Health inspection·May 17, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident # 28's Care plan updated 12/28/2023 revealed that resident prefers to sleep in a brief and only covered with a sheet while in bed. Review of Resident's # 29 face sheet dated 5/16/2024 revealed a [AGE] year-old male, admitted [DATE] with diagnosis that include cutaneous abscess of the right lower limb ( a collection of pas that forms in the skin), unspecified dementia ( mild cognitive impairment that has not been diagnosed as a specific type ) and Benign prostatic hyperplasia ( an age associated prostate gland enlargement that can cause urination difficulty). Review of Resident's # 29 review of admission MDS dated [DATE] revealed a BIMS of 0 (Severe cognitive impairment) Review of Resident's # 29 review of care plan dated 3/22/2024 revealed no intervention regarding foley drainage bag covering. Observation of Resident # 28 at 5/14/2024 at 1:30 pm during a Hoyer lift transfer by CNA C and CNA D, resident's top and bra were removed, and she remained uncovered till placed in the bed. After transfer CNA C attempted to cover resident with a top sheet and resident responded, I have been naked this whole time, its kind of late don't you think?' Observation of Resident # 5 on 5/14/2024 at 11:00 am, ADON was performing wound care on the resident with the door to the room open and the privacy curtain not drawn. Resident #5's foley drainage bag was not covered with a privacy bag. Observation of Resident # 29 on 5/16/2024 at 07:30 am receiving wound care by LVN B, resident's foley catheter bag was uncovered and hanging on the side of the bed. Interview with CNA C 5/14/2024 at 1:45 pm stated that Resident # 28 does not sleep in any clothes and it did not occur to her that she might have wanted to be covered while in the Hoyer lift. Interview with CNA D on 5/14/2024 at 1:50 pm stated that the Resident # 28 was usually transfer with no top or bra on. Interview with Resident # 28 on 5/14/2024 at 2 pm stated that she was a little embarrassed because she was showing everything she had with observers in the room during the transfer. Interview ADON on 5/15/2024 at 11:30 am She stated that she was not aware the door to Resident # 5's room door was open, but that no one could have seen anything. When asked if the resident was at risk from someone observing her care, she said she didn't see how. She stated that the foley privacy bag was placed when up out of bed. Interview with Resident # 5 on 5/15/2024 at 1:00 pm she was not aware the door was open and would like it to be closed when they are doing care for her. Interview with LVN B on 5/17/2024 at 07:50 am she stated that the Resident # 29's foley privacy was attached to his wheelchair and is hard to remove each time they put him in bed. Interview with DON on 5/14/2024 at 4:30 pm she stated that her expectation was that all residents are treated with respect and dignity and should be asked the preference because they can change. She stated any care should be done with the resident's door closed and the privacy curtain pulled so if the roommate needs to come in the resident's privacy will be secured. She stated the Resident # 28 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 2 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was care planned to sleep with no shirt on, but a transfer was not the same. She stated not showing the resident respect and maintaining their dignity can lead to embarrassment, and possible depression. Foley drainage bags should have a privacy bag always covering them. Interview with ADM on 5/14/2024 at 5:00 pm he stated that his expectation is that this is the resident's home, and they should be respected and treated with dignity at all times. He stated doing a procedure with the door open and the curtain not pulled is no per policy and can put the resident at risk of embarrassment. Review of policy foley catheter revised October 2020 stated that Foley catheter drainage bag should be covered with a privacy bag at all times. Review of policy Resident Rights undated reveals You have the right: 4. To be treated with courtesy, consideration and respected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 3 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 5 (Rooms 28, 32, 34, 36, and 64) of 20 resident rooms reviewed for environment. The facility failed to ensure the ceiling tiles in rooms [ROOM NUMBERS] were free from stains and drooping on 05/14/24, 05/15/24, and 05/16/24. The facility failed to ensure the blinds in rooms 28, 32, 36, and 64 were free from missing slats on 05/14/24, 05/15/24, and 05/16/24. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment, lack of privacy, and diminished quality of life. Findings included: Observation of room [ROOM NUMBER] on 05/14/24 at 9:02 AM revealed slats missing from the blinds. During an observation and interview on 05/14/24 at 11:57 AM, room [ROOM NUMBER] revealed three ceiling tiles with stains and one of the tiles was drooping. LVN A stated when she saw a problem, she reported it to the maintenance man but if it was an emergency, she would call him. She stated there was a log book out in the main hall that could be used for work orders. She stated she told the maintenance man yesterday about the ceiling tiles and they were supposed to get fixed today. Observation of room [ROOM NUMBER] on 05/15/24 at 3:45 PM revealed slats missing from the blinds. Observation of room [ROOM NUMBER] on 05/16/24 at 10:31 AM revealed two ceiling tiles with large stains. Slats were missing from the blinds. Observation of room [ROOM NUMBER] on 05/16/24 at 10:32 AM revealed slats missing from the blinds. During an interview on 05/16/24 at 10:33 AM, the HSKP stated he had been working in his current position for a couple of months. He stated if he saw something broken or dirty, he would deal with the problem if it was part of his duties or report to the maintenance man. He stated there was a logbook, but most people use an app to report maintenance problems. By scanning a QR code, the staff would have access to the app, a program where they entered the date, time location, and the maintenance concern or problem. During an interview on 05/16/24 at 10:42 AM, the Maint. Dir. stated there was an app that allows anyone to enter data or work orders into the program. He stated he got a notification on his phone when the work order was placed. A regional person was also able to monitor the work orders. He stated the administrative staff were assigned a group of rooms and they were to check the rooms routinely and report the results in daily meetings. He stated things like missing slats on blinds were reported in the meetings. He stated it was full-time job keeping up with the blinds. During an interview on 05/16/24 at 4:17 PM, the ADM stated administrative staff complete environmental rounds daily. The electronic system to report work orders was monitored by the maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 4 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0584 director, a regional consultant and himself. He stated he expected repairs to be made in a timely manner. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/17/24 at 9:15 AM, the DON stated the administrative staff complete daily Angel rounds . She stated the angel rounds was the name given to the daily environmental and sanitary checks. She stated they were looking for blind slats, call lights, lights working, and a tidy room. She stated she fixed things as she could or would enter a work order into the electronic system. She stated residents should have a neat and clean environment. Residents Affected - Some Review of the policy Maintenance Service revised November 2021, reflected in part, 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2b. Maintaining the building in good repair and free from hazards. Review of Attachment F Resident Rights Under Federal Law, revised 02/22/22, reflected in part, 1. The resident has a right to a dignified existence, self-determination, communication with access to, persons and services inside and outside the Center. Review of Attachment G Resident's Rights under Texas Law, revised 02/22/24, reflected in part, You have a right: 2) to safe, decent and clean conditions; 6) to privacy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 5 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment of 4 (Residents # 5, Resident # 10, Resident # 24 and Resident # 58) of 24 reviewed for comprehensive care plans. 1.The facility failed to ensure Resident # 5's care plan dated 5/3/2024 was resident by behaviors, mood and medication documented brief and generic. 2.The facility failed to ensure Resident # 10's care plan dated 4/11/2024 reflected his pain and interventions to ensure resident had the best possible quality of life. 3.The facility failed to ensure Resident # 24's care plan dated 4/11/2024 was individualized to meet resident needs and preferences. 