Health inspection·October 29, 2025

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete proposed change. During an interview on 10/28/2025 at 03:05 PM, Charge Nurse C said nurses should notify the resident and his or her responsible party of new physician's orders and changes in physician orders. She said there were times when the resident or responsible party did not agree to orders or changes. Charge Nurse C said it was the resident's right to disagree with the doctor. She said she would let the doctor or nurse practitioner know if a resident or responsible party had a concern or did not agree with any orders. During an interview on 10/29/2025 at 11:30 AM, the DON said the nurses were responsible for notifying residents and responsible parties of changes in care and treatment. She said it was important for the residents and responsible parties to be informed and given the opportunity to participate in the decision-making process. The DON said she and the ADON reviewed new physician's orders daily in the morning meeting. She said they missed seeing that Resident #3 and the responsible party were not notified of the changes to the insulin dosing and blood sugar testing. A record review of the facility's policy titled Change in a Resident's Condition or Status dated Revised April 2025 indicated the following: Policy StatementOur facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition or status (e.g., changes in level of care, billing/payments, resident rights, etc).5.Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.6. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. Event ID: Facility ID: 675878 If continuation sheet Page 2 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 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 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident #3) and representative was informed of her right to participate in the development and implementation of a person-centered plan of care. The facility failed to facilitate the inclusion of Resident #3 and/or the representative in the care planning process. This failure could prevent residents from incorporating their personal and cultural preferences in developing goals of care. Findings included: Record review of a face sheet dated 10/28/2025 indicated Resident #3 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included a principal diagnosis of COPD (a condition involving constriction and destruction of the airways in the lungs), a co-existing diagnosis of emphysema (a type of COPD involving the air sacs in the lungs), and pre-existing diagnoses of dementia and diabetes mellitus (a chronic condition in which the body does not produce enough insulin to regulate blood sugar levels). Review of the MDS dated [DATE] noted Resident #3 had a BIMS score of 10 indicating her cognition was moderately impaired. She was ambulatory with a walker and was incontinent at times. Review of the MDS dated [DATE] indicated Resident #3 discharged from the facility on 05/02/2025. Record review of Resident #3's medical records indicated a care plan was developed during a previous facility stay from 08/19/2025 - 09/08/24 was revised for the plan of care for the most current stay from 02/27/2025 - 05/02/2025. Record review of scanned documents, progress notes and social worker notes for Resident #3 from 02/27/2025 - 05/02/2025 did not indicate Resident #3 and/or representative had been informed of or invited to participate in the development of a care plan. There was no documentation of a refusal to participate in the care planning process. During an interview on 10/27/2025 at 11:00 AM, Resident #3's representative said she had not been consulted about or included in the care planning process for Resident #3. She said she was never asked to attend a care plan meeting nor was she invited to participate in the development of Resident #3's plan of care during the entire time Resident #3 was at the facility nor was she ever given a copy of a care plan. During an interview on 10/28/2025 at 03:10 PM, the DON said she had been at the facility for about 4 months. She said she could not find any documentation of Resident # 3 or the representative having been invited to a care plan meeting, a care plan meeting being held, or a review of a plan of care for Resident #3. The DON said she, the MDS Coordinator, and Social Worker shared in the care planning process. She said neither she nor the Social Worker were employed at the facility during Resident #3's stay at the facility and could not explain why Resident #3 and the representative had not been invited to a care plan meeting or been given a copy of Resident #3's care plan. A record review of the facility's policy titled Care Plans-Baseline dated Revised March 20244 indicated the following:A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include.but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative;, .4. The resident and/or representative are provided a written summary of the baseline care plan .5. Provision of the summary to the resident and/or resident representative is documented in the medical record. A record review of the facility's policy titled Care Plans, Comprehensive Person-Centered indicated the following: Policy Interpretation and Implementation4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a: participate in the planning process.h. see the care plan and sign it