Health inspection·July 23, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 2022, at 02:21pm entered by CNA B stated Appears that pt was let out of the building by someone entering as the door was locked but it was reported to this nurse that resident was outside in the parking lot. Initially he was not seen but he was near the end of the parking lot, looking out over the street. Asked if he was simply enjoying the sunshine he responded, No I'm trying to go home! Brought inside. Vitals assessed. ADON aware. Administrator aware. Phoned and spoke with [Residents #1's] [family member] who will come up to visit although I did make clear there were no injuries. Monitoring will be completed with resident location. A record review conducted on July 22, 2025, of residents #1'a progress notes dated June 21, 2025, entered by LVN A, resident #1 will discharged from the current facility and placed at a sister facility with a secure unit. A record review of Resident #1 progress notes dated June 22, 2025 at 02:21pm CNA B, reflected that Resident #1 was outside down the street at a stop sign by passerby who called facility to notify staff and also a residents family member from the North side notified staff of resident being outside. Resident brought back into facility by staff and assessed with no injuries.noted and vitals are 124/64,67,18,98.1. When asked where he was going, he stated to my brother's house. Resident taken to his room and placed into bed. 15-minute checks implemented at this time. DON, Administrator, and RP notified of incident. Plans in place to move resident to secure unit once consent from his daughter. Record review of the Wander Risk Scale assessment dated [DATE], at 06:31am reflected that Resident #1 score was a 9 indicating that Resident #1 is at a high risk to Wander. A telephone interview conducted on July 22,2025 at 3pm with LVN A reflected during shift change she received a call from a community member who had been passing by. A community member told her there was a man out by the stop sign sitting in a wheelchair with the facilities name on it. LVN A stated as she was talking to the community member on the phone, the TD A was approaching her pushing Resident #1. LVN A said she thanked the community member and disconnected the call. LVN A said TD A told her she was leaving from the facility when someone told her a resident was sitting in front of the facility near the stop sign. LVN A stated she asked Resident #1 where he was going and he responded, I was going to my [family member] house. LVN A said she completed a head-to-toe assessment and found no injuries or heat exhaustion. She said she then called RN A to inform her on what happened. LVN A said she also called Resident #1's family member, however she did not answer. LVN A was advised by RN A to put Resident #1 on 15min checks. LVN A said she was given an elopement and abuse and neglect in-service. LVN A stated Resident #1 could have received life threatening injuries from being unsupervised during his elopement. An interview conducted on July 22, 2025, at 03:36pm, with TD A reflected she was leaving for the day when she was told by a resident that a man was in a wheelchair was seen near the stop sign. She said she located the resident and seen that it was Resident #1. TD A said she then approached him and returned him to the south side, which was where his room was located. TD A said she took Resident #1 to LVN A who took Resident #1 to complete a head-to-toe assessment. She said that she has never seen Resident #1 elope before. TD A said she received an in-service the next day about elopement and what to do. She said the facility handled the situation in a timely matter and she had no concerns. An interview and observation on July 22,2025 at 11:57am with CN A reflected LVN A got a call from a community member saying they saw someone in a wheelchair with the facility's name on it. TD A and LVN A went to get the resident and completed assessment and found no injuries, his temperature was fine, and he was not over heated. She said that she instructed LVN A to place Resident # 1 on a one-on-one observation, until he was discharged to a sister facility, the next day around 1pm on June 24, 2025. CN A said LVN A informed her she notified the family. CN A said while she was reviewing residents #1's progress notes she noticed resident #1 has eloped before in February. CN A said she believed the resident was found under the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675797 If continuation sheet Page 2 of 8 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 675797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weston 2505 S 37th St Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few awning in front of the building and brought back inside. She stated she did not know why he was not transferred out of the facility at that time. CN A said she was unable to discuss this with the ADM on site at that time because he was no longer the ADM at the facility. CN A said according to the notes she