4.The facility failed to ensure Resident # 58's care plan dated was individualized to resident needs and preferences . These failures could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings included: Review of Resident # 5's face sheet dated 5/16/2024 revealed a [AGE] year-old-female admitted [DATE] with diagnosis that include Stroke (damage to the brain from interruption of its blood supply), Neurogenic bladder (a urinary tract condition that prevents the bladder from emptying properly due to neurological condition), and Hypertension (elevated blood pressure). Review of Resident # 5's annual MDS dated [DATE] revealed a BIMS score of 14 (indicating cognitively intact). Self -care assessment revealed that Resident is Dependent for activities of daily living and transfers. Skin condition assessment revealed an unstageable pressure wound. Review of Resident # 5's care plan dated 5/3/2024 shows generic focus areas with no personalized interventions. Review of Resident # 10 face sheet dated 5/16/2024 revealed a [AGE] year-old male, admitted on [DATE] with diagnosis that include Chronic Obstructive pulmonary disease (a group of lung disease that block airflow and [NAME] if difficult to breathe), Pain unspecified (Acute pain due to trauma) and Fibromyalgia ( a long-term condition that involves widespread body pain and tiredness). Review of Resident # 10 Quarterly MDS dated [DATE] revealed a BIMS score of 15 (cognitively intact). Review of Resident # 10 care plan revised 4/11/2024 revealed no goal or interventions for Pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 6 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident # 24 face sheet dated 5/17/2024 revealed a [AGE] year-old male admitted [DATE] with diagnosis that include Multiple sclerosis ( a disease in which the immune system eats away at the protective covering of nerves) unspecified intellectual disabilities ( a diagnosis given when standardized testing is not possible due to physical, mental health, behavioral or motor factors) and Cognitive communication deficit( a communication difficulty cause by a cognitive impairment that can affect verbal and nonverbal communication) . Review of Resident # 24's Quarterly MDS dated [DATE] revealed moderate difficulty with hearing and unclear speech and was usually understood (difficulty communicating some words or finishing thoughts but was able if prompted or given time), with a BIMS score of 8 (Moderate cognitive impairment). Review of Resident # 24's Care plan revised on 4/11/2024 revealed no problem , interventions or goals related to communication deficit. Review of Resident # 58's face sheet dated 5/17/2024 revealed a [AGE] year-old female admitted on [DATE] with diagnosis that include Schizoffective disorder (A mental health condition including schizophrenia (a disorder that affects a person's ability to thinking, feel and behave clearly). and mood disorder (a mental illness that affects a person's emotional state) and post-traumatic stress disorder (a disorder in what a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of Resident # 58's admission MDS dated [DATE] reveals BIMS of 99 as resident did not participate in assessment. Staff assessment for Mental status revealed a score of 2 (moderate Independence is decision making) Review of Resident # 58's care plan dated 5/16/2024 revealed problem for Psychosocial well-being with a goal of resident will not be exposed to trigger that may cause re-traumatization, interventions are generic and do not address any of the resident's know triggers. Interview with Social Services Director on 5/14/2024 at 1:32 pm stated that Resident # 58 refused to have a trauma assessment completed. She stated that the resident has been seen by the psychiatrist but not the psychologist, Review of psychiatrist Notes: revealed the provider was the NP, not a psychiatrist. Interview with DON on 5/16/2024 at 4:30 pm revealed the Interdisciplinary team is responsible for the care plan, her expectation is the care plans be person centered with all diagnosis covered. She stated that an inaccurate care plan can lead to the resident not having the care they need. Interview with the ADM on 5/16/2024 at 5:00 pm, his expectations are the care plans are up to date and accurate. He stated they have daily stand up meets and issues from the last 24 hours are discussed and the department heads or their designees should be updating the care plan as needed. An inaccurate care plan can lead to inappropriate care and dissatisfaction from the resident. Review of policy titled Comprehensive Care Plans revised 1/26/2024 revealed 6. The comprehensive care plan will include measurable objective and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 7 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview, and record review the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, pain management services for 1 of 6 residents reviewed for pain. (Resident #10) Residents Affected - Few The facility failed to ensure Resident # 10 received his scheduled Oxycodone 5mg every 4 hours for 5/11/2024 at noon to 5/13/2024 at 12:00am for a total of 13 doses. The facility failed to obtain an alternative medication for Resident #10's pain, until 5/12/2024 with the initial dose being given at 7:32 pm leaving Resident #10 in pain for over 24 hours. This failure placed residents at risk of increased pain and decreased quality of life. Findings included: Review of Resident # 10 face sheet dated 5/16/2024 revealed a [AGE] year-old male, admitted on [DATE] with diagnosis that include Chronic Obstructive pulmonary disease (a group of lung disease that block airflow and [NAME] if difficult to breathe), Pain unspecified (Acute pain due to trauma) and Fibromyalgia ( a long-term condition that involves widespread body pain and tiredness). Review of Resident # 10 Quarterly MDS dated [DATE] revealed a BIMS score of 15 (cognitively intact). Review of Resident's # 10 Care plan revealed no goal or interventions for Pain. Review of Resident's # 10 Medication Administration Records revealed that Oxycodone 5 mg by mouth every 4 hours not given and noted as not available on 5/11/2024 12:00 pm, 5/11/2024 4 pm, 5/11/2024 8 pm,5/12/2024 12:00 am, 5/12/2024 04:00 am,5/12/2024 8 am,5/12/2024 12 pm,5/12/2024 4 pm, 5/12/2024 8 pm, 5/13/2024 12 am, 5/13/2024 4 am, 5/13/2024 12 pm, 5/13/2024 4 pm, 5/13/2024 8 pm. Hydrocodone-acetaminophen 10-325 mg every 6 hours was given 5/12/2024 7:32 pm, 5/13/2024 3:42 pm, 5/13/2024 11:30 pm. Review of Resident's # 10 Physicians orders reveal order dated 5/12/2024 for Hydrocodone-acetaminophen 10-325 mg by mouth every 6 hours as needed for pain. Review of Resident # 10 progress notes revealed no entry for 5/12/2024. Review of Resident # 10 pain assessment documented from 5/11/24 thru 5/13/2024 revealed no pain reported. Vital signs were with in normal limits. Interview 5/14/2024 at 11:30 am with Resident # 10, he reported that over the weekend he ran out of his scheduled oxycodone because the pharmacy did not deliver it. He stated he was in pain and all they offered him was Tylenol which was not effective for his type of pain. He stated that the pain was no worse that it normally was when he gets his medication as prescribed, and he was more concerned about the withdrawal. He stated that he was also starting to go into withdrawal before they called the doctor on Sunday to get something for him. He stated this was not the first time that he has missed his pain medication due to reordering error, was unable to give dates of last time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 8 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 5/14/2024 at 4:30 pm DON stated that her expectations are that when a resident does not have a scheduled medication, the nurse was to call the pharmacy which has a 24-hour phone line, if the nurse was unable to obtain medication, she is to escalate it to the supervisor on call. She stated that she was not aware Resident # 10 did not have medication available on Friday and Saturday and when she was notified on Sunday she called and got an order for medication that was available in their E-station which was the Hydrocodone-Tylenol 10-325 mg. Hydrocodone 10 mg is not available in the E- Station dispensing system. Upon investigation the medication was not available due to the prescription was not renewed. The facility has a policy on how and when to reorder medications. She stated the resident does not receive his schedule medication could be at risk for a potential medical complication. Interview on 5/14/2024 at 5:00 pm ADM stated his expectation is that residents receive scheduled medication on time and if that medication is not available policy should be followed, Resident who do not receive their scheduled medication are at risk for medical complications. Review of Policy Ordering and receiving non-controlled medications from the dispensing pharmacy dated 6/1/2022. The only medication policy provided revealed 2. If not automatically refilled by the pharmacy, repeat medications (refills) are [Written on a medication order form/order by peeling the top label from the physician order sheet and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and or ordered electronically} ordered as follows: