Health inspection·December 23, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many - Resident #16 (100 Hall) developed a rash to his stomach, was treated for scabies and placed on contact isolation. - Resident #84 (100 Hall) developed a rash on his stomach, was treated for scabies and placed on contact isolation - Resident #109(100 Hall) developed a rash to his abdomen/trunk, was treated for scabies and placed on contact isolation. - Resident #20 (200 Hall) developed a rash on his arms, was treated for scabies and placed on contact isolation. - Resident #1 (300 Hall) developed a rash and was treated for scabies and was placed on contact isolation. -the facility failed to take prompt actions and identify potential issues early, without Surveyor intervention when Resident #49, who had a tracheostomy (tube inserted into the windpipe to help a person breathe) was observed to be in distress for an unknown period of time. -the facility failed to ensure the oxygen mask was in place to provide continuous oxygen flow to Resident #49 prior to leaving the resident's room. -the facility failed to maintain sterile procedure prior to tracheostomy suctioning for Resident #49. An IJ was identified on 12/18/23. The IJ template was provided to the facility on [DATE] at 04:09 PM. While the IJ was removed on 12/23/23 at 03:20 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for itching, discomfort, pain, secondary skin infections, acute respiratory distress and hospitalization. Findings included: Record review of the facility Infection Control Tracking and Trending for August, September and October of 2023 revealed, the tracking and trending was completed retrospectively for those months on 11/08/23 by the DON. Resident #107 Record review of Resident #107's Face Sheet dated 12/18/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of depression, difficulty swallowing, down syndrome, fluid overload, hypertension. The resident had a diagnosis of Atopic dermatitis (swelling and irritation of the skin) and congenital ichthyosis (a group of rare skin conditions that cause dry, scaly skin that individuals are usually born with) as of 11/03/23, he did not have a diagnosis of Scabies. The resident discharged to the hospital on [DATE]. Record review of Resident #107's Quarterly MDS dated [DATE] revealed, severely impaired cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 2 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many skills for daily decision making, substantial/maximal assistance for most ADLs, an indwelling catheter, frequently incontinent of bowel and application of ointments/medications other than to feet. Record review of Resident #107's undated care plan revealed, focus areas of - ID, DD with PASRR services, potential nutritional problems, potential for pressure ulcer development, impaired cognitive function, a communication problem and tube feeding. There was no focus area to address Resident #107's treatment/diagnosis of scabies. Record review of Resident #107's Order Summary dated 12/18/23 revealed, Resident #107 had orders for Permethrin (an insecticide used to treat scabies) on multiple occasions but was only on contact isolation once: - 06/23/23 Permethrin 5% for dermatitis for 2 days: apply to head to toe topically one time only for 2 days. Leave on for 8-145 hours. - 07/26/23 Permethrin 5% for pruritus: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning. - 08/18/23 Permethrin 5% : apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning per dermatologist. - 11/03/23 Permethrin 5% for prophylactic dermatitis for 2 days: apply at bedtime and leave overnight. Rinse of in AM. - 12//11/23 Permethrin 5% apply topically one time for scabies infestation. Leave in for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23 Contact Isolation- use strict contact precautions with protective garments. Record review of Resident #107's Dermatologist Note dated 07/26/23 revealed: Resident #107 was being seen as a referral from the Medical Director for a rash located on the body throughout. The rash was itchy and red and moderate in severity and it had been present for months. scaling and well demarcated, eczematous patches; differential diagnosis includes irritation dermatitis vs. scabies; plan- Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Follow up in 6 weeks for skin check. Record review of Resident #107's Dermatologist Note dated 11/03/23 revealed: Impression: Eczema associated diagnosis: Scabies; status: worsening, Itch Numerical Rating scale:10; % body surface covered in rash: 70. Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Record review of Resident #107's Physician Note dated 12/13/23 signed by the Medical Director revealed, Resident #107 was seen due to rash noted over the extremities and right upper shoulder that appeared crusted in nature. Diagnosis/Plan: unspecified dermatitis secondary to scabies infection, was started on permethrin cream, repeat treatment after 7 days, clean linens/clothes, deep clean room and contact isolation precautions in place. Record review of Resident #107's MARs from 06/2023 to 12/2023 revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 3 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 - Jun 2023: Permethrin 5% apply to skin at bedtime for dermatitis for 2 days- it was only applied once on 6/24/23. Level of Harm - Immediate jeopardy to resident health or safety - July 2023: Permethrin 5 % apply to skin for persistent dermatoses (a skin defect)- applied on 07/21/23. Permethrin 5% apply topically for pruritus- applied 7/26/23. Residents Affected - Many - August 2023: Permethrin 5 %- applied 08/18/23 - November 2023: Permethrin 5 % prophylactically for dermatitis for 2 day- was only applied on 11/04/23 - December 2023: Permethrin 5% for scabies infestation use strict contact isolation- applied on 12/11/23 at 10:30 PM. Record review of Resident #107's Progress Notes from 12/22/22 to 12/23/23 revealed the resident's rash : - 06/24/23- generalized rash noted to entire body - 07/17/23- resident noted with recurrent rash to upper extremities - 07/23/23 day 7/7 of prednisone for generalized rash to torso. Area clean with red bumps noted from front/back torso. Resident scratching right front chest. - 08/24/23- generalized rash remains. - 09/12/23- Rash noted all over resident skin. - 11/02/23 at 01:30 AM: generalized rash remains pronounced, - 11/04/23 at 03:17 AM: generalized rash remains pronounced, dry, raised in some areas. - 11/04/23 at 10:15 AM : rash was still present to entire body and has new orders for permethrin 5% cream for 2 days and ammonium lactate 12% cream on shower day which will be on Monday 11/6/2023 - 12/14/23 at 02:30 AM- scaly, shedding, redness/self-inflicted scratches noted to skin. Resident on contact isolation There was only one mention of the resident having scabies on 12/12/23 at 04:01 AM- remain in contact isolation for scabies, permethrin cream applied to the entire body; and Resident #107 was first placed on contact isolation on 12/11/23. Record review of Resident #107's Hospital Progress dated 12/15/23 at 10:22 AM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Resident #107's Hospital Wound Care Note dated 12/15/23 at 03:22 PM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 4 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Hospital Infectious Disease Progress Note dated 12/17/23 at 07:46 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) and Topical Permethrin for crusted scabies. Residents Affected - Many Record review of Hospital Infectious Disease Progress Note dated 12/18/23 at 05:32 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) for 4 days and Topical Permethrin for 3 days for crusted scabies. Record review of Resident #107's Medical Diagnoses printed 12/23/23 at 11:39 AM revealed, depression, difficulty swallowing, high blood pressure and atopic dermatitis. There was no documented diagnosis of scabies. An observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #107 was in the bed by the window, he was awake, receiving tube feeding, had a urinary foley catheter and was non interviewable. Resident #107 had fair colored skin with thick, dry, crusty, scaly large areas to the upper body. On both shoulders and upper arms were thick crusty, powdery white areas with red cracks. There were raised red bumps and rash to both forearms and to both upper thighs. The thighs had red scratch marks. The webbing between the thumb and pointer finger on both hands had powdery white irregular bumps. Resident #107 was scratching his groin and upper thighs. The treatment nurse stated he had dermatitis that worsened since he returned from the hospital in October 2023. The treatment nurse stated the rash on Resident #39 and Resident #107 appeared to be the same. She did not mention that Resident #107 had a presumptive diagnosis of scabies or that the resident was being treated for scabies. An observation and interview on 12/15/2023 at 4:00 PM revealed, Resident #107 in the ICU at the hospital with a diagnosis of respiratory failure and sepsis. Resident #107's room door was open and the resident was intubated(a tube into the throat to help breathing). The assigned hospital nurse stated when he was admitted on [DATE] d/t low blood pressures and elevated WBC. The hospital nurse stated they were not notified of the resident having scabies. The hospital nurse picked up her phone that was ringing and said it was the wound care nurse on the line who just told her she completed her evaluation done on 12/15/2023 and thought he might have scabies. The hospital nurses closed the resident's door and set up for contact isolation. Isolation signage was put up on the glass door. In an interview on 12/15/23 at 09:25 AM, MA A said she was present on 11/03/23 when Resident #107 saw the dermatologist. She said due to the rash being chronic and the severity of itching as well as the facility informing them other residents had similar rashes the Dermatologist wanted to treat Resident #107 for scabies. She said the MD ordered Permethrin 5% for Resident #107 to be repeated in 7 days. In an interview on 12/20/23 at 07:55 AM, the Hospital Treatment Nurse said when Resident #107 arrived to the hospital she observed thick plaques and rashes all over the parts of the body she could see (at least 1/3rd ) and she was surprised. She said the hyperkeratotic (a condition that causes skin to thicken in certain places) presentation and the residents history made her believe he had crusted scabies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 5 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Resident #39 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #39's Face Sheet dated 12/23/23 revealed, a 50-year-olf male who admitted to the facility on [DATE] with diagnoses of: chronic pain syndrome, contractures, lack of coordination, anemia and a scabies (onset 12/11/23). Residents Affected - Many Record review of Resident #39's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, dependence for most ADLs and application of ointments/medications other than to feet. Record review of Resident #39's undated Care Plan revealed, focus-impaired visual function, refusal of care (showers/shampoos and general grooming), total assistance with all ADLs except feeding. Focusactual impaired to skin integrity r/t thick skin and callous buildup to feet, he refuses to shower routinely which precipitates dry skin formation; intervention- identify/document potential causative factors and eliminate/resolver where possible; keep skin clean and dry. Record review of Resident #39's NP Note dated 11/30/23 signed by the NP revealed, skin: chronic seborrheic dermatitis ( a chronic inflammatory disorder affecting areas of the head and trunk were glands are located)- refuses showers. Record review of Resident #39's NP Note dated 12/08/23 signed by the NP revealed, Diagnosis/Plan: seborrheic dermatitis- refuses showers. There was no documented description of the resident's rash. Record review of Resident #39's MD note dated 12/13/23 and signed by the Medical Director revealed, Resident #39 had a red rash over the extremities of both upper and lower extremities. The resident was on isolation and was started on permethrin for scabies but he continued to refuse showers and application of creams. Diagnosis/plan: unspecified dermatitis secondary to scabies infection, on contact isolation, on permethrin cream repeated after 7 days and room to be deep cleaned and linens washed. Record review of Resident #39's Clinical Census dated 12/23/23 revealed, Resident #39 shared a room with Resident #107 from 10/24/23 until Resident #107 was discharged to the hospital on [DATE]. Record review of Resident #39's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #39's Progress notes from 12/22/22 to 12/23/23 revealed, Resident #39's had rashes dating back to 06/2023. - 6/13/23 at 04:46 PM- Resident's lower extremities are swollen with wound., Also has rash all over the body but was refusing treatment and medication. - 06/26/2023 at 10:40- The entire body skin observed with rash. There was no other mention of Resident #39 suffering from a rash until 12/14/23 (3 days after being diagnosed with scabies:) - 12/14/23- remain in contact isolation/precautions, generalized skin rash remains to the body. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 6 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Record review of Resident #39's Order Summary dated 12/23/23 revealed, Level of Harm - Immediate jeopardy to resident health or safety - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. Residents Affected - Many - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. Start date 12/19/23. Record review of Resident #39's December 2023 MAR revealed, -Permethrin 5% topically at bedtime for scabies infestation- applied on 12/11/23 at 9:30 PM and 12/19/23 at 12:16 AM. Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #39 was awake, dressed in a hospital gown and brief and was in the bed by the door. Resident #39's arms, legs and hands were contracted. Resident #39 stated it was ok to look at his skin and that areas on his skin were very itchy. Resident #39 had small, red bumps on the scalp, forehead, cheeks, on both elbows, arms and both lower legs had large red bumps. The treatment nurse stated the redness to the elbows and red areas on his back were not new. The treatment nurse stated the new red bumps appeared sometime last week (12/4/2023 to 12/08/2023). The treatment nurse stated these new red bumps occurred at the same time Resident #107's red bumps appeared. Observation and interview on 12/23/2023 at 12:00 PM, Resident#39 was in contact isolation. He had a plate of food on his chest. He had red bumps on his scalp, face and arms and was unchanged from 12/13/23. He said he did receive the treatment cream, then showers the next day. Resident #39 stated he was told the cream was for scabies. He stated that it started with Resident #107 and maybe from not having the bed linens changed and washed. He stated that the bed linens were changed out daily and his personal belongings were removed. He stated he did not feel as itchy. He stated he was able to sleep through the night but during mornings he would feel itchy when he thinks about it. He stated he will be getting out of isolation soon and was happy about that because he wanted to get his money so he can buy soda. Resident #25 Record review of Resident #25's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of ID, schizophrenia, anemia, anxiety, hallucinations, depression and scabies (onset date 12/11/23). Record review of Resident #25's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, substantial to maximal assistance with most ADLs, and always incontinent of both bladder and bowel. There was no documentation of any applications of ointments/medication to the skin. Record review of Resident #25's undated Care Plan revealed, no related focus areas. There was no mention of any skin issues including rashes and scabies. Record review of Resident #25's Clinical Census revealed, Resident #25 shared a room with Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 7 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 #107 since 10/24/23. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #25's NP Note dated 11/27/23 revealed, no documented skin issues. Residents Affected - Many Record review of Resident #25's NP Note dated 11/30/23 revealed- head to toe assessment done due to reports of patient had rash to both sides of his upper and lower extremities. He has elevated red bumps, dry scaly skin scattered to chest, abdominal area, back, both legs and arm but no rashes were observed on the web spaces of his hands, genitals or scalps. Monitor closes due to skin rash issues in the unit. Record review of Resident #25's NP Note dated 12/08/23 revealed, the resident was on hydrocortisone (steroid cream) for skin rash and the rash was unresolved. Record review of Resident #25's NP Note visit date 12/09/23 but signed on 12/18/23 revealed, Resident #25 was noted itching/scratching and had a persistent skin rash likely scabies. Resident #25 was treated with Sulfur 5% nightly for 3 days, with a plan to treat with Permethrin if the rash didn't resolve. Contact Isolation precautions and an oral medication to treat itching. Record review of Resident #25's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #25's Order Summary dated 12/23/23 revealed: - 12/09/23- Sulfur 5% lotion for dermatitis, apply to entire body from neck down, rub in and leave on for 24 hours. - 12/11/23- Permethrin 5%- apply to head to toe topically one time only for scabies infestation. Leave on for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23- Contact Isolation: use strict contact precautions with protective garments, every shift for scabies infestation. Record review of Resident #25's December 2023 MAR revealed, Resident #25 received Permethrin 5% on: - 12/12/23 at 08:43 AM - 12/20/23 at 12:52 AM Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #25 was in the middle bed in a full body, long sleeve jump suit. When the Treatment Nurse removed his body suit, Resident #25 was observed with had light pink, small, raised bumps to both upper arms and on the abdomen. The Treatment Nurse stated Resident #25 was treated with Hydrocortisone cream beginning 11/30/2023 for a rash to both arms and legs. Resident #37 Record review of Resident #37's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: epilepsy, asthma, arthritis, type 2 diabetes and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 8 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 scabies with an onset date of 12/16/23. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #37's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15, rejection of care, substantial/maximal assistance with most ADLs and application of ointments/medications to skin other than feet. Residents Affected - Many Record review of Resident #37's undated Care Plan revealed, no documented focus areas addressing, skin, rashes or scabies. Record review of Resident #37's Census revealed he shared a room with Resident #107 from 08/28/23 to 09/23/23. Record review of Resident #37's Progress Notes from 12/22/22 to 12/23/23 revealed: - 09/22/23 at 02:33 PM the resident had a new rash to both arms, chest and legs. There was no documentation of the resident being placed on contact isolation. - 09/22/23 at 02:49 PM: Change of condition identified in a change in skin condition, the resident has a personal history of infectious and parasitic diseases. Skin Status Evaluation: itching rash and an order was given for Permethrin 5% to chest both legs and both arms which should be washed of in 8-12 hrs, hydrocortisone 1% cream for 7 days and calamine lotion for 2 weeks. There was no documentation of the resident being placed on contact isolation. - 10/02/23 at 10:34 PM: PERMETHRIN CREAM 5% APPLIED ON RESIDENT ENTIRE BODY THIS SHIFT AND TO BE WASHED OFF IN 8-12HRS. - 10/16/23 Resident on day 5/7 of antibiotics for cellulitis. Rash remains. - 10/18/23 Resident still on antibiotics for cellulitis. Rash still present and some itching noted. - 10/20/23 Resident still noted with rash all over his body and treatments continue - 10/27/23 Resident continues with steroid cream to the body for generalized rash, red raised bumps noted. - 10/40/23 Generalized rash red in color and bumpy. - 11/03/23 Rash present to body, generalized mild redness with complaints of mild itching. - 11/06/23 Rash still visible. - 11/08/23 Resident with generalized rash to body, some itching noted-redirected to avoid infection/pain. - 11/21/23 Resident seen by NP, new orders to apply steroid cream to rash all over his body twice daily for 30 days. - 11/24/23 Rash remains reddened pronounced and generalized. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 9 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 - 11/28/23 Rash remains reddened pronounced and generalized Level of Harm - Immediate jeopardy to resident health or safety - 12/06/23 Rash remains reddened. Apply steroid cream to torso, back, upper extremities and thighs. - 12/13/23 Resident was on antibiotics for skin cellulitis and generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted. Residents Affected - Many - 12/14/23 Rash with little improvement. - 12/15/23 generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted and worse. - 12/18/23 Day 1 of Permethrin 5% treatment to body An observation and interview on 12/12/23 at 09:55 AM revealed, Resident #37 lying in bed well dressed and well-groomed with rashes/scabs to his arms. When asked about the rash./sores the resident said everything was ok and would not respond further. Record review of Resident #37's NP Note dated 11/28/23 revealed, evaluation of dermatitis. Patient has rash to upper torso. Record review of Resident #37's NP Note dated 12/09/23 revealed, dermatitis unresolved. Record review of Resident #37's NP Note dated 12/12/23 revealed, dermatitis unresolved. Likely scabies infection will treat with Permethrin, repeat dose if not resolved and contact isolation precautions. Record review of Resident #37's Order Summary sprinted 12/23/23 revealed: - 06/23/23 Permethrin 5% for dermatitis, apply for 2 days. - 09/22/23 Permethrin 5%- apply to arms, legs, chest typically one time only written for 2 days. - 10/02/23 Permethrin 5% for scabies - Contact precautions- use contact precautions with protective garments. There are no previous orders for contact precautions - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments Record review of Resident #37's September 2023 MAR printed 12/23/23 revealed: - 09/22/23 Permethrin 5% applied at 04:45 PM. - 09/22/23 to 09/29/23 hydrocortisone 1% to arms, legs, and chest for pruritis at 09:00 AM and 05:00 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 10 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Record review of Resident #37's October 2023 MAR printed 12/23/23 revealed: Level of Harm - Immediate jeopardy to resident health or safety - 10/02/23 Permethrin 5% applied at 09:29 PM. Residents Affected - Many Record review of Resident #37's November 2023 MAR printed 12/23/23 revealed: - 10/26/23 to 10/31/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis - 11/01/23 to 11/06/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Resident #84 Record review of Resident #84's Face Sheet dated 12/19/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of: Parkinson, dementia, depression, communication deficit and scabies with onset of 12/16/23. Record review of Resident #84's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and application of ointments/medications to the skin other than the feet. Record review of Resident #84's undated Care Plan revealed, no focus areas address rashes, itching or scabies. Record review of Resident #84's Census revealed, he shared a room with Resident #107 from 08/28/23 to 09/23/23 Record review of Resident #84's Progress Notes from 12/22/22 to 12/23/23 revealed, - 09/15/23 Resident noted with rash to entire body. - 10/03/23 Rash red and bumpy in appearance to legs and right thigh. - 10/20/23 Resident still noted with rash all over his body, treatment continues - 10/23/23 Resident given oral steroids for rash to lower legs, and areas of dry skin - 11/03/23 rash to both legs present bumpy and red. - 11/06/23 Dermatology appointment cancelled and will be rescheduled. - 11/16/23 Rash remains reddened, raised and generalized. - 11/30/23 Resident given oral antifungal for rash. - 12/14/23 Resident rash to both legs with little improvement. -12/15/23 Generalized rash/itching remain the same Record review of Resident #84's Order Summary report printed 12/23/23 revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 11 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments Level of Harm - Immediate jeopardy to resident health or safety - 12/16/23 Contact precautions with protective garments every shift Residents Affected - Many An observation on 12/12/23 at 09:55 AM revealed, Resident # 84 lying in bed with a limited range of motion and wedge pillows propping him up. The resident was observed to have a rash on both his arms and had limited communication capability and all he could say his butt burned. - 12/2/23 Permethrin 5% for scabies. Use contact precautions with protective garments In an interview on 12/12//23 at 10:00 AM, the treatment nurse said Resident #84 was previously treated for wounds on his buttocks but the medication was discontinued because the issue had resolved. She said she would visit the resident to reassess him, and notify the wound care doctor about the resident's complaints. The Treatment Nurse did not address the Resident #84's itching. Resident #20 Record review of Resident #20's Face Sheet dated 12/16/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses: dementia, mood disorder, Anxiety disorder and depression. Record review of Resident #20's 5-day MDS dated [DATE] revealed, severely intact cognition as indicated by a BIMS score of 00 out of 15, partial assistance with most ADLs and no application of ointments/medication to the skin. Record review of Resident #20's undated Care Plan revealed, focus- elopement risk/wanderer onset 04/17/23; intervention- intervene as appropriate, distract resident from wandering by offering pleasant diversion, food, conversations, television or books. The care plan does not address any skin issues. Record review of Resident #20's MD Note dated 12/13/23 revealed, resident was started on a steroid cream for itching for 7 days. Skin: new rash to the back of the hand with some redness around it. Record review of Resident #20's Order Summary dated 12/23/23 revealed: - 11/03/23 Prednisone ( a steroid) 20 mg- 1 tablet one time a day for rash for 3 days. - 11/03/23 Hydrocortisone 1 %- apply topically two times a day for rash/dry skin - 11/03/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/03/23 Prednisone 10 mg- 1 tablet by mouth 1 time a day for rash for 5 days starting 11/08/23. - 11/27/23 Prednisone 20 mg- give 2 tablets by mouth daily for pruritus. - 11/27/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/28/23 Hydrocortisone 1 % for pruritus- apply topically two times a day to torso, both upper and lower extremities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 12 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments Level of Harm - Immediate jeopardy to resident health or safety - 12/16/23 Contact Precautions- use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments scheduled for 12/24/23 Residents Affected - Many An observation and interview on 12/12/23 at 09:45 AM revealed, Resident #20 well dressed, well-groomed in a wheelchair in front of his room. The resident was wearing a long sleeve shirt but a rash could be seen at the end of the sleeve of his right arm FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 13 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the 1 of 4 resident's (CR #75), representative of the transfer or discharge and the reasons for the move in writing and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, reviewed for discharges, in that: A notice in writing was not issued to CR #75's family member and to the Ombudsman following the facility-initiated discharge on [DATE]. This failure placed residents at risk of a being discharged without notification, their consent and not having their goals met. Findings included: Record review of CR#72's face sheet revealed the resident was a [AGE] year-old male who was admitted into the facility on [DATE] and was discharged on 11/30/2023. The resident was diagnosed with Alzheimer's disease, anxiety disorder and dementia. Record review of CR #75's MDS, dated [DATE] revealed the resident ambulated by wheelchair and needed moderate to maximal assistance for most ADLs. Record review of CR #75's progress notes, dated 11/29/2023, reflected, Staff reports [CR #75] has been very agitated, refusing care, refusing tx, intrusive, getting into other ways, pushing and physically aggressive and combative with staff when staff attempting to redirect his current behavior. unable to verbally redirect his behaviors and current med plan was not effective to manage behavioral disturbance. Educated and encouraged him to stay away from others personal space and away from exit door due to wandering risk. Mumbling to self and continued to pull his clothing's off him. NP was here to assess and may need to have further evaluation and tx . SW spoke to [family member] regarding his current behavioral [sic] as he was placing self and other in danger, med intervention and referral to [hospital] . [family member] was in agreement with current plan of care. Record review of CR #75's progress notes, dated 11/30/2023, reflected, [CR #75] accepted at [hospital] for further evaluation and treatment. SW spoke to [receiving facility staff] regarding resident not able to return to the facility due to unable to meet his needs and placing self and others in danger . SW also spoke to [family member] regarding resident going to [hospital] for [evaluation] and treatment and Hospital and this SW will work in collaboration to look for an appropriate facility for continued care. Nursing and administration notified . Note written on the same day reflected, The resident was transferred . via stretcher by [EMS] personnel . In a phone interview with the SW on 12/18/23 on 2:34 PM, he stated he documented lengthy notes about CR #75's behavior and talked to the resident's family member about it. He stated he did not plan for the resident to return to the facility due to safety concerns and that was also discussed with the family member. He stated he did not write a letter disclosing the reason for the resident's discharge or send a copy to the Ombudsman because he did not have authority to do so, but only the Administrator had the authority. He stated he talked to Administrator A to issue that notice to the family. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 14 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a phone interview with the family member on 12/19/23 at 11:00 AM, she reported she was told the day of his discharge the reason for it and that he would not be returning to facility due to his condition. She stated she has since not been provided any letter or notice by either the SW or Administrator A regarding the conditions of his discharge. In a phone interview with the Ombudsman on 12/19/23 at 11:39 AM, she stated she was not given a discharge notice regarding CR #75. She said she was not sure if the facility knew to send her a copy of the notice of discharge. In an interview with BOM on 12/19/23 at 12:54 PM, she stated she would not have issued any immediate discharge notices, that would instead be the SW's role and the Administrator would send the notices out. She said she only handled discharges for financial reasons. In an interview with the Corporate Consultant Administrator on 12/19/2023 at 2:00PM, he stated after speaking with the Administrator A over the phone, she revealed to him that she did not issue any discharge notices to the family or Ombudsman concerning CR #75 prior to her resignation. In an interview with Administrator B on 12/20/2023 at 3:00PM, she stated she knew the physician, responsible party and the ombudsman should be notified of the reason of a facility-initiated discharge but did not know if a written notice was required to be given to the RP or ombudsman in the case of an immediate discharge to due possible endangerment to other residents as in CR #75's case. Record review of the facility's policy on Transfer or Discharge Notice, dated March 2021, reflected, . 5) The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location wo which the resident was being transferred or discharged ; an explanation of the resident's rights to appeal the transfer or discharge to the state . 6) A copy of the notice was sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer of discharge was provided to the resident and representative . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 15 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 2 Residents (Resident #49) reviewed for tracheostomy care, in that:. Residents Affected - Few -the facility failed to immediately reposition the oxygen mask over Resident #49's tracheostomy when the resident was found in distress. -the facility failed to immediately suction Resident #49's tracheostomy when the resident was found in distress, with copious (abundant) amounts of secretions at the tracheal tube. -the facility failed to ensure the oxygen mask was in place to provide continuous oxygen flow to Resident #49 prior to leaving the resident's room. -the facility failed to maintain sterile procedure prior to tracheostomy suctioning for Resident #49. An Immediate Jeopardy (IJ) situation was identified on 12/17/23. The IJ template was provided to the facility on [DATE] at 11:36 AM. While the IJ was removed on 12/22/23, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility still monitoring the effectiveness of their Plan of Removal. These deficient practices could place residents who were dependent on oxygen therapy at risk of respiratory distress, respiratory arrest, decline in health and hospitalization. Findings included: Record review of Resident #49's face sheet dated 12/12/2023 revealed a [AGE] year-old female admitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. Her diagnoses included dementia, hypotension (low blood pressure), chronic respiratory failure, tracheostomy status (an airway surgically created through the neck into the windpipe to allow direct access to the breathing tube to provide an airway and to remove secretions from the lungs), impaired swallowing, gastrostomy status (a feeding tube inserted through the abdomen to allow administration of nutrition), seizures, metabolic encephalopathy( brain disturbance caused by conditions that disrupt blood chemistry affecting brain function), traumatic subdural hemorrhage (brain bleed), diabetes and anxiety disorder. Record review of Resident #49's hospital records revealed she was admitted to the hospital on [DATE] for hypoxia (deprivation of oxygen at the tissue level) and hypotension (low blood pressure). The resident had a fever and was having secretions coming out the tracheostomy site. Her diagnoses included septic shock r/t aspiration PNA, acute respiratory failure r/t aspiration PNA and bacterial sepsis (a potentially life threatening infection). The resident was admitted to the ICU and placed on contact and droplet isolation. The resident was discharged to the facility on [DATE] . Record review of Resident #49's quarterly MDS dated [DATE] revealed the resident had minimal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 16 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 - Immediate jeopardy to resident health or safety Residents Affected - Few difficulty hearing, had no speech, was rarely/never understood, rarely/never understood others and had impaired vision. She required total dependence with one-to-two-person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. She had functional limitations in range of motion d/t impairment on both sides of upper and lower extremities. She had medically complex conditions. Section I of the MDS revealed active diagnoses in the last 7 days included respiratory failure and chronic respiratory failure. Section O of the MDS revealed she required oxygen therapy and tracheostomy care while not a resident and while a resident. Record review of Resident #49's order summary report dated 12/12/2023 revealed the following active physician orders: O2 (oxygen) via tracheostomy @ 28-40% (2-5 L/m) to keep oxygen saturation rate at 92% or greater every shift related to tracheostomy status. Suction tracheostomy PRN for patent airway every shift. Monitor for pain every shift. Tracheostomy care every shift, clean stoma with normal saline, pat dry, change dressing every shift. Turning and repositioning every 2 hours. Further review revealed a physician's order for Ipratropium-Albuterol Solution 3ml inhale orally every 6 hours for SOB/Wheezing, pre-Respiratory Treatment Assessment prior to administering medication. Post Nebulizer Assessment every 6 hours . Record review of Resident #49's undated care plan revealed the following, Focus: The resident had altered respiratory status r/t chronic respiratory failure with trach placement. Interventions included administer medications as ordered, monitor for s/sx of respiratory distress and report to the physician, monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea (temporary cessation of breathing, especially during sleep), prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring; and provide oxygen as ordered. Focus: The resident had a tracheostomy r/t chronic respiratory failure. Interventions included: change oxygen tubing per protocol, change trach tubing and cannula per order, ensure trach ties are secured at all times, humidified oxygen as prescribed and suction as necessary. Focus: The resident had oxygen therapy r/t ineffective gas exchange. Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Interventions included: give medications as ordered, monitor for s/sx of respiratory distress and report to MD, prevent abdominal compression and impaired respiratory functioning by routinely checking the resident's position to prevent sliding down in bed. Further review revealed no interventions to address potential complications such as unplanned extubation, aspiration, respiratory infection, tracheal infection and mucus plugging. Further review revealed no mention of hospitalization on 09/05/2023. Resident #49 was admitted to the ICU for aspiration PNA and sepsis. In an interview on 12/15/2023 at 7:22AM, LVN R stated she was new and had been working at the facility for only three weeks. LVN R stated she was assigned to the residents in 200 Hall, including the two residents with tracheostomies. LVN R stated she had respiratory care training for tracheostomy residents during orientation and the topics included oxygen, suctioning, trach care, s/s of infection and secretions. LVN R stated the inservice was conducted by Respiratory Therapy and she could not recall the therapist's name. Observation and interview on 12/15/2023 at 7:40 AM revealed Resident #49 in bed and her upper body leaning to her right side with the top of her head against the wall. The head of the bed was raised. The trach mask connected to the oxygen tubing was not over Resident #49's tracheostomy to provide continuous flow of oxygen and the straps on the mask was very loose. Copious amounts of thick, white secretion were inside the tracheostomy tube covering almost the entire opening and dripped down onto (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 17 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 - Immediate jeopardy to resident health or safety Residents Affected - Few the resident's chest. The resident showed visible signs of distress in that her eyes were opened very wide with a fixed, glassy stare, her eyebrows furrowed, her chest barely moving, and her upper body bent in an awkward position. The resident's arms were bent at the elbows and her hands were contracted into fists. LVN R put on clean gloves, straightened the resident's body upright. The oxygen mask was still not over the resident's tracheostomy. LVN R stated the first thing she would do was to check the resident's oxygen saturation rate and check her blood pressure. LVN R stated she would need to get the equipment from down the hall. LVN R positioned the oxygen mask over the resident's tracheostomy after the Surveyor intervened. LVN R left the room. Resident #49's eyes closed, and her facial muscles relaxed. The oxygen was set at 3L/m. Resident #49's respiration rate was shallow at approximately 20 breaths per minute. At 7:47 AM LVN R returned with the O2 sat monitor and automated BP cuff. Resident #49's oxygen saturation rate fluctuated and then settled at 97% - 98%. At 7:55 AM the resident's BP on her left upper arm was 100/60 and pulse was 71 bpm. The opening to the tracheostomy still had thick secretions. At 7:58AM, LVN R stated she was going to suction the resident. She gathered supplies from the room. LVN R washed her hands and placed the sterile tracheostomy care kit on the bedside table. LVN R opened the kit that contained sterile gloves, bottle of sterile NS (normal saline) and a sterile single use suction catheter. LVN R put on the sterile gloves and stated she forgot to turn on the suction machine. LVN R stopped and was looking around the room. LVN R stated she had sterile gloves on. The Surveyor intervened and asked if she touched the items outside the sterile field would the gloves be sterile or clean. LVN R stated they would be clean and no longer sterile then she removed the gloves. LVN R removed the plastic dust cover and turned on the suction machine. LVN R held the suction machine tubing and was attempting to place the tubing onto the bedside table. The suction tubing slipped and would not stay put on the table without LVN R holding onto it. After LVN R hesitated, the surveyor said if the tubing touched the floor would it be clean. LVN R stated it would become dirty. LVN R asked the Surveyor if it was ok to hang the tubing on the IV pole. LVN R hung the tubing on the IV pole. At 8:07AM LVN R washed her hands, put on pair of non-sterile gloves. LVN R opened the sterile suction catheter package and connected it to the suction machine tubing. LVN R opened the bottle of sterile NS and suctioned some of the sterile NS solution. LVN R moved the oxygen trach mask away from the opening of the tracheostomy. LVN R handled the tip of the sterile catheter then positioned it over the resident's tracheostomy, moving the tip closer to the inside of the tracheal tube. The Surveyor intervened prior to LVN R introducing the catheter tip into the resident's tracheal tube. LVN R stated the gloves were not sterile after the Surveyor intervened. LVN R stated she forgot and needed sterile gloves to prevent infection. LVN R disposed of the gloves and the catheter into the trash. LVN R searched the room and said there were no more sterile suction catheters in the room and that she needed to get another one. LVN R left the room. The oxygen trach mask was not positioned over the resident's tracheostomy. The resident was not receiving the continuous flow of oxygen. The Surveyor intervened, put on clean gloves and quickly placed the mask over the tracheostomy for the resident to start receiving the flow of oxygen. Resident #49's O2 sat was 98%. LVN R returned with supplies. LVN R stated she just forgot to put the trach mask back on the resident . At 8:15 AM the Surveyor exited the room to find a nurse to assist LVN R with suctioning. In an interview on 12/15/2023 at 8:15 AM, ADON B was walking down the hallway. The Surveyor explained that LVN R may need some assistance. ADON B stated the first thing LVN R should have done was suction Resident #49 to ensure the airway was patent and not blocked with secretions. ADON B stated she saw another nurse just then enter Resident #49's room. In an interview on 12/15/2023 at 12:40PM, LVN R stated her shift started at 6:00 AM. LVN R stated she came in late, made her rounds, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 18 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 - Immediate jeopardy to resident health or safety Residents Affected - Few checked on Resident #49 and found her to be OK. LVN R stated she was not too familiar with Resident #49 and did not know her respiratory status. LVN R stated some s/sx of respiratory distress would be facial expressions, eyes widening and labored breathing. LVN R stated when she first entered the room with the Surveyor, the resident was bent to one side, had increased secretions, and she looked tired. LVN R stated the positioning of the trach mask was off of the resident's tracheostomy and the straps to the trach mask should have been tighter. LVN R stated the straps and trach mask could have become loose during patient care. LVN R stated Resident #49 was supposed to have continuous oxygen and it was the nurse's responsibility to ensure the resident was receiving a continuous flow of oxygen. LVN R stated this was important so not to put the resident into respiratory distress. LVN R stated she should have positioned the oxygen mask back first before leaving the room. LVN R stated she forgot because she was nervous. LVN R stated she suctioned Resident #49 after the Surveyor left the room and that she did not have trouble with the procedure. In an interview on 12/15/2023 at 1:10 PM, the DON stated the first thing the nurse should have done was to get an oxygen saturation reading and suction the resident to prevent respiratory distress . In an interview on 12/16/2023 at 2:15 PM, RN D stated LVN R was a new nurse and panicked. RN D stated some s/sx of respiratory distress would be face changes, change in breathing pattern (which was distress), pain and something that would just not be right with the resident. RN D stated the risks to the resident would be respiratory distress, hypoxia, lethargy, infection d/t copious secretions. RN D stated she would not leave the resident, but instead would call for help and yell if she had to. RN D stated the first thing she would have done would be to increase the oxygen setting to ensure Resident #49 was getting enough oxygen. RN D stated she would not leave the resident without the oxygen mask on first. In a telephone interview on 12/16/2023 at 4:45 PM, RT B stated s/sx of respiratory distress would be changes in breathing pattern, bug eyed, crunched forehead and use of accessory muscles. RT B stated the number one s/sx of respiratory distress was restlessness. RT B stated nurses and RTs were responsible to ensure the resident was safe. RT B stated he would put the oxygen back on the resident, do an assessment, ensure the tubing was clean, with no kinks then move to the next assessment and suction clearing the airway. In a telephone interview on 12/18/2023 at 11:45 AM, the MD stated Resident #49 was dependent on oxygen and was totally dependent on staff for ADLs. The MD stated she expected that the oxygen would be on all the time. The MD stated Resident #49 was able to tolerate being off oxygen at times, but waxes and wanes. The MD stated the risks if the resident did not receive continuous oxygen would be respiratory distress, trouble breathing, increased respiratory rate, increased crackles, may have excessive secretions. The MD stated sometimes resident's heartbeat could exceed the normal resting rate and sometimes the blood pressure may change. The MD stated she would expect that nursing staff or RT would suction the resident if there were increased secretions. The MD stated sometimes she would order chest x-rays and/or labs. The MD stated she was not aware that Resident #49 had any issues on 12/15/2023 but there were other physicians that could have been notified. In an interview on 12/21/2023 at 12:19 PM, CNA EE stated she was assigned to Resident #49 and stated the nursing staff must do everything for her as she cannot do for herself. CNA EE stated the resident cannot move her legs, she can move one arm more than the other, when the Surveyor asked if the resident was able to move her limbs. CNA EE stated the signs of distress she saw were when she moved Resident #49's right leg for example and she heard the resident make a noise, sometimes she may cough and sometimes she would raise her eyebrows up and down. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 19 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of the facility's undated policy and procedure titled Skills Checklist - Tracheostomy suctioning, open suction system, read in part: .Objective: To suction a tracheostomy using an open suction system according to the standard of care .perform hand hygiene .Assess the patient's vital signs, breath sounds, respiratory effort and general appearance .remove the lid from the sterile solution and place it upside down on a clean surface .Using sterile technique, open the suction catheter kit and put on gloves. If using individual supplies, open the suction catheter and the gloves, then put on the gloves by first placing the nonsterile glove on your nondominant hand and then placing the sterile glove on your dominant hand. Using your nondominant (nonsterile) hand, pour a small amount of sterile solution into the sterile container. Close the solution bottle using your nondominant hand. Pick up the sterile suction catheter with your dominant (sterile) hand. Coil the catheter around your hand. Using your nondominant (nonsterile) hand, attach the catheter to the tubing. Turn the suction control valve to the on position and set the suction pressure to the lowest possible vacuum pressure needed to effectively clear secretions. Using your dominant (sterile) hand, lubricate the outside of the catheter by dipping in into the sterile solution. With the suction catheter tip in the sterile solution, occlude the suction control valve with the thumb of your nondominant hand; suction a small amount of the solution through the catheter. If the patient has a collar over the tracheostomy tube, move it Preoxygenate the patient with 100% oxygen for 30 to 60 seconds using a handheld resuscitation bag if necessary .Disconnect the handheld resuscitation bag if used. Insert the suction catheter into the tracheostomy tube; don't apply suction while inserting the catheter. Withdraw the catheter while applying intermittent suction and rotating the catheter between your fingertips. Reapply the tracheostomy collar .between suctioning passes . Record review of Lippincott Manual of Nursing Practice 11th Edition, Philadelphia, 2019 Wolters Kluwer, editor [NAME] M. [NAME], Chapter 10 Respiratory Function and Therapy, General Procedures and Treatment Modalities, read in part: .Types of Airways .6. Tracheostomy tube .a. Permits mechanical ventilation and facilitates secretion removal b. Can be for long-term use c. Bypasses upper airway defenses, increasing susceptibility to infection .Mobilization of Secretions - The goal of airway clearance techniques was to improve clearance of airway secretions, thereby decreasing obstruction of the airways. This serves to improve ventilation and gas exchange .Suctioning through an Endotracheal or Tracheostomy tube .4. Maintain sterile technique while suctioning . This was determined to be an Immediate Jeopardy (IJ) on 12/17/2023 at 11:36 AM. The Administrator was notified. The Administrator was provided the IJ template on 12/17/2023 at 11:36 AM. The POR submitted by the Administrator was accepted on 12/21/2023 at 12:20 PM. The POR revealed:

F695 - Respiratory Care The facility failed to ensure that the resident received the necessary treatment and services in accordance with professional practice. 12/15/2023 Resident #49 was assessed by the respiratory therapist and the ADON and notified family and physician. 12/17/2023 Resident #49 not in facility 12/20/2023 Resident returned to the facility. 12/17/2023 remaining resident with a trach was immediately assessed by the respiratory therapist in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 20 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 house. Status-stable and no respiratory distress 12-17-2023 Level of Harm - Immediate jeopardy to resident health or safety 12/17/2023 Identified Nurse re-educated on the policy and procedures for respiratory assessment, oxygen therapy, nebulizer therapy, tracheostomy suctioning and tracheostomy care. Respiratory Therapist provided the 1:1 training with return demonstration. Residents Affected - Few 12/17/203 All Nurses received training respiratory assessment, signs and symptoms of respiratory distress and how to manage respiratory distress. The training also covered principals of oxygen therapy nebulizer Therapy, suctioning, tracheostomy care and emergency care. All nurses are responsible for providing tracheostomy care to residents. Training completion date will be 12/20/2023. New Hire nurses will receive training on respiratory assessment, signs and symptoms of respiratory distress and how to manage respiratory distress. All nurses are provided as well as trach training that was provided by the respiratory therapist. CNAs, and all ancillary departments were educated on sign and symptoms of respiratory distress when to notify the Charge Nurse if respiratory distress was observed. Training was provided by Rn/RCP H and RT B. The training was completed on 12/19/23. The charge nurse will ensure that the resident with trach was monitored with her clinical rounds and note any respiratory distress based on their individual needs of the resident and prn as indicated. The monitoring of trach patients are completed routinely in the shift and prn as indicated by resident clinical condition. The charge nurse will observe the resident to ensure trach collar was in place and resident was receiving adequate oxygen and trach was clear of excessive secretions. Resident with trach will be suctioned per physician orders and as needed based off of the clinical changes in the resident. All new hires will be required to complete training prior to job start. Staff education initiated per DON on 12/17/2023 on identifying signs and symptoms of respiratory distress and assessment. Training completion date 12/19/2023 All nursing staff will receive training prior to their next shift. The Medical Director was notified of the IJ on 12/17/2023. The facility QAPI team reviewed the Respiratory Treatment and Care Policies on 12/20/2023. Monitoring of the plan of removal included: Following acceptance of the facility's Plan of Removal, the facility was monitored from 12/21/23 to 12/22/2023. The surveyor confirmed the facility implemented their plan of removal sufficiently from 12/21/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 21 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 12/22/23 to remove the IJ by: Level of Harm - Immediate jeopardy to resident health or safety Observations on 12/22/23 of the only two residents in the facility with tracheostomies who were receiving oxygen therapy. Residents Affected - Few In an interview on 12/22/23 at 9:15 AM, ADON B stated after discussion with Surveyor on 12/15/23 at 8:15 AM, she did go into Resident #49's room and that the resident was stable. In a telephone interview on 12/22/23 at 5:00 PM, RN/RCP H stated she did assess Resident #49 after LVN R completed tracheal suctioning on 12/15/23 and stated the resident was stable. Interviews were conducted with staff, including LVN R, from all three shifts from 12/21/2023 - 12/22/23: DON, 3 RNs, 4 LVNs, 2 RTs, 7 CNAs, 1 ancillary staff. Nurses were able verbalize their understanding regarding resident assessments for the residents with tracheostomies; all aspects of respiratory care including, tracheostomy care, tracheal suctioning, oxygen therapy, nebulizer treatment, ensuring proper fit with the oxygen tracheostomy mask, respiratory assessments, emergency procedures, signs and symptoms of acute respiratory distress as well as abuse and neglect policies and procedures. CNAs and ancillary staff were able to verbalize their understanding of signs and symptoms of respiratory distress, when to notify the charge nurse. Record review of the December 2023 physician orders, MAR/TAR, progress notes, physician notes and hospital records for the two residents (#49 and #93) with tracheostomies requiring oxygen therapy. Record review of the facility's policies and procedures for change of condition, revised May 2017; resident assessments, revised March 2022; respiratory assessments, date reviewed April 15, 2016; oxygen administration, revised October 2, 2015; tracheostomy emergencies-dislodgement. Record review of staff, competency check lists and training reports conducted 12/15/23 through 12/22/23 for the following: respiratory assessments, signs/symptoms of respiratory distress and how to manage respiratory distress; tracheostomy care; tracheostomy suctioning; oxygen therapy; nebulizer