Inspection·August 16, 2024

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few within 45 feet of the sheet of paper. This surveyor took a picture of the sheet of paper without any employee behind the nurse's station noticing. The sheet of paper remained face-up and available to anyone in the room for 1 minute before RN A was informed of the situation. In an interview with RN A at 4:18 PM on 08/15/2024, RN A stated that the sheet of paper contained HIPAA protected information. RN A stated that she did not know who put the sheet of paper on the medication cart. RN A stated that anyone walking by could see Resident #70's personal medical information. RN A stated that if Resident #70 found out that the facility was not protecting his health information, he might experience disappointment and embarrassment. During an observation at 8:13 AM on 08/16/2024, revealed RN A administered medications to Resident #33 inside Resident #33's room. RN A had the medication cart against the wall opposite of Resident #33's room with the computer monitor facing Resident #33's room. While RN A stepped inside of Resident #33's room, the monitor on the medication cart was left on, displaying Resident #33's personal medical information. The monitor was left on for approximately 1 minute until RN A exited the room and noticed that she had left the monitor on. In an interview with RN A at 8:14 AM on 8/16/2024, RN A stated that she accidentally left the computer screen on while she was administering medications to Resident #33. RN A stated that she typically locked the screen when she was not actively using the computer during medication administration. RN A stated that the personal medical information displayed on the computer screen was HIPAA protected information. RN A stated that if Resident #33 found out that the facility was not protecting her health information, she might experience disappointment and embarrassment. In an interview with LVN D at 11:11 AM on 08/16/2024, LVN D stated that revealing a resident's protected personal information to individuals who do not have a need or right to access the information could potentially cause the resident mental distress if they were informed of the incident. LVN D stated that leaving a printed-out sheet of paper face-up containing a resident's laboratory values in a public place would constitute a HIPAA violation. LVN D stated that leaving a computer screen unattended with a resident's personal medical information would constitute a HIPAA violation. LVN D stated that if she saw a resident's protected medical information displayed publicly, she would hide it and then inform the nearby nurse. LVN D stated that she had not witnessed any instances of HIPAA information being displayed unnecessarily at this facility. In an interview with CNA E at 11:29 AM on 08/16/2024, CNA E stated that leaving a printed-out sheet of paper face-up containing a resident's laboratory values in a public place would constitute a HIPAA violation. CNA E stated that leaving a computer screen unattended with a resident's personal medical information would constitute a HIPAA violation. CNA E stated that if she noticed any HIPAA protected information displayed unnecessarily, she would hide the information and alert a nearby nurse. CNA E stated that revealing a resident's protected personal information to individuals who do not have a need or right to access the information could potentially cause the resident mental distress if they were informed of the incident. CNA E stated that since she had been working at the facility, she had not witnessed any HIPAA violations. In an interview with the DON on 08/16/24 at 2:50 PM, the DON stated that the computer screen was not supposed to be left on and unattended during med pass. The DON stated that leaving the computer screen on and unattended while displaying a resident's person medical information in a public area was a HIPAA violation. The DON stated that she was already aware of the incident earlier in the day with RN A and had already in-serviced RN A on the topic. The DON stated that leaving a sheet of paper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 2 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unattended displaying the laboratory results of a resident in a public area was a HIPAA violation. The DON stated that anytime an employee sees a possible HIPAA violation, they should hide the information from view and then inform the DON. In an interview with the ADM on 08/16/2024 at 3:51 PM, the ADM stated that leaving a printed-out sheet of paper face-up containing a resident's laboratory values unattended in a public place would constitute a HIPAA violation. The ADM stated that leaving a computer screen unattended with a resident's personal medical information would constitute a HIPAA violation. The ADM stated that anytime an employee saw a possible HIPAA violation, they should hide the information from view and then inform their supervisor. The ADM stated that anytime a resident's personal medical information was not protected, individuals who do not have a need or right to know may gather the information. Record review of the undated policy titled Statement of Resident Rights revealed that residents have the right to: 8: have facility information about you maintained as confidential FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 3 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to send a copy of the notice of transfer or discharge, and the reasons for the transfer or discharge in writing to the resident, resident representative, or the Office of the State Long-Term Care Ombudsman for one (Resident #11) of three residents reviewed for transfer and discharge. The facility failed to send the notice of transfer or discharge in writing to Resident #11, Resident #11's representative or the Ombudsman when Resident #11 was discharged to the hospital on 6/27/2024. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: Record Review of Resident #11's face sheet revealed he was an [AGE] year-old male admitted to the facility with an original admission date of 8/07/2023, and the most recent admission date of 7/02/2024. His diagnoses included Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities), Alzheimer's Disease (a brain disorder characterized by changes in the brain that causes the brain to shrink and brain cells to eventually die), End Stage Renal Disease (kidney failure) with heart failure, Chronic Kidney Disease Stage 4 (Stage 4 kidney disease is the last stage before kidney failure), and Renal Dialysis (a treatment for people whose kidneys are failing). Record review from hospital records dated 6/27/2024 revealed that Resident #11 was admitted to the hospital with a primary diagnosis of Acute Kidney Failure, Unspecified. Record review of the Nurse Practitioner's Progress notes dated 6/27/2024 revealed that Resident #11's family representative was notified verbally that resident was being transferred to hospital and why. Record review of hospital discharge paperwork dated 6/28/2024 revealed that Resident #11 was also admitted to the hospital with a UTI. Record Review of a progress note dated 7/2/2024 revealed that Resident #11 returned and was admitted to facility on 7/2/2024. During an interview with the ADON on 8/15/2024 at 2:55pm, the ADON stated the facility would call the family to notify them of transfers or discharges, but not in writing. The ADON stated if it was an emergency, the facility would transfer the resident first, then notify the family verbally after the fact. The ADON stated that if it were an emergency when a resident was discharged , the family would come in after the fact to discuss medications and upcoming appointments, but that was it. During an interview with the DON on 8/15/2024 at 4:19pm, the DON stated that residents were verbally notified when they are going to be transferred or discharged to the hospital, but the facility does not notify residents or their representatives in writing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 4 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the ADM on 8/15/2024 at 4:25pm, the ADM stated Resident #11 was never discharged from the facility, but only transferred to and from the hospital. The ADM stated the facility does not notify via written notice of transfers or discharges. Record review of the facility's policy titled Admission, Transfer and Discharge revised 09/23/2024 revealed that under section Transfer and discharge on page 3, a transfer and/or discharge includes the movement of a resident to a bed outside of the certified community, and before transfer or discharge occurs, the community notifies the resident, and, if known, the family member, surrogate, or representative of the transfer, and the reasons for it. A copy of the documentation of the notice is kept in the clinical record and a copy is sent to the representative of the Office of the State Long Term Care Ombudsman. On Page 5, under Transfer and Discharge, Written notice of transfer or discharge must be given at least 30 days prior, or as soon as practicable when the health of the individual would be endangered, or an immediate transfer or discharge is required by the resident's urgent medical needs. Event ID: Facility ID: 675850 If continuation sheet Page 5 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a PASRR evaluation was completed on newly admitted residents prior to admission or after admission for 2 (Resident #34 and #3) of 8 residents reviewed for PASRR screenings. Residents Affected - Few 1. The facility failed to ensure Resident (R) #34's PASRR Level 1 screening indicated R #34 was positive for mental illness. 