Inspection·August 18, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had a BIMS score of 7 which indicated residents' cognition was severely impaired. Resident #31 was assessed to require assistance with ADLs. Record review of Resident #31's Comprehensive Care Plan, start date of 08/11/2023, reflected Resident #31 had an ADL self-care performance deficit and required staff assistance. Resident was at risk for falls related to unsteady gait, and balance. Intervention: ensure the call light within reach and encourage to use the call light for assistance as needed. Observation/Interview on 08/16/2023 at 10:16 AM revealed Resident #31 was lying in bed watching television. Resident #31's call light was on the floor toward the head of the bed. Resident #31 mumbled when responded to questions. 3. Record review of Resident #41's face sheet, dated 08/17/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute pulmonary embolism ( a sudden blockage in a lung artery), type two diabetes mellitus ( your body does not use insulin properly), and acute kidney failure (kidney damage that happens within a few hours or few days). Record review of Resident #41's Quarterly MDS Assessment, dated 05/24/2023, reflected Resident #41 had a BIMS score of 8 which indicated residents' cognition was moderately impaired. Resident #41 was assessed to require assistance with dressing, walk in corridor, locomotion on and off unit, toileting, dressing, personal hygiene, and bathing. Record review of Resident #41's Comprehensive Care Plan, dated 06/12/2023, reflected Resident #41 had an ADL self-care performance deficit related to fatigue and impaired balance. Resident was at risk for falls related to unsteady gait, and balance. Intervention: ensure the call light within reach and encourage to use the call light for assistance as needed. Observation/Interview on 08/16/2023 at 11:10 AM revealed Resident #41 was lying in bed. His call light was on the floor between the head of bed and the wall Resident #41 stated he used the call light whenever he needed the nurses for anything. Resident stated the call light had been on floor since last night. He stated he did not need assist from the nurses last night or this morning, however, if he did require assistance, he was unable to reach the call light. In an interview on 8/17/2023 at 2:15 PM, CNA C stated all staff were responsible to check call lights when they entered a resident's room. She stated if the call light was not in reach the resident may fall attempting to reach the call light or try to find the call light. CNA C stated a resident may have an emergency such as choking and possibly could die. She stated the resident would not be able to yell for help. She stated there was a possibility a resident may break a bone if the resident fell during the attempt of reaching the call light. In an interview on 8/17/2023 at 2:45 PM, LVN A stated if a resident call light was on the floor and the resident was unable to reach the call light there was a possibility a resident may fall attempting to reach the call light and break a bone. She stated it was everyone's responsibility to place the call light in reach if they observed the call light not in reach of the resident when they enter a resident's room. She stated it was difficult for residents to yell out for help if the staff was not near the residents' room. In an interview on 8/17/2023 at 3:00 PM, CNA D stated if a residents call light was not in reach (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 2 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some there was a possibility a resident may need assistance with anything and may attempt to reach for the call light and fall. She stated if a resident fell there was a possibility of the resident breaking a bone or hitting their head on the floor and have a bump on their head or cut on their head. In an interview on 08/17/2023 at 3:20 PM, The Director of Nurses she expected the call lights be within reach of all residents. She stated if a call light was not in reach when a resident was in their room, the residents would not have any device to use if they needed any type of assistance. She stated some residents were able to yell, however, this was not the appropriate protocol for residents to yell for help. She also stated it was a greater risk for harm if the residents did not have the call light within reach such as falling and breaking a bone. The Director of Nurses stated the nurse supervisor was responsible to monitor CNAs and to ensure call lights were within reach. In an interview on 08/17/2023 at 3:50 PM the Administrator stated all staff were responsible for checking call lights whey they entered a resident's room. He stated he expected all call lights placed within reach of the residents. He stated if the resident was lying in bed and the call light was on the floor the resident had a potential of falling and breaking a bone or have some type of head injury if the resident attempted to reach for the call light. The Administrator stated a resident may need immediate help from the staff and would not be able to call for help by using the call light. He also stated not all residents could yell for assistance. Record Review of the facility's Policy on Call Lights dated 02/23 reflected when a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 