Health inspection·October 12, 2023

F 0607 Further review showed the following: Level of Harm - Minimal harm or potential for actual harm -The Administrator was hired on 08/01/2017, and last EMR/NAR search was conducted on 10/15/2021. -Dietary A was hired on 08/01/2017, and last EMR/NAR search was conducted on 10/15/2021. Residents Affected - Few -Housekeeping A was hired on 01/28/2022, and last EMR/NAR search was conducted on 01/20/2022. A review of the facility Prevention and Reporting of Suspected Resident Abuse and Neglect dated 03/20/2023 read in part, . All potential employees and/or contractors will be screened for a history of abuse, neglect or mistreatment of residents during the hiring/contracting process. Screening will consist of, but not limited to: inquiries into state licensing authorities, Office of the Inspector General (State and Federal); inquiries into state nurse aide registry, reference checks from previous and/or current employees, and criminal background checks. Anyone prospective employee with a disciplinary history or action due to abuse, neglect, mistreatment, or misappropriation will not be hired. Record the results of the screening. File with other employee records . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675625 If continuation sheet Page 2 of 6 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 675625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pasadena 4300 Vista Rd Pasadena, TX 77504 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable for 1 of 6 residents reviewed for PASARR. -Resident #39 had a diagnosis of mental illness and the facility did not coordinate with the appropriate, State-designated authority. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Review of Resident #39's face sheet, dated 10/11/23, revealed Resident #39 was a [AGE] year-old female, re-admitted to the facility on [DATE] (original admission [DATE]), with the following diagnoses: Type 2 Diabetes Mellitus (impaired use of the body's blood sugar), bipolar disorder (a serious mental illness characterized by extreme mood swings), major depressive disorder, recurrent (episodes of depression), end stage renal disease on hemodialysis (loss of kidney function requiring kidney replacement therapy), and cerebral infarction (lack of oxygen to brain causing a cluster of brain cells to die). Review of Resident's 39's admission MDS assessment, dated 06/27/2023, revealed sections related to PASSR including Section A-1500 and Section A- 1510 was left blank which reflected that Resident #39 was not assessed for mental illness on her admission MDS. Section I- Active Diagnoses of the MDS, dated [DATE], revealed resident with bipolar disorder, major depressive disorder, and anxiety disorder. Review of Resident #39's PASARR Level I screening (PL1) dated 06/27/2023 revealed Resident #39 screened negative for Mental illness (MI) by the case manager of the acute care facility from which she transferred. Review of Resident #39's clinical records revealed there was no documented request to have Resident #39 further evaluated by local authorities for mental illness due to her diagnoses of bipolar disorder and major depressive disorder. Interview on 10/11/23 at 1:30 PM, LVN D and LVN M (MDS nurses) said that they shared the responsibilities of completing resident assessments and PASRR. They said Resident #39's PASRR level 1 was marked NO for mental illness, and they did not seek further evaluation for the resident. Both MDS nurses agreed that it was an oversight because they were aware major depressive disorder and bipolar disorder were both qualifying mental illnesses which the resident had and is recorded in her MDS assessment. They said the resident should have been re-evaluated. LVN M said failure to review PASRR level 1 screenings for accuracy and failure to re-evaluate residents with qualifying diagnoses could result in the resident potentially missing out on services. Interview on 10/ 11/23 at 2:54 PM, the Administrator said that he expected all PASRR documentation to be reviewed by the MDS nurses for accuracy. Failure to do so could result in a resident missing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675625 If continuation sheet Page 3 of 6 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 675625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pasadena 4300 Vista Rd Pasadena, TX 77504 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 0644 out on services that he or she might have been eligible. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's PASRR policy (undated) revealed in part: Residents Affected - Few 1. The facility's designated staff will review all potential admission for possible positive PASRR conditions and ensure that CMS Preadmission guidelines are followed. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675625 If continuation sheet Page 4 of 6 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 675625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pasadena 4300 Vista Rd Pasadena, TX 77504 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety in 2 of 2 facility refrigerators and 1 of 1 dry food storage areas reviewed for food procurement in that: - The facility failed to label and date food items in the kitchen walk-in refrigerator and resident refrigerator located in the medical records room. - The facility failed to label and date all food items located in the dry food storage area. These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness. Findings include: Observed on 10/10/23 at 8:30 AM an unlabeled plastic gallon zip bag with cooked lima beans and corn and an unlabeled bag of French Fries in walk-in-refrigerator. Interview on 10/10/23 at 8:30 AM, the DM said the unlabeled and undated items in the walk-in refrigerator were items leftover from the previous night. She said the night cook must have forgotten to label them. The DM said that all food should be labeled with the name of the item and the date it was prepared or opened before it was put away. She said it was important to label and date so they knew when to discard items that could make residents sick. She said whoever was putting away the food should label it, but as the DM, it was ultimately her responsibility to make sure it was done. Observed on 10/10/23 at 8:35 AM an unlabeled plastic bag of shredded coconut in the dry storage area with no date or label. Interview on 10/10/23 at 8:35 AM, the DM repeated that all foods being stored should be labeled. Interview on 10/10/23 at 2:54 PM, the Administrator said his expectation is that all food being put away for storage should be labeled and dated to ensure it is safe and discarded as appropriate. Failure to do so could possibly make residents sick. The DM is responsible for making sure food stored in the kitchen is labeled and dated properly. Observed on 10/12/23 at 11:45 AM the unit refrigerator contained unlabeled food items with no discard dates. These items included a half of a meat and cheese sandwich wrapped in plastic wrap, a cut lemon in a biohazard bag, cheese and wrapped food item in a plastic container with a resident's initials. The freezer unit above the refrigerator contained a grocery bag with plastic containers. The contents of the plastic containers spilled out, and there was a brown liquid frozen in and around the plastic bag. Interview on 10/12/23 at 11:45 AM, LVN E said no particular person was responsible for clearing out the unit fridge, maybe housekeeping. She said that food placed into the refrigerator should have the resident's name and discard date to prevent giving residents old food that could make them sick. Interview on 10/12/23 at 11:47 AM, the HKS said that nursing was responsible for the unit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675625 If continuation sheet Page 5 of 6 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 675625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pasadena 4300 Vista Rd Pasadena, TX 77504 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 refrigerator, and housekeeping had nothing to do with it. Level of Harm - Minimal harm or potential for actual harm Interview on 10/12/23 at 11:50 AM, the DON said she stocked the unit fridge with supplements daily and did not see those items in the fridge. She said the food should be labeled and dated when placing in the refrigerator to know whether it is safe or needs to be discarded. Residents Affected - Some Interview on 10/12/23 at 3:00 PM, the Administrator said all food stored in any refrigerator for resident consumption should be labeled and dated. He said the unit refrigerator did not have an assigned designee to discard unlabeled items, but it will be addressed. Record review of Food Safety policy (undated) read in part, . 2. Protein Salads and Sandwiches . Upon mixing, store in 2 inch depth containers, cover, date, and refrigerate until service . 5. Holding Cold Foods Cover and date foods after they have been cooled . Record review of Foods Brought by Family/Visitors policy (undated) read in part . 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, and the use by date 7. The nursing staff (or designee) is responsible for discarding perishable foods on or before the use by date . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675625 If continuation sheet Page 6 of 6