after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675878 If continuation sheet Page 3 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 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 0553 significant changes are made.5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675878 If continuation sheet Page 4 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive assessment was completed, using the CMS-specified process, within the regulatory time frames for 1 of 3 residents (Resident #4) reviewed for comprehensive assessments. The facility failed to complete a comprehensive MDS assessment for Resident #4 within 14 days of admission to the facility. This failure could place new residents at risk of delays in assessments and the residents' care plans not accurately reflecting their current needs. Findings included: Record review of a face sheet dated 10/28/2025 indicated Resident #4 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral atherosclerosis (a build-up of plaque in the arteries of and leading to the brain which thickens and hardens the arteries of the brain), major depression, diabetes mellitus, anxiety, sleep apnea, atrial fibrillation (a heart rhythm disorder), dysphagia (difficulty swallowing), arthritis, ataxia (lack of muscle coordination), and repeated falls. Record review of an incomplete admission MDS with an ARD date of 10/20/2005 indicated Resident #4 had a BIMS score of 00 (zero-zero) indicating his cognition was severely impaired. Further review of the MDS indicated sections A (identification Information, F (Preferences for Routine & Activities), GG (Functional Abilities), J (Health Conditions), O (Special Treatments, Procedures, and Programs), Q (Participation in Assessment and Goal Setting) and V (Care Area Assessment Summary) were not completed. Record review of Section Z indicated the MDS had not been signed as completed as of 10/29/2025. Record review of Resident #4's MDS history indicated he was admitted to the facility on [DATE], had an admission assessment in progress and was 2 days overdue. During an interview on 10/29/2025 at 11:10 AM, the MDS Coordinator said she did not know why the MDS had not been completed. She said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said she had been the MDS Coordinator for less than a year and was still slow at completing the MDS assessments. She said the Regional MDS Consultant had been helping her, but the Consultant had other buildings to help also. The MDS Coordinator said Resident #4's admission MDS assessment should have been completed by 14 days after admission which was 10/27/2025. Record review of the RAI Version 3.0 Manual: Section 2.2 indicated the following: Policy Interpretation and Implementation1.Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.2.admission Assessment - The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if:.c. the resident has been admitted to this facility and was discharged return not anticipated and did not return within 30 days of discharge.The admission Assessment (Comprehensive) must be completed by the 14th day of the resident's stay (admission date + 13 = completion date). Event ID: Facility ID: 675878 If continuation sheet Page 5 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 3 of 4 residents (Residents #2, #3, #4) reviewed for baseline care plans. The facility failed to ensure Resident #2's and Resident #4's baseline care plans were implemented and made available to nursing staff within 48 hours of admission. The facility failed to ensure Resident #3's baseline care plan included instructions to address the principal diagnosis of COPD. The facility failed to ensure Resident #3's baseline care plan included instructions to address identified risks for hyperglycemia and hypoglycemia. These failures could affect newly admitted residents and place them at risk of receiving inadequate care and services and not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. Findings included: 1.Record review of a face sheet dated 10/28/2025 indicated Resident #2 was an [AGE] year-old female who admitted to the facility 10/06/2025 with diagnoses which included Alzheimer's disease, dementia, aortic stenosis (a condition where the aortic valve in the heart becomes narrowed, restricting blood flow from the heart to the rest of the body), and osteoporosis. Review of Resident #2's MDS dated [DATE] noted resident #2 had a BIMS score of 6 indicating her cognition was severely impaired. Record review of Resident #2's medical records for a baseline care plan indicated the electronic care plan for Resident #2 was completed but not signed by the resident, resident's representative, and by the staff who completed the care plan. Section 5. B. Signature of Resident and Representative indicated LVN C had signed the document in the area designated for Resident #2's signature and dated it 10/22/2025. The spaces on the care plan form designated for the signatures of the resident, resident representative, and staff participating in the development of the care plan were blank. During an interview on 10/29/2025 at 11:10 AM, the DON said the nurses usually printed the baseline care plan from the electronic record, completed it manually, and then gave it to the social worker to get signed. She said sometimes, the nurses completed the baseline care plan in the electronic record, printed it, and give it to the social worker to get signed. The DON said it looked like Resident #2's electronic baseline care plan was completed but not signed by the resident, the resident's representative, nor the facility staff. 