Health inspection·October 16, 2024

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had not been able to work through yet. The BOM said the expectation was that trust funds were kept current and financial statements were given to the resident quarterly and upon request. The BOM could not give an explanation as to why trust funds statements have not been available to residents quarterly or upon request. The BOM stated there was no reason the residents should not have access to their funds unless she was off for the day. The BOM stated by the residents not having access to their financial statements then the residents could be overdrawn on their account and not be aware of it. In an interview on 10/16/2024 at 1:40 PM the ADM stated their expectation was that all residents have access to their money and that the resident trust funds were kept accurate. The ADM stated the residents have the right to receive their financial statements. The ADM stated if the residents did not have access to their financial statements this could negatively affect the residents by the fact that the resident would not know their financial balance in their trust fund. The ADM stated it was the BOM's responsibility to ensure the resident's trust fund financial statements were accurate and available. Review of Resident Personal Funds policy undated reflected under heading policy: The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds. Under heading accounting and records: The individual financial record must be available to the resident through quarterly statements and upon request. Review of Resident Rights undated reflected You, the resident, do not give up any rights when you enter a nursing Facility. The Facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing Facility employee to threaten, coerce, intimidate, or retaliate against you for exercising your rights. You have a right: 13. to access money and property you have deposited with the Facility and to an accounting of your money and property that are deposited with the Facility and of all financial transactions made with or on behalf of you; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 2 of 22 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 10/16/2024 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 interviews 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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 10 residents (Residents #41) reviewed for comprehensive care plans. Resident #41's comprehensive care plan did not reflect Resident #41's ADL care requirements listed in their baseline care plan. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings included: Review of Resident # 41's face sheet dated 10/16/2024 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident # 41's diagnoses included cerebral infarction, type 2 diabetes, major depressive disorder, anemia, hyperlipidemia, bipolar disorder, epilepsy, obstructive sleep apnea, hypertension, chronic systolic congestive heart failure, chronic kidney disease stage 3, convulsions, atherosclerotic heart disease, and cataracts. Review of Resident # 41's initial MDS assessment dated [DATE], reflected Resident # 41's BIMS score was not recorded. Resident # 41's initial MDS reflected under functional abilities and goals that Resident # 41 was a supervision or touching assistance for toileting hygiene, showering/bathing self, and lower body dressing. Resident # 41 was a set-up or clean-up assist for eating, oral hygiene, upper body dressing, personal hygiene, and putting on or taking off footwear. Review of Resident # 41's baseline care plan dated 08/23/2024 reflected Resident # 41 was a set-up or clean up assistance for eating and oral hygiene. Resident # 41 was a partial/moderate assistance for toileting hygiene, upper body dressing, lower body dressing, putting on or taking off footwear, and personal hygiene. Resident # 41 was a substantial/maximum assistance for showering/bathing self. Review of Resident # 41 comprehensive care plan dated 09/04/2024 reflected no ADL care assistance levels documented. In an interview on 10/14/2024 at 1:57 PM Resident # 41 stated they had no concerns with their care. Resident # 41 was in bed napping at time of visit and said they wanted to go back to sleep. In an interview on 10/16/2024 at 12:47 PM the MDS Coordinator stated baseline care plans data carried over to the comprehensive care plans. The MDS Coordinator stated ADL care should be in the comprehensive care plan. The MDS Coordinator stated ADL care can change when the resident has any significant change and at the MDS reviews. The MDS Coordinator stated if the comprehensive care plan did not have ADL information, then this can negatively affect the residents if the staff do not seek out the information needed, and they would have to use their own judgement as to how to provide care for the resident and the resident could not receive the care they need. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 3 of 22 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 10/16/2024 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 In an interview on 10/16/2024 at 1:40 PM the ADM stated that they expected the resident care plans to be completed and accurate to follow the rules and regulations set forth. The ADM stated if the care plans, were not completed and accurate then this could negatively affect the residents by impacting resident care. The ADM stated it was very important to capture the information so the resident can receive quality care. The ADM stated the MDS Coordinator was responsible for completing the care plans. Residents Affected - Few Review of Comprehensive Care Plan policy undated reflected under heading policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under heading policy explanation and compliance guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 4 of 22 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 10/16/2024 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 a. Level of Harm - Minimal harm or potential for actual harm The attending physician or non-physician practitioner designee involved in the resident's care if the physician is unable to participate in the development of the care plan. Residents Affected - Few b. A registered nurse with responsibility for the resident. c. A nurse aide with responsibility for the resident. d. A member of the food and nutrition services staff. e. The resident and the resident's representative, to the extent practicable. f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 5 of 22 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 10/16/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, that included measurable objectives and time frames to meet the resident's mental and psychosocial needs for 1 of 10 residents (Resident #3) reviewed for care plans. The facility failed to update Resident #3's care plan to reflect current needs for meal assistance and refusal of meal assistance. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings included: Review of Resident # 3's face sheet dated 10/14/2024 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident # 3's diagnoses were Parkinson's disease, anxiety disorder, hypercholesterolemia, type 2 diabetes, depressive disorders, insomnia, essential tremor, hypertension, muscle wasting and atrophy, muscle weakness, lack of coordination, history of falling, dementia, and personal history of malignant neoplasm (cancer) of breast. Review of Resident # 3's Quarterly MDS assessment dated [DATE] reflected Resident # 3's BIMS score was not recorded. Resident # 3's MDS Behavior documented behavior not exhibited under refusal of care. Resident # 3's ADL care listed partial to moderate assist for eating. Review of Resident # 3's care plan with a date of 01/15/2018 and a revision date of 05/01/2023 reflected for ADL care of eating the resident requires assistance by staff to eat. Observation on 10/15/2024 at 12:25 PM of Resident # 3 with her lunch tray revealed Resident # 3 to be eating her pureed chicken with her right hand and holding her dessert with her left hand. Resident # 3 was attempting to unwrap her dessert. Further observation of CNA C entering Resident # 3's room and saying, oh I forgot to unwrap her cake then proceeded to unwrap the cake for the resident. In an interview on 10/15/2024 at 2:32 PM CNA C stated Resident # 3 needed assistance with meal set up only and that Resident # 3 fed herself. In an interview on 10/16/2024 at 1:25 PM LVN B stated that Resident # 3 is temperamental and sometimes refused staff assistance with meals and wanted to feed herself. In an interview on 10/16/2024 at 1:30 PM the MDS Coordinator stated any resident refusals should be updated and documented in the care plan. That whatever area of care the resident was refusing, then the ADL care should reflect the interventions in place to mitigate refusals. The MDS Coordinator stated that when they hear of resident refusals, they go to the floor and interview care staff to see what care areas were being refused so they can update the care plan accordingly. The MDS Coordinator stated that if the resident care plan is not complete and accurate then this could negatively affect the resident by not receiving the care needed. The MDS Coordinator stated it was their responsibility to ensure that resident care plans are accurate and current. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 6 of 22 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 10/16/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 10/16/2024 at 1:40 PM the ADM stated that they expected the resident care plans to be completed and accurate with all resident information and to follow the rules and regulations set forth. The ADM stated if the care plans were not completed and accurate then this could negatively affect the residents by impacting resident care. The ADM stated it was very important to capture the information so the resident could receive quality care. The ADM stated the MDS Coordinator was responsible for completing the care plans. Review of Comprehensive Care Plan policy undated reflected under heading policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under heading policy explanation and compliance guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 7 of 22 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 10/16/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care if the physician is unable to participate in the development of the care plan. b. A registered nurse with responsibility for the resident. c. A nurse aide with responsibility for the resident. d. A member of the food and nutrition services staff. e. The resident and the resident's representative, to the extent practicable. f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 8 of 22 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 10/16/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 6 (Resident is #7, and Residents #32) residents reviewed for pain management. Residents Affected - Few The facility failed to ensure Resident #7, and Resident #32 had effective pain management by not evaluating effectiveness of current pain medications. This failure could place resident at risk for increased pain causing undo suffering. Findings included: 1) Record review of Resident #7's face sheet, dated 10/14/24, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included osteoarthritis (a chronic disease-causing cartilage to break down over time), restless leg