A. reordering of medication is done in accordance with the order and delivery schedule developed by the pharmacy provider. B. the nurse who reorders that medication is responsible for notifying the pharmacy of changes in direction for use or previous labeling errors. C. The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 9 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure nurse staffing data including the facility name, the current date, the total number and the actual hours worked was posted and readily accessible to residents and visitors for 2 (05/14/24 and 05/15/24) of 3 days reviewed for nurse staffing information. Residents Affected - Many The facility failed to post the required staffing information on 05/14/24 and 05/15/24. The facility failed to post the required staffing information in a prominent place readily accessible to residents and visitors on 05/14/24. These failures could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. Findings included: An observation on 05/14/24 from 9:42 AM to 9:45 AM revealed no posted staffing information readily accessible. During an observation and interview on 05/14/24 at 9:47 AM, the DON stated the posting was on the bulletin board at the nurse's station. The data sheet was in a plastic sleeve, posted on a bulletin board between several other hanging documents intended for nursing staff. The bulletin board was behind the nurse's station. The document did not contain the facility name. An observation on 05/15/24 at 11:06 AM revealed the posted staffing document did not contain the facility name. The document was dated 06/15/24. An observation on 05/16/24 at 8:51 AM revealed the posted staffing document dated 06/15/24 was still posted. During an interview on 05/15/24 at 9:30 AM, the Corporate Nurses stated the facility did not have a policy regarding posted staffing. During an interview on 05/16/24 at 4:17 PM, the ADM stated he expected the posted staffing to be completed daily and accurately. He stated the page that was dated wrong was a clerical/human thing that could be easily fixed. He stated he believed the form had been updated on 5/15/24 when they were made aware of the error. He stated that other than the one day with the wrong date, the facility consistently posted the information daily. During an interview on 05/17/24 at 9:30 AM, the DON stated it was her expectation that the staffing be posted daily. She stated they recently changed to the staffing coordinator posting the document, previously, the ADON had been responsible. She stated not having the numbers posted could lead to family members who think there should have been more staff and that could turn into a customer service issue. Review of the facility Nursing Department Staffing documents for the last 30 days revealed the facility name was not listed on the documents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 10 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic medications for 1 of 5 residents (Resident #58) reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #58's order, dated 05/03/24, for the psychotropic medication lorazepam (an anti-anxiety medication) PRN was not ordered beyond 14 days without an end date. The facility failed to ensure Resident #58 was monitored for side effects and behaviors related to the use of Abilify (an antipsychotic medication) from 04/23/24 through 05/17/24, and lorazepam (an anti-anxiety medication) from 05/03/24 through 05/17/24. These failures could place residents at risk for receiving unnecessary medication, unwanted side effects, and decreased quality of life. Findings included: Review of Resident #58's admission MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility 04/12/24. Section I (Active Diagnoses) reflected diagnoses that included hypertension (high blood pressure), anxiety disorder (intense and excessive worry and fear), bipolar disorder (a mental illness that causes extreme mood swings), post-traumatic stress disorder (condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations), and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs). Section C (Cognitive Patterns) reflected a BIMS score of 99 indicating she did not complete the interview. Section C also reflected both long- and short-term memory impairment, but she was able to recall that she was in a nursing home. Review of Resident #58's physician order dated 04/23/24, reflected, Abilify Maintena 400mg IM (into the muscle). Please give IM injection once medication is in house. To be given IM monthly once a day on the 23rd of the month. The end date reflected, open ended. Review of Resident #58's Medication Administration Record for May 2024 reflected lorazepam 0.5mg PRN 15 times so far this month. The MAR reflected no side effect or behavior monitoring for the psychotropic medications. Review of Resident #58's physician order dated 05/03/24, reflected Ativan (lorazepam) 0.5mg oral give for agitation and aggression every 8 hours PRN. The end date reflected, open ended. Review of Resident #58's comprehensive care plan reflected a problem, start date 05/15/24, Resident is at risk for adverse drug effects due to psychotropic med use for Schizophrenia, bipolar, anxiety and post-traumatic stress disorder. The goal reflected, Benefit without side effects. Approaches included, Administer medications per MD order, Gradual dose reduction if indicated, and Monitor resident for signs and symptoms of adverse effects (dry mouth, slurred speech, increased lethargy, increased weakness, EPS ) Notify MD PRN. The care plan reflected a problem, start date 04/23/24, I am at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 11 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some risk for side effects of anti-psychotic drug use . The goal reflected, Mood/behavior will improve with less than 2 episodes, and I will not experience signs and symptoms of delirium or adverse drug event through review date. Approaches initiated 04/28/24 included, Report new or worsening symptoms, Routinely monitor for involuntary movements, document side monitoring on flowsheet [sic] During an interview on 05/16/24 at 4:17 PM, the ADM stated they had a high population of residents with psychiatric diagnoses. He stated they implement gradual dose reductions of psychotropic medications as indicated. He stated psychotropic medications are not usually ordered on a PRN basis. He stated an adverse outcome or reaction could happen with any medication not just psychotropic medications. During an interview on 05/17/24 at 9:15 AM, the DON stated all residents taking psychotropic medications are monitored for behaviors and potential side effects. The monitoring was documented on the MAR. She stated it was the responsibility of the nurse who received the order to enter the orders for monitoring the side effects and behaviors. The DON stated it did not meet her expectations that there was no monitoring for Resident #58. The DON stated she and the ADON were responsible for monitoring they psychotropic medications. She stated not having the monitoring in place could lead to staff forgetting to document a behavior or side effect. Review of the Behavioral Assessment, Intervention and Monitoring policy, revised December 2021, reflected in part, Management 9. When medications are prescribed for behavioral symptoms, documentation will include a. Rationale for use; b. Potential underlying causes of the behavior; e. Specific target behaviors and expected outcomes; h. Monitoring for efficacy and adverse consequences . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 12 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 observations, interviews, and record review the facility failed to ensure that residents were free of a medication error rate of 5% or greater (10.34%) for 3 (Resident #1, Resident #50, and Resident #54) of 5 residents reviewed for medication administration. Residents Affected - Some 1) The facility failed to ensure LVN A primed the insulin pen prior to administering insulin to Resident #1 on 05/14/24. 2) The facility failed to ensure MA E administered Senna 8.6mg as ordered instead she gave Senna-S 8.6mg/50mg to Resident #50 on 05/15/24. 