read after the elopement in February, there was no health concerns were found. CN A stated that during the morning meeting's staff discuss residents who are high wonder risk. She said that in the resident's care plans is where staff will find how long a one on one should be. She said the building was not equipped with a wonder guard or alarm system due to cost. CN A said the front door had a code that must be entered to exit and enter the building. She said both incidents took place after hours and at that time there was no one monitoring the doors. CN A stated thought Resident #1 may have eloped by a family member(visitor) letting him out. CN A revealed the facility gave all new residents a Wandering Assessment scale risk, and they are all considered to be a high elopement risk if they are ambulatory or diagnosed with Alzheimer's or dementia. An interview in on July 22, 2025, at 03:19pm with ADON A, reflected she was not present when the incident took place. She stated when she was informed of it, she offered to sit with Resident #1 and provide one on one supervision. She arrived at the facility at 12am on June 22, 2025, and relieved a fellow employee who she did not remember the name of the employee. ADON A said she had never known of Resident #1 to elope prior to this situation. She said when she asked Resident #1 why he left the facility, he would not say how he got out of the door. ADON A said when a resident was at high risk of elopement, they are placed on a two-hour check, if their behavior was persistent, they are placed on a one on one or 15min check. ADON A said there was a binder kept at every nurse's station with the residents who are at risk of elopement. She said there was a receptionist at the front of the building from 8:30am to 5pm on the weekdays and a MOD that worked the front for four hours on the weekend. She reported the door has a lock code to enter and exit that was on 24hours a day. Resident #2A record review, of Residents 2's face sheet undated, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #2 was admitted with diagnosis of wedge compression fracture of second lumbar vertebra, Type 2 diabetes, muscle weakness, displaced fracture of base of neck of left femur, vascular dementia and weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE]th, 2025, reflected she had a BIMS score of 4 which indicated severe cognitive impairment. Review of section G revealed Resident #2 required extensive assistance with bed mobility, transfers, eating and toilet use. A record review of Resident #2's care plan dated June 23, 2025, reflected the following focus areas:*Resident #2 was a wander risk without exit seeking behaviors. The goal of the facility was to maintain Resident's #2 safety throughout her next review date. The interventions were to monitor her behavior for exit seeking behaviors every shift and to distract Resident #2 from wandering by offering pleasant diversions, structure activities, food, conversation, television or a book. *Resident #2 was dependent on staff for meeting emotional, intellectual, physical, and social needs. *Resident #had an ADL self-care performance deficit due to a left femur fracture. *Resident #2 had an impaired cognitive function and dementia.No other interventions were put into place such as 2-hour check or 15 minutes if needed. In an attempted interview with Resident #2 on July 23,2025 at 3:23pm. Resident #2 refused to be interviewed. A record review of Resident #2 Wander Risk Scale-V3 dated June 23, 2025, 1:23pm, reflected that her score is a 13, indicating that she a high risk to wander. Resident #3A record review of Resident #3's factsheet undated, reflected that she was a [AGE] year-old female admitted to the facility on [DATE] with a readmission on [DATE]. Resident #3's was admitted with diagnosis of cerebral palsy, aphasia, COVID-19, epilepsy, cognitive communication, quadriplegia, and a conduct disorder. A record review of Residents #3's quarterly MDS assessment dated [DATE], reflected (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675797 If continuation sheet Page 3 of 8 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 675797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weston 2505 S 37th St Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Residents #3's BIMS score was unable to be completed, due to server cognitive impairment. Furter record review of section GG on the MDS reflected the resident had an impairment on both sides of her body and required a wheelchair to get around. The resident required total assistance with bathing, dressing, personal hygiene transfers. A record review of Residents #3's care plan dated June 23, 2025, reflected she was a wanderer without exit seeking behaviors. The goal of the facility was to maintain Resident #3 safety throughout her next review date. The interventions in place are to monitor her behavior for exit seeking behaviors every shift and to distract Resident #3 from wandering by offering pleasant diversions, structure activities, food, conversation, television