syndrome, and post laminectomy syndrome (a condition where a patient continues to experience pain after spinal surgery). Record review of the facility Pain assessment dated [DATE] reflected Resident #7 denied having any pain within the last five days. The assessment also reflected Resident #7 was taking routine pain medications for pain management. Record review of Resident #7's Quarterly MDS assessment, dated 08/29/2024, reflected he had a BIMS score of 5, which indicated severe cognitive impairment. Resident #7 required partial/moderate staff assistance with personal hygiene, toileting, and showering. The MDS reflected received scheduled pain medication. Record review of Resident #7's care plan dated 01/02/2023 and revised on 09/30/24 reflected he was at risk for pain. Goal: Resident #7 will not have an interruption in normal activities due to pain through the review date. Interventions included Evaluate the effectiveness of pain medications every shift and as needed. Record review of Resident #7's medication administration record dated 10/14/24 reflected he was taking Tylenol with Codeine #3 twice a day and Lidocaine 4% external patch daily for pain. Record review of the electronic medical records on 10/14/24 reflected there were no assessments evaluating the effectiveness of medications daily for the months of September and October 2024. In an interview on 10/15/24 at 09:55 AM Resident #7 stated he occasionally had leg and back pain and he took a pain medication, but he couldn't remember what it was . Resident stated his pain was controlled at this time. 2) Record review of Resident #32's face sheet, dated 10/14/24, reflected he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included osteoarthritis (a chronic disease- causing cartilage to break down over time), chronic obstructive pulmonary disease (a lung disease restricting airflow), and mild cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 9 of 22 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 10/16/2024 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of facility Pain assessment dated [DATE] reflected Resident #32 denied having any pain within the last five days. Record review of Resident #32's Quarterly MDS assessment, dated 08/08/2024, reflected he had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #32 required set up/supervision staff assistance with personal hygiene, toileting, and showering. The MDS reflected received scheduled pain medication. He had pain within the last 5 days of assessment and rated it at a 4 on numeric rating scale (0-10). Record review of Resident #32's care plan dated 02/18/2024 reflected he was at risk for pain related to his medical condition. Goal: Resident #32 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included Monitor /record /report complaints of pain or request for pain treatment. Record review of Resident #32's medication administration record dated 10/14/24 reflected he was taking Lidocaine 4% external patch daily for pain in his right hip for the month of October 2024. Record review of the electronic medical records on 10/14/24 for Resident #32 reflected there were no assessments evaluating the effectiveness of medications daily. In an interview on 10/15/24 at 10:24 AM Resident #32 stated he had occasional phantom pain in his left at the knee amputation area. Resident #32 stated his pain was controlled at this time. In an interview with the DON on 10/16/24 at 11:13 AM she stated residents required routine monitoring of pain to ensure pain management was adequate. If pain management was not adequate, staff would need to reach out to the physician to ensure pain was managed. The DON stated nurses were instructed to monitor for pain every shift. The DON stated she was responsible for monitoring to ensure there was an order in place to monitor pain. She stated the negative effects for not monitoring residents' pain or effectiveness of medications for pain would be the pain would be unmanaged. In an interview with the ADM on 10/16/24 at 12:48 PM she stated her expectation would be for the residents to be comfortable and given their pain medication as needed. She stated pain should be monitored routinely and the DON was responsible for monitoring the pain management program. The ADM stated the negative effects for not monitoring pain would be more pain increased discomfort for the resident. Record review of facility policy titled Pain Management dated 9/1/23 reflected that the facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice the comprehensive person-centered care plan and the residents' goals and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 10 of 22 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 10/16/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 4 residents (Resident #38) reviewed for unnecessary medications. The facility failed to ensure Resident #38's GDR recommended by the pharmacist consultant was followed up on for 6 months for Resident #38's antipsychotic, antianxiety, and antidepressant medications. This failure could place residents receiving antipsychotic medications at risk for adverse health consequences. Findings included: Review of Resident #38's face sheet dated 10/16/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Huntington's disease (is a rare, inherited disease that causes the progressive breakdown (degeneration) of nerve cells in the brain) and Major depressive disorder recurrent severe without psychotic features (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.). Review of Resident #38's Quarterly MDS dated [DATE] reflected Resident #38 was assessed to have a BIMS score of 6 indicating severe cognitive impairment. Resident #38 was assessed not to have verbal behaviors 1 to 3 days during