3) The facility failed to ensure LVN B primed the insulin pen prior to administering insulin to Resident #54 on 05/15/24. These failures placed residents at risk of incorrect doses and not receiving the intended therapeutic benefit of the medications prescribed by the physician. Findings included: 1) Review of Resident #1's quarterly MDS assessment dated [DATE] Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility 07/12/06. Section I (Active Diagnoses) reflected diagnoses including diabetes mellitus (a condition that affects the way the body processes blood sugar), anemia (lack of red blood cells in the blood), hypertension (high blood pressure), dementia, anxiety (intense and excessive worry and fear), and schizophrenia (a disorder that is marked by a combination of symptoms, such as hallucinations or delusions, and mood disorder). Section C (Cognitive Patterns) reflected a BIMS score of 99 indicating the resident was unable to complete the interview. Section C further reflected the resident had no long- or short-term memory impairment and was able to recall the current season, location of her room, and staff names and faces. Review of Resident #1's physician order dated 04/03/24, reflected an order for Novolog Flex Pen (insulin aspart) 18 units TID before meals at 6:30 AM, 11:30 AM, and 4:30 PM. Review of Resident #1's comprehensive care plan initiated 05/07/20 reflected, Category: Nutritional Status Resident requires a therapeutic diet r/t DM (diabetes), HTN (high blood pressure), HDL (high cholesterol), GERD (heartburn). A second entry reflected, Category: Visual Function Resident has impaired vision r/t disease process of DM . No other mention of diabetes noted on the care plan. During an observation and interview on 05/14/24 at 11:37 AM, LVN A checked Resident #1's blood sugar and obtained a result of 575. LVN A stated she needed to call the doctor to report the high blood sugar before administering the insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 13 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 05/14/24 at 11:48 AM, LVN A stated she received an order to give 25 units of aspart insulin subcutaneously for Resident #1. LVN A donned gloves and cleaned the rubber stopper on the insulin pen the attached the needle. She turned the dose selector on the pen to 25 then injected the insulin into Resident #1's abdomen. She did not prime the needle. 2)Review of Resident #50's quarterly MDS assessment dated [DATE] Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility 01/27/23. Section I (Active Diagnoses) reflected diagnoses including cerebrovascular accident (stroke), hemiplegia (paralysis of one side of the body), aphasia (difficulty using or comprehending language), anxiety (intense and excessive worry and fear), depression (persistent feeling of sadness and loss of interest), and chronic idiopathic constipation (a bowel condition that lasts a long time and without an apparent cause). Section C (Cognitive Patterns) reflected a BIMS score of 9 which indicated moderately impaired cognition. Review of Resident #50's physician order dated 02/19/24, reflected an order for Senna 8.6 mg; amount 2; oral give for constipation secondary to slow motility due to history of strokes. Once a morning. Review of Resident #50's comprehensive care plan initiated 01/29/23 did not address constipation. An observation on 05/15/24 at 7:28 AM, revealed MA E checked Resident #50's pulse and blood pressure, then prepared nine medications for administration. She placed a tablet of Senna-S 8.6mg/50mg into the medication cup with eight other medications and administered them to the resident. (Senna-S is a combination medication that contains 8.6mg of a laxative and 50mg of a stool softener) During an interview on 05/15/24 at 3:12 PM, MA E stated as soon as she had given the medication, she knew it was not the right medication. She stated they only had Senna-S in the building. She stated she had put Senna on the medication order form on 04/30/24 but it had not yet arrived at the facility. She stated giving the wrong medication could have caused the resident not to get the intended effect of the prescribed medication. 3)Review of Resident #54's quarterly MDS assessment dated [DATE] Section A (Identification Information) reflected a [AGE] year-old female originally admitted to the facility 04/18/23. Section I (Active Diagnoses) reflected diagnoses including anemia (lack of red blood cells in the blood), diabetes mellitus (a condition that affects the way the body processes blood sugar), dementia, anxiety (intense and excessive worry and fear), and depression (persistent feeling of sadness and loss of interest). Section C (Cognitive Patterns) reflected a BIMS score of 00 indicating severely impaired cognition. Review of Resident #54's physician order dated 02/19/24, reflected an order for Insulin lispro 3 units subcutaneous before meals at 6:30 AM, 11:30 AM, and 4:30 PM. Review of Resident #54's comprehensive care plan revised 05/15/24 reflected, Problem Resident was at risk for hypo/hyperglycemia related to diabetes mellitus. Goal: Resident will not exhibit signs of hypoglycemia or hyperglycemia over the next 90 days. Approach Administer medications and insulin as ordered . During an observation and interview on 05/15/24 at 11:19 AM, LVN B prepared to administer insulin to Resident #54. She cleaned the rubber stopper on the insulin pen, turned the dose selector to 2 then pushed the injection button. She then turned the dose selector to 3, attached the needle, then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 14 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 Level of Harm - Minimal harm or potential for actual harm administered the dose of insulin. LVN B stated that she had burped the pen to remove air bubbles. She stated where she was from, they call it burping but it is the same thing as priming the needle. She stated there was so much going on and she thought she had attached the needle prior to burping it. She stated she was aware that the procedure must be done ever time prior to giving the insulin or the resident may not get the proper dose. Residents Affected - Some During an interview on 05/16/24 at 4:17 PM, the ADM stated he expected medications to be administered as ordered and per the manufacturer's guidelines. He stated adverse outcomes could range from severe to benign (meaning almost nothing) depending on the situation. During an interview on 05/17/24 at 9:15 AM, the DON verbalized the process for ordering over the counter medications. She stated the med aides were supposed to notify the nurse if a medication was not available. She stated there was an order form the med aide filled in and dated. The staff who placed the order signed the form, then the DON signed the form to complete the process. She stated the med aides had all been in-serviced on the process. The DON stated all the nurses were aware of the practice of priming the needle on the insulin pens. She stated there was not a policy or procedure specific to using insulin pens, but they did skills checks on insulin administration. She stated she, along with corporate clinical staff were responsible for education and training. She stated she expected the insulin needles to be primed every time insulin was administered. She stated adverse outcomes to medications varied widely depending on the medication. She stated the resident may not get the therapeutic effect of the desired medication if the wrong medication or dose was administered. Review of the Insulin Administration policy, revised September 2014, reflected in part, Preparation 5. The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Insulin Delivery The forms of insulin delivery include: 3. Pens containing insulin cartridges deliver insulin subcutaneously through a needle. The policy did not reflect any other information regarding insulin pens. Review of the Administering Medication policy, revised April 2019, reflected in part, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 14. Insulin pens containing multiple doses of insulin are for single-resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident. 15. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident. Review of the manufacturer's website https://www.novomedlink.com/diabetes/patient-support/product-education/library/novolog-flexpen-instructions-for-use.html, accessed on 05/16/24, revealed a video NovoLog FlexPen Instructions for Use. The video reflected the air shot to be performed before each dose. After applying the needle, Turn the dose selector to 2 units. Hold the pen upright and tap the pen gently to move air bubbles. Press the 'push' button all the way in. Make sure a drop of insulin appears, if not change the needle and repeat the test . Review of the website https://uspl.lilly.com/humalog/humalog.html#ug1, accessed 05/16/24, reflected the manufacturer's instructions for using the Humalog Kwik Pen. The site reflected, Priming your Pen. Prime before each injection. Priming your Pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime you Pen, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 15 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 Level of Harm - Minimal harm or potential for actual harm turn the dose knob to select 2 units. Step 7: Hold you Pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the needle, and repeat priming steps 6 to 8 . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 16 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, under proper temperature control and labeled in accordance with currently accepted professional principles for 1 (medication room [ROOM NUMBER]) of 2 medication storage rooms and 2 (medication cart #1 and medication cart #2) of 4 medication carts reviewed for medication storage. Medication cart # 1 was left unattended and unlocked on 05/15/2024. Medication Cart #2 was left unattended and unlocked on the secure unit on 05/14/2024. An expired, opened and accessed, medication was stored in the medication room [ROOM NUMBER] refrigerator on 05/15/2024. This failure could allow residents unsupervised access to prescription and over the counter medication and can result in the resident receiving ineffective medication due to expired medications. Findings included: Observation on 5/14/2024 at 10:11 am revealed Medication cart # 2 was unlocked and unattended at the nurse's station where staff were sitting on the other side of the counter. The drawers were not visible to the staff members. The med cart was left unattended for approximately 6 minutes before staff were made aware. LVN A was asked what the policy was for medication carts. LVN A stated that the carts should be locked at all times. LVN A stated that stated she forgot to lock the med cart. A potential negative outcome of an unlocked med cart was that residents could get into the cart, medications or any other supplies inside of the med cart. An observation on 05/15/2024 at 11:33AM revealed an LVN med cart was left unlocked and unattended outside of the Director of Nursing's (DON) office. It was revealed that the med cart contained glucometers, prescriptions and over the counter medications. By pen, mouth and liquid forms of medication. There was also wound cleaner, prescription ointments and dressing supplies. It was revealed that the cart belonged to the Associate Director of Nursing (ADON). ADON stated she was unaware of the unlocked medication cart and had been away from the cart for a few moments. An observation on 05/15/2024 at 11:05AM revealed that there were medications that were undated in Med Cart #2. An interview on 05/15/2024 at 11:07 AM revealed that MA F had been employed at the facility for over a year and had completed trainings on medication labeling. She stated that a potential negative outcome of dating medications was that it wouldn't have the effect of the medication for the resident. An observation of Medication Storage 1 on 05/15/2024 at 10:50AM revealed that inside a locked box of the refrigerator, there was two medications bags that were expired. The medications expired were CMP ABH 1-12.5-2MG/ML Gel with an expiration date of 05/11/2024. CMP ABH 1-25-1MG/ML GEL with an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 17 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 expiration date of 04/07/2024. Level of Harm - Minimal harm or potential for actual harm An interview conducted on 05/15/24 at 10:50 AM with ADON revealed that she was not aware of the expired medications in the medication room [ROOM NUMBER]. She stated that a potential negative outcome of providing expired medications to a resident was that it can cause an adverse reaction to the resident. ADON stated that the expectation was that residents do not receive expired medications, and the medications should be thrown away as soon as possible. Residents Affected - Some An interview was completed with Administrator on 05/16/2024 at 04:35PM revealed that the expectation for expired medications is that they should be disposed of properly and follow the proper process. Administrator stated a potential negative outcome of providing expired medications to residents is that multiple outcomes could occur anywhere from something bad to something nothing at all. He stated depending on the medication could cause death. The expectation for dating medications is that it should be done in compliance within regulation and manufacture. He believes that the staff should be labeling it when they open the medication and place into the cart and stored properly. He stated that a new employee has been hired to ensure that medications are labeled properly. He stated that once this employee starts working, the goal is to have a plan for how often the medication expiration dates are checked. An interview conducted on 05/17/2024 at 09:48AM with MA G revealed that medication administration rights included right route, right dose, right patient, right documentation, right time. MA G stated that steps that she takes to ensure that medications are not expired is to go through her med cart every day and compare it with the expiration date. She stated a potential negative outcome of providing expired medications to residents is that they could get sick. The process for expired medications is to put it in the expired medication box inside of the med room or give to the DON. An interview conducted on 05/17/2024 at 09:52AM with RN A revealed that medication administration rights included right dose, right patient, right route, right documentation and right time. RN M stated that before providing medications she ensures the medication is not expired by looking at the expiration dates on the bottles. A potential negative outcome of providing expired medications to a resident is negative side effects. The process to remove expired medications from the cart is to put them in the discontinued box waiting for the pharmacist to come and destroy them. An interview on 05/17/2024 at 10:30 AM with DON revealed that the expectation for expired medications is that they should be removed from the medication cart, placed in the medication room for destruction, and then logged. A potential negative outcome of residents receiving expired medications is that it depends on the medication, but it could be dangerous. The expectation for dated medications is to have the bottles dated immediately after opening. She stated there is not a potential negative outcome for providing expired medications to residents, but it should not be done. Record Review of the policy titled Storage of Medications undated, stated 1. Drugs and biologicals used in a facility are stored in locked compartments under proper temperature, light and humidity control. Only persons authorized to prepare and administer medications have accessed to locked medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 18 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0791 Provide or obtain dental services for each resident. 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 provide routine dental services to 1 of 2 (Resident #1) residents reviewed for dental services. Residents Affected - Few The facility failed to provide routine dental services for Resident #1, since admission on [DATE], who was being treated for an oral infection. This failure could place residents at risk for decline in oral health, oral infections, and decreased quality of life. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility 07/12/06. Section I (Active Diagnoses) reflected diagnoses including diabetes mellitus (a condition that affects the way the body processes blood sugar), anemia (lack of red blood cells in the blood), hypertension (high blood pressure), dementia, anxiety (intense and excessive worry and fear), and schizophrenia (a disorder that is marked by a combination of symptoms, such as hallucinations or delusions, and mood disorder). Section C (Cognitive Patterns) reflected a BIMS score of 99 indicating the resident was unable to complete the interview. Section C further reflected the resident had no long- or short-term memory impairment and was able to recall the current season, location of her room, and staff names and faces. Review of Resident #1's physician order dated 05/13/24, reflected an order for Augmentin (amoxicillin-pot clavulanate) tablet 500-125mg give 1 tablet oral TID from 5/13/24 to 5/22/24. Review of Resident #1's consolidated physician orders for May 2024, reflected no order for dental care or services. Review of Resident #1's comprehensive care plan, last revised 05/15/24, did not reflect any documentation of an oral infection, dental care, or refusal of dental care. Review of the list of residents to be seen by the dentist revealed Resident #1 had been added to the list with a note referred 05/14/24. Observation and interview on 05/14/24 at 11:37 AM revealed Resident #1 sitting in a chair in her room watching television. Resident #1 reported her pain was 5 on a 1-10 scale when LVN A asked her about her pain. Resident #1 pointed to her jaw indicating the location of the pain. LVN A stated the resident had just received pain medicine a short time before and it probably had not yet taken effect. LVN A stated the resident had some jaw swelling noted and was complaining of pain, the provider was notified, and antibiotics were initiated. During an interview on 05/16/24 at 10:57 AM, the Social Service Director stated there are two dental services that came to the facility. When asked if Resident #1 was on the list to be seen by a dentist she responded, Oh, she refuses a lot of things. She stated the refusals should be documented in the medical record. Requested documentation of previous dental visits, consultations, or refusals from the Social Service Director. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 19 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/16/24 at 1:32 PM, the Social Service Director stated a referral for dental services was placed for Resident #1, but the appointment was not yet scheduled. During an interview on 05/16/24 at 4:17 PM, the ADM stated every one of the residents should be offered dental services. He stated you have to show you did your due diligence and document if the resident refused. He stated the lack of dental care could lead to a variety of problems. During an interview on 05/17/24 at 9:15 AM, the DON stated it was important that residents be offered dental care. She stated they had a general order for dental services that was usually entered when the resident was admitted to the facility. She stated the Social Service Director was responsible for sending out the dental referrals and scheduling dental visits. She stated it did not meet her expectations that Resident #1 did not have orders for dental services. Requested documentation of dental visits, consultations, or refusals from the DON. No documentation of Resident #1's dental visits, consultations, or refusals provided prior to exit of survey. Review of the undated policy Medication and Treatment Orders, Dental Services reflected, Orders for the treatment of the resident's dental problems must be signed by the attending dentist. The policy did not address obtaining routine or emergency dental services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 20 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to prepare food and drink that are palatable, attractive and at a safe and appetizing temperature for two of three meals sampled in that: Residents Affected - Some The facility failed to provide food that was palatable (vegetables with no flavor or seasoning) at a safe and appetizing temperature (sample tray was luke warm.] . This failure could place residents at risk of not being satisfied with their food, decreased food intake, unintended weight loss, hunger, poor nutrition, impeded recovery from illness and injury and diminished quality of life. Findings included: An observation on 5/15/2024 at 12:05pm in the kitchen revealed a tray of pre-seasoned garlic bread cooked in the oven. Sitting beside a toast oven, was another metal tray which contained stacks of toasted, white bread, which was over-cooked and was deep brown/black in color. An interview on 5/15/2024 at 12:10pm DC #2, said they did not have enough of the frozen, pre-seasoned garlic bread and had substituted with toasted Texas toast (a thicker piece of white bread). An observation on 5/15/2024 at 1:10pm two (Surveyor #2 and Surveyor #3) of four members of the survey team sampled a lunch tray. The test tray consisted of pasta and meat sauce, zucchini, garlic bread, cheesecake for dessert, water, and iced tea. The meal appeared visually pleasant. The meal did not have visible steam rising from the food, nor was heat felt with a hand passed over the meal. The pasta and meat sauce were flavorful and seasoned well. The zucchini was pale in color, slightly mushy and had no flavor or seasoning. The garlic bread was a piece of overly toasted, white bread with no butter, garlic, or additional seasoning. The bread was dry, difficult to chew and unpleasant. The food items which should have been hot, were room temperature when tasted. An observation on 5/16/2024 at 12:48pm two (Surveyor #2 and Surveyor #3) of four members of the survey team sampled a lunch tray. The test tray consisted of roasted turkey with brown gravy, stuffing, green beans, and corn bread. The sample tray did not have beverages, a dessert, or condiments. The meal appeared visually pleasant. The meal did not have visible steam rising from the food, nor was heat felt with a hand passed over the meal. The roasted turkey was flavorful and tender to chew. The brown gravy and stuffing were well seasoned and not overly salty. The green beans were soft to chew and had no flavor or seasoning. The food items which should have been hot, were room temperature when tasted. The cornbread had a good flavor, although it was cold to touch and taste and it was not served with butter. On 5/16/2024 at 1:00pm during interview with the DC she stated it was her responsibility to cook and season the food served to residents. She said there are ample spices and seasonings in the kitchen. She said she was unaware the zucchini and green beans lacked flavor as she thought she had seasoned them well enough. She said she does not season with salt, as the residents get a salt packet on their tray. On 5/16/2024 at 1:15pm during interview with the DM she stated that she was responsible to ensure the food served to residents was palatable and hot. She said she was unaware the zucchini and green (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 21 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 Level of Harm - Minimal harm or potential for actual harm beans were not well seasoned. She said she has trained dietary staff to season and prepare foods [NAME] to the way they cook in their own kitchens. She stated understanding of the importance of serving quality food to the residents. She stated one probable reason for the sample tray arriving cold to the unit was because they do not have enough of the lids that fit properly and sometimes, they must use the bottoms as lids. Residents Affected - Some On 5/15/2024 at 2:28pm the surveyor # 2 requested a policy regarding the palatability of food served to residents from the ADM. He stated the facility did not have a policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 22 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for two of three meals sampled. Residents Affected - Some The facility failed to ensure the puree texture was in a form (pudding like consistency that was smooth) to meet resident needs for two of three lunch meals on (5/14/2024 and 5/15/2024) sampled by two (Surveyor # 2 and Surveyor #3) of four survey team members . These failures could place residents at risk of decreased food intake, choking and aspiration. . The finding included: On 5/14/2024 @ 1:10pm an observation of pureed sample meal by two (Surveyor #2 and Surveyor #3) of four survey team members . The pureed meal consisted of Cajun sausage and beans, white rice, breaded okra, a baked roll, and bread pudding. Both team members agreed the sausage and beans had a good flavor but contained small pieces of sausage that required chewing prior to swallowing. The rice had a suitable texture and lacked flavor or seasoning. The okra, bread, and dessert had appropriate puree texture. On 5/14/2024 @ 1:30pm an interview with the Speech Therapist she stated the pureed sausage and beans were an appropriate texture and she did not have concern with the consistency and texture of the puree. On 5/14/2024 @ 1:40pm an observation and interview with the Regional Nurse she stated the pureed sausage and beans were an appropriate apple sauce texture and she agreed with the Speech Therapists' opinion as well. Survey team member asked her to taste the puree and she obliged. She tasted the puree, agreed the puree texture was not appropriate, and was observed chewing the food prior to swallowing. On 5/14/2024 at 2:31pm the Surveyor # 2 emailed a photo of the pureed sausage and beans to the Region 5 Program Manager (PM), who is a Registered and Licensed Dietician. She said the texture was too chunky for an appropriate puree. On 5/15/2024 at 12:50pm an observation of pureed sample meal by two of four survey team members. The pureed meal consisted of pureed pasta, meat sauce, zucchini, garlic bread and cheesecake. Both team members agreed the pasta was not a pureed texture or consistence. The pasta held the form of the serving spoon on the plate. It did not spread easily using the back of a spoon. It tasted gummy and was hard to maneuver around the mouth, using a tongue. The meat sauce, zucchini, garlic bread and cheesecake were an appropriate pureed texture. On 5/15/2024 @ 3:30pm during interview with ADM stated it was the responsibility of the dietary department and nursing staff to ensure residents receive food in a form designed to meet individual needs. One 5/16/2024 at 1:00pm during interview with the DC she stated it was her responsibility to puree (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 23 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the foods and she uses a recipe to ensure the appropriate texture. She said residents could choke if the puree was too thick or chunky. On 5/16/2024 at 1:15pm during interview with the DM she stated it was her responsible to ensure that pureed foods are the correct texture. She said they have recipe they use to ensure the textures are consistent and appropriate. She agreed that the texture of the pureed sausage and beans on 5/14/2024 was not smooth enough and could cause a choking hazard for the residents. Review of facility policy titled DYS L1-Pureed Texture, dated 2021. Description - The pureed texture is a mechanical modification of the Regular Diet or any therapeutic diet, designed for people with moderate to severe swallowing difficulty and poor ability to protect their air way. This texture allows pureed food (pudding like consistency) that is smooth and easily stays together. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 24 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and labeling in that: 1.The facility failed to ensure food and beverages were safely stored, labeled, and dated. in refrigerator #1, refrigerator #2, and freezer #1, freezer #2 and in the dry storage area on 05/14/24. 