Health inspection·June 5, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm known. She stated Resident #16 used the call light to ask staff to get her up from bed or to put her back into bed. The DON stated staff should keep the call light within Resident #16's reach at all times. She stated all floor nursing staff was to check call light placement when entering the room. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 2 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to choose health care and providers of health care services consistent with his or her interests, assessments, and plan of care for 1 of 8 Residents (Resident #61) whose records were reviewed for health care services. Resident #61 expressed her desire to find a psychiatrist within the community. The SS worker told Resident #61 she could select a psychiatrist of her choice but because the facility provided in house psychiatry services, she would have to secure her own transportation. This deficient practice could affect any resident exercising their rights to choose their own health care providers and result in a direct violation of the resident's right to autonomy. The findings were: Review of Resident #61's quarterly MDS assessment, dated 3/31/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, Manic Depression (Bi-polar disorder) and Seizure Disorder. Further review revealed Resident #61's BIMS was 6 out of 15 indicative of severe cognitive impairment. Review of Resident #61's Care Plan dated 3/31/24 read: Resident has bipolar disorder, current episode depressed, severe, with psychotic features and is at risk for hallucinations, delusions and behaviors. Two (2) of the approaches included Administer medications as ordered, monitor effectiveness, side effects and notify MD as needed. Psych consult as needed per MD referral. Observation and interview on 6/2/24 at 10:24 AM revealed Resident #61 was lying in bed. Resident #61 expressed her concerns about her mental health provider and immediately became very loud and presented as being very angry. Resident #61 stated her counselor recommended she see a psychiatrist. The SS Worker refused to refer her to a community Psychiatrist and told her she could see the in-house NP. Resident #61 stated she did not want to see the NP. She stated the SS Worker further stated if she did get a referral for a community Psychiatrist then she would have to get her own transportation. Resident #61 continued to express her frustration and anger about the situation for about 15 to 20 minutes. She stated she did not understand why she was being forced to see the NP. Interview on 06/05/24 at 09:49 AM with SS Worker revealed Resident #61 was being followed by a Psy services organization for medication management and she received counseling services from a different provider. The services were provided in-house. The SS Worker stated she referred Resident #61 to a local provider in private practice for Psychiatric services. The SS Worker stated the provider was within network with the Resident's insurance. She stated she shared the information with Resident #61 and the Resident walked away because she didn't like the answer. The SS Worker stated Resident #61 wanted someone who would come see her at the facility. SS Worker stated transportation was offered in house but was told Resident #61 would have to find her own transportation because Psy services and counseling was offered in house. The SS Worker stated she could not remember who provided her with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 3 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0561 the guidance. Level of Harm - Minimal harm or potential for actual harm Interview on 06/05/24 at 02:45 PM with the DON revealed she was not sure if the facility would provide Resident #61 with transportation to a community Psychiatrist since Psy services were offered in house. The DON stated Resident #61 had family who could take her to appointments. The DON stated the facility provided all residents with transportation to specialist and other appointments as needed. She stated she started her position during January 2024 and was learning the processes. Residents Affected - Few Interview on 06/05/24 at 3 PM with the DON revealed she talked with Corporate Regional Reimbursement MDS Coordinator and she said the facility would provide transportation for Resident #61 even if she saw a community Psychiatrist. She stated there had been a miscommunication but was not sure on whose behalf. When asked how there had been miscommunication, she stated I don't know but we will provide transporation. The DON stated they usually discuss Resident concerns, appointments and the like during morning meetings to ensure they were all on the same page. Review of a facility policy, Resident Rights, revised October 2009) read: Employees shall treat all residents with kindness, respect and dignity. 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. choose a physician and treatment and participate in decisions and care planning; 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 4 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident # 15) reviewed for privacy. Residents Affected - Few The facility failed to ensure CMA E locked the computer, which exposed Resident #15's morning medication list after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings include: Record review of Resident # 15's face sheet, dated 6/4/24, revealed a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses that included Acute Kidney Failure ( occurs when your kidneys suddenly become unable to filter waste products from your blood) , aphagia (The loss of the ability to swallow) and Right hemiplegia ( is a condition that causes paralysis on the right side of the body due to damage to the brain or spinal cord. Record review of Resident # 15's quarterly MDS assessment, dated 3/24/24, revealed Resident # 15 had a BIMS score left blank, which indicated resident was unable to complete interview. Observation on 06/04/24 at 9:30 AM-9:40 AM revealed that CMA E prepared Resident # 15's morning medication, walked away from the computer (did not lock screen), and displayed morning medication orders for Resident # 15. In an interview on 06/4/24 at 9:42 AM, CMA E stated she forgot to lock the