Health inspection·July 28, 2023

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few different facility in the past. Resident #43 stated he demanded that he keep his eye drops on the day he was admitted to the facility, which they allowed him to do. Resident #43 denied being assessed to see if he could safely administer the eye drops and insisted that he did not need to be assessed as he was smart and more capable than the staff. Resident #43 stated he was able to distinguish the difference in the eye drops and identified each one by the size of the bottles, design of the caps, and the position of labels. Resident #43 stated he did not need the eye drops spread on his bed to identify them; he was just never told to put them in a secure place. Resident #43 stated he knew the eye drops could be toxic to others, but he had a keen sense of his environment. He stated he could tell if someone was coming near his bed if he was there in the room; however, he sometimes left the room and did not put the eye drops in a secure place. Observation on 07/27/23 at 9:30 AM revealed the following eye drops were still not secured and on Resident #43's bed: Simbrinza Ophthalmic Suspension 1-0.2 % (Brinzolamide-Brimonidine Tartrate), Rhopressa Ophthalmic Solution 0.02 % (Netarsudil Dimesylate), Pilocarpine HCl Ophthalmic Solution 1 % (Pilocarpine HCl), and Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8 MG/ML (Dorzolamide HCl-Timolol Maleate). Interview on 07/28/23 at 11:15 AM with LVN D revealed she had worked at the facility for two weeks. She stated she worked with Resident #43. LVN D stated she was aware the resident had prescribed eye drops in his possession and that he refused to let the nurses keep them. LVN D stated Resident #43 was able to administer the eye drops himself, but she would stand and watch him administer them. Interview on 07/28/23 at 11:20 AM with ADON B revealed she had worked at the facility since September 2022. She stated she was familiar with Resident #43 and was not aware that he had possession of his prescribed eye drops. ADON B stated the eye drops should have been in the medication cart. ADON B stated she did not know if Resident #43 had an assessment for self-administration of medication but agreed to check. She stated Resident #43 should have been assessed if he was administering his own eye drops. Interview on 07/28/23 at 11:30 AM with the Administrator revealed it was her expectation for residents to be assessed by the clinical team before self-administering medication. She stated she was unaware that Resident #43 had possession of his medications and was self-administering without an assessment. When asked if the medications that were self-administered needed to be in a secured box or location, the Administrator stated they did not have to be if the resident was assessed determined safe to have the medication. When asked about other residents getting ahold of the medications, the Administrator stated there were no residents on the hall who exhibited behaviors of wandering and going into other rooms, since those residents would be in the facility's secured unit. Interview on 07/28/23 at 12:24 PM with the DON revealed he was unaware that Resident #43 had possession of his eye drops or that he was self-administering them. The DON stated Resident #43 had only requested to self-administer his eye drops on 07/26/23 and the physician was notified then for an order. The DON stated an assessment was given to Resident #43 on 07/26/23 as well. The DON stated the risk of a resident having possession of medication and self-administering without being assessed could be inappropriate consumption and the wrong resident getting ahold of the medication. Interview and observation on 07/28/23 at 1:45 PM with Resident #43 revealed there were no eye drops on the resident's bed. When asked where the eye drops were, Resident #43 opened his drawer and stated he was asked by staff to store them there. Resident #43 stated, Can you believe that after 40 days of being here someone came in my room this morning to assess me and see if I could safely give (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 2 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few myself these eye drops. When asked if the nurses watched him before when he administered his eye drops, he stated No. Resident #43 proceeded to pull an albuterol inhaler out of the drawer and stated, They didn't say anything about this. Resident #43 stated he was able to administer his own inhaler but did not use it often. He stated he had to keep it on him because it would be hard to ask for it while unable to breathe. Interview on 07/28/23 at 1:15 PM with LVN D revealed she was not aware that Resident #43 had possession of his albuterol inhaler. She stated it was PRN and she did not have to sign off for it on a regular which is how it likely got overlooked. Interview on 07/28/23 at 3:00 PM with ADON B revealed she recalled Resident #43 telling her on 07/26/23 during a smoke break that he had his eye drops in his room. ADON B stated she immediately completed a self-administration of medication assessment on