2.The facility failed to ensure kitchen staff DC #2 and DC #3 were properly wearing hair nets and properly wearing and changing gloves on 05/14/2024 and 05/15/2024. These deficient practices could place residents at risk of foodborne illness. The findings included: Observation of Refrigerator #1: At 8:35am on 5/14/2024 revealed a one gallon of milk labeled with an expiration date of 5/21/2024 did not contain an opened-on date. At 8:35am on 5/14/2024 revealed a one-gallon plastic container of dill pickles that did not contain an opened-on and use-by date. At 8:35am on 5/14/2024 revealed a white plastic container with plastic wrap placed loosely on the top of the container. It had label that read, Peaches, made on 5/9/2024, use by 5/11/2024. At 8:35am on 5/14/2024 revealed a white plastic container with plastic wrap on the top of the container. It had a label that read, Mixed vegetables, made on 5/8/2024, use by 5/10/2024. At 8:35am on 5/14/2024 revealed a transparent plastic container with plastic wrap around the top of the container. Handwritten date of 5/9/2024 on the plastic wrap. Inside the container was orange slices. At 8:35am on 5/14/2024 revealed sealed bag labeled Chicken Fried Steak 5/6/2024. Observation of Freezer #1: At 8:37am on 5/14/2024 revealed a sealed plastic bag labeled Pull Pork made 5/8/2024, Use-by 5/10/2424. At 8:37am on 5/14/2024 revealed a plastic bag, twisted at the top, contained unidentifiable brown disks (resembled meat). The bag did not have a label and there were ice crystals formed on the individual items inside the bag. At 8:38am on 5/14/2024 revealed a plastic bag, twisted at the top to close it, contained items resembling pretzels and there was no label. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 25 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0812 Observation of Refrigerator #2: Level of Harm - Minimal harm or potential for actual harm At 8:39am on 5/14/2024 revealed an unsealed bag of red grapes with a label that read, 4/28/2024. Observation of Freezer #2: Residents Affected - Many At 8:41am on 5/14/2024 revealed a blue plastic bag, which contained brown, round objects (resembled meatballs) with ice crystals formed on each object, and there was no label. At 8:41am on 5/14/2024 revealed a translucent plastic bag of rectangle, grooved items (resembled Churro snacks), there was no label, and the bag had a hole in the side. Observation of the Dry Goods Pantry: At 8:41am on 5/14/2024 revealed an opened and twisted bag containing four round, yellow objects (resembled cookies), there was no label. At 8:41am on 5/14/2024 revealed a white paper napkin and a dirty metal knife, sitting on a cardboard box, next to a stack of disposable metal pie tins containing a graham cracker crust, and on the wire metal shelf. At 8:41am on 5/14/2024 revealed an opened black bag, closed with a black binder clip, and was labeled Plain Potato Chips and dated 3/19/24. Observation of steel table in kitchen: At 8:44am on 5/14/2024 revealed a blue tray with two small plates of orange cake and a small plastic bag with two cookies. These items were not labeled with a date, and they were not listed on the menu for the day observed. Observation of Refrigerator #1: At 10:51am on 5/15/2024 revealed a white plastic container, printed Chopped Garlic, and a handwritten date of 3/27. At 10:52am on 5/15/2024 revealed two unopened packages of sliced turkey breast, and a handwritten date of 5/4/2024. At 10:52am on 5/15/2024 revealed there was a plastic container, sealed with a white lid, printed Potato Salad. The container was approximately 40% full and did not have a label with an opened-on and use-by date. At 10:52am on 5/15/2024 revealed a reusable white container with sealed lid. It had a label that said, Apple Jelly 5/8/2024. At 11:46 on 5/16/2024 revealed a white plastic container, printed Chopped Garlic, and a handwritten date of 3/27. It was the same container observed on 5/15/2024. On 05/14/2024 @ 12:03pm observation of DC #2 who was plating food for residents. While wearing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 26 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0812 Level of Harm - Minimal harm or potential for actual harm gloves, she pulled her cell phone out of pocket, looked at it and resumed plating food without changing gloves. On 5/15/2024 at 12:05pm observation of DC #3 who was plating food for residents with bangs hanging out of hairnet across her forehead and down to her ear. Residents Affected - Many On 5/16/2024 at 1:00pm during interview DC stated it is the responsibility of all dietary staff to ensure all food items are stored and labeled with proper dates. She said residents could become ill if they eat expired food. On 5/16/2024 at 1:15pm during interview DM stated it was the responsibility of all kitchen staff to ensure food items are stored and labeled properly. She said it was her and the DC's responsibility to clean out the refrigerator and discard expired items. Review of the facility's policy revised 1/2024 Storage and Labeling states: All food items will be stored in a sealed container and a label with the opened-on and use-by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 27 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program, designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable disease and infections in 14 ( Residents # 5,#9,#10, #23,#26,#28,#29,#31,#33, #41, # 58, # 61, and # 66) of 23 residents that were reviewed for infection control and transmission-based precautions policies and practice in that: Residents Affected - Some 1.The facility failed to ensure CNA I, MA J, MA K, CNA L and ST did not grab Resident's 9 (Resident #9, # 23. #26, # 29 #31, # 33, #41, #61, and #69) of 23, cup by the rim with bare hands, contaminating the tops of the rims, during the meal service on the secure unit on 5/12/2024 and 5/13/2024 at lunch time. 2.The facility failed staff failed to follow hand hygiene 3(resident # 5, 10, and 28) of 23 A. on 5/14/2024 at 11:00 am ADON did not use Proper hand hygiene and wound care techniques while performing wound care on Resident # 5. B. On CNA D and CNA E use Proper hand hygiene when providing peri-care for peri-care for incontinence(the inability to control bladder or bowel) care for Resident # 28. C LVN B failed to use proper hand hygiene 0513/2024 when performing wound care on This Resident # 10. 3-. The facility failed to ensure that staff were not following the dress code by having long nails which was stated as the facility dress code for infection control. This Failure could but the residents at risk for infection and possible injury including gastric upset, and skin tears. Findings included: Review of Resident # 5's face sheet dated 5/16/2024 revealed a [AGE] year-old-female admitted [DATE] with diagnosis that include Stroke (damage to the brain from interruption of its blood supply), Neurogenic bladder (a urinary tract condition that prevents the bladder from emptying properly due to neurological condition), and Hypertension (elevated blood pressure). Review of Resident # 5's annual MDS dated [DATE] revealed a BIMS score of 14 (indicating cognitively intact). Self -care assessment revealed that Resident is Dependent for activities of daily living and transfers. Skin condition assessment revealed an unstageable pressure wound. Review of Resident # 9's Face sheet dated 5/16/2024 revealed a [AGE] year-old female admitted [DATE] with diagnosis that I include Dementia (a group of thinking and social symptoms that interferes with daily functioning) Review of Resident # 9's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicates cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 28 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident # 21's face sheet dated 5/16/2024 revealed an [AGE] year-old female admitted on [DATE] with diagnosis that include Dementia (a group of thinking and social symptoms that interfere with daily functioning). Review of Resident # 21's Quarterly MDS dated [DATE] revealed the staff assessment for mental status determined moderate Impaired decision making, requires cues and supervision, resident unable to complete BIMS score. Review of Resident # 23 face sheet dated 5/16/2024 revealed an [AGE] year-old male admitted on [DATE] with diagnosis that include Alzheimer's (a progressive brain disorder that causes memory loss and cognitive decline), Dementia (a group of thinking and social symptoms that interfere with daily functioning). Review of Resident #23's quarterly MDS dated [DATE] revealed a BIMS score of 3 which reflect a severe cognitive impairment. Review of Resident # 26's face sheet dated 5/16/2024 revealed a [AGE] year-old female admitted on [DATE] with diagnosis that include Dementia ( a group of thinking and social symptoms that interfere with daily functioning), Diabetes type 2 ( A long term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident's # 29 face sheet dated 5/16/2024 revealed