computer screen when she walked away from the computer; she added that Resident # 15's private medical information was possibly exposed. In an interview on 06/04/24 at 10:49 AM, the DON stated she was not aware Resident #15's records were left open and unattended. The DON stated it was her expectation for facility nursing staff to uphold HIPAA and lock computer screens when they were away from them. The DON stated all staff were to ensure residents charts were protected at all times. The DON stated leaving residents charts open and unattended could give unauthorized access to resident charts. The DON stated her ADON was responsiable for overseeing compliance of this task and it was monitored by doing at random computer screen checks. Record review of the facility policy entitled Confidentiality of Information, 2001, revised March 2014, Revealed: The facility will safe guard all residents' records, whether medical, financial, or social in nature, to protect the confidentiality of the information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 5 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 revealed residents has a right to a clean and comfortable and homelike environment, including but not limited to receiving support for daily living including clean bed for 1 of 8 Residents (Resident #56) for 3 of 4 survey days (6/2/24 to 6/5/24) whose environment was observed for clean linens. Nursing staff failed to ensure they changed Resident #56's bed sheets for 3 of 4 survey days (6/2/24 to 6/5/24. Resident #56's bed sheets were stained with brown spots and had residue all over them. This deficient practice could affect any resident and contribute to feelings of low self-esteem. The findings were: Review of Resident #56's quarterly MD'S assessment, dated 4/12/24, revealed Resident #56 was admitted to the facility on [DATE], with diagnoses including Hypertension (high blood pressure), ESRD (also called end-stage kidney disease or kidney failure, occurs when chronic kidney disease, the gradual loss of kidney function, reaches an advanced state. In end-stage renal disease, your kidneys no longer work as they should to meet your body's needs) and PVD (a condition that affects the blood vessels outside of the heart and brain). Further review revealed Resident #56's BIMS was 12 out of 15 indicative of some cogntive impairment; required supervision or touching assistance, from partial to moderate assistance by 1 staff for ADL's and had limited range of motion on one side, lower extremity. Review of Resident #56's Care Plan, revised 3/20/24, revealed there was no mention of interventions for Resident #56's ADL's. Observation on 6/2/24 at 10:21 AM revealed Resident #56's bed was not made; the linens including the sheets, pillow case and blankets were dingy. The fitted sheet had brown stains and crumbs all over it. Observation and interview on 06/05/24 at 12:45 PM revealed Resident #56's bed was not made. The linens including the sheets, pillow case and blankets were dingy. The fitted sheet had brown stains and crumbs all over it. Interview with Resident #56 revealed the male CNA A, who showered him would not change out his sheets. Resident #56 stated he mentioned his sheets were dirty to the CNA's, but it did not do any good. Resident #56 stated he was a clean man and liked to sleep on clean linens but what could he do. He could complain but it didn't matter because it didn't help. Interview on 6/5/24 at 1 PM with MA D revealed she was working as an aide today (6/5/24) and knew Resident #56 very well. She stated he was a clean man. She looked at his bed and stated the linens were not clean; the fitted sheet was stained and there were crumbs all over it. She stated the pillow case was bad, very dirty. CMA stated she would feel horrible if she had to lay down in the bed with the sheets looking like they did. She stated Resident #56 was fairly independent but he did not help with showering and changing his linens. Interview on 6/5/24 at 1:45 PM with the DON revealed the CNA's were responsible for changing out the Resident's bed linens on shower days. She stated the nurse's could make sure this was done when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 6 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 FORM CMS-2567 (02/99) Previous Versions Obsolete they made their daily rounds. The DON stated that maintaining a clean envioronment including changing out the Resident's sheets was a basic right. It promoted feelings of satisfaction. Review of a facility policy, Resident Rights, revised October 2009) read: Employees shall treat all residents with kindness, respect and dignity. 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. Event ID: Facility ID: 675641 If continuation sheet Page 7 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base d on observation, interview and record review the facility failed to provide Preadmission Screening for individuals with a mental disorder for 1 of 1 Resident (Resident #61) whose records were reviewed for PASRR services. Residents Affected - Some The facility failed to recognize on the Level 1 PASRR screening that Resident #61 had a mental illness diagnosis of Bi-polar Disorder which would qualify her for a PASRR evaluation. This deficient practice could affect residents with a mental illness and could result in Resident's not receiving mental health services as needed. The findings were: Review of Resident #61's quarterly MDS assessment, dated 3/31/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, Manic Depression (Bi-polar disorder) and Seizure Disorder. Further review revealed Resident #61's BIMS was 6 out of 15 indicative of severe cognitive impairment. Review of Resident #61's Care Plan dated 3/31/24 read: Resident has bipolar disorder, current episode depressed, severe, with psychotic features and is at risk for hallucinations, delusions and behaviors. Two (2) of the approaches included Administer medications as ordered, monitor effectiveness, side effects and notify MD as needed. Psych consult as needed per MD referral. Review of Resident #61's electronic medical record revealed there was no PASRR level 1 on file. Observation and interview on 6/2/24 at 10:24 AM revealed Resident #61 was lying in bed. Resident #61 expressed her concerns and immediately became