Health inspection·August 5, 2025

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few shower on 06/24/25. Shower sheet was signed by CNA-GG. Record review of Resident#1 skin assessment dated [DATE] reflected that there wasn't any alterations in skin integrity noted. The Assessment was conducted by LVN-BB. Record review of Resident #1's progress note dated 06/25/25 reflected that she had mild swelling and warmth to touch to her left arm. The NP was notified, and X-ray was ordered, Tylenol 325 mg 2 tabs was given., vitals recorded and was within range. Rp was notified and care was continued. Resident #1 Physician's order dated 08/14/23 reflected that 2 tablets be given by mouth every 8 hours as needed for Pain. Record review of Resident #1 MAR dated 06/25/25 reflected that she was given 2 tabs of Tylenol 325 mg. Record Review of Resident #1's X-Ray report dated 06/25/25 reflected that she had sustained an Acute fracture across the left humerus neck (broken arm)with subtle displacement of bony edges, overlying soft tissue swelling as noted. Record review of Resident #1's progress note dated 06/30/25 reflected that she had one fall in the past three months. Date, time, and how the fall occurred was not documented in the progress note. In an Interview on 07/02/25 at 10:30 am with the DON, Administrator, and Regional Nurse, all stated that when a resident had a fall Head-to-Toe assessment must be done, the NP, the ADON or DON needs to be notified, and the results of the assessment must be documented. They stated that LVN A did not complete a Head-to-Toe assessment, she failed to notify the facility medical staff, and she also failed to notify the DON. Therefore, due her not following policy, LVN-A was terminated. On 07/02/25 at 11:00 am, an unsuccessful attempt was made to contact LVN-A and CNA-A, but both parties did not answer their phone. In an interview on 07/02/25 at 3:30 PM, the NP stated that she did not receive a call from the facility notifying her that Resident #1 had a fall. She said that she if she had been given a call, she would have given an order for Resident #1 according to the result of the assessment. In an interview on 08/04/25 at 4:20 pm with LVN BB, she stated that on 06/24/25 she was notified by CNA-GG that Resident #1 was complaining of pain to her left arm. LVN-BB stated that she assessed Resident #1's left arm by pulling up Resident#1 sleeve and observed that her arm did not have any redness nor any swelling. LVN BB said that she also conducted a range of motion assessment on Resident#1's arm and Resident#1 did not complain of any pain. However, on 06/25/25, LVN-BB stated that CNA-GG went to get Resident#1 up out of bed, and she complained of pain to her left arm. LVN-BB stated that she assessed Resident#1, and Resident#1 stated that her arm was hurting. LVN-BB said that she notified the NP, and an order was given to have an X-ray performed on Resisdent#1's arm. LVN-BB stated she ordered the X-ray, and she gave Resident#1 two 325 mg Tylenol for pain. On 08/04/25 at 5:35pm, an unsuccessful attempt was made to contact LVN-A and CNA-A, but both parties did not answer their phone. In an interview on 08/04/25 at 6:11pm with CNA-GG, she stated that on 06/24/25 she was trying to get Resident#1 ready for her shower when Resident#1 complained of pain to her left arm. CNA-GG stated that she reported to LVN-BB that Resident#1 was complaining of pain to her left arm. In an interview on 08/04/25 at 6:33pm with CNA-HH, she stated that on 06/23/25, she came to work and Resident#1 was already in bed asleep. In an interview on 08/05/25 at 11:20am with the ADON, he stated that LVN-BB reported to him on 06/25/25 that Resident#1 was experiencing pain in her left arm. The ADON stated that he told LVN-BB to call the NP for an order for an X-ray. The ADON stated that the X-ray was performed and as result of the X-ray Resident#1 was sent to the Hospital. The ADON stated that 06/25/25 was the first time it was reported to him that Resident#1 was having pain. In an interview on 08/05/25 at 11:35am with the Wound Care Nurse, she stated that LVN-BB called her on 06/25/25 to come to station for 4 because Resident#1 was complaining of pain. The Wound Care Nurse stated that she and the ADON both witnessed CNA-GG attempting to put a shirt on Resident#1 when she started showing signs of pain. The Wound Care Nurse stated that LVN-BB was told to call the NP, and get an order for an X-ray. The Wound Care Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated that when the results of the x-ray came back that Resident#1 had an Acute fracture across left humerus neck with subtle displacement of bony edges, overlying soft tissue swelling, as noted, she was sent to the hospital. The Wound Care Nurse stated that 06/25/25 was the first time it was reported to her that Resident#1 was having pain. In an interview on 07/02/25 at 3:30PM, the NP stated that she did not receive a call from the facility notifying her