treatments; infection control and conducted by Respiratory Therapists and DON. Record review of LVN R's re-education, competency check list completed on 12/18/23. QAPI meeting worksheet dated 12/20/23, included respiratory care/respiratory distress, abuse/neglect, infection control was attended and signed by: Administrator, DON, ADON, IP, Wound care nurse, Social Services, Activities, Housekeeping Director, Maintenance Director, Medical Records Director, and Medical Director. The Administrator was unavailable. The Chief Officer of Operations was informed the Immediate Jeopardy (IJ) was removed on 12/22/2023 at 5:10 PM. While the IJ was lowered on 12/22/23, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility still monitoring the effectiveness of their Plan of Removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 22 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure that licensed nurses possess the specific competencies and skill sets necessary to provide nursing services to meet the residents' needs safely, and in a manner that promotes each resident's rights, physical and mental well-being as identified through resident assessments, and described in the plan of care for one of 16 (LVN R) facility staff reviewed for competencies and skill sets for assessments, in that: LVN R failed to take prompt actions and identify potential issues early, without Surveyor intervention when Resident #49 was observed to be in distress for an unknown period of time. LVN R failed to ensure Resident #49 was receiving continuous oxygen prior to leaving the resident alone. LVN R failed to ensure sterile gloves were used prior to handling the sterile suction catheter for Resident #49. An Immediate Jeopardy (IJ) situation was identified on 12/17/23. The IJ template was provided to the facility on [DATE] at 11:36 AM. While the IJ was removed on 12/22/23, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility still monitoring the effectiveness of their Plan of Removal. These failures in competencies could place residents at risk of their needs not being met safely, decline in health or hospitalization. Record review of Resident #49's face sheet dated 12/12/2023 revealed a [AGE] year-old female admitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. Her diagnoses included dementia, hypotension (low blood pressure), chronic respiratory failure, tracheostomy status (an airway surgically created through the neck into the windpipe to allow direct access to the breathing tube providing an airway and to remove secretions from the lungs), impaired swallowing, gastrostomy status(a feeding tube inserted through the abdomen to allow administration of nutrition), seizures, metabolic encephalopathy ( brain disturbance caused by conditions that disrupt blood chemistry affecting brain function), traumatic subdural hemorrhage(brain bleed), diabetes and anxiety disorder. Record review of Resident #49's hospital records revealed she was admitted to the hospital on [DATE] for hypoxia (deprivation of oxygen at the tissue level) and hypotension (low blood pressure). The resident had a fever and was having secretions coming out the tracheostomy site. Her diagnoses included septic shock r/t aspiration PNA, acute respiratory failure r/t aspiration PNA and bacterial sepsis (a potentially life threatening infection). The resident was admitted to the ICU and placed on contact and droplet isolation. The resident was discharged to the facility on [DATE] . Record review of Resident #49's quarterly MDS dated [DATE] revealed the resident had minimal difficulty hearing, had no speech, was rarely/never understood, rarely/never understood others and had impaired vision. She required total dependence with one-to-two-person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. She had functional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 23 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few limitations in range of motion d/t impairment on both sides of upper and lower extremities. She had medically complex conditions. Section I of the MDS revealed active diagnoses in the last 7 days included respiratory failure and chronic respiratory failure. Section O of the MDS revealed she required oxygen therapy and tracheostomy care while not a resident and while a resident. Record review of Resident #49's order summary report dated 12/12/2023 revealed the following active physician orders: O2 (oxygen) via tracheostomy @ 28-40% (2-5 L/m) to keep oxygen saturation rate at 92% or greater every shift related to tracheostomy status. Suction tracheostomy PRN for patent airway every shift. Monitor for pain every shift. Tracheostomy care every shift, clean stoma with normal saline, pat dry, change dressing every shift. Turning and repositioning every 2 hours. Ipratropium-Albuterol Solution 3ml inhale orally every 6 hours for SOB/Wheezing, pre-Respiratory Treatment Assessment prior to administering medication. Post Nebulizer Assessment every 6 hours. Record review of Resident #49's undated care plan revealed the following, Focus: The resident had altered respiratory status r/t chronic respiratory failure with trach placement. Interventions included administer medications as ordered, monitor for s/sx of respiratory distress and report to the physician, monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea (temporary cessation of breathing, especially during sleep), prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring; and provide oxygen as ordered. Focus: The resident had a tracheostomy r/t chronic respiratory failure. Interventions included: change oxygen tubing per protocol, change trach tubing and cannula per order, ensure trach ties are secured at all times, humidified oxygen as prescribed and suction as necessary. Focus: The resident had oxygen therapy r/t ineffective gas exchange. Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Interventions included: give medications as ordered, monitor for s/sx of respiratory distress and report to MD, prevent abdominal compression and impaired respiratory functioning by routinely checking the resident's position to prevent sliding down in bed. Further review revealed no interventions to address potential complications such as unplanned extubation, aspiration, respiratory infection, and mucus plugging. Further review revealed no mention of hospitalization on 09/05/2023 when Resident #49 was admitted to the ICU for aspiration PNA and sepsis . In an interview on 12/15/2023 at 7:22AM, LVN R stated she was new and had been working at the facility for only three weeks. LVN R stated she was assigned to the residents in 200 Hall, including the two residents with tracheostomies. LVN R stated she had respiratory care training for tracheostomy residents during orientation and the topics included oxygen, suctioning, trach care, s/s of infection and secretions. LVN R stated the inservice was conducted by Respiratory Therapy and she could not recall the therapist's name. Observation and interview on 12/15/2023 at 7:40 AM revealed Resident #49 in bed and her upper body leaning to her right side with the top of her head against the wall. The head of the bed was raised. The trach mask connected to the oxygen tubing was not over Resident #49's tracheostomy to provide continuous flow of oxygen and the straps on the mask was very loose. Copious amounts of thick, white secretion were inside the tracheostomy tube covering almost the entire opening and dripped down onto the resident's chest. The resident showed visible signs of distress in that her eyes were opened (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 24 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few very wide with a fixed stare, her eyebrows furrowed, her chest barely moving, and her upper body bent in awkward position. The resident's arms were bent at the elbows and hands were contracted into fists. LVN R put on clean gloves, straightened the resident's body upright. The oxygen mask was still not over the resident's tracheostomy. LVN R stated the first thing she would do was to check the resident's oxygen saturation rate and check her blood pressure. LVN R stated she would need to get the equipment from down the hall. LVN R positioned the oxygen mask over the resident's tracheostomy after the Surveyor intervened. LVN R left the room. Resident #49's eyes closed, and her facial muscles relaxed. The oxygen was set at 3L/m. Resident #49's respiration rate was shallow at approximately 20 breaths per minute. LVN R returned at 7:47 AM with the O2 sat monitor and automated BP cuff. Resident #49's oxygen saturation rate fluctuated and then settled at 97% - 98%. At 7:55 AM the resident's BP on her left upper arm was 100/60 and pulse was 71 bpm. The opening to the tracheostomy still had thick secretions. At 7:58AM, LVN R stated she was going to suction the resident. She gathered supplies from the room. LVN R washed her hands and placed the sterile tracheostomy care kit on the bedside table. LVN R opened the kit that contained sterile gloves, bottle of sterile NS (normal saline) and a sterile single use suction catheter. LVN R put on the sterile gloves and stated she forgot to turn on the suction machine. LVN R stopped and was looking around the room. LVN R did not move. LVN R stated she had sterile gloves on. The Surveyor intervened and asked if she touched the items outside the sterile field would the gloves be sterile or clean. LVN R stated they would be clean and no longer sterile then she removed the gloves. LVN R removed the plastic dust cover and turned on the suction machine. LVN R held the suction machine tubing and was attempting to place the tubing onto the bedside table. The suction tubing slipped and would not stay put on the table without LVN R holding onto it. After LVN R hesitated, the surveyor asked if the tubing touched the floor would it be clean. LVN R stated it would become dirty. LVN R asked the Surveyor if it was ok to hang the tubing on the IV pole. LVN R hung the tubing on the IV pole. At 8:07AM LVN R washed her hands, put on pair of non-sterile gloves. LVN R opened the sterile suction catheter package and connected it to the suction machine tubing. LVN R opened the bottle of sterile NS and suctioned some of the sterile NS solution. LVN R moved the oxygen trach mask away from the opening of the tracheostomy. LVN R handled the tip of the sterile catheter then positioned it over the resident's tracheostomy, moving the tip closer to the inside of the tracheal tube. The Surveyor intervened prior to LVN R introducing the catheter tip into the resident's tracheal tube. LVN R stated the gloves were not sterile after the Surveyor intervened. LVN R she stated she forgot and needed sterile gloves to prevent infection. LVN R disposed of the gloves and the catheter into the trash. LVN R searched the room and said there were no more sterile suction catheters in the room and that she needed to get another one. LVN R left the room. The oxygen trach mask was not positioned over the resident's tracheostomy. The resident was not receiving the continuous flow of oxygen. The Surveyor intervened, put on clean gloves and quickly placed the mask over the tracheostomy for the resident to start receiving the flow of oxygen again. Resident #49's O2 sat was 98%. LVN R returned with supplies. LVN R stated she just forgot to put the trach mask back on the resident. At 8:15 AM the Surveyor exited the room to find a nurse to assist LVN R with suctioning. In an interview on 12/15/2023 at 8:15 AM, ADON B was walking down the hallway. The Surveyor explained that LVN R may need some assistance. ADON B stated the first thing LVN R should have done was suction Resident #49 to ensure the airway was patent and not blocked with secretions. ADON B stated she just saw another nurse enter Resident #49's room. In an interview on 12/15/2023 at 12:40PM, LVN R stated her shift started at 6:00 AM. LVN R stated she came in late, made her rounds, checked on Resident #49 and found her to be OK. LVN R stated she was not too familiar with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 25 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #49 and did not know her respiratory status. LVN R stated some s/sx of respiratory distress would be facial expressions, eyes widening and labored breathing. LVN R stated when she first entered the room with the Surveyor, the resident was bent to one side, had increased secretions, and she looked tired. LVN R stated the positioning of the oxygen trach mask was off the resident's tracheostomy and the straps to the trach mask should have been tighter. LVN R stated the straps and trach mask could have become loose during patient care. LVN R stated Resident #49 was supposed to have continuous oxygen and it was the nurse's responsibility to ensure the resident was receiving a continuous flow of oxygen. LVN R stated this was important so not to put the resident into respiratory distress. LVN R stated she should have positioned the oxygen mask back first before leaving the room. LVN R stated she forgot because she was nervous. LVN R stated she suctioned Resident #49 after the Surveyor left the room and that she did not have trouble with the procedure. In an interview on 12/15/2023 at 1:10 PM, the DON stated the first thing the nurse should have done was to get an oxygen saturation reading and suction the resident to prevent respiratory distress. In an interview on 12/16/2023 at 2:15 PM, RN D stated LVN R was a new nurse and panicked. RN D stated some s/sx of respiratory distress would be face changes, change in breathing pattern (which was distress), pain and something that would just not be right with the reident. RN D stated the risks to the resident would be respiratory distress, hypoxia, lethargy (lack of energy), infection d/t copious secretions . RN D stated she would not leave the resident, but instead would call for help and yell if she had to. RN D stated the first thing she would have done would be to increase the oxygen setting to ensure Resident #49 was getting enough oxygen. RN D stated she would not leave the resident without the oxygen mask on first. In a telephone interview on 12/16/2023 at 4:45 PM, RT B stated s/sx of respiratory distress would be changes in breathing pattern, bug eyed, crunched forehead and use of accessory muscles. RT B stated the number one s/sx of respiratory distress was restlessness. RT B stated nurses and RTs were responsible to ensure the resident was safe. RT B stated he would have put the oxygen back on the resident, do an assessment, ensure the tubing was clean, with no kinks then move to the next assessment and suction clearing the airway. In a telephone interview on 12/18/2023 at 11:45 AM, the MD stated Resident #49 was dependent on oxygen and was totally dependent on staff for ADLs. The MD stated she expected that the oxygen would be on all the time. The MD stated Resident #49 was able to tolerate being off oxygen at times, but waxes and wanes. The MD stated the risks if the resident did not receive continuous oxygen would be respiratory distress, trouble breathing, increased respiratory rate, increased crackles, may have excessive secretions. The MD stated sometimes a resident's heartbeat could exceed the normal resting rate and sometimes the blood pressure may change. The MD stated she would expect that nursing staff or RT would suction the resident if there were increased secretions. The MD stated sometimes she may order chest x-rays and/or labs. Record review of LVN R's inservice records for Respiratory Competency Performance for Tracheal Suctioning and Oxygen Administration Competency Review, dated 12/01/2023 and reviewed by a Respiratory Care Practitioner, revealed LVN R was proficient. Record review of the facility's undated procedure titled Skills Checklist - Tracheostomy suctioning, open suction system, read in part: .Objective: To suction a tracheostomy using an open suction system according to the standard of care .perform hand hygiene .Assess the patient's vital signs, breath sounds, respiratory effort and general appearance .remove the lid from the sterile solution and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 26 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few place it upside down on a clean surface .Using sterile technique, open the suction catheter kit and put on gloves. If using individual supplies, open the suction catheter and the gloves, then put on the gloves by first placing the nonsterile glove on your nondominant hand and then placing the sterile glove on your dominant hand. Using your nondominant (nonsterile) hand, pour a small amount of sterile solution into the sterile container. Close the solution bottle using your nondominant hand. Pick up the sterile suction catheter with your dominant (sterile) hand. Coil the catheter around your hand. Using your nondominant (nonsterile) hand, attach the catheter to the tubing. Turn the suction control valve to the on position and set the suction pressure to the lowest possible vacuum pressure needed to effectively clear secretions. Using your dominant (sterile) hand, lubricate the outside of the catheter by dipping in into the sterile solution. With the suction catheter tip in the sterile solution, occlude the suction control valve with the thumb of your nondominant hand; suction a small amount of the solution through the catheter. If the patient has a collar over the tracheostomy tube, move it Preoxygenate the patient with 100% oxygen for 30 to 60 seconds using a handheld resuscitation bag if necessary .Disconnect the handheld resuscitation bag if used. Insert the suction catheter into the tracheostomy tube; don't apply suction while inserting the catheter. Withdraw the catheter while applying intermittent suction and rotating the catheter between your fingertips. Reapply the tracheostomy collar .between suctioning passes . Record review of the facility policy and procedure for Respiratory Assessment, reviewed : April 15, 2016, revealed in part: Introduction .The normal respiratory rate for an average adult was 12 to 20 breaths/minute; however, it's important to know the patient's normal baseline respiratory rate to detect changes in the patient's condition Implementation .Count respirations by observing the rise and fall of the patient's chest during breathing .Identifying Respiratory Patterns: type-Apnea, Characteristics-Periodic absence of breathing, Possible causes-Mechanical airway obstruction, Conditions that affect the brain's respiratory center . This was determined to be an Immediate Jeopardy (IJ) on 12/17/2023 at 11:36 AM. The Administrator was notified. The Administrator was provided the IJ template on 12/17/2023 at 11:36 AM. The POR submitted by the Administrator was accepted on 12/21/2023 at 7:44 PM. The POR revealed:

