Inspection·February 18, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Hypertension, convulsions, anemia, major depressive disorder, L - AKA. Able to make needs known; ambulate via wheelchair. Record review of Resident #77's annual MDS assessment dated (ARD) 09/15/23 completed 09/25/23 revealed he had a BIMS score of 15 which indicated he was cognitively intact. Review of section J-1800 (fall History) was left blank. Reviewed of section L oral\dental status obvious or likely cavity or broken natural teeth was left blank. Record review of the facility's accident and incident log from 09/01/23 to January 29/2024 revealed Resident #77 had an unwitnessed fall on 10/23/23 and 12/03/23. Record review of Resident #77's nurse's note dated 12/3/2023 12:35AM read in part- Resident was noted on the floor in his room sitting next to his powered wheelchair. Staff members assisted resident back to bed. Head-To-Toe assessment done. No injuries noted. Record review of Resident #77's nurse's note dated 10/23/2023 09:48 read in part- Post Fall Evaluation fall Details: Date / Time of Fall: 10/23/2023 9:00 AM Fall was not witnessed. Fall occurred bedside. Resident was reaching for item(s) at time of the fall. Reason for the fall was evident. Reason for fall: Not close enough to reach item Did an injury occur as a result of the fall. Observation and interview on 01/30/24 at 5:00PM, revealed Resident #77 was in the dining room having dinner. Observation revealed he had mechanical altered diet and had a cup of chicken noodle soup in his hand. During an interview, he said he had no teeth on his upper oral cavity and cannot chew very well. He stated it was hard to eat some of the tougher foods like meat or pizza without his upper dentures, and usually the staff were good about getting him something different to eat and hit his soup for him. He said he had dentures at a point but lost them. He said, he which he could have them back. He said he had move from place to place on several occasions and did not know where he lost them. Interview on 1/30/24 at 3:40 PM, the DON stated he was not responsible for MDS assessment. He said that was the responsibility of the MDS staff. In an interview with MDS coordinator A on 01/31/24 at 3:00PM, she looked at the MDS and said Resident #77 should be assessed for his lack of natural teeth on his upper oral cavity and for his falls. He said there was an overlap of staffing personnel at a point, but she would correct all identified assessment and correct what needed to be corrected. She said the facility had hired a second staff to assist with the MDS. Facility's policy on accuracy of MDS was requested from MDS coordinator A on 01/31/24 ,she said she followed the RAI Manual FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 2 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0641 Ensure each resident receives an accurate assessment. 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 complete an assessment which accurately reflected the resident's status for 2 of 24 (Resident #77 #93) residents reviewed, accuracy of assessment in that: Residents Affected - Some The facility failed to assess Resident #77 and Resident #93 for fall on the quarterly MDS assessment after a fall. This failure could place residents at risk of not having accurate assessments, which could compromise their plan of care. Findings included: Resident #77 Record review of Resident #77's nurse's note dated 12/3/2023 12:35AM read in part- Resident was noted on the floor in his room sitting next to his powered wheelchair. Staff members assisted resident back to bed. Head-To-Toe assessment done. No injuries noted. Record review of Resident #77's nurse's note dated 10/23/2023 09:48 read in part- Post Fall Evaluation fall Details: Date / Time of Fall: 10/23/2023 9:00 AM Fall was not witnessed. Fall occurred bedside. Resident was reaching for item(s) at time of the fall. Reason for the fall was evident. Reason for fall: Not close enough to reach item Did an injury occur as a result of the fall. Observation and interview on 01/30/24 at 5:00PM, revealed Resident #77 was in the dining room having dinner. Observation revealed he had mechanical altered diet and had a cup of chicken noodle soup in his hand. During an interview, he said he had no teeth on his upper oral cavity and cannot chew very well. He stated it was hard to eat some of the tougher foods like meat or pizza without his upper dentures, and usually the staff were good about getting him something different to eat and hit his soup for him. He said he had dentures at a point but lost them. He said, he which he could have them back. He said he had move from place to place on several occasions and did not know where he lost them. Resident #93 Record review of Resident #93's face sheet dated 01/30/24 revealed a 66 -year-old female admitted to the facility on [DATE]. Her diagnoses included Hypertension, Bipolar disorder, schizophrenia, major depressive disorder. Record review of Resident #93's quarterly MDS assessment dated [DATE] revealed section J fall history was left blank. Record review of the facility's accident and incident log from 09/01/23 to January 29/2024 revealed Resident #93 had an unwitnessed fall on 08/29/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 3 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0641 Record review of a nurse's note dated 08/29/24 03:31 PM read in part Resident #93 had a fall on 08/9/23. Level of Harm - Minimal harm or potential for actual harm Staff on rounds called to the attention of this nurse regarding this patient fall, on arrival patient was observed sitting on the floor. Patient has intermittent confusion but able to express self verbally. Patient stated that she wanted to get to her closet before she slide to the floor sitting on her buttock, explained that her head did not hit anywhere, rather she went down on the floor Residents Affected - Some In an interview with MDS coordinator A on 01/31/24 at 3:00PM, she looked at the MDS and said Resident #93's MDS was an oversight She said she would do an ammendment to correct the identified MDS. Facility's policy on accuracy of MDS was requested from MDS coordinator A on 01/31/24 ,she said she followed the RAI Manual FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 4 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 2 out of 25 residents (Resident #122, and Resident #115) reviewed for comprehensive care plans. The facility failed to care plan PTSD for Resident #122 when he was admitted with it. The facility also failed to care plan his assistance with ADLs. The facility failed to care plan PTSD for Resident #115. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life. Findings include: 1. Record review of Resident #122's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original admission date of 8/1/23. He had diagnoses of facial weakness after a stroke, dysphagia (trouble swallowing), muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, PTSD, and hemiplegia and hemiparesis (weakness and paralysis) after a stroke affecting the dominant side. Record review of Resident #122's admission MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. According to the MDS, the resident required limited assistance and one-person physical assistance with personal hygiene, toilet use, dressing, bed mobility, and physical help with baths/showers. He had impairment on one side of his upper extremities and one side of his lower extremities and used a wheelchair. He was always incontinent of bowel and bladder. The admission MDS revealed he was diagnosed with PTSD. Record review of Resident #122's care plan dated 9/12/23 revealed a Focus: Behavior Management (Initiated: 8/30/23). Goal: Left blank. Interventions: Monitor for signs/symptoms of infection (Initiated 8/30/23). Notify provider of new onset finding (Initiated: 8/30/23). Focus: Resident #122 has depression r/t admission (Initiated: 8/3/23, Revised: 8/3/23). Goal: Resident #122 will exhibit indicators of depression, anxiety, or sad mood less than daily by review date (Initiated: 8/3/23, Revised: 1/30/24, Target: 3/6/24). Resident #122 will remain free of s/sx of distress, symptoms of depression, anxiety, or sad mood by/through review date (Initiated: 8/3/23, Revised: 1/30/24, Target: 3/6/24). Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness (Initiated: 8/3/23). The care plan did not mention anything about his PTSD or ADLs. Record review of Resident #122's medical records revealed a psychiatric note from MD B on 12/27/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 5 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm that revealed the resident had PTSD. According to the note, Resident stopped me at the dining area, he reported he is having nightmares of war combat mostly when he hears other residents yelling out for help, amenable to medication adjustment to current psychotropics [medication that affects behavior, mood, thoughts, or perception]. He denies worsening of his depression, denies increased anxiety, he denies SI/HI/AVH. Residents Affected - Few In an interview and observation with Resident #122 on 1/30/24 at 9:56am, he was sitting in his wheelchair. He said he was waiting for PT/OT to come get him. 2. Record review of Resident #115's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original admission date of 6/16/22. He had diagnoses of peripheral vascular disease (circulatory condition which narrows blood vessels and reduces blood flow to limbs), type II diabetes (body does not produce insulin or is resistant to it), atherosclerosis of arteries of both legs (plaque buildup in arteries), abnormalities of gait and mobility, muscle wasting and atrophy, reduced mobility, congested heart failure (heart does not pump well), varicose veins (twisted/enlarged veins) of left and right lower extremities with ulcers, HIV, PTSD, and a history of falling. Record review of Resident #115's Annual MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15, which indicated moderately impaired cognition. According to the MDS, the resident was diagnosed with PTSD. Record review of Resident #115's care plan dated 5/17/23, revealed a Focus: Resident #115 has a venous ulcer [from poor circulation]/anterior [front] lower left leg (Initiated: 10/5/22, Revised: 10/5/22). Goal: Resident #115's pressure ulcer will show signs of healing and remain free from infection by/through review date (Initiated: 10/5/22, Revised: 1/2/24, Target: 3/26/24). Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Specify treatment: Clean with normal saline/wound cleanser, apply Xeroform gauze [type of wound care dressing] then cover with dry dressing (Initiated: 10/5/22, Revised: 10/5/22). Avoid positioning the resident on the location of the pressure ulcer, lower left leg (Initiated: 10/5/22, Revised: 10/5/22). The care plan did not mention Resident #115's PTSD. Record review of Resident #115's medical record revealed a psychiatric note from MD B on 1/10/24, that revealed the resident had PTSD. In an interview on 1/30/24 at 2:28pm with MDS Coordinator A, she said the nurses updated the acute care plans and the MDS Nurses updated the comprehensive care plans. She said the nurses would be in charge of adding falls and anything acute to the care plans. She said she looked through the progress notes and the risk assessments to update the care plans. She also said she was the only MDS Nurse until the MDS Coordinator B started November 1, 2023. However, she said the MDS Coordinator B worked between that facility and the other one. In an interview with the DON on 1/30/24 at 3:44pm, he said the MDS's primary responsibility was to do the care plan. He said the basic care plans, like admissions, were done by the nurses. He said sometimes the nutritionist, MD, nurse, and social services came together and updated the resident's plan of care, but MDS was still responsible for updating the care plan. In an interview with the Administrator on 1/30/24 at 4:00pm, she said the MDS Nurse was responsible for writing care plans. She said the Regional MDS Nurse was over the facility MDS Nurse. She also said the Regional MDS Nurse asked the DON to review/sign the MDS' care plans while they were short a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 6 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS Nurse. She said one of the MDS Nurse's left around mid-2023, leaving them with only 1 MDS Nurse, and the DON helped until the new MDS Nurse took over on November 1, 2023. In an interview with the Social Worker on 1/31/24 at 2:30pm, she said she did not update the care plans very much, only when it had to do with social services, like updating the code status of the resident. She said the MDS Nurses updated the care plans. In an interview with the Social Worker on 2/1/24 at 1:03pm, she said she did not care plan suicidal ideations unless the resident was actively suicidal. She said she checked Resident #122 daily to see how he was and performed a Trauma Screen on him. She also said she did care plan PTSD, especially if they came in with it and this resident was one of the few who came in with PTSD. She did not know why Resident #122 and Resident #115's PTSD were not care planned. Record review of the facility's policy and procedure on Care Plans-Baseline (revised March 2022) read in part: A baseline plan or care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable. 2. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed .4. The resident and/or representative are provided a written summary of the baseline care plan .that includes .a. The stated goals and objectives of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 7 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 5 (Resident #29, Resident #44, Resident #115, Resident #86, and Resident #122) out of 25 residents reviewed for care plan accuracy. The facility failed to care plan Resident #29's fall from 11/14/23. The facility also failed to remove the Restorative Program from her care plan when she was no longer on the program. The facility failed to care plan Resident #44's fall from 9/2/23. The facility also failed to care plan Resident #44's ST he was receiving. The facility failed to remove the pressure ulcer to the left lower leg of Resident # 115's care plan. The facility also failed to care plan Resident # 115's OT he was receiving, his code status, and the oxygen. The facility failed to remove the left arterial/ischemic ulcer from Resident #86's care plan, when his wounds had resolved. The facility also failed to remove the IV antibiotics and wound treatment. The facility failed to care plan Resident #122's UTI, OT/PT and his code status. These failures could place residents at risk for their medical, physical, and psychosocial needs not being met. Findings include: 1. Record review of Resident #29's undated face sheet revealed she was an [AGE] year-old female admitted [DATE], with an original admission date of 2/10/16. She had diagnoses of type II diabetes (body does not produce insulin or is resistant to it), lack of coordination, dysphagia (trouble swallowing), UTI, muscle wasting and atrophy, abnormalities of gait and mobility, rhabdomyolysis (breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood), myocardial infarction (heart attack), severe protein calorie malnutrition, vascular dementia (brain damage from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 8 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some impaired blood flow to your brain), and acute embolism/thrombosis (blood clot) of deep veins of right lower leg. Record review of Resident #29's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 out of 15, which indicated severely impaired cognition. It also revealed she had moderately difficult hearing, unclear speech, sometimes understood others, and had impaired vision. According to the MDS, she was dependent with showers/baths, upper body dressing/lower body dressing, putting on/taking off footwear, and personal hygiene. She was substantial/maximal assistance with oral hygiene and toileting hygiene and used a wheelchair. She was substantial/maximal assistance with oral hygiene and toileting hygiene and used a wheelchair. She was also dependent with rolling in bed, transfers, sit to stand, sit to lying, and lying to sitting. According to the Annual assessment, she had not had any falls since admission/entry or reentry or the prior assessment. According to the MDS, the resident was not receiving Restorative Nursing. Record review of Resident #29's care plan dated 11/2/22, revealed a Focus: Resident #29 is at risk for falls r/t confusion, slightly impaired mobility, b/b incontinence. 