that Resident #1 had a fall. She said that she if she had been given a call, she would have given an order for Resident#1 according to the result of the assessment. Record review of the facility's policy regarding to Accidents and Incidents date 03/2025 revealed in part, All accidents and incidents involving residents, employed, visitors, vendors , etc., occurring on our premises shall be investigated and reported to the administrator The following information also has to be documented in the report , the time the physician was notified and the instructions of the physician, and the date and time the resident's family were notified, the condition of the injured person, including his/her vital signs, the disposition of the injured (i.e., transferred to hospital, or put to bed. Record Review of In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON regarding falls management and changes in resident conditions. Record Review of In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON/ADON regarding Abuse & Neglect/Exploitation, and Who is the Abuse coordinator. Record Review of In-service Training Report dated 06/26/2025 revealed facility administrative staff were educated by the Regional [NAME] President of Operations regarding Reporting Guidelines HHSC Provider Letter #2024-14. Record Review of In-service Training Report dated 06/27/2025 revealed 6am-2pm and 2pm-10pm facility staff were educated by the administrator/ DON regarding resident's rights. Record Review of In-service Training Report dated 06/27/2025 revealed facility 6am-2pm staff were educated by DON/ADON on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of In-service Training Report dated 06/28/2025 revealed facility all staff and all shifts were educated by RN Weekend Supervisor on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of In-service Training Report dated 06/28/2025 revealed all staff and all shifts were educated by RN Weekend Supervisor Fall and incident Protocol. The protocol call being License Nurse assesses resident, notify the MD/NP, RP if needed, DON, Neuro Checks, and implement Doctors orders promptly. Record Review of In-service Training Report dated 06/30/2025 revealed facility 6am-2pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of In-service Training Report dated 06/30/2025 revealed facility 6am-2pm, 2pm-10pm and 10pm-6pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of In-service Training Report dated 07/01/2025 revealed facility leadership staff were educated by Director of Regulatory Compliance on Topic of Abuse & Neglect. Record Review of facility resident interviews-safe review dated 06/27/2025 reflected Residents #2, #3, #4, #5, and #6 were interviewed to ensure that they were feeling safe while living at the facility. Residents were asked the following questions: 1.Do you feel safe here? 2. If you have a concern or compliant, do you feel comfortable reporting It?3. Are you afraid of anyone here?4.When the staff come to your room, do they knock, tell you their name and why they are there? Residents #2, #3, #4, #5, and #6 answered the questions in a manner that assured facility staff that they all felt safe and that they had no concerns with staff or other residents at the facility. Record Review of facility's resident audits for recent falls dated 06/28/2025, and 07/01/2025 reflected Residents #7, #8, #9, & #10 were properly assessed, notifications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few were made, progress notes were written, SBAR, changes in condition were documented if needed. Record Review of a facility email dated 07/01/2025 reflected the Administrator placed a phone call to LVN-A at 4:52pm on 07/01/2025 informing her that her employment had been terminated. In an interview on 07/02/25 at 10:00am with the DON, Administrator, and Regional Nurse, all stated that when a resident had a fall that a Head-to-Toe assessment must be done, the NP must be notified, the ADON, or DON needs to be notified. And the result of the assessment must be documented. They stated that LVN A did not complete a Head-to-Toe assessment, she failed to notify the facility medical staff, and she also failed to notify the DON. In an interview on 07/02/25 at 3:40pm with LVN-B, she stated that she was in-serviced on 06/26/25 regarding resident falls. She stated that she was told to complete a head-to-toe assessment, call the facility medical staff, call the ADON, or DON, and the residents RP if the resident isn't their own RP. LVN-B also stated that and SBAR must be performed, and that the assessment must be documented in the resident's progress notes. In an interview on 07/02/25 at 3:45pm with LVN-C, he stated that he was in-serviced on 06/26/25 regarding resident falls. He stated that he must perform a head-to-toe assessment on the resident, call the NP, call the ADON, or DON, and the RP if necessary. He also stated that neuro checks must be conducted if the resident hit their head, an SBAR must