F726 - Nursing Services The facility failed to ensure residents received the necessary services to provide professional standard of care. Immediate Action: Nursing Services 12/17/2023 Resident #49 not in facility 12/20/21 Resident # 49 returned to the facility 12/15/2023 Resident #49 was assessed by the respiratory therapist and the ADON and notified family and physician. 12/17/2023 remaining resident with a trach was immediately assessed by the respiratory therapist in house. Status-stable and no respiratory distress 12-17-2023 12/17/2023 Nurse Identified re-educated on the policy and procedures for respiratory assessment, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 27 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0726 Level of Harm - Immediate jeopardy to resident health or safety oxygen therapy, nebulizer therapy, tracheostomy suctioning and tracheostomy care. RRT provided the 1:1 training with return demonstration. 12/17/203 Licensed Staff were provided education on respiratory assessment, signs and symptoms of respiratory distress and how to manage respiratory distress by the RT. Training completion date will be 12/20/2023. All RNs, LVNs, received the training provided by RRT. Residents Affected - Few All departments, housekeeping, dietary, maintenance, receptionist, nurses assistants, physical therapy were educated on signs and symptoms of respiratory distress and to notify the Charge Nurse immediately if respiratory distress was observed. All new hires will be required to complete training prior to job start. Staff education initiated per DON on 12/17/2023 on identifying signs and symptoms of respiratory distress and assessment. Training completion date 12/19/2023 All staff will receive training prior to their next shift. The Medical Director was notified of the IJ on 12/17/2023. Following acceptance of the facility's Plan of Removal, the facility was monitored from 12/21/23 to 12/22/2023. Monitoring of the plan of removal included: The surveyor confirmed the facility implemented their plan of removal sufficiently from 12/21/23 - 12/22/23 to remove the IJ by: Observations on 12/22/2023 at 10:25 AM of the only two residents in the facility with tracheostomies who required oxygen therapy (Resident #49 and Resident #93) revealed the residents were in no visible distress, oxygen trach masks were securely in place over the tracheostomy, no secretions noted, had clean dressings, oxygen settings were set at the physician's prescribed orders and emergency respiratory supplies were in place. The observation demonstrated the facility provided necessary nursing services to meet the resident's respiratory safety needs. In an interview on 12/22/23 at 9:15 AM, ADON B stated after discussion with Surveyor on 12/15/23 at 8:15 AM, she did go into Resident #49's room and that the resident was stable. In a telephone interview on 12/22/23 at 5:00 PM, RN/RCP H stated she did assess Resident #49 after LVN R completed tracheal suctioning on 12/15/23 and stated the resident was stable. The interviews demonstrated the facility followed up to ensure Resident #49 was stable after LVN R completed respiratory care on 12/15/2023. Interviews were conducted with staff, including LVN R, from all three shifts from 12/21/2023 - 12/22/23: DON, 3 RNs, 4 LVNs, 7 CNAs and 1 ancillary staff. Nurses were able to verbalize their understanding regarding resident assessments for the residents with tracheostomies; all aspects of respiratory care including, tracheostomy care, tracheal suctioning, oxygen therapy, nebulizer treatment, ensuring proper fit with the oxygen tracheostomy mask, respiratory assessments, emergency procedures, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 28 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few signs and symptoms of acute respiratory distress; how to manage distress as well as abuse and neglect policies and procedures. CNAs and ancillary staff were able to verbalize their understanding of signs and symptoms of respiratory distress, when to notify the charge nurse. Record review of the facility's policies and procedures for change of condition, revised May 2017; resident assessments, revised March 2022; respiratory assessments, date reviewed April 15, 2016; oxygen administration, revised October 2, 2015; tracheostomy emergencies-dislodgement. Record review of RNs and LVNs competency check lists and training reports conducted 12/15/23 through 12/22/23 for the following: respiratory assessments, signs/symptoms of respiratory distress and how to manage respiratory distress; tracheostomy care; tracheostomy suctioning; oxygen therapy; nebulizer treatments; infection control and conducted by Respiratory Therapists and DON. Record review of LVN R's re-education, competency check list completed on 12/18/23. The Administrator was unavailable. The Chief Officer of Operations was informed the Immediate Jeopardy (IJ) was removed on 12/22/2023 at 5:10 PM. While the IJ was lowered on 12/22/23, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility still monitoring the effectiveness of their Plan of Removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 29 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (Resident#8) and 1 of 3 Med Carts (100 Hall Back Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure the 100 Hall Back Nursing Cart did not contain expired Byetta (an injectable drug used to manage blood sugars in residents with type 2 diabetes) for Resident #8. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and hospitalization. Findings include: Record review of Resident #8's Face Sheet dated 12/13/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, hypertension, insomnia and type 2 diabetes. Record review of Resident #8's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, supervision with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #8's undated Care Plan revealed, focus- type 2 diabetes; goal= no complications related to diabetes; intervention- diabetes medication as ordered by doctor. In an observation and interview on 12/15/23 at 10:07 AM, inventory of the medication 100 Hall Back Nursing Cart with LVN S revealed: - one open and in use Byetta 10 Pen for Resident #8 with an open date of 11/03/23 with pharmacy instructions to Discard 30 Days at room temperature (12/04/23). LVN S said nursing staff are expected to check their carts daily for expired and inappropriately labeled medications. She said multidose injectables/container are to be labeled with the date opened to track the expiration date and once expired the medication should not be used. LVN S said after injectable antidiabetic medications expired, they are less effective in controlling blood sugars and use could place residents at risk for uncontrolled blood sugars. She said since the medication could not be used it must be discarded immediately in the sharps container. In an interview on 12/18/23 at 01:20 PM, the DON said nursing carts should be checked daily as used for expired medications. She said injectable antidiabetic medications are labeled on the date in-use in order to track the expiration date and should before discarded once expired. The DON said after an injectable antidiabetic expired it becomes less effective and it should be discarded in the sharps container because use could place residents at risk for uncontrolled blood sugars. Record review of the facility policy titled Storage of Medications revised 09/2018 revealed, 8- Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 30 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 FORM CMS-2567 (02/99) Previous Versions Obsolete or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. III- Expiration Dating (Beyond-Use Dating); 5- When the original seal of a manufacturer's container or vial was initially broken, the container or vial will be dated. 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. 9. Disposal of any medications prior to the expiration dating will be required if contamination or decomposition was apparent. Event ID: Facility ID: 675789 If continuation sheet Page 31 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 observation, interview, 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, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 out of 4 medication carts (200 Hall Nursing Cart) reviewed for medication storage. - The facility failed to ensure the 200 Hall Front Nursing Cart did not contain inappropriately labeled and in use protein supplements. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: In an observation and interview on 12/15/23 at 10:04 AM, inventory of the 200 Hall Front Nursing Cart with the LVN R revealed: one open and in use bottle of Active Liquid Protein with no open date and manufacturer's instructions to discard 3 months after opening. LVN R said nursing staff are expected to check their carts daily as used for inappropriately labeled and expired supplements. He said multidose liquid protein containers should be labeled with the open date in order to track expiration. He said he was unaware that the liquid protein was only good for 3 months and since the bottle did not have an open date it could be expired and could not be used. He said use of expired liquid protein could place resident's at risk of GI upset so the item must be discarded. In an interview on 12/18/23 at 01:20 PM, the DON said nursing carts should be checked daily as used for expired and inappropriately labeled medications. She said injectable and multidose containers such as liquid protein are labeled on the date in-opened in order to track the expiration date and should before discarded once expired. The DON said the use of expired protein supplements could place residents at risk for GI issues so it must be discarded. Record review of the facility policy titled Storage of Medications revised 09/2018 revealed, 8- Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. III- Expiration Dating (Beyond-Use Dating); 5- When the original seal of a manufacturer's container or vial was initially broken, the container or vial will be dated. 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. 9. Disposal of any medications prior to the expiration dating will be required if contamination or decomposition was apparent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 32 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for 13 out of 15 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #51, Resident #61, Resident #81, Resident #84, Resident #95, Resident #100, Resident #107, Resident #109) and 4 of 5 Staff ( CNA AA, CNA BB, CNA CC, CNA D and CNA S) reviewed for infection control. Residents Affected - Many - The facility failed to implement environment controls and surveillance to prevent a scabies outbreak. Resulting in 13 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #51, Resident #61, Resident #81, Resident #84, Resident #100, Resident #107, Resident #109) and 4 Staff ( CNA AA, CNA BB, CNA CC and CNA S). - Administration was aware that residents and staff had contracted the same unspecified rash over multiple months (September through December) and did not implement infection control procedure. - The facility failed to retain an IP with qualified training, complete tracking and trending of infections from August to October of 2023. -CNA D failed to change gloves, perform hand hygiene after peri care and prior to touching clean items for Resident #95 (identified outside of the IJ). -CNA D failed to perform hand hygiene prior to leaving the resident's room after providing peri care to Resident #95 (identified outside of the IJ). An IJ was identified on 12/15/23. The IJ template was provided to the facility on [DATE] at 03:00 PM. While the IJ was removed on 12/19/23, at 02:39 PM. The facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for contracting a severe contagious skin infection, resulting in severe itching, discomfort, pain, decreased quality of life, and hospitalization. Findings included: Record review of the facility Infection Control Tracking and Trending for August, September and October of 2023 revealed, the tracking and trending was completed retrospectively for those months on 11/08/23. Resident #107 Record review of Resident #107's Face Sheet dated 12/18/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of depression, difficulty swallowing, down syndrome, fluid overload, hypertension. The resident had a diagnosis of Atopic dermatitis and congenital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 33 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety ichthyosis (a group of rare skin conditions that cause dry, scaly skin that individuals are usually born with) as of 11/03/23, he did not have a diagnosis of Scabies. Record review of Resident #107's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, substantial/maximal assistance for most ADLs, an indwelling catheter, frequently incontinent of bowel and application of ointments/medications other than to feet. Residents Affected - Many Record review of Resident #107's undated care plan revealed, focus areas of - ID, DD with PASRR services, potential nutritional problems, potential for pressure ulcer development, impaired cognitive function, a communication problem and tube feeding. There was no focus area to address Resident #107's treatment/diagnosis of scabies. Record review of Resident #107's Order Summary dated 12/18/23 revealed, Resident #107 had orders for Permethrin (an insecticide used to treat scabies) on multiple occasions but was only on contact isolation once: - 06/23/23 Permethrin 5% for dermatitis for 2 days: apply to head to toe topically one time only for 2 days. Leave on for 8-14 hours. - 07/26/23 Permethrin 5% for pruritus: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning. - 08/18/23 Permethrin 5%: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning per dermatologist. - 11/03/23 Permethrin 5% for prophylactic dermatitis for 2 days: apply at bedtime and leave overnight. Rinse of in AM. - 12//11/23 Permethrin 5% apply topically one time for scabies infestation. Leave in for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23 Contact Isolation- use strict contact precautions with protective garments. Record review of Resident #107's Dermatologist Note dated 07/26/23 revealed: Resident #107 was being seen as a referral from the Medical Director for a rash located on the body throughout. The rash was itchy and red and moderate in severity and it had been present for months. scaling and well demarcated (defined boundaries), eczematous (skin conditions with redness and itching) patches; differential diagnosis includes irritation dermatitis vs. scabies; plan- Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Follow up in 6 weeks for skin check. Record review of Resident #107's Dermatologist Note dated 11/03/23 revealed: Impression: Eczema associated diagnosis: Scabies; status: worsening, Itch Numerical Rating scale:10; % body surface covered in rash: 70. Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Record review of Resident #107's Physician Note dated 12/13/23 signed by the Medical Director revealed, Resident #107 was seen due to rash noted over the extremities and right upper shoulder that appeared crusted in nature. Diagnosis/Plan: unspecified dermatitis secondary to scabies infection, was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 34 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 started on permethrin cream, repeat treatment after 7 days, clean linens/clothes, deep clean room and contact isolation precautions in place. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #107's MARs from 06/2023 to 12/2023 revealed: Residents Affected - Many - Jun 2023: Permethrin 5% apply to skin at bedtime for dermatitis for 2 days- it was only applied once on 6/24/23. - July 2023: Permethrin 5 % apply to skin for persistent dermatoses- applied on 07/21/23. Permethrin 5% apply topically for pruritus- applied 7/26/23. - August 2023: Permethrin 5 %- applied 08/18/23 - November 2023: Permethrin 5 % prophylactically for dermatitis for 2 day- was only applied on 11/04/23 - December 2023: Permethrin 5% for scabies infestation use strict contact isolation- applied on 12/11/23 at 10:30 PM. Record review of Resident #107's Progress Notes from 06/24/23 to 12/23/23 revealed the resident's rash: - 06/24/23- generalized rash noted to entire body - 07/17/23- resident noted with recurrent rash to upper extremities - 07/23/23 day 7/7 of prednisone for generalized rash to torso. Area clean with red bumps noted from front/back torso. Resident scratching right front chest. - 08/24/23- generalized rash remains. - 09/12/23- Rash noted all over resident skin. - 11/02/23 at 01:30 AM: generalized rash remains pronounced, - 11/04/23 at 03:17 AM: generalized rash remains pronounced, dry, raised in some areas. - 11/04/23 at 10:15 AM : rash was still present to entire body and has new orders for permethrin 5% cream for 2 days and ammonium lactate 12% cream on shower day which will be on Monday 11/6/2023 - 12/14/23 at 02:30 AM- scaly, shedding, redness/self-inflicted scratches noted to skin. Resident on contact isolation There was only one mention of the resident having scabies on 12/12/23 at 04:01 AM- remain in contact isolation for scabies, permethrin cream applied to the entire body; and Resident #107 was first placed on contact isolation on 12/11/23. Record review of Resident #107's Hospital Wound Care Note dated 12/15/23 at 03:22 PM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 35 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Hospital Infectious Disease Progress Note dated 12/17/23 at 07:46 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) and Topical Permethrin for crusted scabies. Residents Affected - Many Record review of Hospital Infectious Disease Progress Note dated 12/18/23 at 05:32 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) for 4 days and Topical Permethrin for 3 days for crusted scabies. Record review of Resident #107's Medical Diagnoses printed 12/23/23 at 11:39 AM revealed, no diagnosis of scabies. An observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #107 was in the bed by the window, he was awake, receiving tube feeding, had a urinary foley catheter and was non interviewable. Resident #107 had fair colored skin with thick, dry, crusty, scaly large areas to the upper body. On both shoulders and upper arms were thick crusty, powdery white areas with red cracks. There were raised red bumps and rash to both forearms and to both upper thighs. The thighs had red scratch marks. The webbing between the thumb and pointer finger on both hands had powdery white irregular bumps. Resident #107 was scratching his groin and upper thighs. The treatment nurse stated he had dermatitis that worsened since he returned from the hospital in October 2023. The treatment nurse stated the rash on Resident #39 and Resident #107 appeared to be the same. She did not mention that Resident #107 had a presumptive diagnosis of scabies or that the resident was being treated for scabies. An observation and interview on 12/15/2023 at 4:00 PM revealed, Resident #107 in the ICU at the hospital with a diagnosis of respiratory failure and sepsis. Resident #107's room door was open and the resident was intubated The assigned hospital nurse stated when he was admitted on [DATE] d/t