or a book. As well as maintain visual checks every two hours. The care plan reflected that Resident #3 has impaired cognitive function/dementia or impaired thought processes. No other interventions were put into place such as 2-hour check or 15 minutes if needed. A record review of Resident #3 Wander Risk Scale-V3 dated June 23, 2025, 1:23pm, reflected that her score is a 11, indicating that she a high risk to wander. An interview conducted on July 22, 2025, at 03:49pm with the DON reflected her expectations of staff were to call her when a resident eloped. She said since she arrived on June 30, 2025, her practice has been that once a new resident enters the facility, she personally completes a Wander Risk Assessment. The DON stated if a resident was a high risk of elopement, but showing no behaviors, then she has them on two-hour checks. She stated if the resident's behavior become evident of higher risk of elopement, then the resident was placed on a one on one- or 15-min check. The DON reported currently Resident #2, and Resident #3 were on high risk of elopement. Interventions are currently in place. The interventions include behavior monitoring on every shift for exit seeking behaviors, and distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, or what the residents prefers. DON A stated at this time Resident #3 was labeled as discharged in electronic medical record due to her being out of the facility on a family pass since July 20, 2025. The DON stated she received an in-service on July 22,2025, for wandering. Facility's Wandering and Elopement policy dated March 2022, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. An (IJ) Immediate Jeopardy was identified on July 22, 2025at 08:25pm., due to the above failures. The ADM was notified on July 22, 2025. The ADM was provided with the (IJ) Immediate Jeopardy template on July 22, 2025, at 08:30pm, and a Plan of Removal (POR) was requested.A plan of removal was first submitted by the Regional Nurse on July 22, 2025. The plan of removal was accepted on July 23, 2025, at 03:25pm.Plan of Removal Date Initiated: July 22, 2025The faculty must ensure that each resident received adequate supervision to prevent accidents. The facility failed to ensure Resident #1 did not elope from the facility in February 2025 and again on June 21, 2025. With a change in condition the facility could have prevented elopement.Residents at risk for elopement could be affected by this deficient practice. Action: An Inservice was provided to the DON and Administrator by the Regional Director of Clinical Services regarding missing resident/elopement procedures, resident identification binder, and hourly rounding on those residents identified as high risk. Comprehension will be verified by return verbal summary of the education presented and attendance will be monitored via an Inservice signature log.Person(s) Responsible: RDCSDate: July 22, 2025 Action: An Inservice was provided to direct care staff regarding missing resident/elopement procedures and residents in the elopement identification binder prior to the beginning of their shift. Comprehension will be verified by return verbal summary and attendance will be monitored via an Inservice signature log. Those staff who are PRN or on PTO, LOA, or FMLA will receive the education prior to their next scheduled shift.Person(s) Responsible: DON/DesigneeDate: July 23, 2025 Action: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675797 If continuation sheet Page 4 of 8 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 675797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weston 2505 S 37th St Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Residents identified to be at high risk will be placed in an elopement identification binder placed at the nursing stations and front desk. The elopement identification binder will contain the resident profile and a picture. Person(s) Responsible: Maintenance Director/DesigneeDate July 22, 2025Action: All licensed nursing staff will be educated prior to the beginning of the next scheduled shift regarding conducting hourly rounds for those residents identified as high risk. Comprehension will be verified by return verbal summary of the education presented and attendance will be documented via an Inservice signature log. Those staff who are PRN or on PTO, LOA, or FMLA will receive the education prior to their next scheduled shift. Person(s) Responsible: Charge NurseDate: July 22, 2025Action: Wandering Risk Assessments will be conducted upon admission, quarterly, or with new wandering behavior. Those identified as high risk will have applicable interventions initiated. Person(s) Responsible: DON/DesigneeDate: July 22, 2025Action: All residents at high risk and listed in the elopement identification binder will be reviewed daily in the morning meeting process and in the weekly We Care Meeting to review for exit seeking behaviors.Person(s) Responsible: DON/DesigneeDate: July 22, 2025 Action: All residents identified as high risk will