the assessment period. Resident #38 was assessed to take antipsychotic, antianxiety, and antidepressant medication. Review of Resident #38's comprehensive care plan reflected a focus area initiated on 02/08/2023 The resident uses psychotropic medications related to disease process; Resident has diagnosis of Huntington's disease. Goal included the resident will be/remain free of psychotropic drug related complications . Further review reflected a focus area initiated on 08/09/2023 The resident has depression. Intervention included, administer medications as ordered, and monitor for side effects. Another focus area initiated on 02/22/2023 reflected Resident #38 used antianxiety medications. Interventions included, administer medications as ordered and monitor for side effects. Review of Resident #38's consolidated physician orders dated 10/01/2024 reflected the following medication orders dated 12/23/2023: Abilify 15 mg QD (antipsychotic), Celexa 30mg QD (antidepressant), and Clonazepam 1mg BID (anti-anxiety). Review of Resident #38's consultant pharmacist / provider communication dated 05/21/2024 reflected This resident has been taking Abilify 15mg QD, Celexa 30mg QD, and Clonazepam 1mg BID since 12/23. Please evaluate the current dose and consider a dose reduction. No physician response was noted on the communication. Review of Resident #38's consultant pharmacist medication regimen review recommendations pending a final response dated 06/01/2024 reflected his GDR was still pending. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 11 of 22 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 10/16/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #38's consultant pharmacist / provider communication dated 07/10/2024 reflected This resident has been taking Abilify 15mg QD, Celexa 30mg QD, and Clonazepam 1mg BID since 12/23. Please evaluate the current dose and consider a dose reduction. No physician response was noted on the communication. Review of Resident #38's consultant pharmacist medication regimen review recommendations pending a final response dated 08/01/2024 reflected his GDR was still pending. Review of Resident #38's consultant pharmacist / provider communication dated 09/16/2024 reflected This resident has been taking Abilify 15mg QD, Celexa 30mg QD and Clonazepam 1mg BID since 12/23. Please evaluate the current dose and consider a dose reduction. No physician response was noted on the communication. In an interview on 10/16/2024 at 10:00 AM the VP of clinical Operations stated the DON was responsible for the pharmacy review recommendations. She stated she did not find the GDR for Resident #38 that had been returned from the MD. The VP of clinical Operations stated it was not done. She stated the facility had 7 days from the time the pharmacy recommendation was received to get a response back from the MD and if not received from the MD it needed to be sent to the medical director. She stated by the facility not following up on the GDRS it could lead to negative outcomes for the resident and the residents potently continuing medication that they do not need. In an interview on 10/16/2024 at 10:21 AM the DON stated she had been having trouble getting the recommendations back from the MDs. She stated she was not aware it had been since May that Resident #38's GDR was requested by the pharmacist. She stated there was a MD change in July. The DON stated Resident #38's GDR got missed due to the MD change. She stated the resident was seen by psychiatry in September and his meds were reviewed but the GDR was not reviewed or signed. The DON stated by not following up on the pharmacy recommendations it could lead to negative resident outcomes. Review of the facility's policy Medication Monitoring: Medication Regimen Review and Reporting dated 01/2024 reflected .The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), laboratory and diagnostic test results, behavior monitoring information, and information from the nursing care center staff and other health professionals involved in the resident's care . The findings are communicated to the director of nursing or designee and the medical director. These findings are documented and filed with other consultant pharmacist recommendations in the resident's chart . The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. a. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 12 of 22 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 10/16/2024 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 observations, interviews, and record review, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed for all residents for 2 of 2 meals observed. The facility failed to follow the posted menus for two lunch services served at the facility on Monday, 10/14/2024 and Tuesday, 10/15/2024. These failures could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss. Findings included: Observation of posted menus on 10/14/2024 at 9:30 AM revealed menu items for lunch meal service to be chicken fried chicken, cream gravy, mashed potatoes, parslied carrots, dinner roll, and bread pudding. Observation of lunch meal service on 10/14/2024 at 12:08 PM revealed resident meal trays being served with chicken fried steak, cream gravy, mashed potatoes, parslied carrots, dinner roll, and bread pudding. Observation of posted lunch menus on 10/15/2024 at 10:40 AM revealed menu items for lunch meal service to be pinto beans and sausage, steamed rice, mixed greens, cornbread, and frosted red velvet cake. Observation of lunch meal preparation and pureed process on 10/15/2024 at 10:43 AM revealed residents on pureed diets were to be receiving pureed chicken. Further observation revealed all residents were to be receiving glazed vanilla cake. Observation