2.Record review of a face sheet dated 10/28/2025 indicated Resident #3 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included a principal diagnosis of COPD (a condition involving constriction and destruction of the airways in the lungs), a co-existing diagnosis of emphysema (a type of COPD involving the air sacs in the lungs), and pre-existing diagnoses of dementia and diabetes mellitus (a chronic condition in which the body does not produce enough insulin to regulate blood sugar levels). Record review of an MDS dated [DATE] noted Resident #3 had a BIMS score of 10 indicating her cognition was moderately impaired. Further review of the same MDS indicated Resident #3 was ambulatory with a walker and was incontinent at times. Record review of an MDS dated [DATE] indicated Resident #3 discharged from the facility on 05/02/2025. Record review of medical records indicated Resident #3 was initially admitted to the facility on [DATE]. A MDS dated [DATE] indicated Resident #3 was discharged on 09/08/2024 with return not anticipated. Further review of medical records indicated a care plan developed during a facility stay from 08/19/2025 - 09/08/24 was revised for the plan of care for the most current stay from 02/27/2025 05/02/2025. The revised care plan included a problem with a start date for 08/20/2024 and identified as a Baseline Care Plan for new admission to skilled nursing facility, edited 02/28/2025. The revised baseline care plan indicated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675878 If continuation sheet Page 6 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete #3's principal diagnosis of COPD and co-existing diagnosis of emphysema were not addressed in the care plan. The revised care plan indicated there were no goals or interventions to address identified risks of hypoglycemia (low blood sugar levels) and hyperglycemia (high blood sugar levels). Record review of scanned documents, progress notes and social worker notes for Resident #3 from 02/27/2025 - 05/02/2025 did not indicate Resident #3 and/or representative had been informed of the development of a care plan. During an interview on 10/27/2025 at 11:25 AM, Resident #3's representative said she had not been consulted about or included in the care planning process for Resident #3. During an interview on 10/28/2025 at 03:10 PM, the DON said she had been at the facility for about 4 months. The DON said she, the MDS Coordinator, and Social Worker shared in the care planning process. She said neither she nor the Social Worker were employed at the facility during Resident #3's stay at the facility and could not explain why Resident #3's revised care plan did not address the principal diagnosis for which Resident #3 was re-admitted to the facility. She said she did not know why Resident #3 and the representative had not been given a copy of Resident #3's care plan. 3. Record review of a face sheet dated 10/28/2025 indicated Resident #4 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral atherosclerosis (a build-up of plaque in the arteries of and leading to the brain which thickens and hardens the arteries of the brain), major depression, diabetes mellitus, anxiety, sleep apnea, atrial fibrillation (a heart rhythm disorder), dysphagia (difficulty swallowing), arthritis, ataxia (lack of muscle coordination), and repeated falls. Record review of an incomplete admission MDS with an ARD date of 10/20/2005 noted Resident #4 had a BIMS score of 00 (zero-zero) indicating his cognition was severely impaired. Record review of Resident #4's electronic medical records revealed Resident #4's had an undated baseline care plan that was incomplete and had not been signed by Resident #4 or Resident #4's representative. A record review of a paper copy of a baseline care plan dated 10/14/2025 for Resident #4 indicated the blank baseline care plan was printed, manually completed, and signed and reviewed with Resident #4's responsible party on 10/16/2025. The completed and signed baseline care plan was not in the electronic health record. During an interview on 10/29/2025 at 03:15 PM, the DON said she found Resident #2's and Resident #4's manually completed baseline care plans in a stack of papers in medical records. She said it took her a while to find them. She said the care plans had not been scanned into the computer and therefore, were not a part of the electronic health records and were not available or communicated to the nursing staff. The DON said the baseline care plan could not be updated to reflect the residents' changing needs if it was not in the computer to begin with. The DON said it would be better to complete the baseline care plans in the electronic chart to ensure the nursing staff had access to baseline care plans. A record review of the facility's policy titled Care Plans - Baseline Care Plan dated Revised March 2024 indicated the following: A baseline plan of care to meet the residents' immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.1.The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include.but not limited to the following: a.Initial goals based on admission orders and discussion with the resident/representative;, .b.Physician ordersc.Dietary