2. The facility failed to ensure Resident (R) #3's PASRR Level 1 screening indicated R #3 was positive for mental illness. These failures placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: 1. Record review of R #34's face sheet dated 08/16/24 indicated an [AGE] year-old female initially admitted [DATE] and readmitted [DATE] with the diagnosis of schizoaffective disorder (A mental health condition of a combination of symptoms of schizophrenia and mood disorders. Cycles of severe symptoms are often followed by periods of improvement. Symptoms may include hallucinations, delusions, depressed episodes, and manic periods.) Record review of R #34's quarterly Minimum Data Set assessment dated [DATE] indicated R #34 had a Brief Interview of Mental Status Assessment score of 10 (moderate impaired cognition). R #34 did not display any behaviors during the assessment period. The assessment indicated an active diagnosis of Schizophrenia and Depression. Record review of R #34's comprehensive care plan dated 07/15/24 reflected I require psychotropic medications and I am at potential risk for side effects related to my medication regimen. Diagnosis: Anxiety, Schizoaffective disorder, Antianxiety Medication Regimen, Antidepressant Medication Regimen . Record review of R #34's August 2024 physicians orders reflected Anti-manic Side Effects Chart all appropriate codes; ANTIMANIC TARGETED BEHAVIOR IS: Sudden mood changes. No directions specified for order: Prozac Oral Capsule 40 MG (Fluoxetine HCl- use to treat major depressive disorder, obsessive/ compulsive disorder, panic disorder.), Order Summary: Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium-Used to treat seizure and bipolar disorder management) Give 2 capsule by mouth one time a day for mood stabilizer May be swallowed whole or capsule opened and sprinkled on small amount (1 teaspoonful) of soft food (egg, pudding, applesauce) to be used immediately (do not store or chew). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 6 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of R #34's PASRR (Preadmission Screening and Resident Review) dated 12/26/23 revealed #2. Mental Illness: Is there evidence or an indicator this is an individual that has a Mental Illness? No. 2. Record review of R #3's face sheet dated indicated a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE]. Her diagnoses included hemiplegia and hemiparesis following unspecified stroke affecting unspecified side dated 08/15/17, systemic lupus erythematosus dated 02/21/18, major depressive disorder, recurrent severe without psychotic features dated 06/14/18, generalized anxiety disorder dated and panic disorder dated 10/15/18, schizophrenia, unspecified dated 11/08/18, Mood disorder due to known physiological condition with depressive features dated 11/19/18, bipolar disorder, current episode mixed, severe, with psychotic features dated 01/24/19, vascular dementia and unspecified dementia, unspecified severity, with other behavioral disturbance dated 10/01/22, schizoaffective disorder, bipolar type dated 10/31/22 (A mental health condition of a combination of symptoms of schizophrenia and mood disorders. Cycles of severe symptoms are often followed by periods of improvement. Symptoms may include hallucinations, delusions, depressed episodes, and manic periods), bipolar disorder, unspecified dated 02/10/22. Record review of R #3's undated Level 1 PASRR but listed her age as 60-years-old at the time of screening indicating the year was 2021) PASRR Level 1 was blank for section C. Mental Illness: Is there evidence or an indicator this is an individual that has a Mental Illness? Intellectual Disability: Is there evidence or an indicator this is an individual that has an Intellectual Disability? Developmental Disability: Is there evidence or an indicator this is an individual that has a Developmental Disability (related condition) other than an intellectual disability (e.g., Autism, Cerebral Palsy, Spina Bifida)? There was no evidence of a Level 2 screening. Record review of R #3's PASRR Level 1 dated 04/01/19 was marked No to all three questions in section C. There was no evidence of a Level 2 screening. Record review of R #3's PASRR Level 1 dated 05/29/24 was marked Yes to Mental Illness question #2 in section C. and No to questions 1, 3, and 4 in section C regarding Dementia, Intellectual ability or Developmental Disability, respectively. There was no evidence of a Level 2 screening. Interview with RN B on 08/16/24 at 11:18 AM revealed she said she was responsible to ensure all residents had PASRR screenings and referrals. RN B could not provide an answer as to why R #34's and R #3's PASRR mental screening questions were answered incorrectly. RN B said the local authority would change the screening and then said she would find out the answer and get back to the surveyor. In a subsequent interview with RN B on 08/16/24 at 2:23 PM she stated R #34's and R #3's screenings were done incorrectly and should have been triggered as positive since R #34 and R #3 had mental illness diagnoses. RN B stated she would be resubmitting the correct positive PASRR information to local state authority agency used that would determine if R #34 and R #3 qualified for PASRR services. RN B stated she felt the error had not negatively impacted R #34 or R #3. RN-B also stated there was no answer as to why the PASRR Level 1 screenings were done incorrectly as a previous employee had conducted the initial screenings. She stated it was a team effort to monitor and audit PASRR screenings but overall, the ADM had responsibility for overseeing PASRR screenings accuracy. Interview on 08/16/2024 at 2:55 with the ADM revealed she stated the accuracy of the PASRR was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 7 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0645 Level of Harm - Minimal harm or potential for actual harm initially the responsibility of the admissions department; but the process was a team effort. The ADM called RN B into the meeting and where at this time RN B stated the responsibility fell on the MDS Coordinator, which was RN B. The ADM stated if the PASRR screening was incorrect or if an evaluation was not conducted, the resident was at risk of not receiving additional PASRR services he/she may have been qualified for. Residents Affected - Few Record review of the facility's policy titled, Comprehensive Assessments revised January 2024 reflected, Compliance guidelines: Pre-admission screening determines whether the community can provide the level and scope of services required by the resident's medical and mental condition. This assessment is important because it is the initial source of information that will ultimately determine the resident's comprehensive care plan. Pre-admission screening and resident review (PASRR) screen is required of all individuals with mental illness (MI) or mental retardation (MR}, regardless of the applicant's source of payment. The screen lists the specialized services that are required and identifies the services the state is responsible to provide. The community is responsible for providing the other needed services. These screening are provided within fourteen days of the resident's admission to the community, when there has been a significant change in the resident's condition, quarterly, and annually (every twelve months). PASRR preadmission screens: Residents with mental illness or mental retardation: The community coordinates resident assessments with pre-admission screening to maximize the resident assessment process. The state is responsible for conducting the PASRR screen, preparing the PAS RR report, and providing or arranging specialized services that the screen shows to be needed. The PASRR screen lists the specialized services that are required and identifies the services that the state is responsible to provide. The community is responsible for providing the other needed services. The community does not admit new residents with mental illness (MI) or mental retardation (MR) unless approved by the appropriate state mental health or mental retardation agency. The state is required to provide specialized services either directly or through arrangement. Preadmission screening is required of all individuals with MI or MR, regardless of the applicant's source of payment. Residents admitted or readmitted following a discharge from an acute care stay are exempt from the screening requirement if: Readmissions following hospitalizations. Individuals who are admitted to the nursing community directly from a hospital after receiving acute inpatient care at the hospital, require nursing community services for the condition for which the individual received care in the hospital, and have been certified by their attending physician prior to admission to the nursing community that they are likely to require less than 30 days of nursing community services. Individuals who have a terminal illness as defined for hospice purposes in 42 Code of Federal Regulations, in the definition of terminally ill; and residents who transfer from their current nursing community residence to a new nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 8 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0645 Level of Harm - Minimal harm or potential for actual harm community residence. Have not had any interruption in continuous nursing community residence other than for acute care hospitalization; and have not had any change in their mental condition. For residents who transfer from one nursing community to another, the transferring nursing community is responsible for ensuring copies of the most recent PASRR assessment accompany the transferring resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 9 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychological needs that were identified in the comprehensive assessment for revisions for care plans for 1 (Resident #41) of 4 residents reviewed for care plans. The facility failed to ensure Resident #41's (R#41) most recent care plan was updated for a fall with injury on 08/11/24, updated fall precautions, bed in low position, call light in place/within reach, scoop mattress, and fall matt on floor beside bed. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The findings included: Record review of R#41's face sheet dated 07/20/2024 indicated a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE]. Diagnoses included unspecified dementia, lack of coordination, osteoporosis (brittle bones), high blood pressure, muscle wasting and weakness, insomnia, overactive bladder, and abnormal gait. Record review of R#41's quarterly MDS revealed she had a BIMS score of 3 indicating severe cognitive impairment, and she required staff assistance for all ADL's, including ambulation, transfers and mobility. Record review of physicion orders dated 01/31/21 indicated R#1 was taking anticoagulants: Plavix Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day related to personal history of transient ischmic attacks (TIA), and cerebral infarction without residual deficits Pharmacy Active 1/30/2021. Aspirin EC 81 mg Give 1 tablet by mouth one time a day for prophylaxis (prevention) related to personal history of transient ischmic attacks (TIA), and cerebral infarction without residual deficits *DO NOT CRUSH* Pharmacy Active 4/14/2021. Record review of progress notes dated 08/11/24 at 2:42 pm revealed the resident was found on the floor post fall-reports uncertain of how the fall happened. No witnesses. R#41 was lying on the bed with gauze compression to left forehead, a large bruise to left forehead, and a laceration to the left brow. R#41 was sent to a local hospital for evaluation. At 8:15 pm R#41 was returned to the facility with negative x-rays and CT scans, a band aid over the left brow, and purple bruising to the left eye and forehead. A fall matt was placed beside the bed, fall precautions were initiated, the bed was placed in low position, and the call light was placed in reach. R#41 was encouraged to use the call light to prevent falls. Record review of R#41's quarterly care plan dated 08/05/24 revealed R#41 was at risk for falls related to poor balance, weakness, and muscle wasting because of a stroke-created on 08/07/20, date initiated 06/16/22, revision on 08/05/24. A fall was dated 07/11/24. Interventions included bed at appropriate height when unattended initiated 08/11/20, Floor Grip strips next to bed. Date Initiated: 07/12/24, Remind resident regularly to call for assistance in efforts to prevent falls. Date Initiated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 10 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/02/20, Routine rounds to help with safety checks by all team members. Date Initiated: 08/07/20. I choose not to follow recommendations made by my physician and/or clinical team. I am noncompliant with safety recommendations of using my wheelchair instead of my walker which has resulted in falls due to poor balance and coordination. Date initiated: 03/29/21. Interventions included coordinate appointments/referrals and transportation as indicated Date initiated 03/29/21, Keep clutter out of wheelchair and off bed to help prevent falls initiated 05/10/22, provide and review care choices; review advanced care planning initiated 03/29/21. I require an anti-platelet, blood thinning medication and I am at risk for abnormal bleeding, bruising and skin injury. Date Initiated: 12/02/20, Revision on: 05/14/2024. Target Date: 08/06/2024. Administer medications as ordered by doctor. Date Initiated: 12/02/20, Inspect my skin during care and report all skin injuries as indicated. Date Initiated: 12/02/20. Monitor me for abnormal bleeding and monitor my skin for excess bruising as indicated. Date Initiated: 12/02/20. There were no revision dates in R#1's care plan for the active anticoagulant orders. The fall on 8/11/24 was not addressed in the care plan. Observation and interview with R#41 on 08/14/24 at 2:21 pm R#41 revealed she was awake and alert. Her left eye had a deep purple discoloration around the entirety of her eye and upward into her left forehead. There were steri-strips on her left brow. She was sitting on her bed that had a scoop mattress. There was a fall mat in place, and the bed was low to the ground. She stated she tripped & fell at the nurse's station on a Tuesday and got a black eye. She denied having to go to the ER or being hurt anywhere else. She stated she could see clearly from both eyes. In an interview with the ADON on 08/16/24 at 3:00 pm she stated it was all nursing staff's responsibility to update the care plans because they were important to the well being of the residents. She stated R#1's care plan should have been updated to reflect the unwitnessed fall she had on 08/11/24. The ADON stated R#41's care plan should have reflected the specific fall precautions and preventions, as well as revisions for the anti-coagulants. Record review of the facility policy titled, Care Plans revised January 2023 revealed the care plan should be initiated upon admission, continued to be developed during the initial 48-72 hrs., throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI manual. Additional updates to the care plan may be done as indicated. The care plan should be considered a part of the medical record and should be utilized in conjunction with the complete medical record. The care plan should serve as a guide, which should direct care needs, care choices and care preferences. However, the care plan is not an all-inclusive reflection of prescribed or recommended care by the IDT. It is utilized in conjunction with the complete medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 11 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #4 and #70) of 3 residents reviewed for indwelling urinary catheters. 1. Resident #4's catheter tubing was dragging on the ground underneath his wheelchair in the lobby area outside resident halls 500 and 600 at 10:58 AM on 08/14/2024. Resident #4's catheter bag and tubing were dragging on the ground underneath his wheelchair in the dining room during lunch at 12:39 PM on 08/14/2024. 2. Resident #70's catheter bag was on resting on the floor as he laid in bed at 3:00 PM on 08/14/2024. These deficient practices could place residents with indwelling urinary catheters at-risk for urinary tract infections and/or pain. Findings included: Record review of Resident #70's face sheet reflected a [AGE] year-old male with an initial admission date of 04/15/2024 and a current admission date of 06/03/2024. Pertinent diagnoses included Acute Kidney Failure, Paraplegia (paralysis of the legs and lower body), and Type 2 Diabetes (chronic metabolic disease in which the body does not produce enough insulin). Record review of Resident #70's quarterly MDS assessment section C, cognitive patterns, dated 07/20/2024 reflected a BIMS score of 10 (moderate impairment). Record review of Resident #70's care plan dated 07/11/2024 revealed a focus that reflected I require a catheter indwelling Catheter, r/t: Neuromuscular bladder dysfunction (bladder's muscles and nerves are not communicating properly with the brain), Skin Breakdown / Wound Care. Interventions listed for the focus reflected: Catheter Care every shift and as indicated, Provide catheter secure band/tape as indicated. Offer/provide a privacy bag or cover drainage bag as indicated. Change catheter per my physician's orders Check tubing for kinks each shift & during care encounters. Foley Catheter 16Fr 10CC, change monthly and PRN. Monitor for s/sx infection. Monitor for s/sx discomfort and abnormalities report those findings to MD as indicated. Record review of Resident #70's on 08/16/2024 orders revealed the following active orders: CHANGE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 12 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FOLEY [catheter] IN 7 DAYS dx: colonized UTI revised on 08/13/2024. Foley catheter care with perineal wipes and/or soap and water Q SHIFT and PRN revised on 06/04/2024. Foley Catheter 16Fr (size of catheter) 10CC (clean intermittent catheterization), change monthly and PRN revised on 06/04/2024. Record Review of Resident #4's face sheet reflected a [AGE] year-old man with an original admission date of 04/26/2013 and a current admission date of 10/01/2021. Pertinent diagnoses included Unspecified Intellectual Disabilities, Type 2 Diabetes, and Obstructive Uropathy (urine flow is blocked in the urinary tract, causing urine to back up and injure the kidneys). Record review of Resident #4's Optional State Assessment MDS section C, cognitive patterns, dated 06/05/2024 reflected a BIMS score of 6 (severe impairment). Record review of Resident #4's care plan dated 07/15/2024 revealed a focus that reflected, I require a suprapubic catheter r/t Dx of Urinary retention r/t Prostate condition Dx: OTHER OBSTRUCTIVE AND REFLUX UROPATHY. Catheter to only be changed by urologist, Dr. At times like to have f/c tubing inside clothes. Interventions listed for the focus stated: Catheter Care every shift and as indicated. Provide catheter secure band/tape as indicated. Offer/provide a privacy bag or cover drainage bag as indicated. Change catheter per my physician's orders. Check tubing for kinks each shift & during