very loud and presented as being very angry. Resident #61 expressed frustration about the facility not being supportive of her mental health. She stated she had been Bi-polar for 20 years and required psychiatric services and anti-psychotic medication which assisted with managing her disorder. Interview on 06/05/24 at 03:41 PM with Regional reimbursement MDS Coordinator and the MDS Coordinator revealed she provided the MDS Coordinator with guidance when completing the screenings. She stated they coded Resident #61 not being mentally ill when she was initially admitted to the facility. However, it was an error and would be correcting it. Regional reimbursement MDS Coordinator stated the purpose of ensuring the screenings were filled out correctly and referring Residents to the LA for assessment was so the Resident's could receive the services they needed based on their identified needs. She further stated that if Residents met the criteria to receive services they would also be eligible for community services in the event they returned to the community. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 8 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 - Few 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 observation, 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 for 1 of 3 (Resident #71) residents reviewed for comprehensive assessments. The facility failed to ensure that Resident #71's care plan documented interventions for the diagnosis of General anxiety disorder. This failure could place residents at risk of not receiving proper care and services related to the disease process. The findings were: Record review of Resident # 71's face sheet, dated 6/4/24, revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis that Included General anxiety disorder (involving a persistent feeling of anxiety or dread that interferes with how you live your life), Cerebral infarction ( is a condition that occurs when blood flow to the brain is disrupted, resulting in necrotic tissue in the brain ) and Type 2 diabetes ( is a chronic condition that occurs when the body doesn't produce enough insulin or doesn't use insulin properly, resulting in high blood sugar levels). Record review of Resident # 71's Care Plan, dated 4/03/24, reflected no specific listing to address General anxiety disorder. Record review of Resident # 71's admission MDS, dated [DATE], revealed that Resident # 71 had a BIMS score of 14, which indicated intact cognition. Interview with the MDS nurse on 6/04/24 at 2:20 p.m., reveiled, she was responsible for updating the care plans .The MDS nurse stated she did not know why Resident # 71's addressed General anxiety disorder was not care planned. She added that by her not updating the care plan, Resident # 71 risked not having all team members on same page when providing care . Interview with the DON on 6/04/24 at 2:35 p.m. revealed Resident # 71 had diagnosis of General anxiety disorder that was not care planned , and it was her expectation the care provided was care planned accordingly to ensure all team members are on the same page when providing care. The DON stated the ADON was responsible for ensuring that care plans were completed, and she currently monitors this monthly intermittently which was why this was missed. Record review of facility policy titled Care Plans, Comprehensive Person-Centered 2001, Revised December 2016, revealed that The Comprehensive, Person-Centered care plan is developed within 7 days of completion of the required comprehensive assessment MDS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 9 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 8 Residents (Resident #56) whose records were reviewed for ADL care. Residents Affected - Few Nursing staff failed to ensure Resident #56 received a shower on 6/3/24 and on 6/5/24. This deficient practice could affect any resident and contribute to feelings of low self-esteem. The findings were: Review of Resident #56's quarterly MDS assessment, dated 4/12/24, revealed Resident #56 was admitted to the facility on [DATE], with diagnoses including Hypertension (high blood pressure), ESRD (also called end-stage kidney disease or kidney failure, occurs when chronic kidney disease, the gradual loss of kidney function, reaches an advanced state. In end-stage renal disease, your kidneys no longer work as they should to meet your body's needs) and PVD (a condition that affects the blood vessels outside of the heart and brain). Further review revealed Resident #56's BIMS was 12 out of 15 indicative of some cogntive impairment; required supervision or touching assistance, from partial to moderate assistance by 1 staff for ADL's including showers and had limited range of motion on one side, lower extremity. Review of Resident #56's Care Plan, revised 3/20/24, revealed there was no mention of interventiions for necessary care for any ADL's including showers for Resident #56 . Observation and interview on 06/05/24 at 12:45 PM revealed Resident #56 was sitting in his wheelchair in the bathroom getting toilet paper. Further observation revealed Resident #56's looked upkept (his hair looked uncombed, he had not been shaved). Interview with Resident #56 revealed CNA A would shower him and he did a good job but it was on his terms. Resident #56 stated he mentioned to the CNA's he had not showered like in 2 weeks, but it did not do any good. Resident #56 stated he was a clean man and liked to shower like anyone else. He stated he could complain but it didn't matter bc it didn't help. Interview on 6/5/24 at 1PM with MA D revealed she was working as an aide today (6/5/24) and knew Resident #56 very well. She stated he was a clean man. She stated she thought Resident #56 received showers on Tuesday's, Thursday's and Saturday's during the morning shift. She stated she had not showered Resident #56 on this date, 6/5/24 (Wednesday). Interview on 6/5/24 at 2 PM with LVN B revealed she was a full time employee and worked from 7 AM to 7 PM. She stated the CNA's worked from 6 AM to 6 PM. LVN B stated the CNA's would communicate regularly with her; would tell her when they showered Residents per their scheduled shower days or if they refused. LVN B stated she could see the CNA's in and out of the shower room with the Residents. She presented a