orders,d.Therapy servicese.Social services; andf.PASRR recommendations, if applicable 2.The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. Event ID: Facility ID: 675878 If continuation sheet Page 7 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 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 set forth 483.10(c)(3, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #2) reviewed for comprehensive assessments. The facility failed to ensure a comprehensive person-centered care plan was developed and completed within 21 days of admission to the facility for Resident #2. This failure could place residents at risk of a delay in receiving care and services to meet medical and nursing needs. The findings included: Record review of a face sheet dated 10/28/2025 indicated Resident #2 was an [AGE] year-old female who admitted to the facility 10/06/2025 with diagnoses which included Alzheimer's disease, dementia, aortic stenosis (a condition where the aortic valve in the heart becomes narrowed, restricting blood flow from the heart to the rest of the body), and osteoporosis. Review of an MDS dated [DATE] revealed Resident #2 had a BIMS score of 6 indicating her cognition was severely impaired. Record review of Resident #2's medical records indicated a comprehensive care plan had not been completed. During an interview on 10/29/2025 at 11:10 AM, the MDS Coordinator said she, the DON, and the ADON shared responsibility for developing and implementing the care plans. She said for new admissions, the comprehensive care plan was to be done within 7 days of the completion of the comprehensive assessment and no more than 21 days after admission. She said that since the comprehensive MDS had not been completed, the comprehensive care plan had not been completed. She said Resident #2's comprehensive care plan should have been completed no later than 10/27/2025. The MDS Coordinator said she was working on getting caught up. The MDS Coordinator said the facility used RAI Version 3.0 Manual as the guide for completing MDS assessments and care plans. During an interview on 10/29/2025 at 03:15 PM, the DON said she, the ADON, and the Social Worker were new to the facility and were working on processes to get caught up and organized. She said she was not aware Resident #2's comprehensive care plan had not been completed. Review of CMS's RAI Version 3.0 Manual Section 2.2 indicated the Care Plan Completion Date must be dated by the end of the 7th calendar day following the completion date of the admission Comprehensive Assessment and can be no later than day 21 (admission date +21 = Comprehensive Care Plan due date). A review of the facility's policy titled Care Plans, Comprehensive Person-Centered and dated 2001 with a revision date of March 2022 indicated the following: Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in status), and no more than 21 days after admission. Event ID: Facility ID: 675878 If continuation sheet Page 8 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 8 residents reviewed for accidents. (Resident #1).The facility did not prevent Resident #1, who was wearing a Wanderguard bracelet, from leaving the facility unsupervised on 09/07/2025. Resident #1 was found at the intersection of the county road the facility resided on and a state farm to market road approximately 1.3 miles from the facility. The facility was not aware the resident was missing for approximately 1 hour. The noncompliance was identified as PNC. The IJ began on 09/07/2025 and ended on 09/09/2025. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of potential accidents, injuries, harm, or death. Findings included:Record review of a face sheet on 10/27/2025 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] with diagnoses including: schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and mood disorders, such as depression or mania), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between mania and depression), psychosis (a mental health condition characterized by a loss of touch with reality), anxiety disorder a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), depression (a common and serious mental health condition that significantly impacts a person's mood, thoughts, and behavior) and cognitive communication deficit (a difficulty in communication caused by problems with underlying cognitive functions like memory, attention, and executive function, rather than a language or speech impairment).Record review of a quarterly MDS dated [DATE] indicated Resident #1 had clear speech, usually understood others and was usually understood, he had a BIMS score of 07 indicating severe cognitive impairment. He had disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). He exhibited no wandering or other behaviors. He required set-up or clean up assistance with ADLs and he could feed himself. He was occasionally incontinent of bladder and continent of bowel. He was independent with mobility and walking unassisted. Record review of care plans for Resident #1 indicated he had a care plan initiated on 06/21/2025 and revised on 09/08/2025 indicating he was at risk for wandering. Goals included: ensure staff awareness of resident's risk, monitor for expressions of wanting to go home and assess quarterly and as needed for wandering/elopement risk. He had another care plan initiated on 09/08/2025 which indicated he was at risk for