Health inspection·October 2, 2023

F 0755 D from the night shift. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's controlled drug record form for her lorazepam (Ativan) reflected LVN A administered the medication on the following dates and times: 09/04/23 at 3:00 PM and 09/04/23 at 8:00 PM. Residents Affected - Few Review of Resident #1's controlled drug record form for her hydrocodone reflected LVN A administered the medication on the following dates and times: 09/04/23 at 8:00 AM, 09/04/23 at 12:00 PM, 09/04/23 at 4:00 PM, and 09/04/23 at 9:00 PM. Review of Resident #1's progress notes on 09/04/23 made by LVN A reflected the following at 8:26 PM: Res is very confused this night. In and out of bed several times. Comes out of room barefoot and walking without walker or wheelchair. Unable to redirect r/t cognition. Have toileted resident and offered many snacks. Some taken well, other refused. Took night meds without issue, new order for reduction in Trazadone given as well. Bed is in low position and call light in reach. Review of the facility's Provider Investigation Report for Incident Intake ID: 449202 reflected the following under the investigation summary portion: On 9/4 [09/04/23] charge nurse (RN B) arrived for her 6-2 [6:00 AM-2:00 PM] shift and began her count. Charge nurse noticed medication for resident (Resident #1) was signed for by the 2-10 [2:00 PM-10:00 PM] shift nurse (LVN A). the medication was signed for at 8am and 12pm. Charge nurse (RN B) stated during her interview that these times immediately raised a red flag since the nurse in question only works the 2-10 shift. This employee then brought her findings to the DON. The DON began her investigation. The DON was able to determine that the medication was signed out at 8am and 12 pm by nurse, (LVN A). When the nurse in questions was interviewed she stated she had given to much. During the interview the nurse stated that she did not follow the MD orders. Nurse also stated that this resident has two orders for Ativan. This resident does not have a PRN order. The DON and HR requested a drug test from the nurse. The test came back positive for morphine. The nurse states that she did not have a prescription for the morphine. The DON explained to the nurse that she would be suspended pending an investigation due to the documented medication, drug test, and discrepancies in her interview. The employee was terminated. Interview with staff revealed that the nurse would sit at the nurse station for a long period of time and that there were no behaviors noted in regard to the staff. Interview statements also indicated that the resident was more confused. Nursing staff assessed resident and there were no adverse effects or injuries noted. Nursing facility to continue to proved care for resident. Safe surveys did not reveal any findings of abuse or neglect. [sic] In an email written by the DON, dated 09/05/23, reflected the following: LVN A was suspended today pending investigation on a possible drug diversion. Residents' narcotic sheet with entries for 8 am and 12 noon. (LVN A) only works 2-10 shift this day (9/4/23). When I asked (LVN A) why the narcotic log had times she didn't work, she stated she had given to much. I gave (LVN A) the order for the Hydrocodone. Hydrocodone 5/325 take one by mouth every 4 hours as needed for pain. (LVN A) stated she gave the med: On arrival of her shift (2 PM) 4:00 P.M. 8:00 P.M. Before she left (10:30 P.M.) When asked why the med was given so close together, she stated she didn't know. When asked if she followed MD's orders, she stated no. Ativan prescription was not given per MD orders. Ativan 0.5 mg PO every 8 hours as needed for anxiety. (LVN A) signs the narc sheet for twice during her shift. 9/4/23 3:00 P.M. 8:00 P.M. When asked why she gave the medication twice during her shift (LVN A) stated she has two orders one routine and one PRN. Resident does not have a PRN order. I asked (LVN A) if she signed the PRN medication on the EMAR, she stated no. When asked if she knew she is supposed to sign the PRN meds on the EMAR, (LVN A) stated yes. Drug test given. Positive for Morphine. I asked (LVN A) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 2 of 7 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 675905 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grapevine 1500 Autumn Drive Grapevine, TX 76051 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 if she had any prescriptions, she stated she is taking Tramadol. [sic] Level of Harm - Minimal harm or potential for actual harm Review of an in-service, dated 09/05/23, and titled Narcotic Count, PRN med Administration, 24-hour report F/U, Following MD orders revealed current nursing staff were in-serviced. Residents Affected - Few Review of LVN A's timesheet, dated 10/02/23, reflected on 09/04/23 she clocked in at 2:01 PM, clocked out at 8:00 PM, clocked in at 8:30 PM, and clocked out at 10:23 PM. Review of a personnel action form, dated 09/05/23, for LVN A revealed she was suspended pending an investigation for a drug diversion and ultimately involuntarily terminated on 09/05/23. In an interview via phone on 10/02/23 at 10:56 AM with LVN A, she revealed she did not have any documentation in front of her and the situation regarding Resident #1's medications was a long time ago, but she would try her best to remember what happened on 09/04/23. LVN A said she did administer Resident #1 hydrocodone on 09/04/23 during her 2:00 PM-10:00 PM shift and documented the administration on the resident's narcotic count