the resident. ADON B provided the surveyor with an assessment. Record review of Resident #43's self-administration of medication assessment revealed it had an effective date and time of 07/26/23 at 9:04 AM. The assessment revealed Resident #43 was fully capable of administering eye drops and needed assistance with administering inhalants. Interview on 07/28/23 at 4:24 PM with the DON revealed he was also unaware that Resident #43 had possession of his albuterol inhaler. Review of the facility's policy titled Self-Administration of Medication, revised February 2021, revealed in part the following: Policy Heading-Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administration of medications is safe and clinically appropriate for the resident .8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 3 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 3 residents (Residents #19, #24, and #47) of 3 residents reviewed for oxygen. Residents Affected - Some The facility failed to ensure Residents #19, #24 and #47 had orders for oxygen administration. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment. Findings included: Record review of Resident #19's face sheet, dated 07/28/23, revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia without behavioral disturbance (decrease in memory and thinking abilities), chronic obstructive pulmonary disease (inflammatory lung disease), schizoaffective disorder (mood disorder), congestive heart failure, and type II diabetes. Review of Resident #19's care plan, revised 07/27/23, revealed the resident received oxygen therapy as needed. Interventions included Change oxygen tubing and clean concentrator filter weekly, provide extension tubing or portable oxygen apparatus, monitor for s/sx of respiratory distress and report to MD PRN, notify charge nurse if oxygen tubing needs to be removed/replaced, oxygen via nasal prongs set at (2)L, and promote lung expansion and improve air exchange by positioning with proper body alignment. Record review of Resident #19's quarterly MDS assessment, dated 06/07/23, revealed Resident #19 was cognitively intact with a BIMS score of 13 and required limited assistance by one person with most ADLs. Record review on 07/26/23 at 2:25 PM of Resident #19's physician orders revealed no current orders for oxygen use. Review of discontinued orders revealed the last order for oxygen use was for oxygen at 2-3 liters per minute via nasal cannula continuous per concentrator with a start date of 07/14/20 and a discontinued date of 04/02/21. Record review on 07/27/23 at 9:00 AM of Resident #19's current physician orders revealed an order for oxygen as needed at 2 liters per minute per nasal cannula with a start date of 06/28/23 and a created date of 07/26/23. Record review of Resident #24's face sheet, dated 07/28/23, revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease (inflammatory lung disease), acute and chronic respiratory failure, type II diabetes, generalized epilepsy (seizure disorder), and hypoxic ischemic encephalopathy (brain injury). Review of Resident #24's care plan, revised 07/12/23, revealed the resident received oxygen therapy related to chronic obstructive pulmonary disease, respiratory failure, and shortness of breath. Interventions included Give medications as ordered by physician monitor for s/sx of respiratory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 4 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 distress and report to MD PRN, oxygen at 2-4 liters per minute per nasal cannula, and position resident to facilitate ventilation/perfusion matching. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #24's quarterly MDS assessment, dated 05/17/23, revealed Resident #24: Residents Affected - Some - cognition moderately impaired (BIMS 11). -required extensive assistance and one-person assist with most ADLs. Record review on 07/26/23 at 2:27 PM of Resident #24's physician orders revealed no current orders for oxygen use. Review of discontinued orders revealed the last order for oxygen use was for oxygen at 2-4 liters per minute via nasal cannula per every shift with a start date of 07/01/22 and a discontinued date of 11/20/22. Record review on 07/27/23 at 9:05 AM of Resident #24's current physician orders revealed an order for oxygen at 2 liters per minute via nasal cannula with a start date of 06/27/23 and a created date of 07/26/23. Record review of Resident #47's face sheet, dated 07/27/23, revealed the resident was a [AGE] year-old female with an initial admission date of 02/11/22 and re-admission date of 05/18/23. The resident's diagnoses included: Malignant neoplasm of the mouth (is where a tumor develops on the surface of the tongue, mouth, lips, or gums) and carcinoma in situ of buccal mucosa (cancer that affects flat cells that make up the top layer of the buccal mucosa). Record review of Resident #47's MDS assessment, dated 06/01/23, revealed she had a BIMS score of 7, which indicated the resident's cognition was severely impairment. The MDS reflected the resident was on oxygen. Record review of Resident #47's care plans, on 07/27/23 at 2:54 PM oxygen use was