elopement and required a secured unit as evidence by impaired safety awareness and at risk for injury from others while residing in secure/ memory unit due to altered cognition and history of elopement. Care plan goals included: Will remain safe within the facility through the next review date. Interventions included: monitor for early warning signs of any behaviors and anticipate behavior(s) and redirect when in close proximity to others that might invoke aggression.Record Review of Resident #1's admission Elopement Risk assessment dated [DATE] indicated the resident had a score of 9. The assessment tool indicated a score of 10 or higher indicated a high risk for elopement. The interdisciplinary team had determined a Wanderguard (a wearable device used in senior living facilities to prevent residents at risk of wandering from leaving a protected area) was not indicated at that time as the resident was not actively exit seeking.Record Review of Resident #1's Elopement Risk assessment dated [DATE] indicated the resident had a score of 4. The interdisciplinary team had determined a Wanderguard was indicated at this time as the resident did leave the facility without notifying anyone.Record Review of Resident #1's Elopement Risk assessment dated [DATE] indicated the resident had a score of 7. The interdisciplinary team had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675878 If continuation sheet Page 9 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few determined the resident needed to be in the secure unit as he had eloped from the facility without staff knowledge and was found by the police approximately 1.3 miles from the facility.Review of Resident #1's Progress Notes in the electronic record indicated on 06/21/2025 he was seen on the driveway of the facility by facility staff. A visitor turning into the facility driveway stopped and gave the resident a ride back to the front door where he was brought inside. He was assessed with no injuries and said he was going to see his brother. A Wanderguard was placed on the resident to alert staff if he left the facility again.Review of Resident #1's Progress Notes in the electronic record indicated the resident did not exhibit any exit seeking behavior from 06/21/2025 until 09/07/2025.A review of the facility investigation report indicated the incident occurred on 09/07/2025 and was reported to the state agency on 09/08/2025 with no times indicated. Resident #1 was last seen at 8:20 AM on 09/07/2025 going towards his room. He was found by the sheriff and police departments about a mile away and the facility was called by the local police at approximately 9:45 AM. Resident #1 returned to facility at 10:00 AM with no injuries noted. Resident #1 was placed on the secure unit for his safety. Review of a handwritten statement dated 09/07/2025 indicated CNA B saw Resident #1 in the dining room at 6:20 AM and he left at the same time as she did and returned to his room. She indicated she gave him his breakfast at 7:45 AM in his room. She said she saw him last at 8:20 AM walking toward his room to go to the bathroom. She said he was acting his normal self and seemed fine. She said she began making her morning rounds getting residents ready for the day.Review of a handwritten statement dated 09/07/2025 indicated CNA Y saw Resident #1 during breakfast and again around 8:00 AM. The statement indicated she and her partner began their morning rounds of getting residents up and ready for the day and did not see the resident elope.During an interview on 10/27/2025 at 9:55 AM, LVN C said she was charge nurse over the secure unit and Hall 100. She said Resident #1 now resided on the secure unit. She said he did not reside on her halls the day he eloped. She said since he had been placed on the unit he had not tried to exit the unit and she said he had no behavior issues. She said all the staff received inservices and training on what actions to take when the alarm sounded indicating a resident with a Wanderguard had walked through an exit door. LVN C produced a purple loose-leaf binder labeled Missing. She said the binder had a list of residents with Wanderguard bracelets and a list of residents residing on the secure unit that included their face sheets with a photo and included their room numbers. She said they were to use the binder to help identify which residents to check immediately when an alarm sounded and they thought someone left the building.During an interview on 10/27/2025 at 10:05 AM LVN X said she was a PRN nurse and she was charge nurse on the 300 and 400 halls. She said they had inservices and training on elopement. She said she did not have any residents that were exit seeking but did have Wanderguard bracelets.During an observation and interview on 10/27/2025 at 10:20 AM Resident #1 was lying on his bed in his room on the secured unit. He appeared clean and well groomed. He said he did leave the building a while back and he heard voices in his head telling him to go see his uncle at his warehouse. He said the police brought him back to the facility. He then told a fantastical story about working for a major satellite and communications company in 1963 (he was born in 1962). He said they could place microchips in animals and people so they could be found by GPS (global positioning system) and he had a microchip in his brain. During an interview on 10/27/2025 at 11:15 AM LVN