have all applicable interventions documented on their care plan. Person(s) Responsible: DON/DesigneeDate: July 22, 2025 Action: Signage has been placed on public access door prompting Please check with staff before letting any resident out of the building alone.Person(s) Responsible: ADMDate: July 22, 2025 Action: The RDCS will audit the missing entries report once weekly x 8 weeks to ensure compliance with hourly visual and behavior monitoring checks. The RDCS will randomly select three staff members weekly to ensure compliance within servicing x 8 weeks. The RDCS will attend one weekly We Care Meeting to ensure compliance with weekly monitoring. Person(s) Responsible: RCDSDate: July 22, 2025 Action: A root cause analysis was conducted by the Ad Hoc Committee members. It was determined that the root cause was as follows: Multiple leadership changes have resulted in educational deficiencies for a high turnover staff population regarding the elopement policies, appropriate interventions for those with wander/exit seeking behaviors, and notification of the Admin/DON regarding wandering/exit seeing behaviors. Person(s) Responsible: IDT Date: July 22, 2025Action: An Ad Hoc QAPI was conducted to complete a root cause analysis and review the plan of removal with IDT team and Medical Director. Person(s) Responsible: AdministratorDate: July 22, 2025 Monitoring on July 23, 2025, included the following:Observation made on July 23, 2025, at 09:50am of sign on front for out and inside of facility asking that all visitors and staff check with staff at desk before letting any resident out of the facility alone. Observation made on July 23, 2025, at 10:05am of alarm on 12 exit doors. All alarms functioning properly. Interview and record review on July 23rd, 2025, at 10:23am with ADM revealed he observed maintenance completing emergency door checks that morning. ADM stated the code to the front door changes when it needs to be. ADM Provided a log of signed log's indicating that a member of maintenance had in fact conducted door checks every morning for the last six months. Interviews conducted from July 22, 2025, through July 23, 2025, between 11:30am and 2pm, with LVN B, CNA A, CNA B and ADON B, reflected they had all been in-serviced on July 22, 2025, on wandering. They stated there was a red binder at every nurse's station and in front at the receptionist desk with the high risk of elopement residents. They said they have all been informed that when a resident was at high risk of elopement, they need to have eye's laid on them every hour. LVN B, CNA A, CNA B and ADON B stated that they have no concerns regarding the facility and the supervision of the residents. Interview on July 23, 2025, at 12:07 with CNA C reveled her last in-service was July 23, 2025, on wandering. She said during the in-service she was reminded the binder with high risk for wandering binder was red and was placed at every nurse's station. She said she learned new ways to stop a resident from elopement such as talking to them, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675797 If continuation sheet Page 5 of 8 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 675797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weston 2505 S 37th St Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few making sure someone always has an eye on them or keeping them busy when wandering behavior was evident. Interview on July 23, 2025, at 02:46m ADON B reveled she received her last in-service on wandering July 23, 2025. She said that her definition of eloping was when a resident was attempting to try to get out of the facility. ADON B stated when she sees a resident attempting to elope, she plans to stay with the resident for one and one and do a one. She stated she will then contact the DON and receive further instructions. ADON B said there was a high-risk monitoring binder with the high-risk wanders in the book that was kept at each of the nurse station and the front desk. ADON said some signs of wandering behavior she will look for will include a resident stating that they want to go home over and over, staying near the door, and or appearing anxious.Interview on July 23, 2025, at 02:55pm with RN A reveled she had in serviced all staff on wandering and how to detect wandering behavior in residents. She stated a resident must present signs of elopement once before she expected staff to let her, or the DON know so the resident's behavior can be assessed. Record review on July 23, 2025, at 03:01pm reflected the updated care plan of Resident 2 and Resident 3 and been updated to reflect being checked on every hour as opposed to every two hours. Record review on July 23, 2025, at 3:05pm of QAPI reflected the root cause for residents' elopement was due to multiple leadership changes have resulted in educational deficiencies for a high turnover staff population regarding the elopement policies, appropriate interventions for those with wander/exit seeking behaviors, and notification of the Admin/DON regarding wandering/exit