3 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation , interview, and record review the facility failed to ensure residents had the right to personal privacy of his or her personal male and right to send and promptly receive unopened mail and other letters, packages, materials delivery to the facility for residents for one of one facility. Residents Affected - Some The facility failed to implemet a system for delivering mail received on Saturdays to residents the date of receipt and instead of distributed mail received Saturday on Mondays. This failure could place the residents in facility at risk of not receiving mail in a prompt manner and could result in a decline in the residents' psychosocial well-being and cause them to feel disconnected from family, friends, and current events. Findings included: In a group confidential interview on 08/16/2023 at 2:40 PM, all eight resident attendees stated they do not receive mail on Saturdays at the facility because there was no one in the office on Saturdays. Residents stated that mail was provided to them by the AD Monday through Friday. In an interview on 08/18/2023 at 9:23 AM, the AD stated that she has worked for the facility for over three years. The AD stated that she works Monday through Friday and that she was responsible for distribution of the mail. The AD stated that they do not distribute mail on Saturdays and the residents were aware. The AD was asked if she knew mail was supposed to be distributed on Saturday and she stated that this was how it has always worked. The AD stated that they do not have an exterior mailbox, so mail was not delivered to the facility on Saturdays. In an interview on 08/18/2023 at 9:40 AM, the Administrator stated that mail was delivered to the facility on Saturdays. The Administrator stated that the mail was brought into the facility and placed in the mail slot of the BOM's area. The Administrator stated that they have discussed nurses distributing the mail on Saturdays, but he was unaware if it was distributed. In an interview on 08/18/2023 at 10:12 AM, the AD stated that she was corrected and informed that the mail was delivered on Saturdays through a slot into the BOM's area. The AD was asked if this area was accessible to others on the weekend and she advised it was not. In an interview on 08/18/2023 at 10:29 AM, the BOM stated that the mail was delivered through the slot into her locked office area. The BOM stated that the delivered mail from Saturday stays in her office area until she gathers it on Monday morning and provides it to AD for distribution. The BOM stated that the residents mail has not been delivered on Saturday since at least January of 2023. In Review of facility Resident Rights Policy, revised 10/2021, which includes the Texas Health and Human Service Residents Rights poster available in English and Spanish. Rights under privacy and confidentiality state Send and receive unopened mail and to receive help in reading or writing correspondence. Facility advised that there was no other reference or policy that related directly to mail and the distribution thereof. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 4 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for three of fifteen residents reviewed for care plans. (Resident #20, #22, and #30) A) The facility failed to ensure Resident #20's Comprehensive Care Plan reflected a revision of decline in cognitive abilities that impact a person's ability to do everyday activities. B) The facility failed to ensure Resident #22's Comprehensive Care Plan reflected a revision of Resident #22 had shortness of breath. C) The facility failed to ensure Resident #30's Comprehensive Care Plan reflected a revision of his plan of care to reflect Resident #30's current skin condition. This failure could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical well-being. Findings included: A) Review of the face sheet for Resident #20 reflected she was admitted on [DATE] with diagnoses of Multiple Sclerosis, Anemia, other specified Anxiety Disorders, Intracerebral Hemorrhage, Asthma, Neuropathic bladder, Scoliosis and Repeated Falls. Review of the MDS annual assessment for Resident #20 dated 5/17/23 reflected a BIMS score of 4 which indicated her cognitive function was severely impaired. Her functional assessment reflected the resident required extensive assistance for all ADLs except mobilizing in her wheelchair and eating. The assessment of her bowel and bladder function reflected she was frequently incontinent. Review of the Care Plan dated 7/31/23 for Resident #20 reflected interventions were in place for: DNR status, Insomnia, ADL self-care deficits, Hospice Care, Fall Risk, Psychotropic Medications, MS and Scoliosis. Her plan reflected she should have oxygen therapy of 2 L/min to keep her saturation above 95 %. Review of the Daily Oxygen Saturation levels for Resident #20 dated from 8/11/23 to 5/31/23 reflected her saturation varied from 96 to 97 %. Review of physician's orders for Resident #20 reflected oxygen at 2L/min as needed for shortness of breath dated 8/02/23. B) Review of the face sheet for Resident #22 reflected she was admitted on [DATE] with diagnoses of Cerebral Palsy, Lyme disease, type 2 Diabetes, Anxiety disorder, Abnormal posture, and Unspecified Intellectual disabilities. No