not addressed. Record review of Resident #47's July 2023 physician orders revealed there were no orders for oxygen. Interview and observation on 07/26/23 at 11:16 AM with Resident #19 revealed he was sitting in his wheelchair with a portable oxygen tank on the back, but the resident was not wearing the nasal cannula tubing. Resident #19 stated he only used the oxygen when he felt short of breath. Resident #19 stated he did not always need the oxygen. Observation revealed there was an oxygen concentrator in the resident's room that was not plugged in. Resident #19 stated there were not enough outlets to keep the oxygen concentrator plugged in and besides he did not use it often. Observation on 07/26/23 at 11:31 PM revealed Resident #47 was receiving 2 liters of oxygen via nasal cannula. The tubing was dated 07/26/23 Interview and observation on 07/26/23 at 11:25 AM with Resident #24 revealed he was lying in bed and was wearing his nasal cannula with the oxygen concentrator on and set at 2 liters per minute. Resident #24 stated he used the oxygen continuously. He stated the nurses always checked his oxygen concentrator and made sure that he was wearing the nasal cannula. Observation on 07/27/23 at 10:45 AM with Resident #24 revealed he was lying in bed and was wearing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 5 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some his nasal cannula with the oxygen concentrator on and set at 2 liters per minute. Resident #24 was asleep and did not show any signs of distress. Observation on 07/27/23 at 11:10 AM with Resident #19 revealed he was going down the hallway in his wheelchair with his portable oxygen tank and was wearing the nasal cannula. The oxygen setting was at 2 liters per minute. Resident #19 stated he felt like he needed to use the oxygen. The resident stated he was fine and did not show any signs of distress. Interview on 07/27/23 at 1:30 PM with LVN C revealed she had worked at the facility for about one year. She stated she worked with Resident #19 and Resident #24. LVN C stated both residents used oxygen and she saw them both with the oxygen on continuously. When asked what the physician orders stated regarding oxygen use for Resident #19 and Resident #24. LVN C stated she had to check the orders in the system because she did not know by memory. After checking the orders, LVN C stated Resident #19 had an order for oxygen at 2 LPM as needed, and Resident #24 had an order for oxygen at 2 LPM continuously. LVN C stated she relied on the orders and MAR to administer the right medication and treatments to the residents. LVN C stated she could not recall if the physician orders for oxygen use was in the system prior to 6:00 PM on 07/26/23 for Resident #19 and Resident #24. She stated the orders should have been there. Interview on 07/27/23 at 1:45 PM with CNA E revealed she had worked at the facility for 2 years. CNA E stated she worked with Resident #19 and Resident #24. She stated she only saw Resident #19 use his oxygen sometimes. CNA E denied knowing the physician's order for Resident #19's oxygen use and stated that was beyond her scope of work. CNA E stated the nurses assisted residents with their oxygen and would only let the aides know if there was a change in how often the residents should be seen with the oxygen on. CNA E stated Resident #24 always had his oxygen on and denied knowing the physician's order for his oxygen use as well. CNA E stated the aides had access to the care plans, which would tell them if a resident required oxygen. Observation and interview on 07/27/23 at 2:54 PM with Resident #47 revealed she was on the hallway without oxygen. She stated she uses oxygen while in her room and she did not know how many liters she was supposed to be on. Resident #47 stated she did not have shortness of breath, and she did not know whether she needed to be on oxygen. Interview with the DON on 07/27/23 at 4:20 PM revealed resident #47 was on oxygen. DON stated Resident #47 had been in and out of hospital and he thought the system dropped the orders and staffs did not notice. DON stated the re-admitting nurses were supposed to re-enter the orders with each readmission. DON stated the failure was nurses knew their residents on oxygen and every time they go to hospital and back, they administer oxygen and they had not been verifying whether the orders are in the system. Interview on 07/28/23 at 11:20 PM with the Administrator revealed it was her expectation for the clinical team to ensure that all active physician orders were entered in the system. She stated the facility recently went through a change of ownership and switched their electronic health record system around 07/06/23. She stated the switch caused issues with data, including the orders, being carried over which could have been why there was a delay in some of the orders being entered into the system. The Administrator stated not having active physician orders in the system could place the residents at risk of not receiving the appropriate treatment. Interview on 07/28/23 at 11:54 AM with the DON revealed he had been employed at the facility