be done, and all the information must be documented in the resident's progress notes. In an interview on 07/02/25 at 3:55pm with LVN-D, she stated she was in-serviced on 06/26/25 regarding resident falls. She said the in service pertained to conducting a head-to-toe assessment when a resident has a fall, call the medical staff, RP, if necessary, call the ADON, or DON and let them know that there was a fall. Also document the assessment, and SBAR in the resident's progress notes. In an interview on 07/02/25 at 4:05pm with LVN-E, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated the in service taught her to conduct a head-to-toe assessment, call the facility medical staff, call the ADON, DON, and the residents RP if necessary and perform and SBAR and document the finding in the resident's progress notes. In an interview on 07/02/25 at 4:15pm with CNA-A, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA, her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:20pm with CNA-B, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA, her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:25pm with the Receptionist, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that as a receptionist, his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:35pm with the Director of Therapy, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that if she witnessed a resident fall then her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:40pm with the Director of EVS, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall, then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:45pm with the Director of Maintenance, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall, then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. The noncompliance was identified as Past Non-Compliance. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. On 07/03/25 at 4:35 p.m. the facility's Administrator and DON were notified of the past noncompliance IJ. A plan of removal was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 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 0580 requested. An IJ template was provided to the Administrator on 07/03/25 at 4:35 p.m. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to ensure LVN-A adequately assessed, monitored, provided appropriate interventions, and contact the physician immediately when Resident #1 complained of pain after a fall which resulted in an acute fracture of her left humerus (the long bone in the upper arm). The noncompliance was identified as Past Non-Compliance. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. This failure placed residents who experience falls with injury at risk of not receiving adequate treatment in a timely manner, further injury, and pain.Findings included: Record Review of Resident #1's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), Primary insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or experiencing non-restorative sleep), lack of coordination (impaired balance or coordination), muscle weakness (decreased strength in the muscles), Hyperlipidemia (abnormally high levels of lipids in the blood), Rheumatoid Arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), and Unspecified Osteoarthritis (a type of arthritis where the specific location is not identified in the medical record). Record review of Resident #1's significant change in status MDS dated [DATE] revealed she had a BIMS score of 3 (severe cognitive impairment). Record Review of Resident #1's Care Plan dated 06/25/25 revealed she was at risk for falls due to unsteady gait, poor awareness with visual deficit, altered cognition and poor safety awareness. Interventions included: Anticipate and meet the resident's needs; Be sure the call light is within reach and encourage the resident to use it for assistance as needed; Ensure resident wears appropriate footwear when ambulating or mobilizing in wheelchair; Keep needed items in reach; and Physical Therapy evaluate and treat as ordered or as needed. Observation of Resident #1 on 07/01/2025 at 12:50 p.m. revealed she resided in the facility's locked unit. Resident #1 was in bed. Resident #1 was in bed with her left arm in a splint to keep it immobilized. Her bed was in the lowest position (the bed frame was adjusted to be as close to the floor as possible), fall mats were in place and her call light was in reach. Record Review of Resident #1's progress note dated 06/23/25 reflected that the following note was written by LVN A: Nurse witnessed the resident on floor in front of room [ROOM NUMBER], lying on her left side. An assessment/observation were completed with no verbal c/o pain or discomfort. The resident was assisted to bed with no complaints of uncontrolled pain. Record review Resident#1 progress note dated 06/25/25 reflected that she had mild swelling and warmth to touch to her left arm. The NP was notified, and X-ray was ordered, Tylenol 325mg 2 tabs was given., vitals recorded and