shower book which revealed Resident #56 received showers on Monday's, Wednesday's and Friday's. Further review revealed he did not receive a shower on 6/3/24 and on 6/5/24. LVN B stated MA D did not tell her Resident #56 refused a shower on this date. She stated she was not aware that Resident #56 had not showered or if he refused. Interview on 6/5/24 at 1:45 PM with the DON revealed the CNA's knew they were responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 10 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0677 Level of Harm - Minimal harm or potential for actual harm showering Resident's on their scheduled shower days. The CNA's were supposed to tell the charge nurse if a Resident refused a shower. She stated the nurse's provided oversight. The DON stated there had not been any Residents of late that had complained about not receiving showers. The DON stated maintaing the Residents clean promoted dignity and feelings of self-worth. The DON stated she was not aware Resident #56 was not getting showers on his scheduled days. Residents Affected - Few Review of a facility policy, Resident Rights, revised October 2009) read: Employees shall treat all residents with kindness, respect and dignity. 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. Review of a facility policy, Shower/Tub Bath, Revised October 2010, read: The purpose of this procedure are to promote cleanliness, provie comfort to the resident and to observe the condition of the resident's skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 11 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 8 Residents (Resident #12) reviewed for falls. Nursing staff failed to provide adequate supervision for Resident #12 which resulted in her experiencing a fall on 6/3/24. On 6/5/24 nursing staff failed to ensure the fall mats were next to her bed to cushion her fall in an effort to prevent injuries related to having a history of frequent falls. These deficient practices could affect residents at risk for falls and could result in avoidable falls and injuries. The findings were: Review of Resident #12's quarterly MDS, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure), Alzheimer's Disease (causes the brain to shrink and brain cells to eventually die. Alzheimer's disease is the most common cause of dementia, a gradual decline in memory) and Hemiplegia (is a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body. It causes weakness). Further review revealed Resident #12's BIMS was 1 out of 15 indicative of severe cognitive impairment; was dependent on 1 to 2 staff for all ADL's; experienced moderate pain on a frequent basis and had a history of falling. Review of Resident #12's Care Plan, revised 5/15/24, read: Individual requires max assist x 1 person with ADL'S due to CVA; Resident is unable to make daily decisions without cues/supervision R/T dx. Alzheimer. Resident is unable to make daily decisions without cues/supervision R/T dx. Alzheimer's. One of the interventions included Re-direct resident when potential for injury is evident. Further review revealed Resident 12 was at risk for falls and had experienced falls. Interventions included Fall mat in place while in bed. Check room for hazards and keep a safe environment at all times. Observe frequently and assist as needed; place in supervised area when out of bed if needed. Review of Resident #12's incident/accident log revealed she had multiple falls including: 1. On 12/6/23 Resident #12 had an unwitnessed fall with no injuries. Agitation noted. Review of post-fall evaluation, dated 12/7/24, revealed plan of care included frequent checks through shift and education on using call light when assurance is needed. 2. On 12/24/23 Resident #12 had an unwitnessed fall; was found by her bed. Agitation noted. No injuries were noted. Review of post fall evaluation, dated 1/2/24, revealed plan of care included education on safety and frequent checks. 3. On 1/4/24 Resident #12 had an unwitnessed fall. Staff believed slid out of bed. Agitation noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 12 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 No injuries were noted. Level of Harm - Minimal harm or potential for actual harm Review of post fall evaluation, dated 1/9/24, revealed the plan of care included medication review. Residents Affected - Few 4. On 1/8/24 Resident #12 had an unwitnessed fall. She was found on floor at base of wheelchair in dining room. Resident noted throwing self off floor. Agitation noted. Intervention included medication review. No injuries were noted. It was noted interventions were unsuccessful. Review of post fall evaluation, dated 1/9/24, revealed plan of care included medication review. 5. On 4/7/24 Resident #12 was found on the floor mats next to her bed. Staff believed she fell out of bed. Agitation noted. No injuries were noted. Review of post fall evaluation, dated 4/11/14, revealed the plan of care included Hospice to complete a volunteer coordinator assessment. 6. On 5/4/24 at 9:36 AM and then at 11:29 AM revealed Resident #12 had an unwitnessed fall in her room. Staff noted Resident #12 was agitated. She had pulled the mattress off the bed; the covers and wedges were also on the floor. Review of of post fall evaluation, dated 5/10/24, revealed plan of care included medication adjustments. 7. On 5/8/24 Resident #12 was found on top of the floor mat next to her bed. No injuries noted. Staff noted agitation and increased the dose of Clonazepam (anti-anxiety medication.) Review of post fall evaluation, dated 5/13/24, revealed the plan of care included rearrange bed in room. 8. On 5/11/24 Resident #12 had an unwitnessed fall in her room. No injuries noted. Resident #12 noted with restlessness. Review of post fall evaluation, dated 5/20/24, revealed plan of care included frequent rounding for resident. 