A said he was the charge nurse on the 500 and 600 halls and he had been on duty when Resident #1 left the facility. He said Resident #1 had been a resident on his hall and he wore a Wanderguard bracelet. He said he heard the front door alarm sound around 9:00 AM on 09/07/2025. He said he went to the front door and looked outside and there were family members and residents sitting outside. He said he did not see any resident not accompanied by a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675878 If continuation sheet Page 10 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few family member. He said he did not see an unaccompanied resident. He said there were residents with Wanderguards outside but were with a family member. He said he assumed they had set off the alarm accidentally. He said he did not do a facility sweep of residents with Wanderguard bracelets to ensure any other residents had exited the facility unaccompanied. He said he did not know Resident #1 was missing from the facility until the police department called and said they had picked up Resident #1 down the road. He said the resident was returned to the facility and assessed for injuries. He said he had no injuries and was placed in the secure unit for his safety. He said the direct care staff received inservices regarding elopement and reporting of elopement. He said they had a purple notebook that contained a list of all residents in the facility fitted with a Wanderguard and all residents currently residing on the secure unit. He said their face sheets along with photos were also in the binder. He said they were to look at the binder and check those residents immediately if the door alarm sounded and they could not see a reason for the alarm to have sounded.During an interview on 10/27/2025 at 11:25 AM the DON said she and her two ADONs were jointly responsible for keeping the purple binder labeled missing accurate and up to date. She said it contained a list of residents currently wearing Wanderguard bracelets and residents residing on the secure unit along with their current face sheets and photos. She said Resident #1 eloped on the weekend but she was notified and aware the resident was returned to the facility by the local police. She said she did not know how far away he was when he was found. She said staff were to check the purple binder if the alarm went off to see who to check on immediately to see if they were missing from the facility. She said sometimes family members take residents outside to sit and visit or to take them to appointments and set off the alarm accidentally. She said Resident #1 had not been exit seeking prior to his leaving the facility on 09/07/2025. She said he would not even go outside until the day he left. She said the resident had been seen by psychological/psychiatric services and he did sometimes get current events confused with daily events. During an interview on 10/27/2025 at 12:105 PM CNA B said she had worked on the hall Resident #1 resided on the day he left the facility. She said she worked mostly the day shift (6AM-6PM). She said on the day he left the facility he had been his normal self. She said she had seen him up early around 6:20 AM and served him his breakfast at 7:45 AM. She said she had last seen him around 8:20 AM walking back to his room to go to the bathroom. She said he had not been exit seeking prior to that day. She said he would walk around the facility but usually around the nurses' station and in the dining room. She said she never saw him going toward the exit doors. She said they received inservices about resident elopement procedures after Resident #1 got out. She said the purple binder at the nurses' station had a list of all the residents with Wanderguard bracelets and if the alarm sounded and no one was immediately seen outside they were to check all the residents inside to make sure everyone was accounted for. If they could not find someone they were to let the charge nurse know. During an interview on 10/27/2025 at 12:07 PM MA E said she had received inservices regarding resident elopement and what facility staff actions should be when the door alarms sounded. She said Resident #1 did not normally exit seek. She said it was out of character for him to leave the building.During an interview on 10/27/2025 at 2:35 PM the local police officer that was called by the sheriff's department to help identify a person they found walking down the county road at the intersection of a state farm to market road. He said Resident #1 could give his name and they called the facility and they said he was a resident at the facility. He said Resident #1 was found about 1.3 miles from the facility and he called the facility at 9:43 AM. He said the resident was okay and did not appear to have any injuries. He said the police department returned the resident to the facility at 10:00 AM. During an interview on 10/28/2025 at 10:00 AM the interim Administrator said he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675878 If continuation sheet Page 11 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few not officially at the facility when Resident #1 eloped on 09/07/2025. He said his first day was 09/08/2025. He said the previous administrator was no longer at the facility but did not know how long they had been gone. He said the Corporate Director of Operations was in charge of the facility