sheet. LVN A said Resident #1 had an order for hydrocodone which was for one tablet every six hours. LVN A said most people had an order for two tablets of hydrocodone every four hours so she got confused and accidentally administered Resident #1 too many hydrocodone pills because she had popped an extra pill each time. LVN A said Resident #1 was on hospice and had a lot of pain and was complaining of pain on 09/04/23 which was why she administered the hydrocodone to her. LVN A said she did document on the narcotic count sheet that the medication was administered at times when she was not working (referring to the 8:00 AM and 12:00 PM administrations). LVN A said that she documented it that way because she had administered too many pills to Resident #1 and should have been following the physician's order for just one tablet of the hydrocodone. LVN A said she also gave Resident #1 two pills of Ativan that day but could not remember why or what doctor's order she was following to administer it. LVN A said Resident #1 did not experience any adverse effects to the additional medications. LVN A said she did not take the medications for herself or administer them to any other residents. LVN A said she succumbed to the pressure and knew it was wrong to inaccurately document the wrong times of the medication administration. LVN A said she recognized her mistake and she should have asked another nurse to come and waste the medication and only administer Resident #1 what she was ordered by the doctor. LVN A said she no longer worked at the facility after this situation. In a follow-up interview via phone on 10/02/23 at 11:07 AM with LVN A, she revealed she knew for sure that she did not give anything that would have hurt Resident #1 and did not give her anything the doctor did not order for her. LVN A said she wanted to make that clear that she was not trying to harm Resident #1 in anyway. In an interview on 10/02/23 at 12:50 PM with RN B, she revealed she was caring for Resident #1 on 09/04/23 and 09/05/23 from 6:00 AM to 2:00 PM. RN B said on 09/05/23 Resident #1 was complaining of pain so when she went to the resident's drug control sheet she saw that the hydrocodone was signed out on her shift by LVN A the day prior (09/04/23). RN B said she knew that she herself did not administer the medications and it had to be an error. RN B said she immediately counted Resident #1's hydrocodone and the count was correct and matched the count on the narcotic sheet. RN B said it was normal for Resident #1 to complain of pain but she did not ask for pain medications every day which was why the doctor made the hydrocodone PRN. RN B said she was not only alerted to the incorrect timing of the medication administration but also that Resident #1 was administered so many pills in one shift because that was not normal for her to ask for that many pain medications. RN B said she immediately took the information to the DON. RN B said she did not notice any changes in Resident #1 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 3 of 7 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 675905 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grapevine 1500 Autumn Drive Grapevine, TX 76051 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 09/05/23 and was not sure if she was administered the medications or not. Level of Harm - Minimal harm or potential for actual harm In an interview on 10/02/23 at 3:25 PM with the Administrator, she revealed it was brought to her attention by the DON there could have been a potential drug diversion regarding Resident #1. The Administrator said the DON completed the investigation but that they did finalize that there was possibly missing pills from her recollection. The Administrator said she reported it to HHSC as the Abuse Coordinator for the facility. The Administrator said Resident #1 was stable and the staff monitored her after they were informed of the situation. The Administrator said was not a change in Resident #1's status that led them to believe LVN A administered the hydrocodone or Ativan pills to her. The Administrator said she was never given any indication LVN A would do something like this and had no suspicions of her or anyone else diverting drugs. The Administrator said LVN A no longer worked at the facility after this situation. Residents Affected - Few In an interview on 10/02/23 at 3:36 PM with the DON, she revealed RN B was working the day shift on 09/05/23 and brought her Resident #1's narcotic count sheet. The DON said the sheet showed that LVN A had signed out narcotics for 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM or 9:00 PM on 09/04/23. The DON said LVN A did not work the day shift so the 8:00 AM and 12:00 PM medications that were signed out was odd. The DON said she immediately suspended LVN A pending the investigation, assessed Resident #1 for pain and overmedication. The DON said Resident #1 was stable, did not appear to be in any pain or to be overmedicated. The DON said during her investigation she also noticed that LVN A had administered Resident #1 Ativan twice as indicated on the narcotic count sheet for Resident #1's Lorazepam. The DON said she saw that LVN A had signed out the Lorazepam at 3:00 PM and at 8:00 PM on 09/04/23 when the medication was ordered to be given at bedtime. The DON said she contacted Resident #1's RP and doctor regarding the situation. The DON said when she interviewed LVN A she could not get any clarity from her about the discrepancy in the medications and that LVN A's answers were that she gave