revealed pureed residents did not receive pureed cornbread. Observation on 10/15/2024 at 1:15 PM of Resident # 3's tray card slip revealed menu items of pureed baked pork chop, pureed cornbread, and pureed red velvet cake. In an interview on 10/16/2024 at 11:22 AM The Dietary Manager stated the chicken fried chicken that was supposed to be on Monday lunch menu was unavailable. The Dietary Manager stated the RD had texted a response to DM H stating that the chicken fried steak was an appropriate substitution. The Dietary Manager stated when substitutions were made the substitution log was completed. The Dietary Manager stated any menu substitutions were communicated to residents and staff by being written on the dry erase board that was in the dining room and told to the residents when the dietary staff go to get daily meal selections. The Dietary Manager stated they had not completed the substitution log for the chicken fried chicken because they had not had the time to complete the log yet. The Dietary Manager stated they do not reprint the daily posted menus or the week at-a-glance menu when any substitutions were made since they write the menu with any substitutions on the dry erase board. This failure could affect the resident's negatively by them not knowing what foods are being served for their meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 13 of 22 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 10/16/2024 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 In an interview on 10/16/2024 at 1:40 PM the ADM stated menus being followed was essential, so the resident was aware of the foods being offered. The ADM stated it was essential for the menus that were posted to be accurate. The ADM stated if the menus posted were not accurate this could negatively affect the residents because it could lead to resident confusion. The ADM stated it was the Dietary Managers responsibility to ensure the menus were posted and that they were accurate. The ADM stated they expected the substitutions logs to be completed and any substitutions to be communicated to the staff and residents. The ADM stated if the substitutions were not communicated to the residents that the residents could be surprised when they received their meals. Review of substitution log reflected no documentation for the lunch meal on 10/14/2024 of chicken fried steak being substituted for chicken fried chicken. Further record review of substitution log reflected documentation for lunch meal on 10/15/2024 incorrectly dated with date of 10/14/2024 for lunch meal pureed pork chops being substituted with pureed chicken. No documentation recorded for red velvet cake being substituted with vanilla cake. Review of the menu substitutions policy dated 10/1/2018 and revised on 06/01/2019 reflected under heading policy: The facility believes that a well-balanced menu, planned in advanced and served as posted, is important to the well-being of its residents. The menus will be served as planned except for emergency situations when a food item is unavailable. Under heading procedure: 4. All changes to the menu will be recorded on the Menu Substitution Approval Form. Review of the menu planning policy dated 10/1/2018 and revised on 06/01/2019 reflected under heading procedure: Dated current menus will be posted in all dining areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 14 of 22 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 10/16/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. Residents Affected - Some 1. The kitchen test tray of the lunch meal on 10/15/2024, the foods were bland, unappealing, and inedible. The kitchen test tray beverages of iced tea and iced water lacked ice. The kitchen test tray's cornbread and cake were both very dry and crumbly. 2. The facility failed to follow the puree diet recipe. The pureed garlic bread, pureed vanilla cake, pureed meat sauce and pureed pasta were all mixed with water during the puree process for the lunch meal on 10/15/24 and 10/16/2024 instead of something with nutritive value such as broth, milk, or juice. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included: Observation on 10/15/2024 at 10:43 AM of DA F revealed DA F pureed the vanilla cake with water instead of milk or something of nutritive value. DA F did not have any recipe out for the pureed food. Observation on 10/15/2024 at 12:28 PM of the kitchen test tray revealed the iced tea and iced water both to be without ice. Kitchen test tray consisted of pinto beans with sausage, rice pilaf, collard greens, cornbread, and glazed vanilla cake. The kitchen test tray pinto beans and sausage was warm but lacked flavor. The rice pilaf was warm and had good flavor. The collard greens were warm but lacked flavor and tasted like dirt. The cornbread and cake were both very crumbly and dry. Observation on 10/16/2024 at 11:10 AM of [NAME] G revealed [NAME] G pureed the garlic bread, meat sauce and pasta with hot water instead of milk or something of nutritive value. [NAME] G did not have any recipe out for the pureed food. In an interview on 10/15/2024 at 10:43 AM DA F stated that they usually thin the pureed products with water or milk depending on what the dessert was. DA F stated when asked as to why they used water instead of milk for the cake, they could not provide an answer. DA F stated they did not know if using water affected the nutritive value of the food. In an interview on 10/16/2024 at 11:10 AM [NAME] G stated the reason she used hot water to thin the pureed food was because the milk would make the food products cold. [NAME] G stated they were unsure if using water would affect the nutritive value of the foods. [NAME] G stated they have not seen a list of appropriate liquids to thin