was within range. Rp was notified and care was continued. Record review of Resident#1 progress note dated 06/30/25 reflected that she has had one fall in the past three months. Date, time, and how the fall occurred was not documented in the progress note. Record Review of Resident #1's X-Ray report dated 06/25/25 reflected that she had sustained an Acute fracture (a sudden and complete break in a bone) across the left humerus neck (upper arm) with subtle displacement (broken bone fragments are slightly out of alignment) of bony edges, overlying soft tissue swelling as noted. In an interview on 07/02/25 at 10:00am with the DON, Administrator, and Regional Nurse revealed they all stated that when a resident had a fall that a head-to-toe assessment must be done, the NP must be notified, the ADON, or DON needed to be notified. And the result of the assessment must be documented. They stated that LVN A did not Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few complete a head-to-toe assessment, she failed to notify the facility medical staff, and she also failed to notify the DON. In an interview on 07/02/25 at 3:30PM, the NP stated that she did not receive a call from the facility notifying her that Resident #1 had a fall. She said that if she had been given a call, she would have given an order for Resident#1 according to the result of the assessment. In an interview on 08/11/25 at 11:30am with Resident#1 RP he stated that he was not notified of Resident#1 fall on the 23rd of June until the 25th of June when the facility was getting ready to send her to the hospital. In an interview on 08/05/25 at 11:20am with the ADON he stated that LVN-BB reported to him on 06/25/25 that Resident#1 was experiencing pain in her left arm, The ADON stated that he told LVN-BB to call the NP for an order for an X-ray. The ADON stated that the X-ray was performed and as result of the X-ray Resident#1 was sent to the Hospital. The ADON stated that 06/25/25 was the first time it was reported to him that Resident#1 was having pain. In an interview on 08/05/25 at 11:35am with the Wound Care Nurse she stated that LVN-BB called her on 06/25/25 to come to station for 4 because Resident#1 was complaining of pain. The Wound Care Nurse stated that she and the ADON both witnessed CNA-GG attempting to put a shirt on Resident#1 when she starting sowing signs of pain. The Wound Care Nurse stated that LVN-BB was told to call the NP and get an order for an X-ray. The Wound Care Nurse stated that when the results of the x-ray came back as Resident#1 had an Acute fracture across left humerus neck with subtle displacement of bony edges, overlying soft tissue swelling as noted she was sent to the hospital. The Wound Care Nurse stated that 06/25/25 was the first time it was reported to her that Resident#1 was having pain. Record review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting revised on 03/27/25 revealed, Policy Statement. All accidents or incidents involving residents, employees, visitors, and vendors occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Record Review of facility's internal investigation documentation dated 06/24/2025 regarding the incident of Resident #1 having a broken arm reflected that the facility interviewed staff beginning on 06/24/2025. Staffed interviewed were staff LVN-A, B, C, D. Record Review of an In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON regarding falls management and changes in resident conditions. Record Review of an In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON/ADON regarding Abuse & Neglect/Exploitation, and Who is the Abuse coordinator. Record Review of an In-service Training Report dated 06/26/2025 revealed facility administrative staff were educated by the Regional [NAME] President of Operations regarding Reporting Guidelines HHSC Provider Letter #2024-14. Record Review of In-service Training Report dated 06/27/2025 revealed 6am-2pm and 2pm-10pm facility staff were educated by the administrator/ DON regarding resident's rights. Record Review of an In-service Training Report dated 06/27/2025 revealed facility 6am-2pm staff were educated by DON/ADON on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of ‘In-service Training Report dated 06/28/2025 revealed all staff and all shifts were educated by RN Weekend Supervisor on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of an In-service Training Report dated 06/28/2025 revealed facility all staff and all shifts were educated by RN Weekend Supervisor Fall and incident Protocol. The protocol call being License Nurse assesses resident, notify the MD/NP, RP if needed, DON, Neuro Checks, and implement Doctor's orders promptly. Record Review of an In-service Training Report dated 06/30/2025 revealed facility 6am-2pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of an In-service Training Report dated 06/30/2025 revealed facility 6am-2pm, 2pm-10pm and 10pm-6pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of