a [AGE] year-old male, admitted [DATE] with diagnosis that include cutaneous abscess of the right lower limb ( a collection of pas that forms in the skin), unspecified dementia ( mild cognitive impairment that has not been diagnosed as a specific type ) and Benign prostatic hyperplasia ( an age associated prostate gland enlargement that can cause urination difficulty). Review of Resident's # 29 admission MDS dated [DATE] revealed a BIMS of 0 (Severe cognitive impairment) Review of Resident # 28's face sheet dated 5/16/2024 revealed a [AGE] year-old female admitted [DATE] with diagnosis that include hemiplegia (a symptom that causes paralysis on one side of the body, either the right or the left and cam be complete or severe) and Hypertension (elevated blood pressure). Review of Resident # 28's quarterly MDS dated [DATE] revealed a BIMS score of 15 (indicating resident is cognitively intact). Self-Care assessment revealed that Resident is Dependent for activities of daily living, and transfers. Resident is wheelchair bound. Review of Resident # 29's face sheet dated 5/16/2024 revealed a [AGE] year-old male, admitted [DATE] with diagnosis that include cutaneous abscess of the right lower limb ( a collection of pas that forms in the skin), unspecified dementia ( mild cognitive impairment that has not been diagnosed as a specific type ) and Benign prostatic hyperplasia ( an age associated prostate gland enlargement that can cause urination difficulty). Review of Resident # 29's admission MDS dated [DATE] revealed a BIMS of 0 (Severe cognitive impairment) Review of Resident # 31's faces sheet dated 5/16/2024 revealed an [AGE] year-old female admitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 29 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [DATE] with diagnosis that include Stroke (Damage to the brain from interruption of its blood supply), Hypertension ( elevated blood pressure) and Atrial Fibrillation ( an irregular often rapid heart rate that commonly causes poor blood flow). Review of Resident # 31's Quarterly MDS dated [DATE] revealed a BIMS score of 12 Moderate cognitive impairment. Review of Resident # 33's face sheet dated 5/16/2024 revealed a [AGE] year-old male admitted [DATE] with diagnosis that include Stroke (damage to the brain from interruption of its blood supply) and Dementia (a group of thinking and social symptoms that interfere with daily functioning). Review of Resident # 33's admission MDS dated [DATE] revealed a BIMS of 8 a Moderate impaired cognitive impairment. Review of Resident 41's face sheet dated 5/16/2024 revealed a [AGE] year-old male admitted on [DATE] with Diagnosis that include Stroke (damage to the brain from interruption of its blood supply) and dementia ( a group of thinking and social symptoms that interfere with daily functioning). Review of Resident # 58's face sheet dated 5/17/2024 revealed a [AGE] year-old female admitted on [DATE] with diagnosis that include Schizoaffective disorder (A mental health condition including schizophrenia (a disorder that affects a person's ability to thinking, feel and behave clearly). and mood disorder (a mental illness that affects a person's emotional state) and post-traumatic stress disorder (a disorder in what a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of Resident # 58's admission MDS dated [DATE] reveals BIMS of 99 as resident did not participate in assessment. Staff assessment for Mental status revealed a score of 2 (moderate Independence is decision making) Review of Resident # 61's face sheet dated 5/17/2024 revealed a [AGE] year-old female admitted on [DATE] with diagnosis Dementia (a group of thinking and social symptoms that interfere with daily functioning) and Diabetes type 2 (A long term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident # 61's Quarterly MDS dated [DATE] revealed a BIMS score of 5 a severe cognitive impairment. Review of Resident # 66's face sheet dated 5/17/2024 revealed a [AGE] year-old male admitted [DATE] with diagnosis that include Dementia (a group of thinking and social symptoms that interfere with daily functioning) and Aphasia (the inability or refusal to swallow). Review of Resident # 66's admission MDS dated [DATE] revealed a BIMS score of 12 which can indicate moderately cognitive impairment. Observation of the Secure unit dining room on 5/12/2024 at 12:45 pm revealed CNA I, MA J, MA K, CNA L, and ST were passing lunch trays, the drinks were in a gray bin and all staff were grabbing the glasses by the rim, placing them on the tray, carry the tray to the resident s( # 9,#23.#26,#29,#31,#33,#41,#61, and #69)and grab the glasses by the rims to place them on the table. Glasses had ill fitting coffee cup lids on them. All Staff used Hand sanitizer between trays. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 30 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0880 Level of Harm - Minimal harm or potential for actual harm Observation of the Secure unit dining room on 5/13/2024 at 12:30 pm revealed CNA I, MA J, MA K, CNA L, and ST were passing lunch trays, the drinks were in a gray bin and all staff were grabbing the glasses by the rim, placing them on the tray, carry the tray to the Resident 's ( #9,#23,#26,#29,#31,#33,#41,#61 and #69) and grab the glasses by the rims to place them on the table. Glasses had ill-fitting coffee cup lids on them. All Staff used Hand sanitizer between trays. Residents Affected - Some Observation on 5/14/2024 at 11:00 am of ADON performing wound care on Resident # 5, the ADON preformed improper use of hand sanitizer by not rubbing the sanitizer till dry between changing gloves. Wound care was improperly preformed by ADON by not cleaning the wound properly, swiping the moist gauze up and then down the wound, which led to cross contamination. Observation on 5/14/2024 at 1:30 pm of can D and can E performing peri care (The process of washing the genital and anal areas of the body) on Resident # 28, CNA D improperly used hand sanitizer by only rubbing on the palms for her hands prior to applying gloves. CNA E improperly used hand sanitizer by not rubbing until dry and applied gloves prior to hand sanitizer dried prior to putting on gloves. Observation on 5/15/2024 at 08:00 am of LVN B failed to use proper hand hygiene with the sanitizer by not allowing the sanitizer to dry completely prior to applying gloves. Observation on 5/13/2024 at 12:30 pm of CNA I and MA K with fingernails longer than ¼ inch and appeared colored, unsure is nail polish or other coloring as an example gel or powdered nails. Observation on 5/14/2024 at 11 am ADON with nails longer than ¼ inch and appeared colored purple with sparkles, unsure if the coloring was due to nail polish, gel or colored powder on the nails. painted. Interview on 5/13/2024 at 1:00 pm with CNA L, stated that she was not aware she was grabbing by the top of cups when she placed them on the tray and place them in front of the resident, and did not think about the resident drinking from the area she touched, she added that the cups are hard to get out of the gray bucket with out grabbing by the top. Interview on 5/14/2024 at 11:20 am with ADON, she was not aware that she was not using the hand sanitizer correctly, she was not aware that she did not clean the wound using proper technique when performing wound care on Resident # 5. She stated she was recently check off on wound care and she was nervous and thought that may be the reason. Interview on 5/14/2024 at 1:45 pm with CNA D asking if she would not do anything different during the peri care she stated no, when pointed out that she did not use the hand sanitizer correctly while doing the peri care on Resident #28, she stated she was not aware. Interview on 5/14/2024 at 1:50 pm with CNA E stated that she got nervous and rushed during the procedure. She was not aware that she used the hand sanitizer incorrectly during peri-care on Resident # 28. Interview on 5/14/2024 at 4:30 pm with DON her expectation was that staff always use proper hand hygiene. She stated that nurses that perform wound care have been educated and checked off by the wound care company as they do not have a dedicated wound care nurse. She stated that she was not familiar with the dress code policy that required nails be ¼ inch and unpainted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 31 of 32 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 5/14/2024 at 5:00 pm with ADM, his expectations are that all staff follow all aspects of the infection control policy including hand hygiene and the dress code. He stated that he had never read the dress code policy and that department heads are responsible for enforcing the dress code. Review of policy Infection control policy dated October 2020 6 b Policies and Procedures reflect as the standards of the infection prevention and control program. Review of Dress code revised October 2019 revealed 9. Fingernails must be trimmed to a length not to exceed ¼ inch, Fingernail polish and artificial nails are prohibited, as they may result in infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 32 of 32