the pureed foods with. In an interview on 10/16/2024 at 11:22 AM DM H stated the RD told the dietary staff that pureed foods could be thinned with water. DM H said the recipes say water can be used to thin food products. DM H went to the recipe binder to show the state surveyor the recipes. DM H could not provide the pureed recipes. DM H then stated, oh I must not have printed them yet. DM H then went to the computer and printed the pureed recipes. Upon review of the recipes, DM H stated they had never seen the appropriate liquid sheet and it must be new to the recipes. DM H stated using water to thin the pureed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 15 of 22 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 10/16/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some food can affect the nutritive value of the food products but that was why we use very small amounts of water. DM H stated they expected the recipes to be followed by the dietary staff. DM H said they provided lots of training and in-services regarding technique. DM H said it was their responsibility to print the recipes for the dietary staff. In an interview on 10/16/2024 at 1:40 PM the ADM stated the ADM expected the dietary staff to follow the RD recommendations and to follow recipes for the pureed foods. The ADM stated that not following recipes could affect the nutritive value of the foods. The ADM stated not following the recipes could negatively affect the residents by the residents could choke or not get the nutrients they need. Review of recipes undated for garlic bread, meat sauce and pasta, red velvet cake reflected the following: cooking liquid, broth, gravy, or other suitable liquid may be substituted for liquid in recipe when pureeing foods. Review of recipes undated appropriate liquid sheet for pureed foods reflected the following: Add the appropriate liquid in the amounts specified in the recipe for the item being pureed. *Entrees - Broth or other appropriate sauce/gravy from menu - tomato sauce, cheese sauce, cream gravy, etc. *Starch - Whole Milk or Sauce from menu Vegetables - Broth, Cooking liquid, or Sauce from menu Dessert - Milk *Bread, crackers, muffins, Pancakes, - Milk or Juice Ensure the liquid selected for pureeing is appropriate for the person's diet order. Ensure the liquid selected for pureeing is appropriate for the person's diet order. Review of in-service dated 06/11/2024 reflected topics included recipes and spreadsheets attended by 5 dietary staff members including [NAME] G and DA F. Review of in-service dated 08/15/2024 reflected topic of proper foodservice procedures attended by 5 dietary staff members including [NAME] G and DA F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 16 of 22 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 10/16/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning the ice machine scoop receptacle, storing, and stacking wet dishes on top of each other, ensure dish machine sanitizer levels are within the required range, utilization of an ice scoop receptacle with a lid, cleaning the walk-in cooler floor of food debris) for facility annual survey 10/14/2024-10/16/2024. 2. The facility failed to ensure temperature logs were being completed for nourishment refrigerators for the facility annual survey 10/14/2024-10/16/2024. 3. The facility failed to ensure all items were covered and stored properly for the facility annual survey on 10/14/2024-10/16/2024. 4. The facility failed to label and date all food items in the kitchen for facility annual survey on 10/14/2024-10/16/2024. 5. The facility failed to discard expired food product in the kitchen for facility survey on 10/14/2024-10/16/2024. These failures could place residents at risk of foodborne illness. Findings included: Observation on 10/14/2024 at 9:35 AM revealed an ice scoop receptacle to have water standing in bottom of the bin with what appeared to be black and brown debris floating on water surface and under water surface on bottom of scoop receptacle. Further observation revealed the scoop receptacle lid was broke off and in the bottom of the sink next to the ice machine. Observation on 10/14/2024 at 9:37 AM revealed the inside of the ice machine door seal and inside of ice machine door to have what appeared to be white, black, and brown mold growth on upper inside of the door and seal. Observation on 10/14/2024 at 9:40 AM revealed the clean dish storage to have trays of drinking glasses stored upside down while still wet on the inside. Observation on 10/14/2024 at 9:44 AM of sliced bread, hot dog buns, and hoagie buns that had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 17 of 22 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 10/16/2024 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 0812 receipt date of November 10. Level of Harm - Minimal harm or potential for actual harm Observation on 10/14/2024 at 9:48 AM of dry storage area revealed: Residents Affected - Many 1. An opened package of spaghetti noodles that were sealed properly with a date of 9/18 (unsure if this is receipt date open date or use by date). 2. An opened package of macaroni noodles that were sealed properly with a receipt date of 10/10/24. No open date or discard date. 3. An opened package of spiral pasta noodles that were sealed properly with a receipt date of 6/18/24. No open date or discard date. 4. A container labeled noodles that contained salad croutons. 5. A opened box of egg noodles not sealed properly and undated. 6. A opened container of cornstarch dated with an open date of 7/2/24 and a discard date of 8/2/24. 7. A opened container of granola cereal dated with an open date of 7/12 and a discard date of 8/12. 8. A case of oat and fruit granola with an expiration date of 06/2024. 