care encounters. EBP (Enhanced Barrier Precautions): Practice EBP as indicated. May change foley bag Q 2 weeks PRN. Monitor for s/sx infection. Monitor for s/sx of discomfort and abnormalities report those findings to MD as indicated. Suprapubic Catheter to be changed by MD in office. Notify [doctor name] if any leakage, excessive sentiment, or change in condition r/t coude catheter (specialized urinary catheter with a bend at the end). Record Review of Resident #4's orders on 08/16/2024 revealed the following active orders: Suprapubic catheter care with perineal wipes and/or soap and water Q SHIFT and PRN revised on 05/03/2023. Suprapubic Catheter 16 Fr to be changed by MD in office. Notify Dr if any leakage, excessive sentiment, or change in condition r/t coude catheter revised on 05/03/2023. Suprapubic cath[eter] to be replaced PRN at Corpus [NAME] Urology group with [doctor name] revised on 05/02/2024. During an observation at 10:58 AM on 08/14/2024 revealed in front of the nurse's station outside resident halls 500 and 600, Resident #4 was sitting in his wheelchair with his catheter bag and tubing underneath the wheelchair. The catheter tubing was resting on the ground as Resident #4 was sitting in his wheelchair. An interview was attempted with Resident #4 at 11:00 AM on 08/14/2024, but Resident #4 was not interviewable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 13 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation at 12:39 PM on 08/14/2024 revealed Resident #4 was sitting in his wheelchair in the dining room with his catheter bag and tubing underneath his wheelchair. The catheter bag and tubing were both resting on the floor as Resident #4 was sitting in his wheelchair. During an observation at 3:00 PM on 08/14/2024 revealed Resident #70 was lying in his bed in his room. While Resident #70 was in bed, his catheter bag was resting on the floor near the foot of the bed closest to the door. In an interview with Resident #70 at 3:00 PM on 08/14/2024, Resident #70 stated that the catheter bag was not usually on the floor. Resident #70 stated that the catheter tubing did not pull on him causing any increase in discomfort. Resident #70 stated that his bag had a leak in it approximately one month ago, but it was fixed shortly afterwards. In an interview with LVN D at 11:11 AM on 08/16/2024, LVN D stated that it was not appropriate for a catheter bag or tubing to be on the floor. LVN D stated that dragging a catheter bag or tubing on the floor could potentially cause contamination and lead to an infection. LVN D stated that she had witnessed that happen once in the facility with Resident #4. LVN D stated that she had seen Resident #4's Foley bag on the floor before. LVN D stated that sometimes the bag may fall after it was clipped onto his wheelchair. LVN D stated that about one and a half months ago, Resident #4's foley bag leaked, causing it to be changed. LVN D stated that Resident #4 complained often about the location of his catheter bag, and that it was difficult to get it in a safe spot that he was comfortable with. LVN D stated that she had discussed with other nurses about how best to deal with Resident #4's catheter bag and tubing. In an interview with CNA E at 11:29 AM on 08/16/2024, CNA E stated that it was not okay for a resident's catheter bag or tubing to be on the floor. CNA E stated that a catheter bag or tubing on the floor was unsanitary and may harm the resident through unnecessary pulling. CNA E stated that if she saw a bag on the floor she would secure the bag and ensure it did not have any leaks. CNA E stated she had witnessed Resident #4's catheter bag on the floor, but had never seen Resident #70's bag on the floor. In an interview with the DON at 2:50 PM on 08/16/2024, the DON stated that a catheter bag and tubing should not be on the floor. The DON stated that leaving a catheter bag or tubing on the floor could lead to contamination and possible an infection. The DON stated that Resident #4 refused the leg strap to secure the tubing up higher towards his leg. The DON stated that she was going to try his calf area but that Resident #4 would not let her touch him. The DON stated that she had seen Resident #4's tubing on the floor one other time but did not remember when she saw it. The DON stated they were going to try and put tape around Resident #4's leg to secure his foley catheter. In an interview with the ADON at 3:00 PM on 08/16/2024, the ADON stated they had tried to reposition the catheter bag for Resident #4 with a strap and Velcro. The ADON stated they tried putting the bag on Resident #4's leg but he did not like the bag on his leg. The ADON stated that have tried putting it in an extra bag and anchoring Resident #4's catheter bag higher on the chair. The ADON stated that leaving a catheter bag on the floor could contribute to an infection. Record review of the facility policy Routine Resident Care last revised on January 2023 reflected under GUIDELINES: 7. Incontinence / catheter care should be offered and provided timely in according to individual needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 14 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0690 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy Infection Prevention and Control last revised on April 2024 reflected under Prevention of Infection (2) Instituting measures to avoid complications or dissemination and (3) Educating staff and ensuring they adhere to proper techniques and procedures. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 15 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 6 residents (Resident #59) reviewed for medication administration in that: The facility failed to ensure Resident #59's medication was fully administered after a nebulizer (electric device that turn liquid medicine into a mist) treatment was initiated, leaving Resident #59 left over medication in the nebulizer container allowing Resident #59 access to the medication at a later time. This deficient practice could affect residents and place them at risk of not receiving therapeutic dosage and drug diversion. The findings included: Record review of Resident #59's face sheet dated 8/15/24 reflected a [AGE] year-old-female with an original admission date of 6/22/23. Diagnoses included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), emphysema (lung condition that causes shortness of breath and damages the air sacs in the lungs), and chronic respiratory failure. Record review of Resident #59's care plan dated 6/26/23 and a revision date of 8/15/24 stated: Resident #59 was at risk of experiencing shortness of breath due to COPD. Resident #59 preferred to monitor own pulse with a pulse oximeter. Interventions included: Administer respiratory treatments/nebulizers as ordered by the doctor. Monitor oxygen saturation as ordered by the doctor. Record review of Resident #59's care plan did not indicate Resident #59 turns off/on nebulizer treatments. Record review of Resident #59's physician orders dated 2/3/24 stated: Ipratropium-Albuterol (combination of two bronchodilators that relax muscles in the airways to increase air flow to the lungs) 0.5-2.5 mg/3 ml Solution Use one vial per handheld nebulizer every 6 hours as needed for shortness of breath or wheezing. Record review of Resident #59's MDS dated [DATE] indicated Resident #59 had an active diagnosis of asthma, COPD, or chronic lung disease, and respiratory failure. Resident #59's BIMS was a 12 (moderate cognitive impairment). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 16 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 08/14/24 at 03:11 PM Resident #59 started her own nebulizer treatment while in bed. Resident #59 stated she was supposed to take her nebulizer treatment every 6 hours but used left over medication when she felt short of breath. In an interview on 08/15/24 at 01:59 PM CNA A stated she had seen Resident # 59 use the nebulizer machine on her own once before about a month ago. CNA A stated she redirected Resident #59 to use the call light to notify the nurse for medication administration and educated Resident #59 that the charge nurse needs to be the one to administer the medication. CNA A stated she had informed the charge nurse (name unknown) about Resident #59 self-administering the medication but could not state what happened after she informed the charge nurse. In an interview on 8/15/24 at 02:03 PM LVN A stated Resident #59's nebulizer treatment was a prn medication and the charge nurse was the one who administers the medication. LVN A stated the nebulizer machine did stay in Resident #59's room but, the medication was locked up in the medication cart. LVN A stated she had never seen or had been notified that Resident #59 was self-administering the medication. LVN A stated Resident #59 was not supposed to self-administer any medication. LVN A stated the process for administering nebulizer treatments was to assess the resident 's vitals, get the medication from the cart and instill the medication into Resident #59's nebulizer machine and assist putting the face mask over the resident 's face. LVN A stated after about 15 to 20 minutes, the charge nurse would go back to assess Resident #59 to make sure the treatment was successful and to make sure all the medication was taken. LVN A stated the nurse usually checks when the treatment was completed to ensure the full amount of medication was used. LVN A stated if she saw Resident #59 self-administering the medication, she would educate Resident #59 on letting the charge nurse know she was experiencing shortness of breath and required medication. LVN A stated if there was