4/13/23-Fall, fell out of bed on left side, denies pain, no injuries noted, notified MD and RP. Encourage resident to ask staff for assistance (Initiated:11/13/20, Revision: 6/8/23). Goal: Resident #29 will be free of falls through the review date (Initiated: 11/13/20, Revision: 1/30/24, Target: 4/14/24). Focus: Resident #29 is on a Nursing Restorative Program to maintain BUE ROM (Initiated: 6/8/23). Goal: Resident #29 will maintain her functional abilities with bilateral upper and lower ROM and strength during this quarter (Initiated: 6/8/23, Revision: 1/30/24, Target: 4/14/24). Interventions: BUE AROM 3x10 reps in all planes (Initiated: 6/8/23). Perform seated exercise including ankle pumps, knee extensions and seated marches 3x10 reps 3x5xweek (Initiated 6/8/23). Record review of Resident #29's medical record revealed a progress note from RN A on 11/14/23 at 7:35am, that said, Resident noted sitting on floor in front of bed rambling through her clothes .CNA found resident sitting on floor as she pass res room. Wheelchair near resident. Resident stated I did not fall, I was getting my clothes. Pt is a poor historian. Assessed res and assisted back into w/c. No apparent injuries noted. Denies hitting head, no lumps, bump or bruises noted. Able to move all extremities without difficulty. Denies pain and no s/s of discomfort noted . Record review of Resident #29's tasks for January 2023 revealed no Restorative Nursing program. Record review of Resident #29's Physician Orders for January 2023 revealed no orders for Restorative Nursing. 2. Record review of Resident #44's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original admission date of 6/8/20. He had diagnoses of cerebrovascular disease (disorders that affect the blood vessels and blood supply to the brain), atherosclerotic heart disease of coronary artery (plaque buildup of the main artery to the heart causing heart problems), flaccid hemiplegia (paralysis of one side), traumatic brain injury, dementia, intracranial injury without loss of consciousness (brain injury), seizures, history of falling, dysphagia (trouble swallowing), and contracture of left elbow and left hand. Record review of Resident #44's Quarterly MDS assessment dated [DATE] revealed a BIMS score was not performed due to his severely impaired cognition. According to the MDS, the resident was totally dependent with one-person physical assist with personal hygiene, toilet use, dressing, transfers, bed mobility, showers/baths, and locomotion on/off unit. The MDS said the resident had no falls since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 9 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admission/entry or reentry or the prior assessment. The MDS indicated Resident #44 had not had ST in the last 15 days. Record review of Resident #44's care plan dated 12/14/22, revealed a Focus: The resident is at risk for falls r/t impaired cognition and mobility (Initiated: 6/26/20, Revised: 1/12/21). Goal: Resident #44 will be free of minor injury through the review date (Initiated: 8/17/20, Revised: 1/25/24, Target: 3/19/24). Interventions: Review information on past falls and attempt to determine cause of falls. Record possible root causes .(Initiated: 9/11/20). Focus: Resident #44 has had an actual fall due to poor balance, unsteady gait: 10/8/20 had a fall, 11/1/20 had a fall with no injury, 5/17/21 actual fall with no apparent injury, 5/10/22 actual fall, 9/20/22 fall from bed (Initiated: 8/17/20, Revised: 6/29/23). Goal: Resident #44 will resume usual activities without further incident through the review date (Initiated: 8/17/20, Revised: 1/25/24, Target: 3/19/24). Interventions: Actual Fall: 8/14/23 Resident #44, laying on floor mat. No mention of Speech Therapy on the care plan. Record review of Resident #44's medical record revealed a progress note from LVN C on 9/2/23 at 2:15am that said, Resident found on the floor beside his bed in his room at 2:15am. Observed resident low bed beside him. Resident aphasic [unable to speak due to stroke] and unable to explain what happened. Head to toe assessment completed with passive ROM and no visible injuries or pain noted at this time. Resident was assisted back to his low bed with other staff assistance . Record review of Resident #44's Physician Orders revealed the following orders from NP A: ST Evaluation and Treatment. Coughing with meals and medication. Ordered on 1/4/24. Pt to receive ST to address dysphagia (trouble swallowing) at 5x/week for 4 weeks. Ordered on 1/5/24. In an observation on 1/29/24 at 10:00am, Resident #44 was laying on his back in bed. The bed was in the lowest position, and there was a fall mat next to his bed. The resident was aphasic (unable to speak due to stroke) and unable to speak, although he appeared to be trying to speak. The resident had a right arm that was contracted, and the resident had missing teeth. 3. Record review of Resident #115's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original admission date of 6/16/22. He had diagnoses of peripheral vascular disease (circulatory condition which narrows blood vessels and reduces blood flow to limbs), type II diabetes (body does not produce insulin or is resistant to it), atherosclerosis of arteries of both legs (plaque buildup in arteries), abnormalities of gait and mobility, muscle wasting and atrophy, reduced mobility, congested heart failure (heart does not pump well), varicose veins (twisted/enlarged veins) of left and right lower extremities with ulcers, HIV, PTSD, and a history of falling. Record review of Resident #115's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15, which indicated moderately impaired cognition. According to the MDS, he was totally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 10 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0657 Level of Harm - Minimal harm or potential for actual harm dependent on one-person physical assistance with personal hygiene, toilet use, dressing, locomotion on/off the unit, transfers, baths/showers, and bed mobility. According to the MDS, the resident did not have any unhealed pressure ulcers/injuries, venous/arterial ulcers, or any other ulcers, wounds, or skin problems. The MDS did indicate he was receiving ointments/medications to his body other than his feet. The MDS did not indicate he was on any oxygen, and indicated his OT ended on 6/2/23. Residents Affected - Some Record review of Resident #115's care plan dated 5/17/23, revealed a Focus: Resident #115 has a venous ulcer [from poor circulation]/anterior [front] lower left leg (Initiated: 10/5/22, Revised: 10/5/22). Goal: Resident #115's pressure ulcer will show signs of healing and remain free from infection by/through review date (Initiated: 10/5/22, Revised: 1/2/24, Target: 3/26/24). Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Specify treatment: Clean with normal saline/wound cleanser, apply Xeroform gauze [type of wound care dressing] then cover with dry dressing (Initiated: 10/5/22, Revised: 10/5/22). Avoid positioning the resident on the location of the pressure ulcer, lower left leg (Initiated: 10/5/22, Revised: 10/5/22). The care plan did not mention Resident #115's OT he was receiving, his code status, or the oxygen. Record review of Resident #115's Physician Orders revealed the following order from NP B: Clarification order for OT QD 3x/week x 4 weeks to be seen for ther ex [therapeutic exercises], ther act [therapeutic activities], group therapy, ADL retraining secondary, to generalized weakness. Ordered on 12/4/23 at 4:24pm. Record review of Resident #115's Physician Orders revealed the following order from MD A: O2 @ 2 L via NC PRN SOB. Ordered on 6/6/22 at 8:16pm. Full Code, Ordered on 6/16/22. In an interview and observation with Resident #115 on 1/30/24 at 9:52am revealed he was lying in bed and had a left above the knee amputation. The resident was confused and said he had been there for 20 years. There was no oxygen in use at that time. 4. Record review of Resident #86's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original admission date of 10/6/23. He had diagnoses of cerebrovascular disease (disorders that affect the blood vessels