9. A case of popcorn with a best by date of 9/16/24. 10. A case of instant oatmeal with a best by date of 6/17/24. 11. A dry supply bin of oatmeal with a scoop inside the bin. Observation on 10/14/2024 at 9:59 AM of the walk-in refrigerator cooler revealed a bag of shredded cheese not sealed properly with a date of 9/24 (unsure if this is receipt date, open date, or discard date). Further observation of walk-in cooler revealed floor to have food debris all over the floor. Observation on 10/14/2024 at 10:03 AM of the baking ingredient shelf revealed an opened package of brownie mix with a date of 9/24 (unsure if this is receipt date, open date, or discard date). Observation on 10/14/2024 at 10:09 AM of clean dish storage revealed a stack of clean food storage bins stored upside down stacked together while still wet on the inside. Observation on 10/15/2024 at 10:27 AM of nourishment refrigerator temperature logs revealed evening temperature for 10/14/2024 not recorded and morning temperature for 10/15/2024 not recorded. Observation on 10/15/2024 at 10:43 AM of [NAME] G doing pureed preparation for lunch meal service revealed [NAME] G just rinsed the blender under hot running water. [NAME] G did not wash or sanitize the blender prior to use after receiving it dirty from having the dessert already been pureed. [NAME] G did not wash the blender in between food items of chicken and collard greens. [NAME] G just rinsed the blender under hot running water between food products. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 18 of 22 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 10/16/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm In an interview on 10/14/2024 at 10:43 am [NAME] G stated they normally wash, rinse, and sanitize the blender and allow it to dry between each food product but they did not this time because the state surveyor was here to watch the puree process and she was trying to hurry so we did not have to wait. This failure could negatively affect the residents by cross contamination of food products and possible food allergy reactions. Residents Affected - Many In an interview on 10/15/2024 at 10:43 AM CNA E stated it was the nurse's responsibility for taking the temperatures twice daily on the nourishment refrigerators. This failure could negatively affect residents if the temperature range of the refrigerator was not within regulation and possible food borne illness. In an interview on 10/16/2024 at 11:22 AM DM H stated their expectation concerning labeling and dating of food items were that the food items would be labeled and dated upon receipt, when opened or prepared, and dated at that time with a discard date. DM H stated if the food items were not labeled and dated appropriately then the facility could possibly be using expired food which could lead to food borne illness. DM H stated it was everybody's responsibility for labeling and dating but that the ultimate responsibility was theirs to ensure the labeling and dating was occurring. DM H stated their expectation concerning general cleaning was that daily and weekly, deep cleaning was being completed per the cleaning schedules. DM H stated their expectation for dish washing of food production equipment was that the proper 3 step process was followed of wash, rinse, and then sanitize. DM H stated taking the temperature and the cleaning of the nourishment refrigerators responsibility was on the nursing staff. In an interview on 10/16/2024 at 1:40 PM the ADM stated labeling and dating were very important and that they were a big fan of it. The ADM stated if the labeling and dating were not done correctly then the residents run the risk of receiving expired food or getting food poising. The ADM stated it was the DM H 's responsibility to ensure that labeling and dating was occurring in the kitchen. The ADM stated they expected the kitchen to be kept as clean as possible to follow regulations. The ADM stated if the kitchen was not kept clean then the residents could get food borne illness. Review of kitchen cleaning schedules dated for the week of 10/14/2024 reflected the weekly cleaning schedule had been completed for cleaning of the microwave, ovens, plate lowerator, and steam table. The weekly cleaning schedule for ingredient bins, janitors closet, and kitchen cabinets and drawers had not been completed. The monthly cleaning schedule had been completed for the freezers dated 10/14/2024. The monthly cleaning schedule for ice machine, kitchen floor power cleaned refrigerators and cooler, vent hood and filters, and surfaces-clean, vacuum, and dust behind and under appliances had not been completed. The daily cleaning schedule had been completed for Monday 10/14/2024 for the following items: can opener, coffee machine, dish machine, juice machine, knife rack, microwave, range and grill, steam table, steamer and steam kettle. The daily cleaning schedule had not been completed on Monday 10/14/2024 for the following items: storeroom, sinks ad faucets, scales, robocoupe & mixers & blenders, refrigerator & freezer & cooler wipe out and sweep, other equipment, food & dish carts, empty garbage, doors & walls & windows, cleaning cloths, counters, cutting boards, dining room tables & chairs & floors. Review of Cleaning Schedule policy dated 10/1/2018 reflected under heading policy: The facility will maintain a cleaning schedule prepared by the Nutrition & Foodservice Manager and followed by employees as assigned to ensure that the kitchen is clean and free of hazards. Under heading procedure: 1. The Nutrition & Foodservice Manager will develop a cleaning schedule for daily, weekly, and monthly cleaning. Sample forms for daily cleaning, weekly cleaning, and monthly cleaning follow