since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 6 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10/2022. He stated Resident #19 and Resident #24 had received oxygen therapy from the time he started as DON and before then according to the notes. The DON looked at the discontinued and active physician orders for Resident #19 and stated the resident had an order for oxygen as needed with a start date of 06/28/23 and he acknowledged that the order was created on at 6:50 PM on 07/26/23. The DON stated Resident #19 had multiple orders for oxygen use starting in the year of 2020 that went from continuous use to PRN. The DON stated Resident #19 had an order for continuous oxygen use at 2-3 LPM with a start date of 07/14/2020 and a discontinued date of 04/02/2021. The DON stated he could not find another order for oxygen use until the order that was started on 06/28/23 and created in the system at 6:50 PM on 07/26/23. The DON could not state why there was no order in place for oxygen use for Resident #19 prior to him working at the facility; however, he stated the resident may not have needed oxygen during those times. The DON also could not state why Resident #19 did not have an order for oxygen use in place after he started as DON until 06/28/23. He stated there should have been an as needed order for oxygen in place for Resident #19 at that time. The DON looked at the discontinued and active physician orders for Resident #24 and stated the resident had an order for continuous oxygen with a start date of 06/27/23 and he acknowledged that the order was created on at 6:45 PM on 07/26/23. The DON stated Resident #24 had an order for oxygen use that was discontinued on 11/22/22 and he could not find another order for oxygen use until the order that started on 06/27/23. The DON stated there should have been an ongoing order for oxygen use in place for Resident #24. The DON stated it was the responsibility of the clinical management team and nurses to ensure that all active orders were in the system. He stated the facility had been experiencing issues with their new system and the orders not carrying over, and they were working on getting everything updated. The DON stated with Resident #19 and Resident #24 both being diagnosed with chronic obstructive pulmonary disease, the risk of not having orders for oxygen use in the system could be not being treated appropriately and respiratory failure. Interview with the DON on 07/28/23 at 11:58 AM revealed resident #47 did not have orders for oxygen. DON stated they failed to put oxygen orders on re-admission on [DATE] and it was his responsibility to monitor and audit all orders are in medication administration record. DON stated he has no excuse of not having orders for Resident #47. DON stated Resident #47 had been in and out of hospital and he thought the system dropped the orders and staffs did not notice since Resident #47 was put on oxygen as a needed when she had COVID on 2/11/22. DON stated the re-admitting nurses were supposed to re-enter the orders with each re-admission. DON stated the failure was nurses knew Resident #47 was on oxygen and every time she went hospital and back, they administer oxygen and they have not been verifying whether the orders are in the system. He stated the risk of administering oxygen with no orders can interfere with her health since she has a lot of comorbidities (presence of two or more diseases or medical conditions in a patient). DON stated he has done competency training yearly and randomly on staffs. Interview on 07/28/23 at 2:20 PM with ADON A revealed she had worked at the facility since 10/2022. She stated she was helping on the floor and was working with Resident #19 and Resident #24. ADON A could not state if the residents had physician orders for oxygen use in the system prior to 6:00 PM on 07/26/23 as she did not routinely work with the residents. ADON A stated she had to check for the current physician orders to know how the residents' oxygen needed to be administered since she did not normally work with them. ADON A stated if she ever saw where physician orders were not entered in the system and she knew a resident typically received a certain treatment, she would use her nursing judgement and notify the physician. Interview with LVN H on 07/28/23 at 04:28 PM revealed Resident #47 was supposed to be on oxygen as needed but she was not sure of the orders and how many liters she was supposed to be on. LVN H (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 7 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm stated Resident#47 had been in and out of hospital and she does not remember the last time she checked on her tank to see how many liters she was on. LVN H stated she knew she was supposed to check on the resident's oxygen flow rate and physician orders every shift. She stated the resident was supposed to have orders to be on oxygen. LVN H stated the risk of administering oxygen with no orders might cause oxygen poisoning. Residents Affected - Some Record review of the facility's undated policy titled, Medication Administration, revealed in part the