left over medication after the treatment, the nurse would either empty the medication or ensure the rest was administered depending on the amount that was in the nebulizer container. In an interview on 08/16/24 at 09:28 AM the DON stated without a self-assessment resident should not be self-administering medication. The DON stated she did not want to answer any questions at that time until she looked into Resident #59's chart and history as she was not familiar with facility requirements. In an interview on 08/16/24 at 10:21 AM the DON stated Resident #59 was very independent and had a care plan dated 6/26/24 stating Resident #59 had a history of turning off the nebulizer machine during the middle of a treatment. The DON stated Resident #59 was not self-administering the medication as she was not putting any medication into the nebulizer container, and it was Resident #59's right if she wanted to turn off her nebulizer machine if she wanted to. The DON stated she could not answer why there was still medication left in the nebulizer container but stated the nurse administering the medication should have been assessing Resident #59 before and after the medication administration. The DON stated she talked with Resident #59 and stated Resident #59 was on hospice and did not want to self-administer medication but at times, Resident #59 turns off her nebulizer treatment to go to the bathroom and liked to leave some medication for later when she needed it. The DON stated Resident #59 was nearing the end of life and felt secure knowing there was some medication in the nebulizer container when she was feeling short of breath. The DON stated Resident #59 should have been taking the medication every 6 hours and the nurses were assessing her before and after. The DON stated Resident #59 was receiving the medication every 6 hours as needed even though Resident #59 saved a little medication for a later time. The DON would not answer if she thought Resident #59 finishing her medication at a later time was considered not following the physician orders due to it was the same amount of medication she was originally administered. The DON stated she felt there would be no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 17 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm negative outcome for Resident #59 as she was nearing end of life and it brought Resident #59 comfort. The DON stated hospice was going to come and assess Resident #59 to try and get the order changed to be given in a shorter time frame instead of every 6 hours. Record review on 08/16/24 at 11:40 AM of Self Administration of Medications form noted no data found. Residents Affected - Few Record review of facility's Medication Administration Policy dated 3/2019 stated: Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner. 6. Administer medications as ordered by the physician. Routine medications shall be administered according to the established medication administration schedule for the community. 7. Avoid leaving medications with the resident to self-administer unless the resident is approved for self-administration of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 18 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen and two of two resident nutrition rooms reviewed for dietary services in that: 1. The facility failed to ensure that both of the reach- in refrigerators and both of the reach- in freezers had separate thermometers inside and/ or at the front near the door per facility policy. 2. The facility failed to ensure that the dry storage room had a thermometer in it per facility policy. 3. The facility failed to ensure that refrigerator and freezer temperatures were recorded three times per day per facility policy. 4. The facility failed to ensure that food/ drink items in the reach- in refrigerators, dry storage area, kitchen area and the resident nutrition rooms were properly stored, labeled, and dated and were not expired. 5. The facility failed to ensure that dirty eating utensils were not placed on a clean surface. 6. The facility failed to ensure that scoops were not left inside containers and were stored properly. 7. The facility failed to ensure that cleaned dishes did not have food or beverage residue in them. 8. The facility failed to ensure that ceilings and walls in the kitchen area were not in disrepair. 9. The facility failed to ensure the kitchen area was free of bugs. 10. The facility failed to ensure that serving utensils were free of hazards. 11. The facility failed to ensure that appliances and food preparation areas were clean and free of possible contaminates. 12. The facility failed to ensure that dishwasher temperatures were logged daily. These findings could place residents at risk for food contamination and/ or food borne illnesses. Findings included: Observation of the facility's kitchen area on 8/14/24 beginning at 9:10am revealed the following: There was no thermometer in the front of either reach- in refrigerator. There was no thermometer in the front of either reach- in freezer. There was no thermometer in the dry storage area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 19 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The refrigerator and freezer logs dated August 2024 had temperatures recorded two times daily (AM and PM) instead of three times daily. The left reach- in refrigerator had hard boiled eggs in a zip top bag that was not labeled or dated. The left reach- in refrigerator had celery in a bag that was not sealed or dated leaving the celery exposed to air. The left reach- in refrigerator had a dark colored liquid substance spilled on the inside of the bottom of it. The right reach- in refrigerator had an unlabeled/undated zip top bag containing a block of cheese slices that were in a clear plastic wrapper. There was a slice of cheese on top of that wrapper. There was a clear plastic container on top of the cook side prep table that contained sliced jalapenos with no label/date on it. There was an open box of salt that was on the shelf above the cook side prep table. There was a silver unsealed bag containing three coffee pods sitting in an open box on top of the juice machine. There was a five gallon bucket sitting on the floor in front and to the left of the left reach- in refrigerator that was not labeled/dated or closed tightly. The bucket contained dill pickle chips in a greenish/brownish liquid. The manufacturer's label on the container read, Refrigerate after opening. In the dry storage room, there was a five gallon bucket on the floor in front and to the right of the right reach- in freezer that was not labeled or dated. The bucket had a white cystalliine substance scattered on the top of the lid in granules and clumps. There was a clear eighteen quart square container with what appeared to be flour in it that had a label that read lunch meat 3/21/22 on one side and a label on the other side that read animal something, however the cook picked up the container and peeled off the label before it could be read. The container had a scoop sitting on top of it that was not in a holder. There was a white, approximately seven gallon container on the floor with a label that read flour on the top, but no date. The label was not readily visible due to another container sitting on top of it. There was a non-sharp knife with a purple jelly like substance on the prep table near the microwave and condiment bins. There was a red ¼ cup measuring cup inside a clear square container with a blue lid that contained a crystalline substance. The container was not labeled or dated. The container was on the bottom shelf of a 4 shelf storage rack that contained pots, pans, and trays. The storage rack was approximately 3 feet away from the deep fryer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 20 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 There was a sugar scoop left inside the sugar container. Level of Harm - Minimal harm or potential for actual harm On a rack that contained cleaned dishes, two of seven bowls had dried food particles inside them, one of five clear cups had a greyish and red substance that appeared to be thickened juice in it, one of five blue two handled cups had a live roach on the outside of it, and a roach ran out from under a second blue two handled cup when it was picked up. There were two other live roaches seen on the tray that contained the blue two handled cups. Residents Affected - Many There were five to ten more live roaches observed on the surfaces of prep tables and clean dish areas throughout the kitchen. There were five to ten more live roaches seen on the floor of the kitchen area. In the clean serving utensils area, there was an ice cream type scoop with a blue plastic handle. The plastic on the handle was peeling off in too many areas to count. (Cook A was notified about this on 8/14/24 at 10:23am. [NAME] A stated it needed to be thrown away.) At 10:39am, the scoop was observed to be sitting in a container of fruit that was to be served for lunch. The water spigot on the side of the coffee pot had a white and brown sticky substance on it. The backsplash area on the dietary aide side of the prep table was splattered with different colored substances that were on the entire backsplash area. There were also three electrical outlets along that backsplash area that did not have outlet protectors on them and had substances on them. The shelf above the dietary aide prep table had five spots of black and white substances on it. The spots were varied in size. There was a white approximately 50 quart cooler on the floor in front of the storage shelves that were to the