at the time of the elopement. During an interview on 10/28/2025 at 10:10 AM the BOM said she had received a group text from the charge nurse along with the other department heads on 09/07/2025 that Resident #1 had eloped and was at the police department. She said staff did not know he had eloped until the police called them.During an interview on 10/28/2025 at 10:20 AM the DON said LVN A called her and told her Resident #1 was at the police department and was being brought back to the facility. She said she also had received the group text. She said she had talked to an administrator that day but could not recall if it had been the previous administrator or the administrator at the local sister facility regarding the elopement.Review of facility undated Wandering and Elopement Policy indicated If a resident is missing, initiate the elopement/missing resident emergency procedure:.initiate a search of the building(s) and premise(s); and if the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies.Facility took the following actions to correct the noncompliance prior to surveyor entrance:Resident #1 returned to the facility 09/07/2025 at 10:00 AM and was placed on the secured memory unit. Resident #1's care plan was reviewed and updated to reflect current status on memory unit.All residents at risk for wandering/elopement were re-assessed and care plans were reviewed and updated to reflect current interventions being utilized for residents at risk for elopement.Elopement/Wandering Resident Policy was reviewed.All nursing staff on all shifts received education on wandering/elopement and resident safety and included new process of doing census check when wander guard alarms. All Wander Guard systems and door alarms were checked for proper functioning.Actions taken post-investigation were:All Wander Guard systems and door alarms are checked routinely for proper operation.The DON or designee will monitor new admissions for elopement risk and ensure interventions are in place daily for 3 weeks.The DON or designee will audit elopement risk assessment weekly for 3 months to ensure care plans reflect the needs and concerns in the assessments.The ad hoc (when necessary or needed) Quality Assurance and Performance Improvement committee that was completed with the medical director and interdisciplinary team will be discussed at QAA meetings for a minimum of three months or until a pattern of compliance is maintained.During an observation and interview on 10/29/2025 at 11:50 AM the DON provided elopement risk audits in the electronic record being done on residents at risk for elopement. She said she reviewed to see if their scores had changed from the previous scores. She said most residents with high scores were in the secure unit and had been. She said she looked at individual reasons for the increased assessment scores if there were any. She said residents may or may not be placed on the secured unit with high scores. She said the interventions were individualized with talking with family and discussing options. She said if a resident was constantly exit seeking and trying to go out the door they would be placed on the unit. She said Resident #1 had a Wanderguard placed the first time he exited the facility without letting anyone know and she said they considered it a fluke because he had not exhibited that behavior before. She said he would walk around the facility but never went to the doors. She said when he left on 09/07/2025 they decided he would be safer on the unit since it was the second time.Review of the October 2025 MARs for residents with Wanderguard bracelets (Residents #2, #5, #6, #7, #8, #9, #10) indicated placement and functioning every shift.Review of the maintenance weekly logs (07/05/2025-10/25/2025) for accurate operation of door monitors and resident wandering system. During multiple interviews on 10/28/2025 from 4:02 PM-4:30 PM and 10/29/2025 from 8:50 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675878 If continuation sheet Page 12 of 13 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 675878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grand Saline 1638 Vz Cr 1803 Grand Saline, TX 75140 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete AM-9:45 AM with nurses, CNAs, and MAs from both shifts (6AM-6PM and 6PM-6AM) (CNA F, CNA G, CNA H, CNA J, CNA K, NA L, LVN M, NA N, MA O, NA P, CNA Q, CNA R, CNA S, CNA T, CNA U, NA V, NA W) indicated they said they had been trained on abuse and neglect, residents at risk for elopement, facility staff response if they saw a resident leave unaccompanied, facility staff response to door alarms sounding, the purple binder containing lists of residents at risk for elopement, and doing a census check of all residents listed in the purple binder. They said if they saw a resident exit the facility they should go out and try to get them to come back inside. They said if the door alarms sounded, they should check the panel to identify which door they should check and then go outside and do a perimeter check around the whole facility and if they did not find anyone, they should report it to their charge nurse or DON. They said they should also use the purple binder to identify residents with Wanderguards and go to their rooms or around the facility to make sure they were all present in the facility. Event ID: Facility ID: 675878 If continuation sheet Page 13 of 13