and blood supply to the brain), unspecified joint pain, insomnia (unable to sleep), muscle weakness, abnormalities of gait and mobility, and lack of coordination. Record review of Resident #86's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. The MDS revealed the resident did not have any pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 11 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ulcers/injuries but indicated he did have a venous/arterial (from poor circulation) ulcer, an infection of the foot, an open lesion on the foot, and moisture associated skin damage (damage to skin from sitting in excess moisture). He was receiving applications of ointments/medications and dressings to his body other than to his feet. Record review of Resident #86's care plan dated 10/19/23, revealed a Focus: Resident #86 has an arterial/ischemic [due to poor circulation] ulcer of the Left Lateral [outside] Forefoot [top part of foot] r/t vascular insufficiency [poor circulation], Left Lateral [outside] Mid forefoot [middle of foot] (reopened area), Vascular f/u scheduled 11/30/23 and completed with angiogram [procedure to see where bad circulation is] (Initiated: 10/9/23, Revised: 1/2/24). Goal: Resident #86 started IV antibiotic for culture positive of MRSA [antibiotic resistant bacteria] of Left Forefoot wound, Vancomycin [type of antibiotic] 1 gram every 12 hrs from 10/29/23-11/12/23 Resolved. Treatment: Cleanse site w/ wound cleanser, pat dry, apply cal ag [Calcium Alginate, type of wound care medication] w/ silver and place dry dressing (Initiated: 10/30/23, Revised: 1/30/24, Target: 1/6/24). Interventions: Monitor/document/report PRN any s/sx of infection (Initiated: 10/13/23, Revised: 10/13/23). Record review of Resident #86's medical record revealed a wound care note from MD C on 1/23/24 that revealed the Left, Lateral [outside] Midfoot [middle of foot] was an arterial ulcer and received an outcome of resolved. Also, the Left, Lateral [outside] Forefoot [top part] was an arterial ulcer and received an outcome of resolved. Record review of Resident #86's Physician Orders for January 2023 revealed no wound care orders and no IV antibiotic orders. In an observation and interview with Resident #86 on 1/29/23 at 9:33am, the resident was laying on his back in bed. He said he was bedbound and unable to get up without a Hoyer lift. He said that he did not have any wounds or sores on him that he was aware of. 5. Record review of Resident #122's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original admission date of 8/1/23. He had diagnoses of facial weakness after a stroke, dysphagia (trouble swallowing), muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, PTSD, and hemiplegia and hemiparesis (weakness and paralysis) after a stroke affecting the dominant side. Record review of Resident #122's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. The MDS indicated he had OT that started on 9/19/23 and ended on 11/8/23 and had PT that started on 9/18/23 and ended on 11/8/23. Record review of Resident #122's care plan dated 9/12/23 revealed a Focus: Behavior Management (Initiated: 8/30/23). Goal: Left blank. Interventions: Monitor for signs/symptoms of infection (Initiated 8/30/23). Notify provider of new onset finding (Initiated: 8/30/23). Focus: Resident #122 has depression r/t admission (Initiated: 8/3/23, Revised: 8/3/23). Goal: Resident #122 will exhibit indicators of depression, anxiety, or sad mood less than daily by review date (Initiated: 8/3/23, Revised: 1/30/24, Target: 3/6/24). Resident #122 will remain free of s/sx of distress, symptoms of depression, anxiety, or sad mood by/through review date (Initiated: 8/3/23, Revised: 1/30/24, Target: 3/6/24). Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness (Initiated: 8/3/23). The care plan did not mention anything about his UTI, OT/PT, or code status. Record review of Resident #122's hospital records from 8/24/23 revealed he went to the hospital for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 12 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0657 Level of Harm - Minimal harm or potential for actual harm dysuria (trouble urinating) and suicidal ideations. According to hospital note from 8/27/23, he was being treated with IV Ertapenem (antibiotic) from 8/24/23-9/6/23 for recurrent UTI's w ESBL (antibiotic resistant bacteria). He also had bilateral (both sides) non-obstructing renal (kidney) stones. Record review of Resident #122's Physician Orders revealed an order from MD C on 1/12/24 at 8:34am for: Residents Affected - Some Clarification order for skilled OT qd 5x/week x 4 weeks for ADL retraining, therapeutic exercises, therapeutic activities, and group therapy, secondary to generalized weakness. Full Code, Ordered 8/1/23. PT to address impaired functional mobility activities. Ordered on 1/18/24. PT to Eval and Treat as indicated. Ordered 1/18/24. In an interview and observation with Resident #122 on 1/30/24 at 9:56am, he was sitting in his wheelchair. He said he was waiting for PT/OT to come get him. In an interview on 1/30/24 at 2:28pm with MDS Coordinator A, she said the nurses updated the acute care plans and the MDS Nurses updated the comprehensive care plans. She said the nurses would be in charge of adding falls and anything acute to the care plans. She said she looked through the progress notes and the risk assessments to update the care plans. She also said she was the only MDS Nurse until the MDS Coordinator B started November 1, 2023. However, she said the MDS Coordinator B worked between that facility and the other location. In an interview with the DON on 1/30/24 at 3:44pm, he said the MDS's primary responsibility was to do the care plan. He said the basic care plans, like admissions, were done by the nurses. He said sometimes the nutritionist, MD, nurse, and social services came together and updated the resident's plan of care, but MDS was still responsible for updating the care plan. In an interview with the Administrator on 1/30/24 at 4:00pm, she said the MDS Nurse was responsible for writing care plans. She said the Regional MDS Nurse was over the facility MDS Nurse. She also said the Regional MDS Nurse asked the DON to review/sign the MDS' care plans while they were short a MDS Nurse. She said one of the MDS Nurse's left around mid-2023, leaving them with only 1 MDS Nurse, and the DON helped until the new MDS Nurse took over on November 1, 2023. In an interview with the Social Worker on 1/31/24 at 2:30pm, she said she did not update the care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 13 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete plans very much, only when it had to do with social services, like updating the code status of the resident. She said the MDS Nurses updated the care plans. Record review of the facility's policy and procedure on Care Plans, Comprehensive Person-Centered (revised March 2022) read in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: .c. trauma-informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment . Event ID: Facility ID: 675791 If continuation sheet Page 14 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with a mental disorder received the appropriate treatment and services to correct the assessed problem and/or attain the highest practicable mental and psychosocial well-being, for one (Resident#122) of 24 sampled residents reviewed for behavioral heath. The facility failed to ensure that Resident #122 had individualized behavioral health needs addressed through a person-centered care plan. The facility failed to ensure that Resident #122's suicidal ideation was addressed and followed up on. An Immediate Jeopardy (IJ) was identified on 02/16/24 at 6:30 PM. While the IJ was removed on 02/18/24 at 5:15PM, 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 is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of not receiving care and services to address their mental health condition such as PTSD. Finding included Record review of Resident #122's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original admission date of 8/1/23. He had diagnoses of facial weakness after a stroke, dysphagia (trouble swallowing), muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, PTSD, and hemiplegia and hemiparesis (weakness and paralysis) after a stroke affecting the dominant side. Record review of Resident #122's admission MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. The admission MDS revealed he was diagnosed with PTSD. Record review of Resident #122's care plan dated 9/12/23 read in partBehavior Management (Initiated: 8/30/23). *Focus: Resident #122 has depression r/t admission (Initiated: 8/3/23, Revised: 8/3/23). *Goal: Resident #122 will exhibit indicators of depression, anxiety, or sad mood less than daily by review date (Initiated: 8/3/23, Revised: 1/30/24, Target: 3/6/24). Resident #122 will remain free of s/sx of distress, symptoms of depression, anxiety, or sad mood by/through review date (Initiated: 8/3/23, Revised: 1/30/24, Target: 3/6/24). *Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness (Initiated: 8/3/23). The care plan did not mention anything about his PTSD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 15 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #122's medical records from the hospital on 8/29/23 revealed he presented to the hospital for dysuria (trouble urinating) and SI. He also had suicidal ideation at his nursing home with plan to hang himself with call bell. He only had these ideas because he wanted to get out of nursing home. He currently denies suicide ideation here. Record review of Resident #122's psychiatric note from 12/27/23 revealed he stopped the Psychiatrist in the dining room to tell him he was having nightmares of war combat mostly when he heard other residents yelling out of help. In an interview with Psychiatric Nurse Practitioner on 2/15/24 at 1:45 pm, she stated seeing Resident #122 every month and evaluates him. She knew he had PTSD and had talked to staff about it and what to do if he was in crisis. She said he told her in the hall in August that he thought about wrapping the call light cord around his neck, but he never did since he did not know how to do it. He told her then he felt trapped and did not want to be here. He wanted to live with his [family member]. She said she immediately recommended to send him to VA for further evaluation because of suicidal thoughts. She said he had never said anything about symptoms or suicidal thoughts since that one time, and she asked him about it at every visit and evaluation., and he had no thoughts of suicide. She said she put him on a low dose of Melatonin in December since he told her he was having nightmares, but on further visits, he said he was not having nightmares anymore. She said she always talked to staff about Trauma Informed Care and to be aware of resident's conditions and be there if they are in crisis because of past events. Record review of Resident #122's medical record revealed a Trauma Informed Care Assessment-PTSD on 1/18/24 given by the Social Worker, that was scored a 5 out of 5 of probable PTSD. The assessment indicated he had PTSD. Record review of Resident #122's progress notes written by the the Social Worker on 1/18/24 stated, Resident approached SW to discuss his increased depression. Per [Resident] he is unable to sleep at night due to continuous noises. Per [Resident] the noise reminds him of his time in the Vietnam War. Per [Resident] the noise triggers his PTSD badly. He is requesting discharge home since his [family member] circumstances have changed. SW and resident called [family member]and she plans on moving to a larger house and will be working in [local] vs [out of town]. SW to send email request to VA to request discharge orders. In an interview with the Social Worker on 2/1/24 at 1:03pm, she said she did not care plan suicidal ideations unless the resident was actively suicidal. She said she checked Resident #122 daily to see how he was and performed a Trauma Screen on him. Observation and interview with Resident #122 on 2/15/24 at 11:25 am the resident was in his room in bed, watching TV bringing his lunch. Resident #122 told me he does not want to be here, he would rather be at home with his family member. He said he was living with his family member, but he had a stroke and had to go to the hospital, then came here. He said one time after he came here in the summer, he felt trapped and did not like being here, he thought about wrapping the call light cord around his neck, but he did not do it since he could not figure out how. He said he does not want to do that anymore but he still wants to go live with his family member. In an interview with Social Worker on 2/15/24 at 12:05 pm, she said she looks out for Resident #122 because of his PTSD, and she sees him every week, often every day. She said she can re-direct him if he is feeling anxious, and sometimes he will come to her office to talk if something is bothering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 16 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few him. She said he is being seen by an NP with Team Health that is part of Deer Oaks, and VA has quarterly meetings with him, as well as SW and RN from VA every month. She said she has talked to the nurses and aides about his PTSD and triggers that might agitate him, and interventions such as re-direct, talking, distractions from the triggers. She said she updates the progress notes with her visits with him. She said he is in a VA NH to Home program where the VA helps him with the transition, and his daughter is moving back to Houston and will buy a house so he can live with her. She said she asks him every time she sees him about any suicidal thoughts, and he says no. Observation on 02/16/24 at 5:00PM, revealed Resident #122 was in bed sleeping. He was clean and dry. His face was covered with his sheet. During an interview with LVN K at 5:15PM, he said Resident #122 usually go to bed after dinner and he sleeps through the night. He said not to disturb him because noise irritate him. LVN K said Resident #122 was a post war veteran and gets irritated when he hears noises. LVN K said he had an in-serviced on 02/15/24 to reduce noise at the nurse's station during shift change. He said he had not observed resident #122 with any sign of behavior. During an interview with the DON on 02/16/24 at 6:00PM, he said Resident #122 had not shown any sign of suicidal ideation since he came back from the hospital around August. He said all active staff were in-serviced on suicidal precaution sometime in August. He said he had initiated an in-service on 02/15/24 when the issue of suicide was brought to his attention. Observation and interview on 02/17/23 at 12:30PM, revealed Resident #122 in his wheelchair in the dining room socializing with other residents. During an interview he said he was waiting for his lunch. Observation revealed no sign of depression. Observation on 02/17/24 from 1:30 to 3:00PM, revealed no concerns. Observation revealed there were two staff nurses on each station (2,3, & 4). Observation and interview on 02/17/24 at 4:30 PM revealed Resident #122 in bed and said he was doing fine. He said he was looking forward to going home as soon as he gets better. He said he was not ready to go home until he was strong enough to transfer himself from his wheelchair to bed. He said he was receiving therapy and working on being strong. He said the only thing he hated was the noise that remind him of the war. He said all he heard during the war were people crying for help and in pain. He said noise brought bad memories to him. He said that was one of the reasons why he had to sleep with his head covered. He denied suicidal ideation. Record review of facility policy on Suicidal Threats (undated) stated: If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. Observation on 02/18/24 at 12:30PM revealed Resident #122 was in church activities in the dining room. He was clean and dry. No concern on observation. Observation at 1:30PM revealed he was observed in his room with his call light on. During an interview, he said he needed to be changed and assisted back to bed. CNA G. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 17 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Administrator was notified an Immediate Jeopardy situation was identified on 2/16/24at 6:36 pm a template was provided. Facility's Plan of removal was accepted on 02/18/24 at 2:00PM and included: [facility] - Plan of Removal F 740 Residents Affected - Few Resident #122's Care Plan and behavioral health concerns and needs were reviewed again on 02/16/2024 by the Interdisciplinary Care Team. The Director of Nursing initiated Safety Rounds for Resident #122 at 7:00 p.m. on 02/16/2024. Resident #122 was interviewed and assessed by the Director of Nursing at 7:15 p.m. and found to have no suicidal ideations and no active suicidal behaviors. Resident #122 was found to be stable and in good mood. A Clinical Chart review of Resident #122 was conducted by the Interdisciplinary Care Team. The Interdisciplinary Care Team updated Resident #122's to add specificity to individualizing the Care Plan to state resident's name instead of using the word resident, added Monitor for Safety, Monitor for Target Behaviors, Behavior Management of PTSD and monitoring Target Behaviors, Monitor for mood due to PTSD, risk for Visual Impairment due history of CVA, ADL Self Care deficit due to history of CVA Completion Date: 02/16/2024 Resident #122's Care Plan was reviewed again on 02/16/2024. Review of Resident #122's Care Plan confirmed that the Care Plan was updated on 09/12/2023 and 02/15/2024 to identify history of PTSD and suicidal ideations. The trauma informed care assessments that were completed 08/03/2023, 01/18/2024 and 02/17/2024 were used to update Resident #122's Care Plan. The facility did determine how to lessen the likelihood of Resident #122's triggers by relocating him closer to the nursing station for safety, closer observation and decreased environmental noise. Information was added to the Resident's Care Plan to address how to lessen the likelihood of triggers on 02/15/2024. Completion Date 02/17/2024 Head to Toe Assessment of Resident #122 - Completed 02/16/2024. Psychiatric Nurse Practitioner was contacted and notified by Director of Nursing concerning Immediate Jeopardy F 740 regarding Resident #122's needs and assessment. Completion Date: 2/16/2024 and 02/17/2024. Resident's attending physician and the Medical Director were notified of the Immediate Jeopardy related to

F740 regarding Resident #122. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 18 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0740 Completion Date: 02/16/2026 and 02/17/2024 Level of Harm - Immediate jeopardy to resident health or safety QAPI Meeting - A Called Ad Hoc QAPI Meeting was held on the evening of 2/16/2024 to review and address the Immediate Jeopardy citation. Completion Date: 02/16/2024 Residents Affected - Few In-services - The Director of Nursing re-educated and in serviced all staff on Managing Residents with Behaviors, Suicide Ideations, Dementia, and other Behaviors. The Objective of the In-Services is to educate staff on (1) Reporting residents who express Suicide Ideations to the licensed charge nurse, Director of Nursing, one of the Assistant Director of Nursing, Weekend Supervisor, Administrator, or other management staff immediately. (2) Educating staff on understanding persons with Dementia, (3) Understanding post-traumatic stress disorder (PTSD), (4) Understanding the importance of keeping residents calm when exhibiting behaviors, (5) The need to provide trauma informed care and culturally sensitive care. Direct care staff will not allowed to provide direct resident care until they have completed Inservice Training on the aforementioned topics. Completion 02/17/2024 Staff were Inservice on using the individualized plan of care to assist with person-centered intervention for each resident. Staff will not be able to provide direct resident care until they have completed Inservice training on using the individualized plan of care to assist with person-centered interventions for each resident. Trauma Informed Care Assessment has been completed on Resident #122. The Trauma Informed Care Assessment looks for psychological symptoms or triggers that prompt recall of a previous traumatic event. The primary purpose is to address the needs of trauma survivors by minimizing triggers or re-traumatization. Completed 02/17/2024 Facility Plan to Ensure Compliance All Residents were reviewed for Diagnosis of PTSD. Four (4) of 125 Residents were identified to have diagnosis of PTSD. The four residents identified Care Plans were reviewed and updated to ensure they are individualized to identify and meet the needs of each resident. The Care Plans of all four residents with a history of PTSD were updated and individualized to add behavior management / risk for behaviors related to PTSD. No other residents were identified with a history of SI. Completion Date: 02/17/2024 Social Worker and/or Registered Nurse completed updated PHQ-9 Assessments on all four (4) Residents with diagnosis of PTSD. (Residents were in bed asleep on 02/16/2024). Social Worker completes a Resident Mood Interview, also known as PH Q-9, on all residents quarterly or as per MDS schedule. The PHQ-9 is a psychological assessment tool to measure depression. No other residents with a history of SI were identified. Completion Date: 02/17/2024 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 19 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Administrator will inform and Inservice Interdisciplinary Team regarding Care Plan Policy including residents with diagnosis of PTSD and updating residents' Care Plans to identify and address the individualized behavioral health needs and person-centered concerns and interventions for all residents. Administrator and Director of Nursing reviewed the Care Plan policy and confirmed that it includes that review of residents who are readmitting from the hospital and includes that person-centered care plans include care planning for physical, mental, and psychosocial well-being of each resident. Care plans are revised relating to behavioral and mental health based on initial assessments, quarterly and as information about the resident and the residents' condition change. Completion: 02/17/2024 Director of Nursing will continue to Inservice all facility staff on Managing Residents with Dementia, PTSD, Suicide Ideation and Other Behaviors. Resident Care Plans are archived in Point Click Care, and all nursing staff have access to Point Click Care. Completion Date: 02/17/2024 Trauma Informed Care Assessment has been completed on all residents identified to have a diagnosis of PTSD. The Trauma Informed Care Assessment looks for psychological symptoms or triggers that prompt recall of a previous traumatic event. The primary purpose is to address the needs of trauma survivors by minimizing triggers or re-traumatization. Completed 02/17/2024 Administrator shall create a Monitoring Tool to monitor Care Plans for residents with diagnosis of PTSD and Suicide Ideations to confirm they have been updated. Completion 02/17/2024 The surveyor confirmed the plan of removal had been implemented sufficiently from 02/17/24 to 02/18/24 by During an interview with facility Administrator and the DON on 02/17/23 at 1:00PM, the Facility Administrator said the facility had initiated training and in-services since the incident was brought to the attention of the facility. She said the DON had in-services with all available staff and will continue to provide in-services till all staff are trained to implement resident's behavior on care plan and the attention of staff during morning meetings. The DON said some of the residents are post war veterans. He said the facility had identified 4 out of 17 residents with the diagnoses of PTSD. He said the facility had gone through all care plans, reviewed and revised their care plan to reflect their diagnoses. The DON said he would continue to provide in service and training to minimize noise during shift change. During an interview with LVN E on 02/17/24 at 5:00PM, she said she had just had an in-services on documentation, answering call lights and paying attention to resident's verbalized concerns. During an interview with CNA G on 02/18/24 at 1:45PM, CNA G said she had an in-service communication with residents and ensuring that their needs are being met and paying attention to their verbal communication. She said she would stay with any resident with suicidal ideation and find out if they have a plan on how. She said she would remain with the residents and notify the nurse in charge and