this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 19 of 22 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 10/16/2024 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 0812 policy. Level of Harm - Minimal harm or potential for actual harm 2. Cleaning tasks will be assigned to positions and included in the job descriptions. Residents Affected - Many 3. The cleaning list will be posted weekly and initialed off and dated by each employee upon completion of the task. The Nutrition & Foodservice Manager or designee will verify that the tasks were completed as assigned. Review of Food Storage policy dated 10/1/2018 and revised on 6/1/2019 reflected under heading policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes an HACCP guidelines. Under heading procedure: d. To ensure freshness. store opened and bulk items in tightly covered containers. All containers must be labeled and dated. e. Provide scoops for items stored in bins, such as sugar, flour, rice and other items. Store scoops covered in a protected area near the food containers. Wash and sanitize scoops weekly or as needed. f. Where possible, leave items in the original cartons placed with the date visible. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place items behind existing supplies, so that the older items are used first. h. Store all items at least 6 above the floor with adequate clearance bet ween goods and ceiling to protect from overhead pipes and other contamination FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 20 of 22 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 10/16/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 6 (Resident #11, and Residents #15) residents reviewed for infection control. Residents Affected - Few LVN B failed to properly sanitize blood pressure cuff when moving from one resident to another resident when administering medications and obtaining blood pressure for Residents #11 and #15. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1) Record review of Resident #11's face sheet, dated 10/16/24, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included paranoid personality disorder, type 2 diabetes mellitus (too much sugar in the blood), and major depressive disorder. Record review of Resident #11's Quarterly MDS assessment, dated 09/30/2024, reflected she had a BIMS score of 9, which indicated moderate cognitive impairment. Resident #11 required staff assistance with eating, personal hygiene, toileting, and showering. Record review of Resident #11's care plan dated 06/02/2021 and revised on 09/23/24 reflected she had an ADL Self Care Performance (Bed Mobility, Transfers, Eating, Bathing, Dressing, and Personal Hygiene) Deficits related to unsteady gait, and hemiparesis (paralysis) to upper extremity. Goal: Resident #11 will maintain current level of function in ADL's, through the next review date. Interventions included Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. 2) Record review of Resident #15's face sheet reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (a loss in cognitive function thinking reasoning and remembering), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), and hemiplegia and Hemiparesis (paralysis) affecting the right dominate side. Record review of Resident #15's Quarterly MDS assessment, dated 09/30/2024, reflected she had a BIMS score of 03, which indicating severe cognitive impairment. Resident #15 required staff assistance with eating, personal hygiene, toileting, and showering. Record review of Resident #15's care plan dated 06/02/2021 and revised on 09/23/24 reflected she had an ADL Self Care Performance (Bed Mobility, Transfers, Eating, Bathing, Dressing, and Personal Hygiene) Deficits r/t: dementia, fatigue, and impaired balance. Goal: Resident #15 will maintain current level of function in ADL's, through the next review date. Interventions included Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. In an observation on 10/15/24 at 08:57 AM, LVN A did not sanitize the blood pressure cuff when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 21 of 22 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 10/16/2024 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 0880 going from resident #15 to Resident #11. Level of Harm - Minimal harm or potential for actual harm In an interview on 10/15/24 at 8:56 AM LVN A stated the blood pressure cuff should have been cleaned between residents. She stated staff were in-serviced on infection control routinely. LVN A stated not cleaning the blood pressure cuff would create cross contamination leading to infections. Residents Affected - Few In an interview on 10/16/24 at 11:13 AM the DON stated the staff needed to disinfect the blood pressure cuff between residents. She stated the nurses were educated on infection control monthly. The DON stated she was responsible for instruction and monitoring of infection control. She stated the negative effects for not cleaning the blood pressure cuff between usage would be passing organisms from one patient to another. In an interview on 10/16/24 at 12:48 PM the ADM stated the nurses were expected to clean the blood pressure cuff between residents. She stated the DON was responsible for management of infection control. The ADM stated negative effects for the resident for not cleaning the blood pressure cuff between residents would be cross contamination and spreading infections. Record review of facility policy titled Infection Prevention and Control Program dated 9/1/2023 Revised 1/23/2024 reflected: Standard Precautions: All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department. Equipment Protocol: All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675885 If continuation sheet Page 22 of 22