respiratory problems were listed. Review of the MDS annual assessment for Resident #22 dated 6/28/23 reflected she was assessed as severely impaired in cognitive skills and decision making. Her functional assessment reflected she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 5 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 required extensive assistance for all ADLs. She was assessed as always incontinent of bowel and bladder. Level of Harm - Minimal harm or potential for actual harm Review of the Care Plan dated 7/31/23 for Resident #22 reflected interventions were in place for: DNR status, PASRR positive, ADL self-care deficit, Nonverbal, Cerebral Palsy, Dysphagia and Tube Feeding. Her care plan reflected oxygen therapy for comfort and shortness of breath as needed. Residents Affected - Few Review of the Facility Monitoring of Oxygen Saturation levels for Resident #22 dated from 8/10/23 to 5/11/23 reflected saturation levels were 95 to 97%. Review of physician's orders for Resident #22 reflected orders dated 7/29/23 Change O2 tubing, bottle and concentrator filter each week on Sunday. Her oxygen therapy was ordered at 2 L/min dated 8/02/23. Observation on 8/17/23 at 8:45 am of Resident #22 during care by LVN E revealed no oxygen tubing or concentrator was available in the room . In an interview on 8/17/23 at 9:15 am, LVN E stated Residents #20 and #22 oxygen use was periodic. She stated Resident #22 had not required oxygen for two or more months. In an interview on 8/17/23 at 2:27 pm, the Primary Care Physician (PCP) Dr O stated Resident #22 had been maintaining oxygen saturation levels of 95 to 96 percent since March 2023. He stated she had no need for PRN or as needed oxygen at this time. In an interview on 8/17/23 at 2:35 pm, LVN E stated Resident #22 had not needed her oxygen since she was on Hospice. She stated if Resident #22 needed oxygen she could get a concentrator or bottle of oxygen from the storage room on the unit. In an interview on 8/18/23 at 8:35 am, LVN G stated since she had been working at the facility Residents #20 and #22 had not needed to use their Oxygen prescribed. She stated she had been able to breath on room air for some time, at least a few months. LVN G stated Resident #20 was up and about every day without supplemental Oxygen. She stated Resident #22 had not required Oxygen to keep her saturation levels up to normal (95 percent or higher) since she started working at the facility. C) Review of Resident #30's Face Sheet dated 08/17/2023 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Pressure ulcer left heel and atherosclerosis of native arteries of left leg (A condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall. Symptoms vary depending on the clogged artery). Review of Resident #30's Quarterly MDS assessment dated [DATE] reflected Resident #30 was assessed to have a BIMS score of 2 indicating severe cognitive impairment. Resident #30 was assessed to require extensive to dependent assistance with ADLs. Resident #30 was further assessed to have one Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.) Review of Resident #30's Comprehensive Care Plan dated 03/27/2023 reflected a focus area The resident has pressure ulcer development to sacrum, left buttock and Stage III right heel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 6 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 Observation and interview on 08/16/2023 at 10:34 AM revealed Resident #30 in his room with the Wound Care Physician receiving wound care for his Stage III to his right heel. Resident #30's Wound Care Physician stated his heel was looking good and had a skin graft in place. She further stated Resident #30 had no other wounds that required treatment. Review of Resident #30's Weekly Wound Nursing assessment dated [DATE] reflected the pressure ulcer to his sacrum area and buttock was healed on 08/09/2023. Review of Resident #30's Consolidated physician orders dated 08/17/2023 reflected wound care orders for Resident #30's right heel. No other wound care orders were noted. In an interview on 08/18/2023 at 9:50 AM with the MDS Coordinator, she stated Resident #30's care plan should reflect the residents current skin condition and the care plan should have been updated to reflect his other pressure ulcers were healed. In an interview on 08/18/2023 at 10:04 AM, the DON stated she expected resident care plans to reflect the current condition of the resident to ensure the residents were receiving the treatment and care they need. Review of the facility's policy Care Plan, Comprehensive Person-Centered dated 03/2022 reflected A 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 .Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 7 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of fifteen residents (Resident # 21, Resident #18, Resident #31 and Resident #13) reviewed for quality of life. Residents Affected - Some The facility failed to ensure Resident#21s, Resident #18's, Resident #31's, and Resident #13's fingernails were trimmed and cleaned. These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life. Findings included: 1. Record review of Resident #21's face sheet, dated 08/17/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis was characterized by one-sided weakness, but without complete paralysis), altered mental status ( a change in mental function that stems from illnesses, disorders and injuries affecting your brain), and unspecified convulsions ( rapid involuntary muscle contractions). Record review of Resident #21's Significant Change MDS assessment, dated 06/28/2023, reflected Resident # 21 had a BIMS score of 1 which indicated residents' cognition was severely impaired. Resident #21 was assessed to require assistance with ADLs. He required extensive assistance with two person assist with personal hygiene. Resident #21 did not reject care. Record review of Resident #21's Comprehensive Care Plan, dated 07/17/2023, reflected Resident #21 had an ADL self-care performance deficit and required staff assistance. Intervention: Resident #21 required staff assistance with personal hygiene. Resident #21 had impaired cognitive function. Observation on 08/16/2023 at 9:40 AM revealed Resident #21 was awake and lying-in bed. Resident #21 had long jagged fingernails on his left and right hands. 2. Record review of Resident #18's face sheet, dated 08/17/2023, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included type two diabetes mellitus (high levels of sugar in the blood), hemiplegia unspecified (involved one sided paralysis- the loss or the ability to move), muscle weakness (lack of muscle strength), and unspecified dementia (experiencing memory loss, poor judgement, and confusion). Record review of Resident #18's assessment, dated 07/19/2023, reflected Resident # 18 was rarely/ never understood. Resident #18's cognition was assessed by the staff. She had poor short- and long-term memory recall. Resident #18's decision making ability was severely impaired. She did not reject care. Resident #18 was assessed to be totally dependent on staff for personal hygiene, toileting, dressing, and bed mobility. Record review of Resident #18's Comprehensive Care Plan, dated 08/09/2023, reflected Resident #18 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 8 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had an ADL self-care performance deficit. Intervention: Check nail length. Trim and clean on bath day and as necessary. Report any changes to the nurse. Resident #18 required staff assistance with personal hygiene. Resident #18 had impaired cognitive function; impaired thought process related to dementia. Resident #18 had a potential for skin tears related to fragile skin. Observation on 08/16/2023 at 10:00 AM revealed Resident #18 was lying in bed. Her fingernails on her middle, forefinger, and ring finger on both hands were jagged. There was a blackish substance underneath her middle and ring finger on her left hand. 3. Record review of Resident #31's face sheet, dated 08/17/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease ( paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without paralysis), muscle weakness ( when full effort does not produce a normal muscle movement), and cognitive communication deficit ( difficulty with thinking and how someone uses language). Record review of Resident #31's Quarterly MDS Assessment, dated 06/28/2023, reflected Resident #31 had a BIMS score of 7 which indicated residents' cognition was severely impaired. Resident #31 was assessed to require assistance with ADLs. He required extensive assistance with two person assist with personal hygiene. Resident #31 did not reject care. Record review of Resident #31's Comprehensive Care Plan, start date of 08/17/2023, reflected Resident #31 had an ADL self-care performance deficit and required staff assistance. Intervention: Resident #31 required staff assistance with personal hygiene. Resident #31 had impaired cognitive function. Observation/Interview on 08/16/2023 at 10:16 AM revealed Resident #31 was lying in bed watching television. His fingernails on right and left hand were jagged. Resident #31's fore finger, middle finger, and ring finger on both hands had blackish/brownish substance underneath the nails. Resident #31 was not interview able. Resident #31 mumbled when responded to questions. 4. Record review of Resident #13's face sheet, dated 08/17/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included type two diabetes mellitus (high levels of sugar in the blood), muscle weakness (when full effort does not produce a normal muscle movement), and osteoarthritis, unspecified site (inflammation of one or more joints. It is the most common of arthritis that affects joints in the hand, spine, knees, and hips). Record review of Resident #13's Quarterly MDS Assessment, dated 06/14/2023, reflected Resident #13 had a BIMS score of 2 which indicated residents' cognition was severely impaired. Resident #13 was assessed to require one staff assistance with ADLs. Resident #13 did not reject care. Record review of Resident #13's Comprehensive Care Plan, dated 06/23/2023, reflected Resident #13 had an ADL self-care performance deficit related to fatigue, and impaired balance. Intervention: check nail length, trim and clean nails on bath day and as necessary. Report any changes to the nurse. Resident #13 required staff assistance with personal hygiene. Resident #13 had impaired through processes related to dementia (the loss of thinking, remembering and reasoning). Observation/Interview on 08/16/2023 at 10:45 AM revealed Resident #13 was sitting in the dining room at a table by