following: Policy heading-medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: .4. Medications are administered in accordance with prescriber orders, including any required time frame On 07/28/23 at 2:30 PM a policy on oxygen/respiratory treatment was requested from the DON and he stated the facility did not have one. Record review of the Resident Census and Conditions of Residents Form CMS-672, provided by the Administrator, reflected there were five residents who had received respiratory treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 8 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for one of two staff (LVN F and LVN G) which resulted in a 45.16% medication error rate after 31 opportunities with 14 errors for three of six residents (Residents #32, Resident #42, and Resident #8) reviewed for medications. Residents Affected - Some 1. LVN F crushed all medications together and mixed them on one cup of pudding without an order to mix the medications together for Resident #32. 2. LVN G failed to follow the physician orders for flushing Resident #42's gastrostomy tube with 5-10 mL (or prescribed amount) of water before, between, and after medications, when she administered medication. 3. LVN G removed Resident #8's patch and immediately placed another one on without allowing 12 hours for rest after removal. These failures could place residents at risk of physical and chemical incompatibilities leading to an altered therapeutic response and put residents who received medications via gastrostomy tube at risk for gastronomy tube blokage and medication interaction. Findings included: 1. Record review of Resident #32's quarterly MDS assessment, dated 06/04/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The assessment reflected the resident cognition was severely impaired with a BIMS score of 5. The resident had diagnoses which included epilepsy (disorder of the brain characterized by repeated seizures), hepatic failure (acute liver failure) and anxiety (feeling of fear, dread, and uneasiness). Record review of Resident #32's, March 2023, Physician Orders revealed the following order: Please crush medication and add to pudding or yogurt. 2. Review of Resident #42's MDS dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and re-admission on [DATE]. The assessment reflected Resident #42 had severely impaired cognition and had diagnoses which included gastrostomy status and dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). Review of Resident #42's July 2023 Physician Orders reflected there was orders for flushing gastrostomy tube with 5-10 ml of free water between each medication administration. 3. Record review of Resident #8's quarterly MDS assessment, dated 06/28/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The assessment reflected the resident cognition was moderately impaired, with a BIMS score of 11. The resident had diagnoses which included low back pain. Record review of Resident #8's July 2023 Physician Orders revealed the following order: Lidocaine Pain Relief 4 % Patch; Apply to Lower back topically one time a day for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 9 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 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 0759 Observation on 07/27/23 at 7:25 AM, revealed LVN F crushed the following five medications for Resident #32 and opened one capsule put them together in one medication cup and mixed with pudding: Level of Harm - Minimal harm or potential for actual harm - Aptiom 800 mg 1 tablet for seizure, Residents Affected - Some - Keppra 1000 mg 1 tablet for seizure, - Carbamazepine 200 mg 1 tablet for seizure, - Topiramate 100 mg 1 tablet for seizures , - Vitamin B 25 mcg 5 tablets (5000 i u) dietary supplement, - Loratadine 10 mg 1 tablet for allergies, and - Gabapentin 300 mg 1 capsule for seizures. She then administered all eleven medications embedded in pudding in one cup by mouth to Resident #32. Observation on 07/27/23 at 8:24 AM revealed LVN G washed hands donned gloves and she was to apply a lidocaine patch on Resident #8's lower back. She was observed removing an old patch dated 07/26/23 and she applied a new patch dated 07/27/23 revealing the old patch was not removed after 12 hours of application. Interview with LVN G on 07/27/23 at 8:34 AM revealed she was aware the evening shift were the ones supposed to remove the patch on Resident #8. LVN G revealed she works with Resident #8 five days in a week and every morning she was the one that removed the patch the evening shift do not remove. LVN G stated she had informed the DON and she could not remember when. She stated she was aware Resident #8 was supposed to have the patch for 12 hours and rest for 12 hours. LVN G stated failure to remove the patch after 12 hours could cause overdose and skin problems. Observation on 07/27/23 at 8:44 AM revealed LVN G prepared Bupropion (depression) 100 mg and Memantine 10 mg for (dementia), put the medication in different cups. LVN G crushed the medication and put in separate cups and went to Resident #42's room. LVN G positioned Resident #42 in an upright position. LVN