Health inspection·October 11, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/11/23 at 09:10 AM, the Regional Reimbursement Manager said she did MDS audits for accuracy. She said she did not review all the MDS assessments. She said Resident #33's MDS should not have been coded for anticoagulant. She said they would correct the inaccurate MDS. During an interview on 10/11/23 at 10:37 AM, RN B said she signed the MDS assessments after the MDS coordinator sometimes. She said it was an oversight that the Aggrenox was coded as an anticoagulant and it should have been coded as a anti platelet. She said the risk to the resident was that it could possibly cause the care plan to have an anticoagulant care area when it should not have. During an interview on 10/11/23 at 11:08 AM, ADON C said Resident #33's MDS assessment should not have been coded for an anticoagulant. She said the MDS coordinator was responsible for ensuring the MDS assessment was accurate. She said they will now discuss the MDS assessments with all the administration staff before sending in the MDS. She said there was no risk to the resident because of the MDS being inaccurate. During an interview on 10/11/23 at 11:17 AM, the DON said the Aggrenox medication was an antiplatelet medication. She said Resident #33's MDS assessment should not have been coded for an anticoagulant. She said there was no risk to the resident because of the MDS being inaccurate. She said the MDS coordinator was responsible for checking that the MDS assessment was accurate. She said the corporate MDS nurse was also responsible for ensuring the MDS was accurate . During an interview on 10/11/23 at 11:24 AM, the Administrator said she expected the MDS assessments to be completed accurately. She said there was no risk to the resident because of it being inaccurate. She said the MDS coordinator was responsible for ensuring that the MDS assessment was accurate. She said the RN that signs the MDS assessments was responsible for ensuring the accuracy of the assessment as well. Record review of the Facility's policy, Certifying Accuracy of the Resident Assessment, last revised November 2019, stated: .Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment . .2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of the assessment . .4. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the Resident Assessment Coordinator, who is a registered nurse FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 2 of 9 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 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 respiratory care was provided with professional standards of practice for 1 of 2 resident reviewed for respiratory care and services. (Resident #142) Residents Affected - Few The facility failed to administer oxygen at 3 liters via nasal cannula as prescribed by the physician for Resident #142. This failure could place residents who receive respiratory care at risk for developing respiratory complications. Findings included: Record review of Resident #142's face sheet dated 10/10/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #142's diagnoses included pneumonia (infection of the air sacs in one or both lungs), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure with hypoxia (not enough oxygen in the blood), and malignant neoplasm of mandible (jaw cancer). Record review of Resident #142's admission MDS assessment dated [DATE], indicated he usually made himself understood and usually understood others. The MDS assessment indicated Resident #142 had a BIMS score of 11, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #142 required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene. Resident #142 was totally dependent on staff with bathing. The MDS indicated Resident #142 was receiving oxygen therapy. Record review of Resident #142's physician summary reported dated 09/17/23-10/10/23, indicated he had an order for oxygen at 3 liters per minute via nasal cannula continuous with a start date of 09/17/23. Record review of Resident #142's care plan dated 10/04/23, indicated he had chronic hypoxic respiratory failure, chronic obstructive pulmonary disease, and a lung mass. Resident #142 required the use of oxygen. The care plan interventions indicated to administer oxygen as ordered. Record review of Resident #142's MAR dated 10/01/23- 10/10/23, indicated he had been receiving oxygen at 3 liters per min via nasal cannula daily. During an observation on 10/09/23 at 10:08 AM, Resident #142 was receiving oxygen at 4 liters per minute via nasal cannula. During an observation on 10/10/23 at 09:01 AM, Resident #142 was receiving oxygen at 4 liters per minute via nasal cannula. During an observation and interview on 10/10/23 at 4:07 PM, Resident #142 was receiving oxygen at 4 liters per minute via nasal cannula. Resident #142 said he did not know who set the oxygen at 4 liters and he said he had not changed the settings on the oxygen concentrator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 3 of 9 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 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 - Few During an interview and observation on 10/10/23 at 4:08 PM, RN A said the oxygen setting was checked every morning. RN A went to Resident #142 and said the oxygen was set at 4 liters per minute. RN A said Resident #142 oxygen was usually set at 4 liters per minute via nasal cannula. RN A said the physician had given an order for oxygen 2-5 liters per minute to keep Resident #142's oxygen saturation above 92 percent. RN A reviewed Resident #142's physician's orders and said Resident #142 had an order for oxygen 3 liters per minute via nasal cannula and could not find the order for when the oxygen was changed. RN A reviewed Resident #142's progress notes and could not find when the physician had given the order for oxygen 2-5 liters. RN A said the nurse who received the order was responsible for ensuring the new oxygen order was transcribed in Resident #142's medical records. RN A said the nurse could administer oxygen without a physician's order . RN A said the Resident #142 was at risk