the DON. She said she would the conversation on the resident chart. Record review on 02/17/24 revealed Resident #118, #122, #209, and 314's clinical record care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 20 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0740 had been updated to include their diagnoses of PTSD. Level of Harm - Immediate jeopardy to resident health or safety Interview on 02/18/24 at 3:34PM RN H said he worked at the facility double on weekend 6AM-10PM shift and was in serviced on suicidal ideation and threats to take the following steps: place the resident on 1 on 1 supervision never leaving the resident, remove any objects in the resident room that the resident could use to try and harm themselves, call the RP, doctor, and Administration. To ensure that all communication with the resident were documented on the resident's clinical record and followed up on. Residents Affected - Few Interview on 02/18/24 at 3:45PM, RN M said he worked the weekends and as needed 6AM-10PM shift. He said he was in-serviced on suicide precautions on 02/17/24 that if a resident expressed suicide ideation to not leave the resident alone, place the resident on to one supervision, remove any objects that resident could use to harm himself, notify the family, doctor, and Administrator. RN K said resident had to remain on one-to-one supervision until sent out for psychiatric evaluation\further notice. Interview on 02/18/24 at 3:50PM CNA F said she was a fulltime staff and had been at the facility for almost a year. She said she remember having an in-service on suicidal threats if a resident expressed harm to themselves. She said that was long time ago when she first started and had just had one yesterday 02/17/24. She said to stay with the resident do not leave them alone, inform the charged nurse, and continue to monitor the residents. She said she would tell the charge nurse, the administrator and continue conversation with the resident till further action is taken. Interview on 02/18/24 at 4:00 PM CNA I said she worked regular full time she said she had been in-serviced on suicidal attempts. CNA I said that if a resident expressed that they wanted to harm themselves she was not to leave the resident alone, have someone to go and inform the nurse, make sure that she removed any objects from the resident room to prevent the resident from harming themselves. She would make sure that she engages the resident in conversation through her shift. She said she had been working at the facility for over a year and had not witness any resident talked about hurting themselves. Interview on 02/18/24 at 4:15 PM LVN T said he worked the 2:00 PM-10:00 PM shift full time. LVN T said she received in-serve on suicidal precautions to never to leave the resident alone and to remove any objects that the resident might use to harm themselves, and to send for the DON and ask a CNA to remain with the resident. She said the last in-services she had was on 02/18/24 this morning to keep noise down during shift change and to pay attention to resident's call light. All resident identified with PTSD diagnoses were observed from 12:00PM to 5:00pm observation revealed no sign of distress. Records review revealed all were updated to reflect monitoring, reporting and documentation. On 2/18/24 at 5:30PM, the Administrator was informed that the Immediate Jeopardy (IJ) was removed, however, the facility remained out of compliant at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm , the facility was continuing to monitor the implementation and effectiveness of their plan of removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 21 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 3 (Nursing Station 3) medication storage rooms reviewed for medication storage in that: The facility failed to keep food out of the refrigerator used only for medication, in the medication storage room on Nursing Station 3. This failure could place residents at risk for infection, and/or worsening health concerns. Findings included: During an observation on 1/31/24 at 3:45pm with LVN A, a bag of salad was observed in the medication storage room refriferator on Nursing Station 3. In an interview and observation on 1/31/24 at 3:51pm with LVN A, she said the bag of salad was hers and she knew she was not supposed to put food in the medication refrigerator. She said she was not supposed to mix the medications with food due to infection control issues. In an interview with the DON on 1/31/24 at 4:35pm, he said he did not expect the staff to check the expiration of the supplies on the bottom and only required them to check the expiration dates of the medication bins. He said he did expect them to not mix expired supplies with other resident items and expected them to put aside expired supplies if they came across any so he could bag them up. The DON said he was in charge of picking up the expired supplies and he would collect all the expired supplies and take them to the nursing programs at the community college. He said the staff did know to not put food in the medication refrigerator though because of cross contamination, and LVN A knew better. Record review of the facility's policy and procedure on Storage of Medication (revised November 2020) read in part: The facility stores all drugs and biologicals in a safe, secure, and orderly manner .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 22 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 2 of 7 residents (anonymous residents) reviewed for food palatability. Residents Affected - Some The facility failed to provide residents meals that was at an appetizing and correct temperature. There failures could cause residents to not eat their food, and which could affect their health. Findings included: Observation on 1/31/2024 at 12:18pm revealed trays being passed out on hall 200, and several trays left sitting on the cart. Observation on 1/31/2024 at 12:21p.m. revealed the temperature for the meat loaf mechanical diet tray was 92.7 . Observation and interview on 1/31/2024 at 12:23p.m. with Anonymous resident, revealed him sitting him in bed with his food on a bedside table. He said his food was only warm a little bit. He said his food could have been a lot warmer. He said he has not had a hot meal in months. He said it is what it is. Observation and interview on 1/31/2024 at 2:25p.m. with another Anonymous resident revealed him sitting up in bed with a bed side table over him with his meal on the bed side table. He said his food was not warm and they could have at least warmed his food. Record review for the Service Line checklist form (date unknown), revealed at the bottom of the page, temperature for hot foods >135 and cold foods < 41. Interview on 1/31/2024 at 3:10pm with the [NAME] , she said she checked the temperatures by using a thermometer. She said sometimes the temperature was off balance, but she would put it in the oven and reheat it. She said it was not good to serve cold food because the residents would not like cold food. She said there had been some residents who have complained about the food being cold. She said she either fixed them another plate or reheated it. She said residents should not be served cold food unless it was a cold plate. She said she normally dips the spoon to the bottom and comes up to the top so make sure it was warm. Interview on 1/31/2024 at 3:34p.m. with CNA A, she said she has been working at the facility for four years. She said staff from dietary services bring the meal trays to the floor and she would pass them out immediately. She said some residents had complained about the food being cold and they would reheat the food in the microwave. She said there are a lot of trays to pass out, and sometimes the food would get cold due to the meal trays sitting on the cart, waiting to be served. She said she believed they had enough staff to pass out the meal trays. She said it was important to serve warm food because no one wants to eat cold food. Record review of the facility's policy titled Quality and Palatability revised on (02/2023) read in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 23 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete part . Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. Food attractiveness refers to the appearance of the food when served to the residents. Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns. Food and liquids/beverages are prepared in a manner, form and texture that meets each resident's needs. The Cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention. Hot liquid foods or beverages will be served in containers (mugs, cups, and bowls) that will minimize the potential for spillage . Event ID: Facility ID: 675791 If continuation sheet Page 24 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, for 2 of 3 medication storage rooms (medication storage room [ROOM NUMBER] and medication storage room [ROOM NUMBER]) reviewed for physical environment, in that: - The facility failed to remove expired blood collection tubes, Tuberculin syringes, inner cannulas for trachs and trachs with inner cannulas, wound dressing kits, IV start kits, viral transport for viruses, and trach adapters with drainage bags from the medication storage room on Nursing Station 3. - The facility failed to remove expired blood collection tubes, IV tubing, a leg bag, IV bags, and IV regulator sets from the medication storage room on Nursing Station 4. These failures could place residents at risk for infection, not receiving therapeutic benefits of the medication and/or worsening health concerns. Findings included: During an observation on 1/31/24 at 3:45pm with LVN A, the following were observed in the medication storage room on Nursing Station 3: 35 red topped blood collection tubes Expired 5/9/21 15 purple top blood collection tubes Expired 6/10/21 2 gold topped blood collection tubes Expired 8/4/21 1 green topped blood collection tube Expired 12/31/20 3 23G x 5/8 1ml Tuberculin syringes Expired 8/31/23 1 Shiley 6.0mm trach inner cannula Expired 3/1/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 25 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0921 - Level of Harm - Minimal harm or potential for actual harm 1 Shiley 6.4mm trach inner cannula Expired 7/24/23 - Residents Affected - Some 1 wound dressing kit with Stat Lock Expired 9/23/23 1 IV start kit Expired 1/31/22 2 universal viral transport for viruses Expired 3/2019 and 9/30/23 2 trach adapters with drainage bags Expired 10/31/19 1 Shiley 6.4mm trach with inner cannula Expired 11/2019 In an interview and observation on 1/31/24 at 3:51pm with LVN A, she said she did not think they drew labs and did not use the lab collection tubes. She said she never checked for expired supplies. She put all the expired supplies in a trash bag and said she would give it to the DON. During an observation on 1/31/24 at 4:15pm with LVN B, the following were observed in the medication storage room on Nursing Station 4: 5 gray topped blood collection tubes Expired 2/28/23 5 red topped blood collection tubes Expired 5/9/21 IV tubing Expired 4/2021, 1 leg bag Expired 10/2022 3 1000ml IV bags of 5% Dextrose Expired 8/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 26 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0921 3-gallon size zip lock bags full of IV regulator sets Expired 3/2019 and 2/28/20 Level of Harm - Minimal harm or potential for actual harm 2 1000ml IV bags of 0.9% Sodium Chloride Expired 12/2023 Residents Affected - Some In an interview on 1/31/24 at 4:26pm with LVN B, she said she did not check under the cabinet for expired supplies. She said she only checked the medication cubbies for expired medications. She said she had never checked the expiration dates on the supplies since she started working at the facility in May 2023 and no one had ever told her to. She said if a resident was given an expired medication or an expired item was used on a resident, it could cause harm. In an interview with the DON on 1/31/24 at 4:35pm, he said he did not expect the staff to check the expiration of the supplies on the bottom and only required them to check the expiration dates of the medication bins. He said he did expect them to not mix expired supplies with other resident items and expected them to put aside expired supplies if they came across any so he could bag them up. The DON said he was in charge of picking up the expired supplies and he would collect all the expired supplies and take them to the nursing programs at the community college. He said the staff did know to not put food in the medication refrigerator though because of cross contamination, and LVN A knew better. Record review of the facility's policy and procedure on Storage of Medication (revised November 2020) read in part: The facility stores all drugs and biologicals in a safe, secure, and orderly manner .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 27 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 out of 1 kitchen as evidence by: Residents Affected - Some Roaches were observed dead in the kitchen, and some were observed crawling in the kitchen area. These failures could place all residents in the facility at risk of infection and a decline in their health. Findings included: Observation on 1/29/2024 at 11:16a.m. revealed a dead roach in the kitchen, near the dishwashing station. Observation on 1/29/2024 at 11:22a.m. revealed two dead roaches inside a tray where the condiments were kept, that was sitting on top of the kitchen counter. Observation on 1/29/2024 at 11:30a.m. revealed two roaches crawling under the stove in the kitchen. Interview on 1/29/2024 at 11:35a.m. with the Dietary Manager, she said the maintenance director that used to work in the building, called Pest Control Company A to come and spray the kitchen a month ago. She said she had not seen any roaches lately, in the kitchen. She said had she seen roaches in the kitchen, she would let the maintenance director know, and would write it in the logbook. She said Maintenance would then call a company to come out spray. Record Review of Pest Control Company A's invoice dated 11/30/2023 revealed date of service on 11/3/2023, and 11/8/2023 for roaches, spiders, and ants, night service for kitchen. Record review of Pest Control Company A's invoice dated 12/31/2023, revealed date of service on 12/8/2023 for roaches, spiders, and ants. Interview on 1/30/2024 at 2:06p.m. with the Maintenance Director, he said he had been working in maintenance for 3 years. He said on 1/29/2024, the staff in the kitchen told him there were roaches in the kitchen. He said he called the pest control guy from Pest Control Company B, who came out to spray the kitchen for roaches. He said he had not looked in the maintenance book to see the last time staff reported roaches in the kitchen before 1/29/2024. The Maintenance Director said for the short time he had been working in the building, no one had told him about the roaches in the kitchen. He said the facility started a new contract with Pest control Company B on 1/29/2024. He said it was important to report issues with roaches in a timely manner because roaches carry diseases and can affect the residents. He said roaches can also get in the food. Interview on 1/29/2024 at 3:09p.m. with the Administrator , she said Pest Control Company A was not affective because she did not see anything happening with eliminating the bugs. She said she just signed a new contract on 1/29/2024 that goes into effect on 2/1/2024 with Pest Control Company B and they would be coming out weekly. She said the purpose of having pest control was to eliminate pest. She said having pest in the kitchen was a sanitation problem. She said it was not healthy or appropriate to have pest in the resident's foods. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 28 of 29 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record Review of the facility's policy titled Pest Control revised on 10/2022 read in part . A program will be established for the control of insects and rodents for the Dining Services Department. The Dining Services Director coordinates with the Director of Maintenance to arrange pest control services monthly, or as needed. All food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin. The center staff will be notified immediately of any concerns. Where applicable, bulk foods will be removed from their original packaging and stored in containers with tight fitting lids . Event ID: Facility ID: 675791 If continuation sheet Page 29 of 29