himself and was watching people. He agreed to exit the dining room and meet in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 9 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some private area. Resident #13's fingernails on right and left hand were jagged and had thick blackish substance underneath each nail on both hands. Resident #13 stated my nails are dirty and he stated he did not know what the black substance was underneath his nails. Resident #13 stated it looked like feces. He stated when he tries to clean himself, he gets feces on his hands, and he was unable to clean his nails. He stated he did ask someone to clean them, but he did not recall the person's name. Resident #13 said he asked someone several times last week and this week. Observation/Interview on 08/17/2023 at 1:15 PM revealed Resident #13 was sitting in the dining room. Resident #13's nails on his right and left hand had a hard blackish substance underneath each nail. Resident #13 smiled and stated, I got my toenails cut you want to see them. Resident #13 stated the doctor cut his toenails today and he stated he asked the doctor if they would cut his fingernails and clean them and the doctor stated he did not cut or clean fingernails only toenails. He stated he did ask someone today but could not recall their name to clean his fingernails and cut them and the person said his nails would be clean and cut tomorrow. In an interview on 8/17/2023 at 2:15 PM, CNA C stated the nurses were responsible for diabetic nail care. She stated the CNAs were responsible for all other resident's nail care such as cleaning , trimming and possibly filing the nails. She stated nail care was usually completed during showers or as needed. She stated nail care was to be completed daily if a resident's nails were dirty or needed to be trimmed. She stated if a resident had a blackish/brownish substance underneath their nails it could be any type of bacteria. CNA C stated there was a possibility a resident may eat with their hands and the blackish substance may transfer from residents' hands to the food. She stated the resident may become physically ill with some type of stomach problems such a vomiting or diarrhea. She stated it was a possibility a resident may need to be assessed at a hospital if it was severe. CNA C stated if a residents' nails were rough there was a possibility a resident may scratch themselves and develop a skin tear or could scratch their eyes. She stated there was a potential a resident may develop and infection in their eyes. She stated she had been in serviced to clean and trim residents' nails in the shower and/or as needed except for diabetic nails. She stated she did not recall when the last in-service on nail care was given by nurse supervisors. In an interview on 8/17/2023 at 2: 30 PM, CNA /MA E stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed, and cleaned nails during showers , however, the nails can be cleaned or trimmed by nurses or CNAs as needed. CNA/MA E stated the nursing staff was expected to clean and trim residents' nails immediately if there were blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. She stated if the nursing staff waited until shower the resident had potential of skin tears because of the residents scratching themselves. said it was a possibility the resident may get an infection from the skin tear. said the blackish substance possibly may be fecal matter underneath the residents' nails. She stated a resident may become physically ill with an intestinal problem and may need to be admitted to the hospital. In an interview on 8/17/2023 at 2:45 PM, LVN A stated it was the nurses and CNAs responsibility to trim, cut and clean residents' fingernails. She stated only the nurses can trim and clean residents with diagnosis of diabetes. LVN A stated if a resident's nails were jagged there was a possibility a resident my infect their skin if the resident scratched themselves and develop a skin tear. LVN A stated if there was a blackish substance underneath a resident's nails there was a possibility the substance was feces. She stated if a resident placed their finger in their mouth the feces could transfer from their fingers to their mouth. LVN A also stated if the resident swallowed the feces or other bacteria a resident may develop a stomach infection such as E coli (eating contaminated food) and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 10 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the resident would require to be hospitalized . She stated the symptoms of a stomach infection may include the following: diarrhea, vomiting and/or loss of appetite. In an interview on 8/17/2023 at 3:00 PM, CNA D stated the nurses was responsible to trim and clean all diabetics nails. She stated it was the CNA's responsibility to clean and trim all other residents' nails. She stated the CNAs usually did nail care when residents received a shower or as needed. CNA D stated if anyone observed a brownish and/or blackish substance underneath residents nails the staff was expected to clean the residents' nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility could be feces or any type of bacteria underneath the residents' nails. CNA D stated if a resident swallowed the bacteria there was a possibility a resident may become very ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated and may require to be transfer to hospital for further medical assessment. CNA D stated if a residents' nails were long or rough a resident may scratch themselves or another resident and cause a skin tear or they could get their nails caught on something and pull the nail off and cause an infection on the finger. She stated she had been assigned to in the past . She did not recall how many times she had been assigned to these residents. Resident # 21, Resident #18, Resident #31, and Resident #13. CNA D stated she was not aware of any of these residents refusing nail care. In an interview on 08/17/2023 at 3:20 PM, the Director of Nurses stated if a resident had dirty nails there was a possibility bacteria could be on their fingers and/or underneath the resident's nails. She stated there was a potential a resident could ingest bacteria from their fingernails into their mouth. She stated it depended on the type of bacteria of what type an illness a resident could receive from the bacteria. The Director of Nurses stated a resident potentially could become ill with stomach issues or any type of infection. She also stated a resident had a potential to scratch themselves and may develop a skin concern such as a skin tear and may develop an infection if the residents' nails were not trimmed properly. She stated it was the nurse supervisor responsibility to monitor nursing staff to ensure residents were receiving proper nail care. In an interview on 08/17/2023 at 3:50 PM, the Administrator stated the residents' nail care was the CNAs responsibility. He stated if a resident was a diabetic it was the nurse's responsibility. The Administrator stated nail care was expected to be taken care of when nails were visibly dirty or needed to be trimmed. He stated if the blackish substance was a certain type of bacterial a resident may become physically ill. He stated there was a possibility a resident may require medical care from the hospital and that depended on what type of bacteria a resident may ingest. He said it was the nurse supervisor's responsibility to monitor residents nail care. Record Review of the facility's Policy on The Care of Fingernails/Toenails dated 4/23 reflected the purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Only licensed personnel can perform nail care on a resident with diabetes. 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 11 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 2 of 2 Residents (Resident #20 and #29) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure that Resident #29's suction equipment was properly cleaned and dated. 1. Failed to date suction tubing and canister. 2. Failed to bag yaunker. 3. Failed to clean suction tubing. The facility failed to replace Resident #20's oxygen tubing. These failures could place residents at risk for respiratory compromise and infection. Findings included: Review of Resident #29's Face Sheet dated 08/17/2023 revealed that he was a [AGE] year old male, with an initial admit date of 10/15/2018 and secondary admission date of 10/20/2022. His diagnoses included Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), Dysphagia (difficulty swallowing - taking more time and effort to move food or liquid from your mouth to your stomach), Pneumonitis (inflammation of lung tissue), Dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and Cough. Review of Resident #29's MDS Quarterly Assessment, dated 07/06/2023 revealed Resident #29 had a BIMS Score of 12, which indicated his cognitive status was moderately impaired. Review of Resident #29's Care Plan, dated 10/20/22 indicated, Focus - Resident to have suction machine at bedside. Goal - Resident to remain free of increase secretions. Interventions / Tasks - Suction Resident as needed for increase secretions. Review of Resident #29's Order Summary Report dated 08/18/2023, indicated that the suction canister and tubing were to be changed every three days when in use by night shift. Order was made and started on 08/18/2023. Review of Resident #29's TAR from 08/01/2023 - 08/17/2023 through the facility's Point Click Care indicated no documentation in reference to the cleaning / documentation for Resident #29's suction machine. Review indicated there was no order for cleaning / changing suction canister / tubing prior to surveyor intervention. Review of physician's orders for Resident #29 dated 8/01/23 reflected no mention of cleaning/changing suction canister, tubingh or Yaunkauer prior to questions from surveyor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 12 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the face sheet dated 8/11/23 for Resident #20 reflected she was admitted on [DATE] with diagnoses of Multiple Sclerosis, Anemia, other specified Anxiety Disorders, Intracerebral Hemorrhage, Asthma, Neuropathic bladder, Scoliosis and Repeated Falls. Review of the MDS annual assessment for Resident #20 dated 5/17/23 reflected a BIMS score of 4 which indicated her cognitive function was severely impaired. Her functional assessment reflected the resident required extensive assistance for all ADLs except mobilizing in her wheelchair and eating. The assessment of her bowel and bladder function reflected she was frequently incontinent. Review of the Care Plan dated 8/05/23 for Resident #20 