to ensure they were properly placed and there was no risk to resident safety. The DON said an ad hoc QAPI meeting was held to discuss further changes or corrective action if needed. Record review of a facility policy titled Resident-to-Resident Altercations revised in December 2016 indicated .Facility staff will monitor residents for aggressiveness/inappropriate behavior towards other residents. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. It was determined these failures placed residents in an IJ situation on 7/16/25 to 7/18/25. The facility corrected the noncompliance on 7/18/25 by the following: Review of minutes from an ad hoc QAPI meeting held on 7/16/25 indicated the following actions had been taken: Residents were already separated. Nurse assessed both residents and ambulance contacted due to extent of non-aggressors injuries.Skin assessments and Safe Surveys to be completed on Male Secure Unit.Notifications to RP, MD, NP, Mental Health NP, Ombudsman, and [NAME] County Judges office completed.[Local] Police Department notified and entered facility resulting in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 3 of 7 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 08/13/2025 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 [Resident #2] being arrested. ([Resident #2] will not be returning.Care Plan reviewed and updated.In-services planned: AN&E, Managing residents with Behaviors, and de-escalation tactics, Supervision.Review of in-service titled Secure Unit Staffing Plan conducted on 7/17/25 was attended by all staff and indicated Both male and female secure unit will be staff with two staff members and the charge nurse/designee will cover staff member on the unit breaks.Review of in-service titled Abuse and Neglect, Res to Res Altercation, De-escalation, COC (Reporting) conducted on 7/17/25 was attended by all staff.Skin assessments were completed on all residents residing on men's secure hall who were unable to be interviewed. Review of monitoring document dated 7/19/25 - 8/12/25 titled 5 staff members to be interviewed over abuse policy and education provided indicated ongoing staff interviews were being conducted weekly. Review of monitoring document dated 7/24/25 - 8/12/25 titled Staffing Reviews indicated ongoing staff reviews were being conducted daily. Review of monitoring document dated 7/18/25 - 8/12/25 titled 5 staff members to be interviewed over abuse policy and education provided indicated ongoing staff interviews were being conducted. Record review of a psychiatric visit summary dated 7/18/25 indicated Resident #1's was evaluated by psychiatric services following the resident-to-resident altercation. Record review of document Identification of residents with prior incidents. Review with MD and psych provider. Indicated residents residing on secured men's halls with similar behaviors were reviewed for placement on 7/18/25. Record review of facility staffing assignment sheets revealed two staff members were assigned to both men's and women's secured units. Observations at various times throughout the investigation revealed two staff members were always on both men's and women's secured units. During staff interviews on multiple shifts at various times and of varying disciplines throughout the investigation indicated all Staff interviewed 5 LVNs (LVN B, LVN J, LVN K, LVN L, LVN O), 4 CNAs (CNA C, CNA E, CNA H, CNA M), 1 Sitter (Sitter D), 1 LCSW, 1 ADON, 1 DA, 1 DON. said they received in-service training following Resident #1's resident-to-resident altercation which included resident-to-resident altercations, managing aggressive resident behaviors, and protecting residents from harm. All staff said they were trained in resident-to-resident altercations and dealing with aggressive resident behaviors. All staff said they were trained to separate residents and to use de-escalation techniques including physical and verbal redirection. All staff verbalized to report any instances of abuse to the facility administrator who is the abuse coordinator. All staff members interviewed said the secure units were to be staffed with two staff members at all times and staff must be relieved before going on break or leaving the unit. Event ID: Facility ID: 675408 If continuation sheet Page 4 of 7 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 08/13/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 8 residents (Resident #3) reviewed for accidents.The facility failed to keep Resident #3 in a safe environment to prevent an elopement on 7/27/2025 when he followed visitors out of the facility.An Immediate Jeopardy (IJ) situation was determined to have begun on 07/27/2025 and ended on 08/01/2025. It was determined to be past non-compliance due to the facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury and accidentsFindings included: Review of an undated admission record for Resident #3 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive cognitive decline) and schizoaffective disorder, bipolar type (combines schizophrenia and bipolar features). Review of a quarterly MDS dated [DATE] indicated he had a BIMS of 0 which indicated severe cognitive impairment. He required total assistance with toileting and personal hygiene; he required substantial assistance with showering/bathing; he required moderate assist putting on/taking off footwear, and with upper and lower body dressing; he required setup or cleanup assistance eating and with oral hygiene. Review of the comprehensive care plan dated 9/4/25 indicated Resident #3 was at risk for elopement related to diagnoses of Alzheimer's disease, dementia (cognitive decline), and schizoaffective disorder. Appropriate interventions were in place including wearing a Wander Guard bracelet (device that alarms if wearer was close to the facility exit doors), checking placement and function every shift, and quarterly or as needed elopement assessments to be completed.During an interview on 8/12/25 at 9:05 a.m., the DON said Resident #3 followed visitors out of the facility on 7/27/25. The DON said Resident #3 had a wander guard bracelet in place at the time of the elopement, but the alarm did not activate. The DON said when a resident had interventions to wear a wander guard the nursing staff checked the device every shift for placement and functionality and signed the wander guard logbook to indicate the checks were completed. The DON said she was not sure why the wander guard alarm system did not activate, but repairs were made to the system. The DON said the maintenance man had begun checking all alarms and door locks daily in addition to continuing the scheduled weekly maintenance checks. During an interview on 8/12/25 at 9:10 a.m., the ADM said at the time of the elopement on 7/27/25, Resident #3 was being housed on Hall A and was wearing a wander guard bracelet. The ADM said the wander guard