for receiving more than the prescribed dose of oxygen which was considered a medication error. During an interview on 10/11/23 at 10:57 AM, ADON C said she expected the physician's orders to be followed when administering oxygen. ADON C said oxygen was considered a medication. ADON C said Resident #142 should have been receiving oxygen at 3 liters per minute via nasal cannula as prescribed. ADON C said the nurses were responsible for ensuring the oxygen was set as ordered when it was signed off on the MAR. ADON C said by not setting the oxygen at the prescribed rate could cause residents to receive too much or not enough oxygen. During an interview on 10/11/23 at 11:05 AM, the DON said she expected oxygen to be set at the prescribed rate. The DON said the nurses were responsible for ensuring the oxygen was set at the correct rate. The DON said not following the physician's order could cause residents to not receive proper oxygenation. During an interview on 10/11/23 at 11:13 AM, the ADM said she expected oxygen to be administered as per the physician's orders. The ADM said the nurse was responsible for following the physician's orders and ensuring the correct oxygen dose was being administered. The ADM said by not setting Resident #142's oxygen as ordered he was at risk for hyperoxygenation (too much oxygen) or could cause him to end up back in the hospital. The ADM said oxygen did require a physician's order. Record review of the facility's policy Oxygen Administration revised October 2010 indicated .The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physical's orders or facility protocol for oxygen administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 4 of 9 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of one medication room reviewed for medications storage (North Side Medication Room). The facility failed to remove an expired medication from the North Side Medication Room. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: During an observation on 10/11/23 at 09:47 AM, this surveyor reviewed the North Side Medication Room with RN A. A 2mL vial of Lidocaine HCL injection 1% (a medication used to alleviate pain and discomfort by numbing the targeted area of the body) was found with an expiration date of September 2013. During an interview on 01/11/23 at 09:55 AM, RN A said the expired lidocaine vial should not have been in the medication room. She said it was missed because it was in the back area of the cabinet. During an interview on 10/11/23 at 11:08 AM, ADON C said the medication aides, nurses, ADON, and DON were responsible for checking the medication room for expired medications. She said the nurses check the medication room each shift. She said if a resident received the medication there would be risk of infection to the resident. During an interview on 10/11/23 at 11:17 AM, the DON said that the Lidocaine vial should not have been in the medication room. She said all nursing staff were responsible for checking the medication room for expired medications. She said it was possible that someone could accidentally grab that medication and give it to a resident. She said if it was given to a resident that it could have been ineffective. During an interview on 10/11/23 at 11:24 AM, the Administrator said she expected the expired medications to be removed from the med room. She said the nursing staff were responsible for ensuring that the medication rooms were checked. She said the risk was possible adverse effects if the medication was given to a resident. Record review of the Facility's policy, Storage of Medications, last revised November 2020, stated: .The facility stores all drugs and biologicals in a safe, secure, and orderly manner . .4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 5 of 9 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the use of psychotropic medications was documented in the clinical record for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #30). The facility failed to adequately monitor Resident #30's side effects regarding her antidepressant medication. This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Record review of Resident #30's face sheet dated 10/10/23, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #30's diagnoses included depression, anxiety, congestive heart failure (condition in which the heart does not pump blood as well as it should), and essential hypertension (high blood pressure). Record review of Resident #30's quarterly MDS assessment dated [DATE], indicated she usually made herself understood and usually understood others. The MDS assessment indicated Resident #30 had a BIMS score of 13, which indicated her cognition was intact. The MDS assessment indicated Resident #30 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #30 was totally dependent on staff for bathing. The MDS assessment indicated Resident #30 received antidepressant medications 6 days out of the 7 days of the look back period. Record review of Resident #30's care plan dated 08/18/23 did not indicate Resident #30 was receiving antidepressant medications. Record review of the performance improvement dated 10/04/23, indicated the facility had identified issues with the residents comprehensive centered care plans and were in the process of updating all care plans. Record review of Resident #30's physician order report dated 09/10/23- 10/10/23, indicated she had the following orders for antidepressant medications: *Duloxetine 30mg: one tablet by mouth once a day with a start date of 07/28/23 *Paxil 10mg: one tablet at bedtime with a start date of 08/30/23 Record review of Resident #30 MAR dated 10/01/23- 10/11/23, indicated she had been receiving Duloxetine 30mg one tablet in the morning ad Paxil 10mg one tablet at bedtime. Record review of Resident #30's Treatments Administration History dated 10/01/23-10/11/23 did not indicate Resident #30's antidepressant side effects were being monitored. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 6 of 9 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/11/23 at 10:57 AM, ADON C said residents who received psychotropic medications should be monitored for side effects. ADON C said the nurses, DON, and herself were responsible for ensuring the side effect monitoring nursing order was in place. ADON C said not monitoring the side effects could cause residents to receive medications for no reason or could cause residents to be over sedated. ADON C said side effect monitoring was documented on the nurse's administration record. ADON C said the DON and herself reviewed the orders upon admission. During an interview on 10/11/23 at 11:05 AM, the DON said she expected residents who received psychotropic medications to have side effect monitoring in place. The DON said the nurses were responsible for ensuring the residents were being monitored for side effects or adverse reactions. The DON said by not monitoring the residents side effects regarding psychotropic medication use could cause them to miss a resident's side effect to that medication and may cause harm to them. During an interview on 10/11/23 at 11:13 AM, the ADM said she expected resident who received psychotropic medications to have documentation on medication side effects. The ADM said the nurse was responsible for ensuring side effect monitoring was in place. The ADM said not monitoring side effects for psychotropic medications could cause residents to be over medicated. The ADM said by not monitoring the effectiveness of the medications the physician will not know when to adjust the medication. Record review of the facility's policy Medication Monitoring Medication Management dated January 2022, indicated . Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug .without adequate monitoring .The facility's medication management support and promotes: .the monitoring of medications for efficacy and adverse consequences .4. The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing bases and with the consideration of resident preferences .Monitoring of Psychotropic Medications: When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medications as well as look for potential adverse consequences .Potential Adverse Consequences: The facility assures that residents are being adequately monitored for adverse consequences such as: anticholinergic effects which may include flushing, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation, constipation, signs and symptoms of cardiac arrythmias such as irregular heart beat or pulse palpitations unstable or poorly controlled blood sugar, weight gain .agitation, distress, tardive dyskinesia (neurological syndrome that results in involuntary and repetitive body movements), cerebral vascular accident (stroke) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 7 of 9 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Expired food was not disposed of. 2. Food was not labeled or dated. 3. Kitchen equipment was not kept free of carbon buildup. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings were: During an observation on 10/09/23 at 9:00 a.m., a cast iron skillet was on the stove that was used to cook breakfast. The cast iron skillet was observed with a thick layer of carbon buildup. The cast iron stove top had a thick layer of carbon buildup. Inside the refrigerator it was observed that a tub of cottage cheese was out of date, 10/04/2023. It was observed 8 bags of hotdog buns without dates or labels and no expiration date was printed on bag. It was observed that a loaf of bread was opened and laying on a serving table with no date or label and no expiration date printed on the bag. During an interview on 10/11/23 at 9:30 a.m., with the Dietary Manager she stated she expects that all her kitchen staff throw away expired food or food past its best use by date. She stated that her staff are not allowed to serve expired food as it could cause foodborne illness. She stated staff are supposed to label and date all items so that they do not serve expired items and if there is no label or date nor an expiration date then there is no way to tell when the food expired. She stated cooking equipment should not have carbon buildup. She stated their cast iron skillet will be replaced after a new skillet they have ordered comes in. She stated their corporate resource staff also told her that some of her skillets and pans needed to be replaced due to age and carbon buildup. During an interview on 10/11/23 at 10:20 a.m., with the Administrator she stated she expected staff to throw away expired food. She stated residents could be placed at risk for foodborne illness and food poisoning. She stated all kitchen staff are responsible to throw away expired food. She stated food should be labeled and dated. She stated staff should label and date food so they know the date ranges of how long the food has been in the kitchen and when to discard it. She stated she expects her kitchen staff to maintain their cooking equipment and ensure it is free from carbon buildup. She stated she expects that if a skillet or pan had carbon buildup it should be cleaned or replaced. Review of the facility document revised April of 2022, Preventing Foodborne Illness - Food Handling provided by the Dietary Manager revealed: Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. The Resident agrees to consult with Nursing and Dietary staff regarding food or beverages brought into the Center. This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food service employees; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 8 of 9 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 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 b. Inadequate cooking and improper holding temperatures; Level of Harm - Minimal harm or potential for actual harm c. Contaminated equipment; and d. Unsafe food sources. Residents Affected - Many All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. This facility only accepts prepared foods from suppliers subject to federal, state or local food service inspections and who remain in good standing with such agencies. Review of the facility document dated 2018, Food Storage provided by the Dietary Manager revealed: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 9 of 9