G checked for the gastrostomy tube placement and checked for residual. She flushed the gastrostomy tube with 10 ml of water administered medication one at a time, she did not flush the gastrostomy tube with water between medications. LVN G flushed the gastrostomy tube with 10 ml of water after medications. Interview with LVN G on 07/27/23 at 9:04 AM revealed she was aware of the order to flush gastrostomy tube with 5-10 ml of water before, between, and after medication administration through gastrostomy tube for Resident #42. She said she forgot to flush the gastrostomy tube between medication administration. She stated it was her responsibility and best nursing standard of practice to check the orders before administration of any medication. LVN G stated failure to check orders could lead to gastrostomy tube blockage and medication interactions. She stated she had received training on medication administration via gastrostomy tube. Interview with LVN F on 07/27/23 at 1:06 PM revealed she had a physician's order to crush (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 10 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medications for Resident #32, but she did not have an order for mixing all the medications together. She stated she was not sure of the effects medications would have on Resident #32 if crushed and administered while mixed with other medications, but she thought there would be some effects due to interactions. She stated she had completed training on medication administration. Interview with DON on 07/27/23 at 2:44 PM revealed the facility policy did not classify whether to crush each medication separately. The DON stated they had orders to crush unless contraindicated. The DON stated he is not sure whether they should have orders to mix after crushing all the medications together. The DON stated the best standard of practice was to put each medication in each cup after crushing. He stated his expectation was nurses should put all medications in different cups because of contraindications and interactions. The DON stated he had completed training on medication administration with staff but not on mixing oral medications. Interview with the DON on 07/27/23 at 2:51 PM revealed his expectation was for the nurses to flush the gastrostomy tube before, between, and after each medication administration as per the doctor's orders and follow the facility policy. He stated failure to check orders to flush the gastrostomy tube may lead to gastrostomy tube being clogged and medication interaction. The DON stated he had trained the nurses on medication administration via gastrostomy tubes. Interview with DON on 07/27/23 at 3:30 PM revealed his expectation was the staff would follow the physician orders. He stated the patch should be off after 12 hours. He stated failure for staff having the patch removed it could contribute to skin issues and Resident #8 could get double dose. He stated he noticed there was no order for removal of the patch after 12 hours. He stated he noticed there was a problem with the way the order was entered to the computer system, it was not completed. Interview with LVN J on 07/27/23 at 3:47 PM revealed she was aware the evening shift were the ones supposed to remove the patch on residents with patches, but she was not aware Resident # 8 had a patch. LVN J stated Resident #8 had no orders for removal. She stated she was aware Resident #8 was supposed to have the patch for 12 hours and rest for 12 hours. LVN J stated failure to have orders to remove the patch after 12 hours could cause Resident #8 to have skin irritation and she should not be getting the recommended therapy. Record review of the facility's current Administering Medication policy revised April 2019, reflected the following: .medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include a) enhancing optimal therapeutic effect of the medication; b) preventing potential medications or food interactions. .24. Topical medications used in treatment's are recorded on the resident's treatment record (TAR) Review of the facility's current Administering Medication Through Enteral Tube policy, dated November 2018, reflected the following: .1. Verify that there is physician's medication order for this procedure. 3. Administer each medication separately and flush between medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 11 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 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 0759 .6. Verify placement of feeding tube. Level of Harm - Minimal harm or potential for actual harm 10. Administer each medication separately Residents Affected - Some .13. If administering more than one medication, flush with 15mls (or prescribed amount) warm sterile water or between medications FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 12 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and assure only authorized personnel to have access to the keys for 1 resident (Resident #43) of 8 residents reviewed for pharmacy services, in that: The facility failed to ensure that Resident #43's prescribed eye drops and albuterol inhaler