9. On 5/24/24 Resident #12 found on the mat on the floor next to the bed. Resident noted with an abrasion on her left elbow. Wound care provided. Review of post fall evaluation, dated 5/27/24, revealed plan of care included bolster mattress. Observation on 6/2/24 at 11: 05 AM revealed Resident #12 lying on a bolstered mattress. There was a foam wedge was on the floor by a mat positioned in front of the bed. The bed was positioned along the back wall perpendicular to the wall. Resident was noted hitting the blinds with her right hand over and over. Further observation revealed Resident #12 speech was minimal She was very thin and had a left hand contracture. The privacy curtain was drawn and the Residents was not visible from the doorway. Observation on 06/03/24 at 12:20 PM OB revealed Resident #12 was lying diagonal across the bolstered mattress. The privacy curtain was drawn across the bed and was not visible from the doorway. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 13 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few window blind was open; the foam wedge was lodged under the mattress closer to the head of the bed;, Resident #12's legs were draped over the mattress. Resident #12 was rambling and kept reaching out in front of her. Further observation revealed no staff in the near vicinity in the hallway. LVN B was at the very end of the hall talking with someone else. Surveyor intervened and called LVN B over to Resident 12's room. Upon walking into the room Resident #12 was face down on the mattress, left arm under her body, knees on the floor mat. LVN B triggered the call light and stated she could not roll the Resident over on her own. There were two staff passing out lunch trays. They did not notice Resident #12 or that the call light was on. LVN B called out and within a few minutes the DON responded. LVN B and the DON rolled Resident #12 back over onto the bed. They lifted her up in bed by using the bed pad. The DON stated Resident #12 ate in her room and was able to feed herself. No injuries were noted. Interview on 06/03/24 at 1:30 PM with LVN B revealed Resident #12 was a high risk for falling. She would roll out of bed all of the time. She stated she was passing out medications and the aides were helping with lunch when Resident #12 rolled out of bed on this date (6/3/24). She stated she was in Resident #12's room about an hour and a half before Resident #12 fell. She stated the Resident did not sustain any injuries. She administered a PRN Clonazepam (anti-anxiety medication). Observation on 06/05/24 at 3:30 PM revealed Resident #12 was lying in bed. The head and foot of the bed were positioned at about a 25 to 30 degree angle. Resident #12 had her legs draped over the hump at the foot of the bed. Further observation revealed two fall mats were positioned away from the bed. Resident #12's bed had been moved and aligned along the wall alongside the right side of the room upon entering the room. Resident #12 was facing the doorway. The privacy curtain was drawn half-way but Resident #12 was still visible from the doorway. Surveyor triggered the call light. Observation and interview on 06/05/24 at 3:47 PM revealed LVN B responded to Resident #12's call light. Interview with LVN B revealed she checked in on Resident #12 about 45 minutes prior to responding to the call light. LVN B was observed repositioning the fall mats and moving them to Resident #12's bedside. She stated the mats were supposed to stay by the side of the bed at all times. All nursing staff was responsible for ensuring placement. LVN B stated the fall mats were meant to cushion a fall and to prevent injuries. LVN B stated she had no idea why the mats were not by the bedside. She stated Resident #12 fidgeted in bed all day. Interview on 06/05/24 at 4:45 PM with the DON revealed Resident #12 was a high fall risk and had rolled out of bed many times and out of her wheelchair once but had not sustained any injuries. She stated all of the falls had been unwitnessed and it was almost impossible to provide Resident #12 with the level of supervision she required. The DON stated the interventions in place included bolstered mattress, foam wedge, low bed, call light within reach, fall mats, non-skid socks, medication review and nursing staff rounded on her frequently. She stated Resident #12 was highly anxious and they increased the dose for Clonazepam and it was effective at times but she continued to fidget in bed. The DON stated the interventions had minimized the risk for injuries but had not minimized the risk for falling because the Resident would roll herself out of bed. The DON stated Resident #12 was also receiving Hospice services. The DON stated all nursing staff was responsible for ensuring all interventions were in place to prevent falls and injuries as much as possible. Review of a facility policy, Falls and Fall Risk, Managing, revised December 2007, read Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Prioritizing Approaches to Managing Falls and Fall Risk. 4. If falling recurs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 14 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Monitoring Subsequent Falls and Fall Risk. 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. Event ID: Facility ID: 675641 If continuation sheet Page 15 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 3 residents (Resident #4, Resident #43 and Resident #52) reviewed for oxygen therapy in that: Residents Affected - Some 1. Residents #4 and #52's, nebulizer tubing was on the bedside table unbagged and undated. 2. Resident #43's filter on the oxygen concentrator had lint build up on it. These failures could place residents who received oxygen therapy at risk for an increase in respiratory complications and or infections. The findings were: 1. Record review of Resident # 4's face sheet dated 6/2/24 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis that included Peripheral vascular disease (is a chronic condition that affects blood vessels outside of the heart and brain), Dementia (a general term for the impaired ability to remember, think, or make decisions that interfere with doing everyday activities) and Osteoarthritis ( disease in which the tissues in the joint break down over time). Record review of Resident # 4's Quarterly MDS dated [DATE] revealed a BIMS score of 11, which indicated moderate cognitive impairment. Record review of Resident #4's Physician monthly orders dated June 2024 revealed an order start date of 5/29/24, Ipratropium - Albuterol Solution for nebulization 0.5 mg -3 mg every 4 hours as needed. Observation on 6/1/24 at 10:35 a.m. revealed Resident # 4 's nebulizer tubing was unbagged, undated, and on the bedside table. 