left of the left reach- in refrigerator. There was a cardboard box of what appeared to be paper plates on the top shelf of the storage rack that was to the left of the left reach-in refrigerator. The top of the box was approximately 6 inches from the ceiling. There were at least 7 cardboard boxes stacked on the floor in the corner to the left of the storage shelves and to the right of another 4 shelf storage rack on the left wall. The left side freezer doors had a black substance all around the edges of the door and on the inside where the door closed. The left side of the left freezer middle shelf had 2 large boxes stacked on top of each other with the boxes touching both the bottom of the shelf and the shelf above. There was no space between the bottom box and the bottom of the shelf. There was no space between the top box and the shelf above. There was no space between the boxes. There was a clump of ice approximately 4 inches long by 1 inch wide on the inside of the left door of the left freezer. There were also smaller clumps of ice on that same door. The right side of the left freezer middle shelf was resting at an angle on top of boxes that were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 21 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 stacked on the bottom shelf. There was no shelf bracket on the right side of the freezer wall to hold the middle shelf straight across. Level of Harm - Minimal harm or potential for actual harm There were multiple spots of different colors of spilled substances on the inside bottom of the left freezer. Residents Affected - Many There was a light brown substance that appeared to be crumbs all over the top of the dishwasher. There was a white hard substance at the bottom edge of the front and both sides of the dishwasher. The dishwasher temperature log was not filled out for 8/11/24, 8/12/24, 8/13/24, or 8/14/24. There was a crack in the ceiling above and to the right of the dishwasher that was approximately 2 feet long. Along the crack, there was a large hole that was approximately 6 inches long by 3 inches wide. The plastic panel that covered the front of the divider wall between the left reach- in refrigerator and the storage shelves was coming off. The ceiling in the dry storage room around the air conditioner vent closest to the entry door had water stains around it, had peeling/chipped paint on the corner with a black/brown substance on the peeling/chipped paint area. Both vents in the dry storage area had a black substance on them. There was a thermostat hanging by a wire from a hole in the ceiling that was on the left side of the divider wall between the left reach- in refrigerator and the storage shelves. The thermostat was hanging approximately halfway down the wall and was not affixed to anything. In an interview on 8/14/24 at 10:00am the DA stated the dishwasher temperature logs were supposed to be filled out daily. The DA stated she was normally the one to fill them out, but she got busy and forgot. She did not clarify whether she forgot to check the temperatures or forgot to document the temperatures. She stated she had worked 2:00pm to 7:00pm on 8/12/24 and 8/13/24. The DA stated it was important to check the temperature of the dishwasher to make sure the dishes were getting clean. The DA was observed filling out the dishwasher temperature log for both the morning and afternoon shifts. When asked about why the afternoon shift should log their own temperature, the DA stated they should do their own so that they knew what the temperature was. When asked about the substance on top of the dishwasher machine, the DA stated it looked like crumbs, but she did not know how or when it got there. The DA stated she deep cleaned at the end of every shift, but that she did not deep clean after her shift on 8/13/24, however she did try to do it at the end of every shift. The DA stated it was important to make sure that the top of the dishwasher was clean to prevent the dishes from becoming contaminated and making residents sick. In an interview on 8/14/24 at 10:09am, [NAME] A stated the salt box on the shelf should be closed so that it doesn't get contaminated. [NAME] A was observed closing the box. [NAME] A stated the scoop with the peeling handle needed to be replaced because plastic could get into the food. In reference to the substance at the bottom of the reach- in refrigerator, [NAME] A stated it was probably water or something and that she would clean it up. [NAME] A stated it could cause Salmonella or food could get contaminated if it was not cleaned up. [NAME] A stated the celery should have been covered and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 22 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dated and that she did not know why it was not done. [NAME] A stated she did not know why the hard boiled eggs were not dated, but she would take care of the celery and the eggs. When asked about the five gallon bucket by the reach- in refrigerator, [NAME] A stated it was probably pickle juice that she needed to throw away. [NAME] A stated that it had been opened for a week. When asked what she thought when she looked inside the bucket, [NAME] A stated the pickle slices didn't look edible. When asked why she thought it looked like that, [NAME] A stated, Because it's been sitting here a while. When asked what the label said, [NAME] A stated she was not aware that it stated to refrigerate after opening. [NAME] A stated it was important to refrigerate things according to the manufacturer's instructions to keep them safe for when it was used again. [NAME] A stated if spoiled food was served, residents could get sick. [NAME] A stated she was going to throw out the bucket and contents. When asked about the backsplash in the dietary aide prep area, [NAME] A stated it should not look like that. [NAME] A stated the dietary aide is responsible for cleaning their area daily. [NAME] A stated if there were food particles or dirt in the electrical outlets it could cause someone to get shocked or cause a fire. In reference to the five gallon bucket in the dry storage area, [NAME] A stated it was pickle juice that needed to be thrown away. [NAME] A stated the scoop that was in the sugar containter did not belong in the container, it belonged in a holder on the side. [NAME] A stated residents could get sick if the sugar got contaminated. In an interview on 8/14/24 at 10:49am, the DM stated that everyone, cooks, dietary aides, and the manager, were responsible for labeling/dating food and cleaning. In reference to the blue handled scoop, the DM stated it should not be used, however it was found in the container of fruit that was to be served for lunch. The DM took the scoop out of the fruit and threw it into the trash. The DM stated the backsplash in the dietary aide's prep area was the dietary aide's responsibility to clean and it being dirty could cause cross contamination. The DM stated if something had gotten into the outlets and someone plugged something in, it could cause sparks or fire. The DM stated the celery should always be completely closed. The DM stated she did not know what was in the bottom of the reach- in refrigerator and that the cooks and dietary aides were responsible for the refrigerators and freezers. The DM stated she tries to check dates/labels on everything every morning. When asked about the container of jalapenos on the cook's prep table, the DM stated they were from Monday (no date given) and the cook was going to throw them out. When asked about the dishwasher, the DM stated the DA would clean it after lunch. The DM stated, We have to spray it down with Lime Away every other day because of the hard water. We did it on Saturday (8/10/24) because I worked on Saturday. The DM stated the bag containing the coffee pods should have been sealed so nothing got into it. The DM stated the white and brown sticky substance on the water spigot on the side of the coffee maker was probably sugar. The DM stated she felt like pest control just sprayed water because the bugs just stayed around. When asked about the freezer doors, the DM stated it was probably mold due to the humidity and that she would get it cleaned up. The DM stated the five gallon bucket in the dry storage room had been there 2-3 days and that the cook would throw it out. The DM stated the bucket does not belong there. The DM stated the hole/crack in the dishwasher room ceiling was noted by the RD during QA rounding on 5/23/24. Reobservation of the kitchen on 8/15/24 at 1:35pm revealed the following: The hole in the ceiling above the dishwasher had been patched. The peeling/chipped paint around the vent in the dry storage room had been patched. The reach- in freezer thermometers were located on the rear right side of the top shelf of each freezer. Both thermometers had boxes and food items on top of and around them. They were moved to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 23 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 front of the top shelf in both freezers. Level of Harm - Minimal harm or potential for actual harm Neither reach- in refrigerator had a thermometer in it. The DM got thermometers from her office and placed them in the refrigerators. Residents Affected - Many The backsplash of the dietary aide prep table was still dirty. The five spots of black and white substances were still on the shelf above the dietary aide prep table. There were cooked French fries in the right side fryer basket of the deep fryer. The deep fryer was turned off. In an interview with the DM on 8/15/24 at 1:40pm, the DM stated the thermometers were supposed to be at the front