seeing behaviorsThe facility will ensure that residents who exhibit wandering behavior and /or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care.On July 23, 2025, at 03:45pm, the ADM was informed the (IJ)immediate Jeopardy was removed. While the (IJ) Immediate Jeopardy was removed on July 23,2025 the facility remained out of compliance at a scope of isolate and severity level of no actual harm because all staff had not been trained on elopement.Findings included:This was an abbreviated /extended survey, and the sample was increased. Resident #1A record review of Resident #1's face-sheet updated, reflected that he was a [AGE] year-old man admitted to the facility on [DATE], with a readmission on [DATE]. Resident 1 was admitted with diagnosis of Unspecified Dementia, Nontraumatic Intracerebral Hemorrhage, Unsteadiness on feet, Bradycardia, Heart Failure, Allergic Rhinitis, Cerebral Infraction, Vitamin D Deficiency, Benign Neoplasm of colon and Anima. A record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 6 which indicated severe cognitive impairment. Review of section GG- functional abilities indicated Resident #1 required moderate assistance for personal hygiene and was dependent for lower and upper body dressing, showering and toileting. Resident #1 required supervision or touching assistance to roll left and right, sit to lying, and lying to sit. Resident 1 required moderate assistance to sit to stand, chair to bed transfer, toilet transfer and tub/shower transfer. A record review of Resident #1's care plan from March,21,2025 reflected Resident #1 was an elopement risk. The goal was the resident's safety would be maintained through the review date. The Interventions were for staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. All CAN's will document wandering behavior and attempted diversional interventions in behavior log. All CNA's will Monitor resident for elopement attempts and for verbalizations of wanting to go home. A record review of Residents #1's Progress Notes reflected Resident #1 was an elopement risk and had over 21 wandering risk scale assessments completed throughout his stay at the facility. Resident 1 had eloped on March 2, 2022, February 2,2025 and June 21, 2025 while at the facility. A record review, of Residents #1's progress notes dated March 2, 2022 at 02:21pm entered by CNA B stated Appears that pt was let out of the building by someone entering as the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675797 If continuation sheet Page 6 of 8 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 675797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weston 2505 S 37th St Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few door was locked but it was reported to this nurse that resident was outside in the parking lot. Initially he was not seen but he was near the end of the parking lot, looking out over the street. Asked if he was simply enjoying the sunshine he responded, No I'm trying to go home! Brought inside. Vitals assessed. ADON aware. Administrator aware. Phoned and spoke with [Residents #1's] [family member] who will come up to visit although I did make clear there were no injuries. Monitoring will be completed with resident location.A record review of Resident #1 progress notes dated July 22, 2025 at 02:21pm CNA B, reflected that Resident #1 was outside down the street at a stop sign by passerby who called facility to notify staff and also a residents family member from the North side notified staff of resident being outside. Resident brought back into facility by staff and assessed with no injuriesnoted and vitals are 124/64,67,18,98.1. When asked where he was going, he stated to my brother's house. Resident taken to his room and placed into bed. 15-minute checks implemented at this time. DON, Administrator, and RP notified of incident. Plans in place to move resident to secure unit once consent from his daughter. Record review of the Wander Risk Scale assessment dated [DATE] at 06:31am reflected that Resident #1 score was a 9 indicating that Resident #1 is at a high risk to Wander. A telephone interview conducted on July 22,2025 at 3pm with LVN A reflected during shift change she received a call from a community member who had been passing by. A community member told her there was a man out by the stop sign sitting in a wheelchair with the facilities name on it. LVN A stated as she was talking to the community member on the phone, the TD A was approaching her pushing Resident #1. LVN A said she thanked the community member and disconnected the call. LVN A said TD A told her she was leaving from the facility when someone told her a resident was sitting in front of the facility near the stop sign. LVN A stated she asked Resident #1 where he was going and he responded, I was going to my [family member] house. LVN A said she completed a head-to-toe assessment and found no injuries or heat exhaustion. She said she then called RN A to inform her on what happened. LVN A said she also called Resident #1's family