was stored in a secured place. This failure could place all residents on the 200 Hall North at risk of drug diversion or misuse of medications. Findings included: Record review of Resident #43's face sheet, dated 07/28/23, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease (disorder of the central nervous system), acute kidney failure, asthma (narrow and inflamed airways), cataract disease (cloudiness in the lens of the eye), and glaucoma (disease of optic nerve). Review of Resident #43's care plan, revised 07/10/23, revealed the resident had an ADL self-care performance deficit related to blindness. Interventions included assistance and supervision by staff with ADLs. The care plan did not address self-administration of medications. Record review of Resident #43's admission MDS assessment, dated 06/20/23, revealed Resident #43 was cognitively intact with a BIMS score of 13 and required limited assistance by one person with most ADLs. Observation and interview on 07/26/23 at 12:15 PM with Resident #43 revealed he was sitting on the side of his bed with personal items and 4 bottles of prescription eyedrops lying on the bed, and not in a secure place. The eye drops observed on the bed included: Simbrinza Ophthalmic Suspension 1-0.2 % (Brinzolamide-Brimonidine Tartrate), Rhopressa Ophthalmic Solution 0.02 % (Netarsudil Dimesylate), Pilocarpine HCl Ophthalmic Solution 1 % (Pilocarpine HCl), and Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8 MG/ML (Dorzolamide HCl-Timolol Maleate). Resident #43 stated he had never been told by staff that his medication had to be locked or put in a secure place. Resident #43 stated he was completely blind did not need the eye drops spread on his bed to identify them because he was able to identify his medications by size, design of the caps, and the position of labels. Resident #43 stated he knew the eye drops could be toxic to others, but he had a keen sense of his environment and could tell if someone was coming near his bed if he was there in the room. However, he stated that he sometimes left the room and did not put the eye drops in a secure place. Observation on 07/27/23 at 9:30 AM revealed the following eye drops were still not secured and on Resident #43's bed: Simbrinza Ophthalmic Suspension 1-0.2 % (Brinzolamide-Brimonidine Tartrate), Rhopressa Ophthalmic Solution 0.02 % (Netarsudil Dimesylate), Pilocarpine HCl Ophthalmic Solution 1 % (Pilocarpine HCl), and Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8 MG/ML (Dorzolamide HCl-Timolol Maleate). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 13 of 14 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 675840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Richland Hills 7146 Baker Blvd Richland Hills, TX 76118 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 Interview on 07/28/23 at 11:30 AM with the Administrator revealed medications that were self-administered did not need to be in a secured box or location if the resident was assessed and determined safe to have the medications. When asked about other residents getting ahold of the medications, the Administrator stated there were no residents on the hall who exhibited behaviors of wandering and going into other rooms, and that those residents would be in the facility's secured unit. Residents Affected - Few Interview on 07/28/23 at 12:24 PM with the DON revealed he was unaware that Resident #43 had possession of his eye drops. The DON stated Resident #43 had only requested to self-administer his eye drops on 07/26/23 and the physician was notified then for an order. The DON stated an assessment was given to Resident #43 on 07/26/23 as well. The DON stated the risk of a resident having possession of medication and self-administering without being assessed could be inappropriate consumption and the wrong resident getting ahold of the medication. Interview and observation on 07/28/23 at 1:45 PM with Resident #43 revealed there were no eye drops on the resident's bed. When asked where the eye drops were, Resident #43 opened his drawer and stated he was asked by staff to store them there. Resident #43 proceeded to pull an albuterol inhaler out of the drawer and stated, They didn't say anything about this. He stated he had to keep it on him because it would be hard to ask for it while unable to breathe. Interview on 07/28/23 at 1:15 PM with LVN D revealed she was not aware that Resident #43 had possession of his albuterol inhaler. She stated it was PRN and she did not have to sign off for it on a regular which is how it likely got overlooked. Interview on 07/28/23 at 4:24 PM with the DON revealed that he was also unaware that Resident #43 had possession of his albuterol inhaler. Review of the facility's Self-Administration of Medication policy, revised February 2021, revealed in part the following: Policy Heading-Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: .8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. The facility census dated 07/26/23 revealed 19 residents resided on the 200 Hall North. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675840 If continuation sheet Page 14 of 14