so that she could compare the temperature inside to the digital reading outside and so that she would still have the temperature in case the digital one went out. The DM stated if she did not have accurate temperatures, she could possibly serve spoiled foods and it could make the residents sick. When the DM was asked how often the temperatures were supposed to be checked, the RD directed the DM to the food storage policy. The DM also stated that pest control had been there that morning. The DM stated she would check labeling and such every morning and if she was not there, the cooks would do it. The DM stated it was usually the morning cook that did the checks and cleaned things out. When asked about a cleaning schedule, the DM pulled some papers out of a large stack of papers on her desk and stated, I go through at the end of the day, make sure everything is done, then sign off on it. In an interview on 8/15/24 at 1:52pm, the RD stated she came in once a month to do QA. The RD stated the DM was ultimately responsible for the kitchen area. The RD stated if there were things on the QA marked no, she would go over it with the DM and do in-services with staff if necessary. In an interview on 8/15/24 at 3:24pm, the MS stated if something needed to be fixed, a request would be put into the electronic maintenance request system. The MS would look at the request, then contact his corporate supervisor. The MS stated the corporate supervisor would say, we'll do this. The MS stated sometimes corporate would send someone to do it, sometimes they would come down to do it, sometimes they would send someone to come help, and sometimes they would tell me to fix it. The MS stated, I just let them know what the problem is and they will send someone to come look at the problem and figure out what needs to be done. There's no specific time frame to fix anything. The MS stated he let corporate know about the kitchen in the middle of June, 2024 and at that time they told him, we'll get it. The MS stated, last night, the corporate guy, (CMI), called and told me not to go home until it was fixed. The MS stated he put some extra braces in it, patched it, textured it, taped it, and painted it. In an interview on 8/16/24 at 10:18am, the ADM stated once a maintenance request went into the electronic system, it went to the MS who could access the portal on the computer or on his cell phone. The ADM stated the MS was supposed to check the maintenance requests daily.The ADM stated she usually got a report of the maintenance requests weekly. The ADM stated if she saw something on the maintenance request, she would let the MS know that it needed to be done, depending on what the priority is. The ADM stated the MS could fix something without having to get with anyone if it was something that did not require an outside vendor or outside resource. The ADM stated if there was something that required an outside resource, the MS would get with her and she would approve it. When asked about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 24 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the ceiling in the kitchen, the ADM stated, Basically it comes down to- the MS knew about it, I knew about it, I asked for it to get completed and it never did. The ADM stated that regional was helping to make sure that things got taken care of in a timely manner. ADM stated she did recall a visit from the RMI, but she did not recall when. The ADM stated it was the responsibility of the MS to fix it. The ADM stated the MS may have been waiting on a more permanent fix, however she should have completed a temporary fix in the meantime. The ADM stated, My expectation would be that there would be a temporary fix for something while waiting on a permanent solution if it could not be permanently fixed in the first place. The ADM stated that, on average, the RMI would come in monthly to as needed and in general, most maintenance stuff did not have to go to regional for approval. ADM stated regional and corporate were a resource for the facility to assist in obtaining things that may have been difficult for her to get. In reference to the other issues with the kitchen, the ADM stated, In general, the DM is responsible to ensure that the policies and procedures are adhered to. Record review of facility's Work Order #4373 revealed the work order was created 5/29/24 by the DM at 10:45am. Updated status on 8/15/24 at 8:13am by MS Set to be completed Issue was crack in ceiling Notes: The ceiling in the dish room is cracked and has an opening. Location: Kitchen Priority: Medium Record review of facility's Work Order #4430 revealed the work order was created 6/25/24 by the ADM at 9:15am. Updated status on 8/15/24 at 8:11am by MS Set to be completed. Issue was kitchen repairs Location: Dry storage and dish room. Due date: 6/25/24. Priority: Medium On 8/16/24 at 10:54am, observation of the 100/200/300 hall resident nutrition room revealed the following: Three of nineteen 3.25 ounce vanilla pudding snacks that were in a cabinet expired 6/13/24. Four of nineteen 3.25 ounce vanilla pudding snacks that were in the same cabinet expired 4/16/24. Eight of fourteen 4 ounce thickened apple juice containers in the same cabinet had a light brown sticky substance on the outside. There was one 4 ounce raspberry sherbet cup in the refrigerator that was completely melted and not dated. There was one 4 ounce strawberry ice cream cup in the refrigerator that was completely melted and not dated. There were four of four plastic bags containing two cookies each that were exposed to air and were not dated, They were in a drawer with other snacks. Observation of the 400/500/600 hall resident nutrition room on 8/16/24 at 11:26am revealed the following: Two of four mildly thick coffee drink mixes that were in a drawer below the coffee pot expired 8/8/24.The other two of four mildly thick coffee drink mix in the same drawer expired 3/24/24. Two of two moderately thick coffee drink mix in the same drawer expired 2/14/24. In an interview on 8/16/24, RN A stated that MR is responsible for the supplies and dietary is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 25 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 responsible for the snacks in the nutrition room. Level of Harm - Minimal harm or potential for actual harm In an interview on 8/16/24 at 1:17pm LVN C stated they usually served snacks three times a day. LVN C stated she did check expiration dates on things and if she found something expired, she would throw it away, check for any other expired items, then she would tell dietary about them. LVN C stated it was the responsibility of everyone who got things out of the nutrition room to make sure stuff was not expired or compromised. LVN C went into the nutrition room and threw away all of the expired items, the unsealed cookies, and the apple juices that had a sticky substance on them. LVN C stated if the residents were served expired food items, it could ultimately cause them to get sick. LVN C stated she thought dietary brought the cookies over that were in the nutrition room yesterday. LVN C stated the last in-service on nutrition rooms was four to six weeks ago. LVN C stated she did not remember what the in-service on 8/1/24 entailed. Residents Affected - Many In an interview on 8/16/24 at 1:27pm the DM stated nurses were responsible for the pudding because they were for medication pass. The DM stated she would take the pudding to them and put the date on them, but she did not check dates on the stuff that was already there. The DM stated she would set the case of pudding down on the counter and let the nurses know that it was there. The DM stated she did not take the cookies to the nutrition room, she would take them to the nurses' station on a cart, leave the cart there, and go back to get it later. In an interview on 8/16/24 at 1:54pm, the ADON stated it was everyone's responsibility to check datescentral supply when they were rotating supplies: nurses when they were getting food or drinks for residents, and the DON and ADON when they were doing random checks. The ADON stated if something was expired, they would pull it and check the rest of the stock of that item to make sure no others were expired. The ADON stated dietary brought the things like pudding and jello to the nutrition rooms. The ADON stated dietary, nursing, housekeeping, and supply were all responsible for making sure things weren't expired and that things that were opened were dated and thrown out after three days. The ADON stated if things did not have a date, they were discarded. The ADON stated the kitchen brought the cookies in baggies over to the nutrition rooms and that room temperature snacks should have been given out right away and the extras/leftovers were to be discarded. The ADON stated if they were going to be kept, they needed to be dated and put into a sealed container. The ADON stated if a residents got expired or contaminated items, it could cause stomach issues. The ADON stated she would do another in-service on nutrition rooms. In an interview on 8/16/24 at 3:08pm, the DON stated MR was the supply person so she would stock the nutrition room with tube feed bottles and supplies. The DON stated dietary was responsible for stocking snack type stuff and they should have been responsible for checking for expired items. The DON stated supply was responsible for making sure the tube feed and supplies were not expired. The DON stated it was everyone's responsibility to check things before they were served or hung to make sure that they were not expired or contaminated. The DON stated that dietary should have been going into the nutrition rooms and rotating/inspecting the food items that were in the refrigerator, freezer, and cabinets/drawers. The DON stated that room temperature snacks and drinks were to be served within four hours. The DON stated if they were not served within four hours, they were to be thrown out. The DON stated if residents ate expired or contaminated items, they could get sick, could get nausea/vomiting/diarrhea which could lead to electrolyte imbalances and that could lead to hospitalization or even death. The DON stated she was not sure when the last in-service was, but that she would get it done on Monday. Record review of the facility's Food Storage Policy number 03.03.003 dated 12/01/11 reflected in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 26 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 part: Level of Harm - Minimal harm or potential for actual harm Policy: The consultant dietician with monitor the storage of foods to ensure that all food served by the facility is of good quality and safe for consumption. All food will be stored according to the state and Federal Food Codes. The following guidelines should be followed. Residents Affected - Many 1. Dry storage rooms a. The storage room is well-ventilated with humidity controls to prevent mold growth. b. For maximum shelf life, dry foods are stored at 50 Degrees Fahrenheit. 