member, however she did not answer. LVN A was advised by RN A to put Resident #1 on 15min checks. LVN A said she was given an elopement and abuse and neglect in-service. LVN A stated Resident #1 could have received life threatening injuries from being unsupervised during his elopement. An interview conducted on July 22, 2025, at 03:36pm, with TD A reflected she was leaving for the day when she was told by a resident that a man was in a wheelchair was seen near the stop sign. She said she located the resident and seen that it was Resident #1. TD A said she then approached him and returned him to the south side, which was where his room was located. TD A said she took Resident #1 to LVN A who took Resident #1 to complete a head-to-toe assessment. She said that she has never seen Resident #1 elope before. TD A said she received an in-service the next day about elopement and what to do. She said the facility handled the situation in a timely matter and she had no concerns. An interview and observation on July 22,2025 at 11:57am with CN A reflected LVN A got a call from a community member saying they saw someone in a wheelchair with the facility's name on it. TD A and LVN A went to get the resident and completed assessment and found no injuries, his temperature was fine, and he was not over heated. She said that she instructed LVN A to place Resident # 1 on a one-on-one observation, until he was discharged to a sister facility, the next day around 1pm on June 24, 2025. CN A said LVN A informed her she notified the family. CN A said while she was reviewing residents #1's progress notes she noticed resident #1 has eloped before in February. CN A said she believed the resident was found under the awning in front of the building and brought back inside. She stated she did not know why he was not transferred out of the facility at that time. CN A said she was unable to discuss this with the ADM on site at that time because he was no longer the ADM at the facility. CN A said according to the notes she read after the elopement in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675797 If continuation sheet Page 7 of 8 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 675797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weston 2505 S 37th St Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete February, there was no health concerns were found. She said the building was not equipped with a wonder guard or alarm system due to cost. CN A said the front door had a code that must be entered to exit and enter the building. She said both incidents took place after hours and at that time there was no one monitoring the doors. CN A stated thought Resident #1 may have eloped by a family member(visitor) letting him out. CN A revealed the facility gave all new residents a Wandering Assessment scale risk, and they are all considered to be a high elopement risk if they are ambulatory or diagnosed with Alzheimer's or dementia. An interview in on July 22, 2025, at 03:19pm with ADON A, reflected she was not present when the incident took place. She stated when she was informed of it, she offered to sit with Resident #1 and provide one on one supervision. She arrived at the facility at 12am on June 22, 2025 and relieved a fellow employee who she did not remember the name of the employee. ADON A said she had never known of Resident #1 to elope prior to this situation. She said when she asked Resident #1 why he left the facility, he would not say how he got out of the door. ADON A said when a resident was at high risk of elopement, they are placed on a two-hour check, if their behavior was persistent, they are placed on a one on one or 15min check. ADON A said there was a binder kept at every nurse's station with the residents who are at risk of elopement. She said there was a receptionist at the front of the building from 8:30am to 5pm on the weekdays and a MOD that worked the front for four hours on the weekend. She reported the door has a lock code to enter and exit that was on 24hours a day. Resident #2A record review, of Residents 2's face sheet undated, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #2 was admitted with diagnosis of wedge compression fracture of second lumbar vertebra, Type 2 diabetes, muscle weakness, displaced fracture of base of neck of left femur, vascular dementia and weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE]th, 2025, reflected she had a BIMS score of 4 which indicated severe cognitive impairment. Review of section G revealed Resident #2 required extensive assistance with bed mobility, transfers, eating and toilet use. A record review of Resident #2's care plan dated June 23, 2025, reflected the following focus areas:*Resident #2 was a wander risk without exit seeking behaviors. The goal of the facility was to maintain Resident's #2 safety throughout her next review date. The interventions were to monitor her behavior for exit seeking behaviors every shift and to distract R Event ID: Facility ID: 675797 If continuation sheet Page 8 of 8