2. Record review of Resident # 52's face sheet dated 6/2/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis that included Vascular dementia ( brain damage caused by multiple strokes), Schizophrenia ( a serious mental health condition that affects how people think, feel and behave) and Major Depressive disorder ( is a serious mood disorder that can affect how people feel, think, and function in their daily lives). Record review of Resident # 52's Quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Record review of Resident #52's Physician monthly orders dated June 2024 revealed an order start date of 5/28/24, Ipratropium - Albuterol Solution for nebulization 0.5 mg -3 mg every 6 hours as needed. Observation on 6/1/24 at 10:40 a.m. revealed Resident # 52 's nebulizer tubing was unbagged and updated on the bedside table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 16 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview with LVN B on 6/1/24, at 10:55 a.m., it was revealed that the night shift changes nebulizer tubing weekly and bags them. However, she did not know why the nebulizer tubing was not being bagged and dated. LVN B stated that residents were at risk of possible respiratory infection due to the nebulizer tubing being undated and unbagged. During an interview with the DON on 6/2/24 at 11:05 AM, she stated that Resident #4 and #52 should have had their nebulizer tubing bagged and dated by the night shift. The DON mentioned that the facility currently uses agency night shift nurses, and it was possible that they had forgotten to date and bag the nebulizer tubing for these residents. She also stated that the ADON oversees this task and assured that she would be monitoring it for compliance. The DON emphasized that Residents #4 and #52 were at risk of possible respiratory infection due to the nebulizer tubing being undated and unbagged. Record review of facility policy dated 2001 revised October 2010 titled Administering medications through a volume handheld revealed Change equipment every 7 days or according to facility protocol. 3. Review of Resident #43's face sheet, dated 6/5/24, revealed he was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Acute upper respiratory infection, Chronic systolic (congestive) heart failure-re-admitting diagnosis (is also called heart failure with reduced ejection fraction. Ejection fraction (EF) is a measurement that represents the percentage of blood the left ventricle pumps out with every contraction), Shortness of breath and Acute pulmonary edema (A condition where fluid accumulates in lung tissues. Causing shortness of breath, wheezing and coughing up blood), Review of Resident #43's quarterly MDS assessment, dated 5/23/24, revealed his BIMS was 15 out of 15 reflecting he did not have cognitive impairment and he received oxygen therapy while a Resident. Review of Resident #43's Care Plan, dated revised 4/9/24, read Oxygen Therapy: Resident requires oxygen therapy related to SOB (shortness of breath); Administer oxygen as ordered, Change canula or mask and tubing as per facility protocol and prn. Further review did not include any instruction on cleaning the filter on the oxygen concentrator. Observation on 6/2/24 at 11:26 AM revealed Resident #43 lying in bed with oxygen infusing via nasal canula at 2L. The filter on Resident #43's oxygen concentrator had a white layer of lint over it. Resident #43 stated he had lived in the facility for 4 1/2 years. He stated staff would change out the water bottle when it ran out and would change out the tubing at the same time. He stated he had not seen staff clean the filter. Observation on 6/5/24 at 11:26 AM revealed Resident #43 lying in bed with oxygen infusing via nasal canula at 2L. The filter on Resident #43 oxygen concentrator had a white layer of lint over it. Observation and interview on 6/5/24 at 12:00 PM with the DON revealed the filter on Resident #43's oxygen concentrator was not clean and full of lint. She stated nursing staff was supposed to clean it every Sunday on the night shift. The DON stated Resident #43 was inhaling lint particles into his lungs via nasal canula and it could cause upper respiratory complications and possibly an infection. The DON stated Resident #43 was highly susceptible to complication because of his condition. The DON further stated nursing staff should check the filter while making rounds and clean it as needed. Record review of facility policy dated 2001 revised October 2010 titled Administering medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 17 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0695 through a volume handheld revealed Change equipment every 7 days or according to facility protocol. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 18 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one of four quarters for 2024 (Quarter 3) reviewed for sufficient nursing staff. According to the PBJ report for Quarter 3 2024 (March 1 through May 31), the facility did not have sufficient staff on weekends. This failure could place residents at risk of diminished quality of life and quality of care. Findings: Record review of the CMS PBJ reports Quarter 3 2024 ( March 1 through May 31) indicated: the facility had a 1-star staffing rating. Record review of CMS PBJ report for Quarter 3 202 (March 1 through May 31) indicated the facility had excessively low weekend staffing. Record review of RN staffing hours for February 2024 - May 2024 revealed that there was no RN coverage on 3/16/24, 3/17/24,3/24/24,3/24/24,3/30/24/3/31/24,4/6/24, 4/7/24, 4/20/24,4/27/24,5/11/24,5/12/24,5/25/24 and 5/26/24. Interview on June 4, 2023, at 8:45 AM: The Director of Nursing (DON) mentioned that there was a lack of licensed nursing (RN) coverage at the facility during weekends which can possibly lead to compromised patient outcomes, longer hospital stays, and increased readmission rates. On 6/05/24 at 11:18 AM, the Administrator mentioned that the facility does not have a staffing policy for licensed RN nursing coverage. Additionally, the administrator noted that there are posted openings for RN weekends, but no one has applied due to the location of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 19 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the attending physician documented in the resident's medical record that the identified irregularity made by the pharmacist had been reviewed and what, if any, action had been taken to address it. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record for 1 of 3 Residents (Resident #25) whose records were reviewed for unnecessary medications. The DON and ADON failed to identify the pharmacist addressed identified medication irregularities to the wrong physician when completing the pharmacy review for Resident #25. This resulted in a delay in the physician's response to the medication irregularity including Zyrtec (used for allergies) and Hydrocodone (used for pain). This deficient practice could affect any resident, delay a physician's response and result in a decline in the residents health. The findings were: Review of Resident #25's quarterly MDS assessment, dated 4/16/24, revealed he was admitted to the facility on [DATE] with diagnoses including Heart Failure ( the heart muscle doesn't pump blood as well as it should), Hypertension (high blood pressure), PVD (disease or disorder of the circulatory system outside of the brain and heart. The term can include any disorder that affects any blood vessels). Further review revealed Resident #25's BIMS was 15 out of 15 indicating no cognitive impairment. Review of Resident #25's Care Plan revised on 6/2/24 revealed Resident #25 had amputation to: Bilateral legs above the knee, recent amputation to left leg. One of the approaches included administer medications as ordered, assess resident response to pain medication and notify MD if pain is not controlled or resident experiences adverse reaction. Review of pharmacy recommendation for Resident #25 dated 5/21/24 read Patient is receiving cetirizine 10 mg po QD and Hydrocodone/APAP 10/325 po TID. These medications have a class D interaction which may increase the risk of CNS depression. Please reduce cetirizine 10 mg po QD PRN allergies. Further review revealed Resident #25's physician had not addressed the pharmacist recommendation. Interview on 6/5/24 at 5:45 PM with the ADON revealed she and the DON were responsible for reviewing the pharmacist recommendations and forwarding to the physician so he could make changes as needed. The ADON stated the pharmacist would provide the reviews via email and they would review and send them forward to the physician within 24 hours. The ADON stated they did not notice that the Pharmacist had addressed the wrong physician; therefore, Resident #25's physician had not had the opportunity to review and respond. Review of a facility policy, Consultant Pharmacist Services Provider Requirements, dated 2007, read Regular and reliable consultant pharmacist services are provided to residents. d. Medication Regimen Reviews (RR) for each Skilled Nursing (SNAFU) resident at least monthly, or more frequently under certain conditions, incorporating the federally mandated standards of care in addition to other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 20 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0756 Level of Harm - Minimal harm or potential for actual harm applicable professional standards. e. Communicate to the responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly. Communicate recommendations for changes in medication therapy and the monitoring of medication therapy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 21 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 - Few 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. Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one medication cart out of two carts reviewed for medication storage , in that : 1. LVN B left the medication cart unsecured on 100 Hallway while administering medications. These deficient practices could place residents at risk for misappropriation, misuse or tampering of medications. The findings included: Observation on 06/04/2024 at 08:28 a.m. on the 100 Hall revealed that the medication cart was left unattended and not locked. During an interview on June 4, 2024, at 08:28 with LVN B, it was revealed that she had left the medication cart unlocked, which was a practice she claimed to have never done before. Her focus on checking a resident led to this oversight. She acknowledged the potential for misappropriation, misuse, and harm if someone were to gain unauthorized access to the cart and acquire medications, including insulin. In an interview conducted on 06/04/2024 at 1:27 p.m. with the Director of Nursing (DON), she unequivocally stated that LVN B was one of her best nurses. She expressed bewilderment at LVN B's oversight in failing to lock the medication cart. The DON emphasized that it is imperative for nurses and medication aides to rigorously adhere to the protocol of securing medication carts when not in use due to the potential risks of misappropriation and harm if unauthorized individuals access the medications. Furthermore, she stated that her Assistant Director of Nursing (ADON) is accountable for overseeing the random locking of medication carts, while her MDS nurse was tasked with daily monitoring of this crucial security measure during rounds. Record review of facilities policy and procedure titled Security of Medication Cart, 2001, revised April 2007 revealed: Medication Carts must be securely locked at all times when out of nurses view. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 22 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 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 1 of 1 kitchen observed for food service. Residents Affected - Many 1. The facility failed to ensure all open items in the freezers were labeled and dated. a. 4 bags of open frozen foods not labeled with contents or date opened/used by 2. The facility failed to ensure all foods in the refrigerator were labeled and dated. a. Two trays of portioned foods covered and not labeled in the reach in refrigerator (1 of 2) 3. The facility failed to ensure all equipment was clean and sanitary. a. Spilled and partially dried liquid in the bottom of the reach in refrigerator (1 of 2) b. The table-mounted can opener had sticky black and brown grime on the blade and along the base of the equipment. These failures affect all the residents who received meals from the kitchen and place them at risk for foodborne