60-70 degrees Fahrenheit is adequate for most products. c. A wall thermometer is used to check the temperature of the dry-storage facility regularly. d. To ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. e. Scoops are used for items stored in bins such as sugar, flour, rice, and other items. Scoops are stored covered in a protected area near the food containers. i. All items are store at least 6 above the floor. 2. Refrigerators a. All refrigerated foods are stored per state and federal guidelines. e. All refrigerated foods are dated, labeled, and tightly sealed . h. A thermometer is placed inside refrigerators near the door where the temperature is warmest. The temperature of all refrigerators is checked using the internal thermometer to make sure the temperature stays at or below 41 degrees Fahrenheit. Temperatures are checked each morning when the kitchen is opened, once during the day and in the evening when the kitchen is closed. 3. Freezers a. All frozen meats .and some dairy products, such as ice cream, are stored in the freezer at 0 degrees Fahrenheit or below to keep them fresh and safe for an extended period of time. d.The freezer is not over-stocked and space is left between items to further improve air circulation. h. A thermometer is placed inside freezers near the door where the temperature is warmest. The temperature of all freezers is checked using the internal thermometer to make sure the temperature stays below 0 degrees Fahrenheit. Temperatures are checked each morning when the kitchen is opened, once during the day, and in the evening when the kitchen is closed. Record review of the Quality Assurance Monitor, Kitchen/Food Service Observation dated 5/23/24 stated in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 27 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 Section 1: Level of Harm - Minimal harm or potential for actual harm Did the Administrator participate in QA rounding? OR were QA results reviewed with the Administrator? Section 2: General Sanitation and Cleanliness Residents Affected - Many Cleaning schedule posted and followed to indicate routine cleaning of equipment. Clean equipment, drawers, shelves, work surfaces . General appearance of kitchen clean: floors, walls, ceilings, vents . Floors, walls, ceilings, molding, and tiles in good repair. All areas free of cracks, holes, and chipped paint. No evidence of pests. If present, is there documentation of pest control service? Section 2 Comments: cracked ceiling in dish room. Section 3: Dishwashing, tableware sanitation and storage Dish Machine logs complete, up to date, and accurate. Trays, dinnerware, cups, and utensils in good condition, free of cracks, chips, and stains and stored properly to prevent contamination. Section 5: Food Storage Refrigerators/Freezers: Refrigerators and freezers are at proper temp; logs complete, internal thermometers present in each cooler/freezer. All other food items covered, labeled, and dated. Coolers and freezers not overstocked to promote air circulation. Shelves, interior fans, gaskets, floors, walls clean and in good repair . Dry Storage: Dry storage temperature is below 85 degrees Fahrenheit, 50-75 degrees F as best practice, thermometer in use, well ventilated. All food items covered, labeled, and dated. All food 6 off floor, labeled, dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 28 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0812 Bulk items covered, labeled, dated; scoops clean and stored outside of bulk containers (scoops stored in protected areas) Level of Harm - Minimal harm or potential for actual harm Section 6: Meal Service Observation Residents Affected - Many Nourishment room: clean, no out of date foods, temp logs in use. Reviewed by: RD Date: 5/23/24 Reviewed with DM: *reviewed in person in kitchen with DM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 29 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests in one of one kitchen reviewed for pests. Residents Affected - Some 1. There were multiple live roaches in the kitchen. This failure could put residents at risk for food contamination and/or food borne illnesses. The findings included: Observation of the facility's kitchen on 08/14/24 at 09:10am revealed live roaches on the floor, food preparation surfaces, and clean dishware throughout the kitchen area. Observation revealed the following: On a rack that contained clean dishware, one of five blue two handled cups had a live roach on the outside of it. A roach ran out from under a second blue two handled cup when it was picked up. There were two other live roaches seen on the tray that contained the blue two handled cups. There were five to ten more live roaches observed on the surfaces of prep tables and clean dishware areas throughout the kitchen. There were five to ten more live roaches seen on the floor of the kitchen area. In an interview on 8/14/24 at 10:49am the DM stated she felt like pest control just sprayed water because the bugs just stayed around. The DM stated that the roach problem had gotten worse since the crack/hole in the ceiling of the dish room appeared. The DM stated the facility had been aware of the ceiling since 5/23/24, but it still had not been repaired. In an interview on 8/15/24 at 1:52pm, the RD stated she came in once a month to do QA. The RD stated that on her QA report dated 5/23/24, she put a comment in Section 2 that stated there was a crack in the ceiling in the dish room. The RD stated that she reviews the QA results with the ADM and the DM. In an interview on 8/15/24 at 4:17pm, the ADM stated that the facility was on a twice monthly pest control schedule, but they would come out more often if necessary. When asked how the pest control technician knew where the trouble areas were, the ADM stated that staff was educated to put a maintenance request into the electronic system stating where and what the problem was so the MS could relay that information to the pest control technician. The ADM stated she was aware of the roaches in the kitchen and that the pest control technician had been out earlier in August to treat the kitchen as well as the rest of the facility for them. Record review of facility's Work Order #4373 revealed the work order was created 5/29/24 by the DM at 10:45am. Updated status on 8/15/24 at 8:13am by the MS reflected: Set to be completed ; issue reflected crack in ceiling; and notes reflected: The ceiling in the dish room is cracked and has an opening. Location: Kitchen Priority: Medium. Record review of facility's Work Order #4430 revealed the work order was created 6/25/24 by the ADM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 30 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm at 9:15am. Updated status on 8/15/24 at 8:11am by the MS reflected: set to be completed; The issue reflected: kitchen repairs; and the location reflected Dry storage and dish room. Due date: 6/25/24. Priority: Medium. Record review of the facility's pest control invoices dated 1/3/24 to 8/16/24 revealed: Residents Affected - Some The open conditions section of the pest control invoices indicated the following five conditions were present in sixteen of sixteen pest control invoices reviewed. The invoices revealed that all of the conditions that contributed to pests entering the facility had been present for six months to five years. Interior- Kitchen Condition: Openings at Plumbing/Electrical Action: Seal Created: 4/3/19 Last Inspected: 8/16/24 Interior- Kitchen Condition: Cracks/ Gaps along baseboards Action: Seal/ Repair Created: 4/3/19 Last Inspected: 8/16/24 Interior- Rooms Condition: Food residue under appliance/ machinery/ equipment Action: Cleaning practices need to be improved Created: 7/10/23 Last Inspected: 8/16/24 Interior- Rooms Condition: Cracks/Gaps around foundation Action: Seal gaps to reduce pest access Created: 9/6/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 31 of 32 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Last Inspected: 8/16/24 Level of Harm - Minimal harm or potential for actual harm Interior- Kitchen Condition: Door leveler not sealed adequately Residents Affected - Some Action: Seal and repair Created 12/6/23 Last Inspected: 8/16/24 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 32 of 32