an In-service Training Report dated 07/01/2025 revealed facility leadership staff were educated by Director of Regulatory Compliance on the topic of Abuse & Neglect. Record Review of facility resident interviews-safe review dated 06/27/2025 reflected Residents #2, #3, #4, #5, and #6 were interviewed to ensure that they were feeling safe while living at the facility. Residents were asked the following questions:1.Do you feel safe here? 2. If you have a concern or compliant, do you feel comfortable reporting It?3. Are you afraid of anyone here?4.When the staff come to your room, do they knock, tell you their name and why they are there? Residents #2, #3, #4, #5, and #6 answered the questions in a manner that ensured facility staff that they all felt safe and that they had no concerns with staff or other residents at the facility. Record Review of facility resident audits for recent falls dated 06/28/2025, and 07/01/2025 reflected Residents #7, #8, #9, & #10 were properly assessed, notifications were made, progress notes were written, SBAR, changes in condition were documented if needed. Record Review of CNA-A witness statement dated 06/30/2025 reflected that CNA-A stated that Resident #1's fall on o6/23/2025 was caused when Resident #1 was getting up from her seat and she accidentally bumped into a resident that CNA-A was assisting. Record Review of a facility email dated 07/01/2025 reflected the Administrator placed a phone call to LVN-A at 4:52pm on 07/01/2025 informing her that her employment has been terminated. LVN-A was terminated because she failed to follow facility policy regarding a resident's fall. Record Review of facility emailed dated 07/01/2025 reflected the Administrator called CNA-A on 07/01/2025 informing her employment has been terminated. CNA-A was terminated for failing to follow policy regarding a resident's fall. In an interview on 07/02/25 at 3:40pm with LVN-B, she stated that she was in-serviced on 06/26/25 regarding resident falls. She stated that she was told to complete a head-to-toe assessment, call the facility medical staff, call the ADON, or DON, and the resident's RP if the resident wasn't their own RP. LVN-B also stated that a SBAR had to be performed, and that the assessment must be documented in the resident's progress notes. In an interview on 07/02/25 at 3:45pm with LVN-C, he stated that he was in-serviced on 06/26/25 regarding resident falls. He stated that he must perform a head-to-toe assessment on the resident, call the NP, call the ADON, or DON, and the RP if necessary. He also stated that neuro checks must be conducted if the resident hit their head. And a SBAR was to be done, and all the information had to be documented in the resident's progress notes. In an interview on 07/02/25 at 3:55pm with LVN-D, she stated she was in-serviced on 06/26/25 regarding resident falls. She said the in- service pertained to conducting a head-to-toe assessment when a resident has a fall, call the RP if necessary, call the facility medical staff, call the ADON, or DON and let them know that there was a fall. Also document the assessment, and SBAR in the resident's progress notes. In an interview on 07/02/25 at 4:05pm with LVN-E, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated the in-service taught her to conduct a head-to-toe assessment, call the facility medical staff, call the ADON, DON, and the resident's RP if necessary; and perform a SBAR and document the finding in the resident's progress notes. In an interview on 07/02/25 at 4:15pm with CNA-A, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:20pm with CNA-B, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA her job is to notify the nurse, and that the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:25pm with the Receptionist, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that as a receptionist his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:35pm with the Director of Therapy she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that if she witnessed a resident fall then her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:40pm with the Director of EVS, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:45pm with the Director of Maintenance, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. Observation of the facility's secure unit on 07/01/2025 from 12:50 p.m. until 1:05 p.m. revealed there were always six staff members inside the locked memory care unit. Observation also revealed that Resident #1 was in her bed, her bed was in the lowest position, fall mats were in place and her call light was in reach. The noncompliance was identified as Past Non-Compliance. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. On 07/03/25 at 4:35 p.m. the facility's Administrator and DON were notified of the past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the Administrator on 07/03/25 at 4:35 p.m. Event ID: Facility ID: 675791 If continuation sheet Page 9 of 9