reflected interventions were in place for: DNR status, Insomnia, ADL self-care deficits, Hospice Care, Fall Risk, Psychotropic Medications, MS and Scoliosis. Her plan reflected she should have oxygen therapy of 2 L/min to keep her saturation above 95 %. Review of Daily Oxygen Saturation levels for Resident #20 dated from 8/11/23 to 5/31/23 reflected her saturation varied from 96 to 97 %. Review of physician's orders for Resident #20 reflected she had oxygen therapy ordered at 2L/min as needed for shortness of breath dated 8/02/23. Observation on 08/16/2023 at 9:59 AM, Resident #29's suction machine was uncovered on a tray table to right of the resident's bed. There was no date located on the tubing or cannister, the yankauer (rigid suction tip used to aspirate secretions from the oropharynx) was not bagged, and there was visible black and green substance growing in several locations on the inside of the tubing. Observation on 08/17/2023 at 9:22 AM, Resident #29's suction machine was still uncovered, with no date located on the tubing or cannister, the yankauer remain uncovered, and a black and green substance was still present in the tubing. Observation on 8/16/23 at 9:45 AM revealed Resident #20's oxygen tubing was dated and labeled 7/10/23. Resident #20 was wearing her oxygen tubing while sitting up in bed. In an interview Resident #20 stated she was comfortable but was unable to answer most questions appropriately. In an interview on 8/16/23 at 10:10 AM, LVN E stated Resident #20's oxygen use was periodic, she stated Resident #20 had periodic drops in her oxygen saturation level. Observation on 8/17/23 at 9:15 AM revealed Resident #20's oxygen tubing had been exchanged and was now dated 8/16/23. In an interview on 08/17/2023 at 1:14 PM, LVN A, stated that she has worked at the facility for over four years in total. LVN A observed the suction machine in the room of Resident #29. LVN A stated that the yankauer should be bagged. LVN A stated that the suction tubing should be dated and changed weekly. LVN A stated that the cannister and tubing to the machine should be dated and changed monthly. LVN A stated that the tubing was supposed to be checked daily and that this obviously slipped through the cracks. LVN A stated that checks of the resident's suction machine were to be logged weekly in the TAR (Treatment Administration Record) . LVN A stated that this failure could result in respiratory infection. In an Interview on 08/17/2023 at 2:04 PM, LVN A pulled up the TAR for Resident #29. LVN A checked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 13 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the system and stated that she was incorrect and that it was not documented. LVN A stated that it would not be logged because it was PRN (as needed) by Resident #29. In an interview on 08/17/2023 at 1:22 PM, the DON observed the suction machine in the room of Resident #29. The DON immediately stated that it was not correct. The DON stated that it should be bagged and that both the cannister and tubing were supposed to be dated. The DON stated that the suction tubing should be dated and replaced weekly, with the cannister begin dated and replaced monthly. The DON observed the green and black substance in the suction line and stated that procedures had not been followed. The DON stated that the suction machine was being removed immediately and cleaned. The Resident #29 indicated that he needed the suction machine and was advised that it would be returned in clean condition shortly. In an interview on 08/18/2023 at 8:00 AM, the DON approached surveyor and stated that the cleaning of Resident #29's suction machine was not being logged in the TAR. In an interview on 8/18/23 at 8:35 am, LVN G stated since she had been working at the facility Resident #20 had not needed to use her Oxygen prescribed. LVN G stated Resident #20 was up and about every day without supplemental Oxygen. She stated Resident #20 had not required Oxygen to keep her saturation levels up to normal (95 percent or higher) since she started working at the facility. In an interview on 08/18/2023 at 8:38 AM, Resident #29 (cognitive with limited speech) acknowledged that he was aware that the suction machine was dirty. Resident #29 indicated that he did not notify medical staff of its condition. Review of the facility's policy, Health for Respiratory Care Equipment Use, dated 10/22, Procedures: 5. Disposable respiratory care supplies will be used whenever possible. If disposable equipment is not available, all reusable equipment will e sterilized or disinfected according to manufacturer's instructions. 6. All non-disposable equipment should be cleaned and decontaminated or sterilized according to the manufacturer's instructions. 7. Re-usable equipment will be cleaned according to manufacturer's instructions. 8. All clean equipment should be covered when to in use for protection against contaminants. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 14 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and include the appropriate expiration dates 2 of 3 medication carts reviewed for medication storage. -The facility failed to date a multi-use product (eye drops) when the product was first opened according to manufacture and professional standards. -The facility failed to ensure expired medications were removed from the medication carts. These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: Observation on 08/16/2023 at 2:31 PM revealed the facility Unit 2 Medication cart with a bottle of Ferrous Gluconate 324mg capsules with the expiration date of 06/30/2023. Observation on 08/16/2023 at 2:45 PM revealed the Unit 2 LVN medication cart with a bottle of Refresh eye drops and a bottle of Systane eye drops without open dates. In an interview on 08/16/2023 at 2:47 PM, LVN A stated the bottle of Ferrous Gluconate was expired and should not have been on the cart. LVN A further stated that all eye drops should be labeled with a date when it was open so you would know when it is expired. In an interview on 08/16/2023 at 3:15 PM, the DON stated that eye drops should be labeled with an open date when they were opened. The DON further stated that the medication carts should be checked by the Nurses during the medication pass to ensure no expired medications were on the carts to ensure residents were not receiving expired medications to might have altered therapeutic effects. Review of the facility's Policy Storage of Medications dated April 2022 reflected The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 15 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure that menus were developed and followed to meet resident nutritional, religious, cultural, or ethnic needs, and resident choices in accordance with the national guidelines for one of one facility. The facility failed to provide residents in the facility with a varied menu, having utilized the same menu for the facility for over a year. This failure could place the residents in the facility at risk of reduced appetite resulting in their nutritional needs not being met and / or weight loss. Findings included: Observation on 08/16/2023 at 9:01 AM, revealed the menu board outside the dining area contained no information as to kitchen menus for the day, week, or month. In a confidential group interview on 08/16/2023 at 2:40 PM, all eight resident attendees stated they were tired of the same menu being served in the facility every week. Residents stated that they were given a copy of the menu and that one has not been posted outside the dining area for over a year. Residents stated they were told they would have a new menu provided to them, but the facility has failed to implement one. In an interview on 08/17/23 at 11:05 AM, the DM was requested to provide menus that have been served by the facility since 08/17/2022. The DM stated that there has only been one menu in the facility since she started on 10/15/22. The DM provided surveyor with the facility's Patient Menu Regular Diet Nutrition Services Menu. The DM stated that they do have their alternate choices, but the menu has remained unchanged. The DM stated that she has gone to the Administrator and discussed her desire to have the menu updated and changed. The DM stated she was advised the menu was going to change this month but did not. The DM stated the menu they serve at the facility was created for the hospital and should not be the same for the residents of the facility due to the duration of their stay. The DM stated that the kitchen provides food service off the menu for the hospital. The DM stated she was aware that residents have complained and continue to complain about the lack of variety. Surveyor referenced hearing a resident complain on 08/16/2023 about mashed potatoes instead of french fries. The DM stated that mashed potatoes were listed on the menu and that they were providing french fries that were ordered on accident but ran out. In an interview on 08/18/2023 at 9:23 AM, the AD stated that the menu in the facility has been brought up numerous times in Resident Council. The AD stated that the current menu being served to residents has been served for more than a year. The AD stated that the menu was supposed to change in June but did not. The AD stated that she was then advised that it would change in August but has not as of this date. The AD stated that she does not believe that facility residents should have the same meals for the length of time they have and felt it was due to a shared menu with the hospital. In an interview on 08/18/2023 at 9:40 AM, the Administrator confirmed that they have utilized the same menu for approximately one year. The Administrator stated that use of the current menu was a decision made above him, but he can understand why the residents would be upset eating the same meals every week for as long as they have. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 16 of 17 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 675885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the undated menu contained a weekly menu for breakfast, lunch, and dinner. Personal Choices were included on the menu, which did not show french fries as a choice. Menu reflected the same dinner of beef stew, dinner roll, green peas, and grapes on Tuesday and Saturday every week. Review of Resident Council minutes dated 05/25/2025 at 2:00 PM (seven residents in attendance), indicated for Dietary: changing menus in Aug. Minutes dated 7/26/2023 at 2:00 PM (four residents in attendance), indicated for Dietary: Ready for new menus .food is tolerate sometimes. Event ID: Facility ID: 675885 If continuation sheet Page 17 of 17