illness. Findings included: Observation of the facility's only kitchen on 06/02/2024 at 9:39 AM revealed 4 bags of opened foods in reach in freezer (1 of 3) were unlabeled and undated. Contents of the opened bags were not labeled on the open bags. Reach in refrigerator (1 of 2) had two trays of portioned foods in small bowls covered in plastic wrap unlabeled with the contents or the date prepared. Reach in refrigerator (1 of 2) had spilled and partially dried liquid on the bottom. Interview with Dietary Aide K on 06/02/2024 at 10:15 AM revealed she received training when she started on food storage and labeling by the Dietary Manager. DA K stated that all kitchen staff are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 23 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 responsible to label any stored foods in the refrigerator, freezer and dry storage when opened. DA K stated that opened food should be labeled with the contents and date used by. DA K stated that the kitchen has a cleaning check list to ensure equipment is clean. Interview with Dietary Manager on 06/04/2024 at 9:48 AM revealed all staff hired receive training from the Dietary Manager or designee on proper food storage and labeling. DM stated that all kitchen staff are responsible to label all food stored in the refrigerator and freezer with the contents and date used by. DM stated the kitchen has a cleaning check list that all kitchen staff work on daily. DM stated by not labeling foods being stored in the refrigerator and freezer the residents were at risk of food born illness. DM also stated by not cleaning up spills or cleaning the table mounted can opener also put residents at risk for food born illness. Record review of the kitchen's daily cleaning check list for the month of June on 06/04/2024 revealed nothing on the checklist had been signed as completed. Record review of the facility's policy Food Receiving and Storage dated December 2008 revealed 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Record review of Facility's policy Sanitization dated December 2008 revealed 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Sea ls, hinges and fasteners will be kept in good repair. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; (B) In (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 24 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 FORM CMS-2567 (02/99) Previous Versions Obsolete food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Event ID: Facility ID: 675641 If continuation sheet Page 25 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 maintain and ensure safe and sanitary storage of residents' food items for 2 (refrigerators in resident room [ROOM NUMBER] and room [ROOM NUMBER]) of 5 residents' refrigerators reviewed in that: Residents Affected - Few The personal refrigerators in two residents' rooms contained food items that were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled. The findings were: Observation on 06/01/2024 at 10:02 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER] contained a burrito with expiration date of 2/12/24, which was unlabeled and undated. Observation on 06/01/2024 at 10:48 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER] contained bologna that was unlabeled and undated. Further observation on 06/01/2024 at 11:54 a.m. revealed the bologna was still present. On June 1, 2024, at 10:37 a.m. during an interview with CNA A, it was confirmed that the refrigerator in resident room [ROOM NUMBER] contained a burrito with an expiration date of 2/12/24. Additionally, the personal refrigerator in resident room [ROOM NUMBER] contained bologna that was unlabeled and undated. During an interview with the Director of Nursing (DON) on June 2, 2024, at 9:47 a.m., the DON confirmed that perishable food in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled foods. The DON stated that the night shift nurses are responsible for overseeing this, and currently, this was not being monitored. Record review of the facility policy, Foods Brought by Family/Visitors, dated 2001, revised December 2008, revealed, .Food brought to the facility by visitors and family is permitted. The nursing staff is responsible for discarding perishable foods after 3 days in a resident's personal refrigerator . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 26 of 27 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 675641 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Seguin 1215 Ashby Seguin, TX 78155 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 Based on interview, observation, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for residents who eat in their rooms in halls 100 and 200. Residents Affected - Some While passing lunch trays in hallways 100 and 200 staff did not sanitize or clean hands in between residents. This failure could place residents at risk for infection. Findings included: Observation of meal services on 06/02/2024 at 12:16 PM revealed the Business Office Manager (BOM) passing trays in the 100 and 200 halls. The BOM went from the rack of trays into resident's rooms with lunch trays then back to the rack of lunch trays in the hallway. The BOM pushed the rack of lunch trays down the hall and repeated the process for all residents eating in their rooms in halls 100 and 200. The BOM did not wash or sanitize her hands after pushing the rack of trays down the hallways or between passing each resident's trays. Interview on 06/02/2024 at 12:33 PM revealed the BOM sanitizes her hands between passing trays when in the dining room. The BOM stated she did not sanitize her hands when passing trays in the hallways because there is no hand sanitizer stations on the hallways. The BOM stated by not sanitizing her hands while passing trays in the hallway she could spread infections and/or germs down the hallways to other residents. Record review of facility policy Food Preparation and Service dated November 2010, Food Service/Distribution, .4. Food service staff, including nursing service personnel, will wash their hands before serving food to residents. Employees also will wash their hands· after collecting soiled plates and food waste prior to handling food trays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675641 If continuation sheet Page 27 of 27