alarm system was tested daily by the nursing staff when a resident was wearing one in the facility, and the door locks and alarms were checked weekly by the maintenance man. The ADM said he was unsure why the wander guard alarm did not activate. The ADM said he had service technicians come to the facility on 7/31/25 and make repairs to the alarm system. The ADM said Resident #3 was moved onto the secure men's unit following the elopement.Review of a witness statement dated 7/28/25 at 1:21 p.m., indicated at approximately 6:20 p.m. a woman visiting the facility rang the doorbell and asked LVN A if the man in the parking lot was a resident. LVN A said she immediately went outside and located Resident #3 walking by the dumpsters. LVN A said she led Resident #3 back inside the building. Review of a witness statement dated 7/30/25 by a visitor indicated on 7/27/25 she and several other visitors exited the facility through the front door. She said Resident #3 was near the nurse's station when they were walking up the hall to the lobby. She said after they exited the facility another visitor noted Resident #3 in the parking lot and went back inside the facility to alert facility staff. Review of an Elopement Event Report dated 7/31/25 at 2:16 p.m., completed by the DON indicated Resident #3 eloped from the facility on 7/27/25 at approximately 6:31 p.m. and was located in the front parking area. The report (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 5 of 7 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 08/13/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few indicated there had been no recent changes in mental status, no recent traumatic events, new diagnosis, new stressors, or medication changes prior to the elopement. The report indicated Resident #3 was assessed for secure unit placement and moved to the men's secure unit.During an observation and interview on 8/12/25 at 10:52 a.m., Resident #3 was in sitting in the dining room of the men's secured unit. He appeared clean and well-groomed with no offensive odors; he had no visible skin tears, marks, or bruising. Resident #3 said he went outside the facility but could not provide any detail as to when, why or how. During an interview on 8/12/25 at 10:30 a.m., LVN B said Resident #3 was the only resident in the facility care planned for a wander guard. LVN B said nurses were responsible for checking the placement and function of wander guards every shift and signing the wander guard book to indicate checks were completed. LVN B said she was not aware of any problems with the wander guard alarm system prior to the elopement on 7/27/25. During an interview on 8/13/25 at 10:45 a.m., the maintenance man said prior to the elopement he was responsible for checking the door locks and all alarm systems weekly. He said he had not identified any problems with the alarm system or door locks prior to the elopement. He said following the elopement a service technician came to the facility and completed repairs. He said he verified all door locks and alarms were functioning following the repairs. He said following the elopement he was now responsible for completing daily checks of door locks and alarms in addition to the scheduled weekly checks. He said he was logging these checks on paper but was now logging the checks in the facility electronic maintenance system.Review of logbook report dated 8/12/25for Task Name: Doors, Locks, Gates & Alarms: Test operation of doors and locks for the last 6 months indicated all weekly checks had been completed and no problems were identified.Review of wander guard logbook from 3/1/2025 to 7/27/25 indicated all daily wander guard alarm tests were completed with no problems identified.Review of facility policy revised on 9/1/23 titled Wandering and Elopements indicated .The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.Review of facility policy revised in December of 2021 titled Emergency Procedure - Missing Resident indicated .Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. It was determined these failures placed residents in an IJ situation on 7/27/25 to 8/1/25.The facility corrected the noncompliance on 8/1/25 by the following: An observation on 8/12/25 at 9:00 a.m., revealed a sign hung on the facility exit door at eye level which stated .Visitors and staff please be cautious of our residents who may be in the foyer or following you to the front entrance/exit door. Notify staff to redirect residents away from the door if needed.During an observation on 8/13/25 from 11:00 a.m. - 11:45 a.m., the maintenance man checked all door magnetic locks and alarms; the locks functioned properly, and alarms were audible. The maintenance man checked wander guard alarm system by holding a wander guard bracelet and walking toward the facility exit; the alarm system sounded audibly. Review of a resident headcount conducted on 7/27/25 indicated all 49 residents in-house were accounted for. Review of Facility Observation Summary Report dated 7/28/25 indicated all residents in the facility received updated elopement assessments. Review of minutes from an all-staff meeting on 7/30/25 indicated all staff received education on exiting doors (be sure that residents were not following them through exit or secure unit doors), Code Pink (staff response to a missing resident), Wandering and Elopement, and Caring for Residents Exhibiting Behavior.Review of an invoice dated 7/30/25 from a service call indicated Roam Alert front door alarm system and two push-bars were repaired/replaced.Review of Code Pink Drill for missing resident dated 7/30/25 indicated a drill took place at 3:30 p.m.Review of Code Pink Drill for missing resident dated 7/30/25 a drill took place at 6:44 p.m. Review of an in-service dated 8/1/25 titled Exit Doors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675408 If continuation sheet Page 6 of 7 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 08/13/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete instructed staff to make sure exit doors were closed when exiting the facility and do not block exit doors.Review of document titled Door Alarms Records indicated daily checks were performed on all door locks and alarms from 8/5/25 to 8/9/25.Review of electronic logbook report indicated daily checks were performed on all door locks and alarms on 8/11/25 and 8/12/25.Interviews with staff of various disciplines and shifts were conducted during the investigation and were all able to verbalize signs of exit seeking behavior and appropriate interventions. All staff were able to verbalize appropriate action to take in the event of a missing resident. Staff interviews included 5 LVNs (LVN B, LVN J, LVN K, LVN L, LVN O), 4 CNAs (CNA C, CNA E, CNA H, CNA M), 1 Sitter (Sitter D), 1 LCSW, 1 ADON, 1 DA, 1 DON. Event ID: Facility ID: 675408 If continuation sheet Page 7 of 7