low blood pressures and elevated WBC. The hospital nurse stated they were not notified of the resident having scabies. The hospital nurse picked up her phone that was ringing and said it was the wound care nurse on the line who just told her she completed her evaluation done on 12/15/2023 and thought he might have scabies. The hospital nurses closed the resident's door and set up for contact isolation. Isolation signage was put up on the glass door. In an interview on 12/15/23 at 09:25 AM, MA A said she was present on 11/03/23 when Resident #107 saw the dermatologist. She said due to the rash being chronic and the severity of itching as well as the facility informing them other residents had similar rashes the Dermatologist wanted to treat Resident #107 for scabies. She said the MD ordered Permethrin 5% for Resident #107 to be repeated in 7 days. In an interview on 12/20/23 at 07:55 AM, the Hospital Treatment Nurse said when Resident #107 arrived to the hospital she observed thick plaques and rashes all over the parts of the body she could see (at least 1/3rd ) and she was surprised. She said the hyperkeratotic presentation and the residents history made her believe he had crusted scabies. Resident #39 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 36 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Record review of Resident #39's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: chronic pain syndrome, contractures, lack of coordination, anemia and a scabies (onset 12/11/23). Record review of Resident #39's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, dependence for most ADLs and application of ointments/medications other than to feet. Record review of Resident #39's undated Care Plan revealed, focus-impaired visual function, refusal of care (showers/shampoos and general grooming), total assistance with all ADLs except feeding. Focusactual impaired to skin integrity r/t thick skin and callous buildup to feet, he refuses to shower routinely which precipitates dry skin formation; intervention- identify/document potential causative factors and eliminate/resolver where possible; keep skin clean and dry. Record review of Resident #39's NP Note dated 11/30/23 signed by the NP revealed, skin: chronic seborrheic dermatitis- refuses showers. Record review of Resident #39's NP Note dated 12/08/23 signed by the NP revealed, Diagnosis/Plan: seborrheic dermatitis- refuses showers. There was no documented description of the resident's rash. Record review of Resident #39's MD note dated 12/13/23 and signed by the Medical Director revealed, Resident #39 had a red rash over the extremities of both upper and lower extremities. The resident was on isolation and was started on permethrin for scabies but he continued to refuse showers and application of creams. Diagnosis/plan: unspecified dermatitis secondary to scabies infection, on contact isolation, on permethrin cream repeated after 7 days and room to be deep cleaned and linens washed. Record review of Resident #39's Clinical Census dated 12/23/23 revealed, Resident #39 shared a room with Resident #107 from 10/24/23 until Resident #107 was discharged to the hospital on [DATE]. Record review of Resident #39's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #39's Progress notes from 12/22/22 to 12/23/23 revealed, Resident #39's had rashes dating back to 06/2023. - 6/13/23 at 04:46 PM- Resident's lower extremities are swollen with wound, Also has rash all over the body but was refusing treatment and medication. - 06/26/2023 at 10:40- The entire body skin observed with rash. There was no other mention of Resident #39 suffering from a rash until 12/14/23 (3 days after being diagnosed with scabies: - 12/14/23- remain in contact isolation/precautions, generalized skin rash remains to the body. Record review of Resident #39's Order Summary dated 12/23/23 revealed, - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 37 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 precautions with protective garments. Level of Harm - Immediate jeopardy to resident health or safety - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. Start date 12/19/23. Record review of Resident #39's December 2023 MAR revealed, Residents Affected - Many -Permethrin 5% topically at bedtime for scabies infestation- applied on 12/11/23 at 9:30 PM and 12/19/23 at 12:16 AM. Observation and interview on 12/13/2023 at 2:00 PM, of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #39 was awake, dressed in a hospital gown and brief and was in the bed by the door. Resident #39's arms, legs and hands were contracted. Resident #39 stated it was ok to look at his skin and that areas on his skin were very itchy. Resident #39 had small, red bumps on the scalp, forehead, cheeks, on both elbows, arms and both lower legs had large red bumps. The treatment nurse stated the redness to the elbows and red areas on his back were not new. The treatment nurse stated the new red bumps appeared sometime last week (12/4/2023 to 12/08/2023). The treatment nurse stated these new red bumps occurred at the same time Resident #107's red bumps appeared. Observation and interview on 12/23/2023 at 12:00 PM, Resident#39 was in contact isolation. He had a plate of food on his chest. He had red bumps on his scalp, face and arms and was unchanged from 12/13/23. He said he did receive the treatment cream, then showers the next day. Resident #39 stated he was told the cream was for scabies. He stated that it started with Resident #107 and maybe from not having the bed linens changed and washed. He stated that the bed linens were changed out daily and his personal belongings were removed. He stated he did not feel as itchy. He stated he was able to sleep through the night but during mornings he would feel itchy when he thinks about it. He stated he will be getting out of isolation soon and was happy about that because he wanted to get his money so he can buy soda. Resident #25 Record review of Resident #25's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of ID, schizophrenia, anemia, anxiety, hallucinations, depression and scabies (onset date 12/11/23). Record review of Resident #25's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, substantial to maximal assistance with most ADLs, and always incontinent of both bladder and bowel. There was no documentation of any applications of ointments/medication to the skin. Record review of Resident #25's undated Care Plan revealed, no related focus areas. There was no mention of any skin issues including rashes and scabies. Record review of Resident #25's Clinical Census revealed, Resident #25 shared a room with Resident #107 since 10/24/23. Record review of Resident #25's NP Note dated 11/27/23 revealed, no documented skin issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 38 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Record review of Resident #25's NP Note dated 11/30/23 revealed- head to toe assessment done due to reports of patient had rash to both sides of his upper and lower extremities. He has elevated red bumps, dry scaly skin scattered to chest, abdominal area, back, both legs and arm but no rashes were observed on the web spaces of his hands, genitals or scalps. Monitor closes due to skin rash issues in the unit. Record review of Resident #25's NP Note dated 12/08/23 revealed, the resident was on hydrocortisone (steroid cream) for skin rash and the rash was unresolved. Record review of Resident #25's NP Note visit date 12/09/23 but signed on 12/18/23 revealed, Resident #25 was noted itching/scratching and had a persistent skin rash likely scabies. Resident #25 was treated with Sulfur 5% nightly for 3 days, with a plan to treat with Permethrin if the rash didn't resolve. Contact Isolation precautions and an oral medication to treat itching. Record review of Resident #25's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #25's Order Summary dated 12/23/23 revealed: - 12/09/23- Sulfur 5% lotion for dermatitis, apply to entire body from neck down, rub in and leave on for 24 hours. - 12/11/23- Permethrin 5%- apply to head to toe topically one time only for scabies infestation. Leave on for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23- Contact Isolation: use strict contact precautions with protective garments, every shift for scabies infestation. Record review of Resident #25's December 2023 MAR revealed, Resident #25 received Permethrin 5% on: - 12/12/23 at 08:43 AM, and - 12/20/23 at 12:52 AM. Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #25 was in the middle bed in a full body, long sleeve jump suite. When the Treatment Nurse removed his body suite, Resident #25 was observed with had light pink, small, raised bumps to both upper arms and on the abdomen. The Treatment Nurse stated he was treated with Hydrocortisone cream beginning 11/30/2023 for a rash to both arms and legs. Resident #37 Record review of Resident #37's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: epilepsy, asthma, arthritis, type 2 diabetes and scabies with an onset date of 12/16/23. Record review of Resident #37's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15, rejection of care, substantial/maximal assistance with most ADLs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 39 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 and application of ointments/medications to skin other than feet. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #37's undated Care Plan revealed, no documented focus areas addressing, skin, rashes or scabies. Residents Affected - Many Record review of Resident #37's Census revealed he shared a room with Resident #107 from 08/28/23 to 09/23/23. Record review of Resident #37's Progress Notes from 12/22/22 to 12/23/23 revealed: - 09/22/23 at 02:33 PM the resident had a new rash to both arms, chest and legs. There was no documentation of the resident being placed on contact isolation. - 09/22/23 at 02:49 PM: Change of condition identified in a change in skin condition, the resident has a personal history of infectious and parasitic diseases. Skin Status Evaluation: itching rash and an order was given for Permethrin 5% to chest both legs and both arms which should be washed of in 8-12 hrs, hydrocortisone 1% cream for 7 days and calamine lotion for 2 weeks. There was no documentation of the resident being placed on contact isolation. - 10/02/23 at 10:34 PM: Permethrin cream 5% applied on resident entire body this shift and to be washed off in 8-12hrs. - 10/16/23 Resident on day 5/7 of antibiotics for cellulitis. Rash remains. - 10/18/23 Resident still on antibiotics for cellulitis. Rash still present and some itching noted. - 10/20/23 Resident still noted with rash all over his body and treatments continue - 10/27/23 Resident continues with steroid cream to the body for generalized rash, red raised bumps noted. - 10/40/23 Generalized rash red in color and bumpy. - 11/03/23 Rash present to body, generalized mild redness with complaints of mild itching. - 11/06/23 Rash still visible. - 11/08/23 Resident with generalized rash to body, some itching noted-redirected to avoid infection/pain. - 11/21/23 Resident seen by NP, new orders to apply steroid cream to rash all over his body twice daily for 30 days. - 11/24/23 Rash remains reddened pronounced and generalized. - 11/28/23 Rash remains reddened pronounced and generalized - 12/06/23 Rash remains reddened. Apply steroid cream to torso, back, upper extremities and thighs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 40 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 - 12/13/23 Resident was on antibiotics for skin cellulitis and generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted. Level of Harm - Immediate jeopardy to resident health or safety - 12/14/23 Rash with little improvement. Residents Affected - Many - 12/15/23 generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted and worse. - 12/18/23 Day 1 of Permethrin 5% treatment to body An observation and interview on 12/12/23 at 09:55 AM revealed, Resident #37 lying in bed well dressed and well-groomed with rashes/scabs to his arms. When asked about the rash/sores the resident said everything was ok and would not respond further. Record review of Resident #37's NP Note dated 11/28/23 revealed, evaluation of dermatitis. Patient has rash to upper torso. Record review of Resident #37's NP Note dated 12/09/23 revealed, dermatitis unresolved. Record review of Resident #37's NP Note dated 12/12/23 revealed, dermatitis unresolved. Likely scabies infection will treat with Permethrin, repeat dose if not resolved and contact isolation precautions. Record review of Resident #37's Order Summary sprinted 12/23/23 revealed: - 06/23/23 Permethrin 5% for dermatitis, apply for 2 days. - 09/22/23 Permethrin 5%- apply to arms, legs, chest typically one time only written for 2 days. - 10/02/23 Permethrin 5% for scabies. - Contact precautions- use contact precautions with protective garments. There are no previous orders for contact precautions. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments. Record review of Resident #37's September 2023 MAR printed 12/23/23 revealed: - 09/22/23 Permethrin 5% applied at 04:45 PM. - 09/22/23 to 09/29/23 hydrocortisone 1% to arms, legs, and chest for pruritis at 09:00 AM and 05:00 PM. Record review of Resident #37's October 2023 MAR printed 12/23/23 revealed: - 10/02/23 Permethrin 5% applied at 09:29 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 41 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 - 10/26/23 to 10/31/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #37's November 2023 MAR printed 12/23/23 revealed: Residents Affected - Many Resident #84 - 11/01/23 to 11/06/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Record review of Resident #84's Face Sheet dated 12/19/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of: Parkinson, dementia, depression, communication deficit and scabies with onset of 12/16/23. Record review of Resident #84's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and application of ointments/medications to the skin other than the feet. Record review of Resident #84's undated Care Plan revealed, no focus areas address rashes, itching or scabies. Record review of Resident #84's Census revealed, he shared a room with Resident #107 from 08/28/23 to 09/23/23 Record review of Resident #84's Progress Notes from 12/22/22 to 12/23/23 revealed, - 09/15/23 Resident noted with rash to entire body. - 10/03/23 Rash red and bumpy in appearance to legs and right thigh. - 10/20/23 Resident still noted with rash all over his body, treatment continues - 10/23/23 Resident given oral steroids for rash to lower legs, and areas of dry skin - 11/03/23 rash to both legs present bumpy and red. - 11/06/23 Dermatology appointment cancelled and will be rescheduled. - 11/16/23 Rash remains reddened, raised and generalized. - 11/30/23 Resident given oral antifungal for rash. - 12/14/23 Resident rash to both legs with little improvement. -12/15/23 Generalized rash/itching remain the same Record review of Resident #84's Order Summary report printed 12/23/23 revealed - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact precautions with protective garments every shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 42 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 - 12/2/23 Permethrin 5% for scabies. Use contact precautions with protective garments Level of Harm - Immediate jeopardy to resident health or safety An observation on 12/12/23 at 09:55 AM revealed, Resident # 84 lying in bed with a limited range of motion and wedge pillows propping him up. The resident was observed to have a rash on both his arms and had limited communication capability and all he could say his butt burned. Residents Affected - Many In an interview on 12/12//23 at 10:00 AM, the treatment nurse said Resident #84 was previously treated for wounds on his buttocks but the medication was discontinued because the issue had resolved. She said she would visit the resident to reassess him, and notify the wound care doctor about the resident's complaints. The Treatment Nurse did not address the Resident #84's itching. Resident #20 Record review of Resident #20's Face Sheet dated 12/16/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses: dementia, mood disorder. Anxiety disorder and depression. Record review of Resident #20's 5 day MDS dated [DATE] revealed, severely intact cognition as indicated by a BIMS score of 00 out of 15, partial assistance with most ADLs and no application of ointments/medication to the skin. Record review of Resident #20's undated Care Plan revealed, focus- elopement risk/wanderer onset 04/17/23; intervention- intervene as appropriate, distract resident from wandering by offering pleasant diversion, food, conversations, television or books. The care plan does not address any skin issues. Record review of Resident #20's MD Note dated 12/13/23 revealed, resident was started on a steroid cream for itching for 7 days. Skin: new rash to the back of the hand with some redness around it. Record review of Resident #20's Order Summary dated 12/23/23 revealed: - 11/03/23 Prednisone ( a steroid) 20 mg- 1 tablet one time a day for rash for 3 days. - 11/03/23 Hydrocortisone 1 %- apply topically two times a day for rash/dry skin - 11/03/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/03/23 Prednisone 10 mg- 1 tablet by mouth 1 time a day for rash for 5 days starting 11/08/23. - 11/27/23 Prednisone 20 mg- give 2 tablets by mouth daily for pruritus. - 11/27/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/28/23 Hydrocortisone 1 % for pruritus- apply topically two times a day to torso, both upper and lower extremities. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact Precautions- use contact precautions with protective garments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 43 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments scheduled for 12/24/23 An observation and interview on 12/12/23 at 09:45 AM revealed, Resident #20 well dressed, well-groomed in a wheelchair in front of his room. The resident was wearing a long sleeve shirt but a rash could be seen at the end of the sleeve of his right arm and a skin tear on the back of his right arm. When asked questions the resident would only respond that he wanted coffee. An observation on 12/15/23 at 03:00 PM revealed, Resident #20 observed in the dining area with a rash on his right hand and arm, a skin tear to the right hand that appeared to be scabbed. An observation on 12/15/23 at 03:23 PM revealed, Resident #20 ambulating in his wheelchair to the front lobby. The resident attempted to open the office door and was instructed by the DON that he could not be in the hallway because he was on isolation. The resident left the office and headed toward the resident rooms, the DON did not escort the resident back to his room or get assistance from other staff. Resident #20 returned 5 minutes later with a mask on his face. In an observation and interview on 12/16/23 at 12:50 PM, Resident #20's room was observed to be empty and the Isolation signage as well as the bin were no longer at the resident's door. The DON said Resident #20 was removed from isolation because the facility was unable to keep him in his room and the resident roamed the building. An observation on 12/16/23 at 03:55 PM revealed, Resident #20 ambulating in the front lobby trying to get access to the office by pulling the door. Resident #100 Record review of Resident #100's Face Sheet dated 12/23/23 revealed, an [AGE] year-old man who admitted to the facility on [DATE] with diagnoses of: dementia, malnutrition, depression, anxiety and scabies with an onset date of 12/18/23. Record review of Resident #100's MDS (Minimum Data Set) dated 11/4/2023 revealed a BIMS (Brief Interview for Mental Status) score of 0 out of 15 indicating Resident # was severely cognitively impaired. Section GG revealed the resident needed substantial/maximal assistance with toileting, showering/bathing, upper and lower body dressing, and personal hygiene. Section M1200 revealed Applications of ointments/medications other than to feet. Record review of Resident #100's Care Plan dated 4/28/2023 revealed in part . The resident has infection of the skin .the resident will be free from complications related to infection through the review date. Record review of Resident #100's Progress Notes from 12/22/22 to 12/23/23 revealed, - 05/09/23 Permethrin Cream treatment for rash all over body - 09/06/23 Resident receiving topical steroid for body itching, less scratching observed. - 10/16/23 Resident observed multiple times scratching arms and che[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 44 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a person designated as the infection preventionist had completed specialized training in infection prevention and control for 1 of 1 staff (DON) reviewed for Infection Preventionist qualifications and role. - The facility failed to ensure the DON had completed the required Nursing Facility Infection Preventionist training course IP which resulted in failure to implement an effective Infection Control Program, resulting in Residents #107, #39, #25, #37, #100, #51, #61, #81, #16, #84, #109, #20, and #1 contracting and being treated for scabies. - The facility failed to ensure the Infection Preventionist completed tracking and trending of infections for August through October of 2023. - The facility failed to ensure that there was a qualified Infection Preventionist from November 4th to December 15th 2023. An IJ was identified on 12/15/23. The IJ template was provided to the facility on [DATE] at 03:00 PM. While the IJ was removed on 12/19/23, at 02:39 PM. The facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for itching, discomfort, pain, secondary skin infections and hospitalization. Findings included: Record review of the facility Infection Control Tracking and Trending for August, September and October of 2023 revealed, the tracking and trending was completed retrospectively for those months on 11/08/23 by the DON. Resident #107 Record review of Resident #107's Face Sheet dated 12/18/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of depression, difficulty swallowing, down syndrome, fluid overload, hypertension. The resident had a diagnosis of Atopic dermatitis and congenital ichthyosis (a group of rare skin conditions that cause dry, scaly skin that individuals are usually born with) as of 11/03/23, he did not have a diagnosis of Scabies. Record review of Resident #107's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, substantial/maximal assistance for most ADLs, an indwelling catheter, frequently incontinent of bowel and application of ointments/medications other than to feet. Record review of Resident #107's undated care plan revealed, focus areas of - ID, DD with PASRR services, potential nutritional problems, potential for pressure ulcer development, impaired cognitive function, a communication problem and tube feeding. There was no focus area to address Resident #107's treatment/diagnosis of scabies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 45 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #107's Order Summary dated 12/18/23 revealed, Resident #107 had orders for Permethrin (an insecticide used to treat scabies) on multiple occasions but was only on contact isolation once: - 06/23/23 Permethrin 5% for dermatitis for 2 days: apply to head to toe topically one time only for 2 days. Leave on for 8015 hours. Residents Affected - Many - 07/26/23 Permethrin 5% for pruritus: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning. - 08/18/23 Permethrin 5% : apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning per dermatologist. - 11/03/23 Permethrin 5% for prophylactic dermatitis for 2 days: apply at bedtime and leave overnight. Rinse of in AM. - 12//11/23 Permethrin 5%c0 apply topically one time for scabies infestation. Leave in for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23 Contact Isolation- use strict contact precautions with protective garments. Record review of Resident #107's Dermatologist Note dated 07/26/23 revealed: Resident #107 was being seen as a referral from the Medical Director for a rash located on the body throughout. The ratch was itchy and red and moderate in severity and it had been present for months. scaling and well demarcated, eczematous patches; differential diagnosis includes irritation dermatitis vs. scabies; plan- Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Follow up in 6 weeks for skin check. Record review of Resident #107's Dermatologist Note dated 11/03/23 revealed: Impression: Eczema associated diagnosis: Scabies; status: worsening, Itch Numerical Rating scale:10; % body surface covered in rash: 70. Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Record review of Resident #107's Physician Note dated 12/13/23 signed by the Medical Director revealed, Resident #107 was seen due to rash noted over the extremities and right should that appeared crusted in nature. Diagnosis/Plan: unspecified dermatitis secondary to scabies infection, was started on permethrin cream, repeat treatment after 7 days, clean linens/clothes, deep clean room and contact isolation precautions in place. Record review of Resident #107's MARs from 06/2023 to 12/2023 revealed: - Jun 2023: Permethrin 5% apply to skin at bedtime for dermatitis for 2 days- it was only applied once on 6/24/23. - July 2023: Permethrin 5 % apply to skin for persistent dermatoses- applied on 07/21/23. Permethrin 5% apply topically for pruritus- applied 7/26/23. - August 2023: Permethrin 5 %- applied 08/18/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 46 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 - November 2023: Permethrin 5 % prophylactically for dermatitis for 2 day- was only applied on 11/04/23 Level of Harm - Immediate jeopardy to resident health or safety - December 2023: Permethrin 5% for scabies infestation use strict contact isolation- applied on 12/11/23 at 10:30 PM. Record review of Resident #107's Progress Notes from 12/22/22 to 12/23/23 revealed the resident's rash : Residents Affected - Many - 06/24/23- generalized rash noted to entire body - 07/17/23- resident noted with recurrent rash to upper extremities - 07/23/23 day 7/7 of prednisone for generalized rash to torso. Area clean with red bumps noted from front/back torso. Resident scratching right front chest. - 08/24/23- generalized rash remains. - 09/12/23- Rash noted all over resident skin. - 11/02/23 at 01:30 AM: generalized rash remains pronounced, - 11/04/23 at 03:17 AM: generalized rash remains pronounced, dry, raised in some areas. - 11/04/23 at 10:15 AM : rash was still present to entire body and has new orders for permethrin 5% cream for 2 days and ammonium lactate 12% cream on shower day which will be on Monday 11/6/2023 - 12/14/23 at 02:30 AM- scaly, shedding, redness/self-inflicted scratches noted to skin. Resident on contact isolation There was only one mention of the resident having scabies on 12/12/23 at 04:01 AM- remain in contact isolation for scabies, permethrin cream applied to the entire body; and Resident #107 was first placed on contact isolation on 12/11/23. Record review of Resident #107's Hospital Wound Care Note dated 12/15/23 at 03:22 PM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Hospital Infectious Disease Progress Note dated 12/17/23 at 07:46 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) and Topical Permethrin for crusted scabies. Record review of Hospital Infectious Disease Progress Note dated 12/18/23 at 05:32 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) for 4 days and Topical Permethrin for 3 days for crusted scabies. Record review of Resident #107's Medical Diagnoses printed 12/23/23 at 11:39 AM revealed, no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 47 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 diagnosis of scabies. Level of Harm - Immediate jeopardy to resident health or safety An Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #107 was in the bed by the window, he was awake, receiving tube feeding, had a urinary foley catheter and was non interviewable. Resident #107 had fair colored skin with thick, dry, crusty, scaly large areas to the upper body. On both shoulders and upper arms were thick crusty, powdery white areas with red cracks. There were raised red bumps and rash to both forearms and to both upper thighs. The thighs had red scratch marks. The webbing between the thumb and pointer finger on both hands had powdery white irregular bumps. Resident #107 was scratching his groin and upper thighs. The treatment nurse stated he had dermatitis that worsened since he returned from the hospital in October 2023. The treatment nurse stated the rash on Resident #39 and Resident #107 appeared to be the same. She did not mention that Resident #107 had a presumptive diagnosis of scabies or that the resident was being treated for scabies. Residents Affected - Many An Observation and interview on 12/15/2023 at 4:00 PM revealed, Resident #107 in the ICU at the hospital with a diagnosis of respiratory failure and sepsis. Resident #107's room door was open and the resident was intubated The assigned hospital nurse stated when he was admitted on [DATE] d/t low blood pressures and elevated WBC. The hospital nurse stated they were not notified of the resident having scabies. The hospital nurse picked up her phone that was ringing and said it was the wound care nurse on the line who just told her she completed her evaluation done on 12/15/2023 and thought he might have scabies. The hospital nurses closed the resident's door and set up for contact isolation. Isolation signage was put up on the glass door. In an interview on 12/15/23 at 09:25 AM, MA A said she was present on 11/03/23 when Resident #107 saw the dermatologist. She said due to the rash being chronic and the severity of itching as well as the facility informing them other residents had similar rashes the Dermatologist wanted to treat Resident #107 for scabies. She said the MD ordered Permethrin 5% for Resident #107 to be repeated in 7 days. In an interview on 12/20/23 at 07:55 AM, the Hospital Treatment Nurse said when resident #107 arrived to the hospital she observed thick plaques and rashes all over the parts of the body she could see (at least 1/3rd ) and she was surprised. She said the hyperkeratotic presentation and the residents history made her believe he had crusted scabies. Resident #39 Record review of Resident #39's Face Sheet dated 12/23/23 revealed, a 50-year-olf male who admitted to the facility on [DATE] with diagnoses of: chronic pain syndrome, contractures, lack of coordination, anemia and a scabies (onset 12/11/23). Record review of Resident #39's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, dependence for most ADLs and application of ointments/medications other than to feet. Record review of Resident #39's undated Care Plan revealed, focus-impaired visual function, refusal of care (showers/shampoos and general grooming), total assistance with all ADLs except feeding. Focusactual impaired to skin integrity r/t thick skin and callous buildup to feet, he refuses to shower routinely which precipitates dry skin formation; intervention- identify/document potential (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 48 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 causative factors and eliminate/resolver where possible; keep skin clean and dry. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #39's NP Note dated 11/30/23 signed by the NP revealed, skin: chronic seborrheic dermatitis- refuses showers. Residents Affected - Many Record review of Resident #39's NP Note dated 12/08/23 signed by the NP revealed, Diagnosis/Plan: seborrheic dermatitis- refuses showers. There was no documented description of the resident's rash. Record review of Resident #39's MD note dated 12/13/23 and signed by the Medical Director revealed, Resident #39 had a red rash over the extremities of both upper and lower extremities. The resident was on isolation and was started on permethrin for scabies but he continued to refuse showers and application of creams. Diagnosis/plan: unspecified dermatitis secondary to scabies infection, on contact isolation, on permethrin cream repeated after 7 days and room to be deep cleaned and linens washed. Record review of Resident #39's Clinical Census dated 12/23/23 revealed, Resident #39 shared a room with Resident #107 from 10/24/23 until Resident #107 was discharged to the hospital on [DATE]. Record review of Resident #39's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #39's Progress notes from 12/22/22 to 12/23/23 revealed, Resident #39's had rashes dating back to 06/2023. - 6/13/23 at 04:46 PM- Resident's lower extremities are swollen with wound, Also has rash all over the body but was refusing treatment and medication. - 06/26/2023 at 10:40- The entire body skin observed with rash. There was no other mention of Resident #39 suffering from a rash until 12/14/23 (3 days after being diagnosed with scabies: - 12/14/23- remain in contact isolation/precautions, generalized skin rash remains to the body. Record review of Resident #39's Order Summary dated 12/23/23 revealed, - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. Start date 12/19/23. Record review of Resident #39's December 2023 MAR revealed, -Permethrin 5% topically at bedtime for scabies infestation- applied on 12/11/23 at 9:30 PM and 12/19/23 at 12:16 AM. Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 49 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many isolation and a PPE cart at the door. Resident #39 was awake, dressed in a hospital gown and brief and was in the bed by the door. Resident #39's arms, legs and hands were contracted. Resident #39 stated it was ok to look at his skin and that areas on his skin were very itchy. Resident #39 had small, red bumps on the scalp, forehead, cheeks, on both elbows, arms and both lower legs had large red bumps. The treatment nurse stated the redness to the elbows and red areas on his back were not new. The treatment nurse stated the new red bumps appeared sometime last week (12/4/2023 to 12/08/2023). The treatment nurse stated these new red bumps occurred at the same time Resident #107's red bumps appeared. Observation and interview on 12/23/2023 at 12:00 PM, Resident#39 was in contact isolation. He had a plate of food on his chest. He had red bumps on his scalp, face and arms and was unchanged from 12/13/23. He said he did receive the treatment cream, then showers the next day. Resident #39 stated he was told the cream was for scabies. He stated that it started with Resident #107 and maybe from not having the bed linens changed and washed. He stated that the bed linens were changed out daily and his personal belongings were removed. He stated he did not feel as itchy. He stated he was able to sleep through the night but during mornings he would feel itchy when he thinks about it. He stated he will be getting out of isolation soon and was happy about that because he wanted to get his money so he can buy soda. Resident #25 Record review of Resident #25's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of ID, schizophrenia, anemia, anxiety, hallucinations, depression and scabies (onset date 12/11/23). Record review of Resident #25's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, substantial to maximal assistance with most ADLs, and always incontinent of both bladder and bowel. There was no documentation of any applications of ointments/medication to the skin. Record review of Resident #25's undated Care Plan revealed, no related focus areas. There was no mention of any skin issues including rashes and scabies. Record review of Resident #25's Clinical Census revealed, Resident #25 shared a room with Resident #107 since 10/24/23. Record review of Resident #25's NP Note dated 11/27/23 revealed, no documented skin issues. Record review of Resident #25's NP Note dated 11/30/23 revealed- head to toe assessment done due to reports of patient had rash to both sides of his upper and lower extremities. He has elevated red bumps, dry scaly skin scattered to chest, abdominal area, back, both legs and arm but no rashes were observed on the web spaces of his hands, genitals or scalps. Monitor closes due to skin rash issues in the unit. Record review of Resident #25's NP Note dated 12/08/23 revealed, the resident was on hydrocortisone (steroid cream) for skin rash and the rash was unresolved. Record review of Resident #25's NP Note visit date 12/09/23 but signed on 12/18/23 revealed, Resident #25 was noted itching/scratching and had a persistent skin rash likely scabies. Resident #25 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 50 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 treated with Sulfur 5% nightly for 3 days, with a plan to treat with Permethrin if the rash didn't resolve. Contact Isolation precautions and an oral medication to treat itching. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #25's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Residents Affected - Many Record review of Resident #25's Order Summary dated 12/23/23 revealed: - 12/09/23- Sulfur 5% lotion for dermatitis, apply to entire body from neck down, rub in and leave on for 24 hours. - 12/11/23- Permethrin 5%- apply to head to toe topically one time only for scabies infestation. Leave on for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23- Contact Isolation: use strict contact precautions with protective garments, every shift for scabies infestation. Record review of Resident #25's December 2023 MAR revealed, Resident #25 received Permethrin 5% on: - 12/12/23 at 08:43 AM - 12/20/23 at 12:52 AM Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #25 was in the middle bed in a full body, long sleeve jump suite. When the Treatment Nurse removed his body suite, Resident #25 was observed with had light pink, small, raised bumps to both upper arms and on the abdomen. The Treatment Nurse stated he was treated with Hydrocortisone cream beginning 11/30/2023 for a rash to both arms and legs. Resident #37 Record review of Resident #37's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: epilepsy, asthma, arthritis, type 2 diabetes and scabies with an onset date of 12/16/23. Record review of Resident #37's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15, rejection of care, substantial/maximal assistance with most ADLs and application of ointments/medications to skin other than feet. Record review of Resident #37's undated Care Plan revealed, no documented focus areas addressing, skin, rashes or scabies. Record review of Resident #37's Census revealed he shared a room with Resident #107 from 08/28/23 to 09/23/23. Record review of Resident #37's Progress Notes from 12/22/22 to 12/23/23 revealed: - 09/22/23 at 02:33 PM the resident had a new rash to both arms, chest and legs. There was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 51 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 documentation of the resident being placed on contact isolation. Level of Harm - Immediate jeopardy to resident health or safety - 09/22/23 at 02:49 PM: Change of condition identified in a change in skin condition, the resident has a personal history of infectious and parasitic diseases. Skin Status Evaluation: itching rash and an order was given for Permethrin 5% to chest both legs and both arms which should be washed of in 8-12 hrs, hydrocortisone 1% cream for 7 days and calamine lotion for 2 weeks. There was no documentation of the resident being placed on contact isolation. Residents Affected - Many - 10/02/23 at 10:34 PM: PERMETHRIN CREAM 5% APPLIED ON RESIDENT ENTIRE BODY THIS SHIFT AND TO BE WASHED OFF IN 8-12HRS. - 10/16/23 Resident on day 5/7 of antibiotics for cellulitis. Rash remains. - 10/18/23 Resident still on antibiotics for cellulitis. Rash still present and some itching noted. - 10/20/23 Resident still noted with rash all over his body and treatments continue - 10/27/23 Resident continues with steroid cream to the body for generalized rash, red raised bumps noted. - 10/40/23 Generalized rash red in color and bumpy. - 11/03/23 Rash present to body, generalized mild redness with complaints of mild itching. - 11/06/23 Rash still visible. - 11/08/23 Resident with generalized rash to body, some itching noted-redirected to avoid infection/pain. - 11/21/23 Resident seen by NP, new orders to apply steroid cream to rash all over his body twice daily for 30 days. - 11/24/23 Rash remains reddened pronounced and generalized. - 11/28/23 Rash remains reddened pronounced and generalized - 12/06/23 Rash remains reddened. Apply steroid cream to torso, back, upper extremities and thighs. - 12/13/23 Resident was on antibiotics for skin cellulitis and generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted. - 12/14/23 Rash with little improvement. - 12/15/23 generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted and worse. - 12/18/23 Day 1 of Permethrin 5% treatment to body An observation and interview on 12/12/23 at 09:55 AM revealed, Resident #37 lying in bed well (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 52 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 dressed and well-groomed with rashes/scabs to his arms. When asked about the rash./sores the resident said everything was ok and would not respond further. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #37's NP Note dated 11/28/23 revealed, evaluation of dermatitis. Patient has rash to upper torso. Residents Affected - Many Record review of Resident #37's NP Note dated 12/09/23 revealed, dermatitis unresolved. Record review of Resident #37's NP Note dated 12/12/23 revealed, dermatitis unresolved. Likely scabies infection will treat with Permethrin, repeat dose if not resolved and contact isolation precautions. Record review of Resident #37's Order Summary sprinted 12/23/23 revealed: - 06/23/23 Permethrin 5% for dermatitis, apply for 2 days. - 09/22/23 Permethrin 5%- apply to arms, legs, chest typically one time only written for 2 days. - 10/02/23 Permethrin 5% for scabies - Contact precautions- use contact precautions with protective garments. There are no previous orders for contact precautions - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments Record review of Resident #37's September 2023 MAR printed 12/23/23 revealed: - 09/22/23 Permethrin 5% applied at 04:45 PM. - 09/22/23 to 09/29/23 hydrocortisone 1% to arms, legs, and chest for pruritis at 09:00 AM and 05:00 PM Record review of Resident #37's October 2023 MAR printed 12/23/23 revealed: - 10/02/23 Permethrin 5% applied at 09:29 PM. - 10/26/23 to 10/31/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Record review of Resident #37's November 2023 MAR printed 12/23/23 revealed: - 11/01/23 to 11/06/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Resident #84 Record review of Resident #84's Face Sheet dated 12/19/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of: Parkinson, dementia, depression, communication deficit and scabies with onset of 12/16/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 53 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #84's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and application of ointments/medications to the skin other than the feet. Record review of Resident #84's undated Care Plan revealed, no focus areas address rashes, itching or scabies. Residents Affected - Many Record review of Resident #84's Census revealed, he shared a room with Resident #107 from 08/28/23 to 09/23/23 Record review of Resident #84's Progress Notes from 12/22/22 to 12/23/23 revealed, - 09/15/23 Resident noted with rash to entire body. - 10/03/23 Rash red and bumpy in appearance to legs and right thigh. - 10/20/23 Resident still noted with rash all over his body, treatment continues - 10/23/23 Resident given oral steroids for rash to lower legs, and areas of dry skin - 11/03/23 rash to both legs present bumpy and red. - 11/06/23 Dermatology appointment cancelled and will be rescheduled. - 11/16/23 Rash remains reddened, raised and generalized. - 11/30/23 Resident given oral antifungal for rash. - 12/14/23 Resident rash to both legs with little improvement. -12/15/23 Generalized rash/itching remain the same Record review of Resident #84's Order Summary report printed 12/23/23 revealed - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact precautions with protective garments every shift - 12/2/23 Permethrin 5% for scabies. Use contact precautions with protective garments An observation on 12/12/23 at 09:55 AM revealed, Resident # 84 lying in bed with a limited range of motion and wedge pillows propping him up. The resident was observed to have a rash on both his arms and had limited communication capability and all he could say his butt burned. In an interview on 12/12//23 at 10:00 AM, the treatment nurse said Resident #84 was previously treated for wounds on his buttocks but the medication was discontinued because the issue had resolved. She said she would visit the resident to reassess him, and notify the wound care doctor about the resident's complaints. The Treatment Nurse did not address the Resident #84's itching. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 54 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 Resident #20 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #20's Face Sheet dated 12/16/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses: dementia, mood disorder. Anxiety disorder and depression. Residents Affected - Many Record review of Resident #20's 5 day MDS dated [DATE] revealed, severely intact cognition as indicated by a BIMS score of 00 out of 15, partial assistance with most ADLs and no application of ointments/medication to the skin. Record review of Resident #20's undated Care Plan revealed, focus- elopement risk/wanderer onset 04/17/23; intervention- intervene as appropriate, distract resident from wandering by offering pleasant diversion, food, conversations, television or books. The care plan does not address any skin issues. Record review of Resident #20's MD Note dated 12/13/23 revealed, resident was started on a steroid cream for itching for 7 days. Skin: new rash to the back of the hand with some redness around it. Record review of Resident #20's Order Summary dated 12/23/23 revealed: - 11/03/23 Prednisone ( a steroid) 20 mg- 1 tablet one time a day for rash for 3 days. - 11/03/23 Hydrocortisone 1 %- apply topically two times a day for rash/dry skin - 11/03/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/03/23 Prednisone 10 mg- 1 tablet by mouth 1 time a day for rash for 5 days starting 11/08/23. - 11/27/23 Prednisone 20 mg- give 2 tablets by mouth daily for pruritus. - 11/27/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/28/23 Hydrocortisone 1 % for pruritus- apply topically two times a day to torso, both upper and lower extremities. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact Precautions- use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments scheduled for 12/24/23 An observation and interview on 12/12/23 at 09:45 AM revealed, Resident #20 well dressed, well-groomed in a wheelchair in front of his room. The resident was wearing a long sleeve shirt but a rash could be seen at the end of the sleeve of his right arm and a skin tear on the back of his right arm. When asked questions the resident would only respond that he wanted coffee. An observation on 12/15/23 at 03:00 PM revealed, Resident #20 observed in the dining area with a rash on his right hand and arm, a skin tear to the right hand that appeared to be scabbed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 55 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many An observation on 12/15/23 at 03:23 PM revealed, Resident #20 ambulating in his wheelchair to the front lobby. The resident attempted to open the office door and was instructed by the DON that he could not be in the hallway because he was on isolation. The resident left the office and headed toward the resident rooms, the DON did not escort the resident back to his room or get assistance from other staff. Resident #20 returned 5 minutes later with a mask on his face. In an observation and interview on 12/16/23 at 12:50 PM, Resident #20's room was observed to be empty and the Isolation signage as well as the bin were no longer at the resident's door. The DON said Resident #20 was removed from isolation because the facility was unable to keep him in his room and the resident roamed the building. An observation on 12/16/23 at 03:55 PM revealed, Resident #20 ambulating in the front lobby trying to get access to the office by pulling the door. Resident #100 Record review of Resident #100's Face Sheet dated 12/23/23 revealed, an [AGE] year-old man who admitted to the facility on [DATE] with diagnoses of: dementia, malnutrition, depression, anxiety and scabies with an onset date of 12/18/23. Record review of Resident #100's MDS (Minimum Data Set) dated 11/4/2023 revealed a BIMS (Brief Interview for Mental Status) score of 0 out of 15 indicating Resident # was severely cognitively impaired. Section GG revealed the resident needed substantial/maximal assistance with toileting, showering/bathing, upper and lower body dressing, and personal hygiene. Section M1200 revealed Applications of ointments/medications other than to feet. Record review of Resident #100's Care Plan dated 4/28/2023 revealed in part . The resident has infection of the skin .the resident will be free from complications related to infection through the review date. Record review of Resident #100's Progress Notes from 12/22/22 to 12/23/23 revealed, - 05/09/23 Permethrin Cream treatment for rash all over body - 09/06/23 Resident receiving topical steroid for body itching, less scratching observed. - 10/16/23 Resident observed multiple times scratching arms and chest - 11/18/23 resident on oral medication for itching and continues to scratch - 12/14/23 mild redness raised area generalized to body. - 12/15/23 red rashes remains on different parts of the body and the resident was now on a topical steroid cream twice daily. - 12/17/23 resident placed on contact isolation precautions. Continues to scratch at sites Record review of resident #100's Orders Summary dared 12/23/23 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 56 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0882 - 5/8/2023 revealed Permethrin External Cream 5% Apply head to Toes for itching for 2 days. Level of Harm - Immediate jeopardy to resident health or safety - 12/17/2023 revealed Permethrin Cream 5% apply to affected areas topically at bedtime for scabies. - 12/17/23 Contact isolation-wear protective garments. Resident had no orders for contact isolation in May 2023. Residents Affected - Many Record review of Resident #100's May 2023 MAR revealed, Permethrin was applied on 05/08/23 at 10:00 PM and 5/11/23. Record review of Review of Resident #100's NP note with [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 57 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 the facility had effective pest control for one of one kitchens, one of three hallways (Hall 200) and in one of five (Resident #14's room) resident rooms reviewed for pest control, in that: Residents Affected - Few The kitchen was found to have multiple live gnats. The 200 Hall was found to have multiple live gnats. The 200 Hall and Resident #14's room was found to have a live cockroach crawling on the floor. This failure placed residents at risk for the potential spread of infection, cross-contamination, and a decreased quality of life. Findings included: Record review of Resident #14's face sheet revealed a [AGE] year-old male admitted on [DATE] and initially admitted on [DATE]. His diagnoses included paranoid schizophrenia, depression, dementia, heart disease and lack of coordination. Record review of Resident #14's annual MDS dated [DATE] revealed a BIMs score of 4 out of 10 indicating he had severe cognitive impairment. He required supervision with all ADLs. Observation and interview on 12/12/2023 at 11:05 AM, Resident #14 was sitting in a wheelchair next to his bed. Observed a live cockroach crawl across the floor in front of the resident. The resident stated that he had seen them before and shrugged his shoulders. Observation of the kitchen on 12/12/2023 at 9:15 AM, revealed multiple gnats flying around the kitchen and swarm of gnats flying out from underneath a bag of hamburger buns in dry storage. Observation on 12/12/2023 at 11:20 AM, revealed several gnats flying around in front of room [ROOM NUMBER]. In an interview with the Kitchen Manager on 12/12/2023 at 9:40 AM, she stated she had never seen that many gnats gather in one place in her kitchen like that before. She stated pest control services comes and treats their kitchen about once a month. In an interview with the Dietary aide on 12/12/2023 at 9:37AM, he stated he usually saw gnats flying around the kitchen primarily on the side where the was due to the drain being located in that area. He stated they have tried to treat the drains themselves with vinegar. He stated he was new so he could not recall how often he had seen pest control services come to the kitchen. Observation and interview on 12/16/2023 at 2:35 PM, a live cockroach was crawling on the floor between rooms [ROOM NUMBERS]. ES H was in the hallway and stated that it was a cockroach and that the facility should not have them. ES H stepped on the cockroach and stated she would report it to the housekeeping supervisor. RN D was also present in the hallway and stated that she would report the cockroach to the Maintenance Director. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 58 of 59 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 675789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with the Maintenance Director on 12/18/23 at 03:48 PM, stated their contracted services for pest control come about every other week and they always treated the kitchen before they left. He stated he recently got a new contracted service 2 months ago and before then, there used to be gnats all over the building. He stated gnats were the primary pest they were trying to manage in the kitchen. He said he had seen a collection of gnats in places in the kitchen before and stated, although it has gotten better, there was still room for improvement in managing the gnats in the kitchen. It's important to have effective pest control to keep pests out of food and to prevent infectious diseases from entering. In an interview on 12/20/2023 at 10:37 AM, the Maintenance Director stated he has worked at the facility for 3 years and there had been an issue with cockroaches and gnats for a long time. He stated the facility should not have them as cockroaches carry disease. He stated the facility had issues with the last pest control company and were not doing a good job. He stated a new pest control company started August 2023. In an interview on 12/20/2023 at 2:42 PM, the Maintenance Director stated no one reported to him about the cockroach seen on 12/16/2023. The Surveyor notified him of the cockroach seen in Resident #14's room. He said he would call Pest Control to come out and treat. In an interview on 12/23/2023 at 10:55 AM, the COO (Chief Officer of Operations) stated he was not the Administrator but stated that the building contracts with a Pest Company to not have issues like cockroaches and gnats. The COO stated every nursing home had them. The COO stated the facility did not have a written policy regarding Pest Control. In an interview on 12/23/2023 at 11:00 AM, the CNO (Chief Nursing Officer) stated cockroaches should not be in the building, they belong outside and that sometimes it cannot be helped that they are inside. The CNO stated the risk was that they are unsanitary. The CNO stated some of the residents have come from living on the streets and some residents like having all their belongings. The CNO stated it was their right to do so and all the facility can do was clean as soon as the resident's leave the rooms. Record review of facility's pest control contract revealed that contract, dated 07/18/2023 was active starting on 08/01/2023 and read in part: .Services to be performed .a)Performing Monthly pest control service, including: coordinating with clients staff to implement an Integrated Pest Management Plan, monitor and track pest issues inside and outside of facility .c) Inspecting and treating interior pest issues including kitchen, laundry, exits and closets . Record review of the facility's pest control service notifications, dated 11/27/2023, revealed the last time they received services were on 11/27/2023 and pest control was scheduled for only monthly visits. They reported seeing German cockroaches in the kitchen, room [ROOM NUMBER] and gnats in the hallways, with dirty drains in the kitchen, excessive moisture in the dish room . as the reason for pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675789 If continuation sheet Page 59 of 59