medications too many times. The DON said LVN A had administered the additional Lorazepam as a PRN order which Resident #1 did not have at the time. The DON said she felt as if LVN A was claiming she overmedicated Resident #1 rather than admit to taking the medications. The DON said she in-serviced all staff regarding not just counting the narcotic count sheet but also paying attention to the administered dates and times to make sure that the information appeared correct. The DON said she instructed all her staff to immediately report any discrepancies going forward in regards to the narcotic count sheet or anything related to residents and their medications. The DON said the facility did not have a specific policy regarding drug diversions or narcotic counts. Review of the facility's Oral Medication Administration policy, dated September 2018, reflected: .2. Review and confirm medication orders for each individual resident on the MAR prior to administering medications to each resident .Discuss the resident's condition with them and determine if there is a need for any 'as needed' medications, such as for pain FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 4 of 7 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 675905 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grapevine 1500 Autumn Drive Grapevine, TX 76051 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for one (Resident #1) of five residents records reviewed for resident records, in that: LVN A failed to accurately document the administration of Resident #1's hydrocodone and lorazepam on 09/04/23 on the resident's MAR. This failure could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included: Review of Resident #1's face sheet, dated 10/02/23, reflected the resident was admitted to the facility on [DATE]. Her diagnoses included anxiety disorder (a group of mental illnesses that cause constant fear and worry) and primary osteoarthritis (a condition that causes several different symptoms that can impact your function and affect your ability to perform your daily activities). Review of Resident #1's Significant Change in Status MDS, dated [DATE], reflected she had a BIMS score of 03, indicating severe cognitive impairment. Review of Resident #1's physician's orders, dated 10/02/23, reflected she was ordered Ativan oral tablet .5 mg (Lorazepam), give 1 tablet by mouth at bedtime related to anxiety disorder as of 07/17/23. Review of Resident #1's physician's orders, dated 10/02/23, reflected she was ordered hydrocodone-acetaminophen oral tablet 5-325 mg, give 1 tablet by mouth every 4 hours as needed for Pain-Moderate: Pain-Severe as of 06/09/23. Review of Resident #1's September 2023 MAR revealed on 09/04/23 the box was checked and initialed by LVN A that Resident #1 received her Ativan as ordered. Review of Resident #1's September 2023 MAR revealed on 09/04/23 the boxes were blank, indicating there was no documentation that she received any hydrocodone-acetaminophen that day. Review of Resident #1's controlled drug record form for her lorazepam (Ativan) reflected LVN A administered the medication on the following dates and times: 09/04/23 at 3:00 PM and 09/04/23 at 8:00 PM. Review of Resident #1's controlled drug record form for her hydrocodone reflected LVN A administered the medication on the following dates and times: 09/04/23 at 8:00 AM, 09/04/23 at 12:00 PM, 09/04/23 at 4:00 PM, and 09/04/23 at 9:00 PM. Review of the facility's Provider Investigation Report for Incident Intake ID: 449202 reflected the following under the investigation summary portion: On 9/4 [09/04/23] charge nurse (RN B) arrived for her 6-2 [6:00 AM-2:00 PM] shift and began her count. Charge nurse noticed medication for resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 5 of 7 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 675905 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grapevine 1500 Autumn Drive Grapevine, TX 76051 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Resident #1) was signed for by the 2-10 [2:00 PM-10:00 PM] shift nurse (LVN A). the medication was signed for at 8am and 12pm. Charge nurse (RN B) stated during her interview that these times immediately raised a red flag since the nurse in question only works the 2-10 shift. This employee then brought her findings to the DON. The DON began her investigation. The DON was able to determine that the medication was signed out at 8am and 12 pm by nurse, (LVN A). When the nurse in questions was interviewed she stated she had given to much. During the interview the nurse stated that she did not follow the MD orders. Nurse also stated that this resident has two orders for Ativan. This resident does not have a PRN order. The DON and HR requested a drug test from the nurse. The test came back positive for morphine. The nurse states that she did not have a prescription for the morphine. The DON explained to the nurse that she would be suspended pending an investigation due to the documented medication, drug test, and discrepancies in her interview. The employee was terminated. Interview with staff revealed that the nurse would sit at the nurse station for a long period of time and that there were no behaviors noted in regard to the staff. Interview statements also indicated that the resident was more confused. Nursing staff assessed resident and there were no adverse effects or injuries noted. Nursing facility to continue to proved care for resident. Safe surveys did not reveal any findings of abuse or neglect. [sic] In an interview via phone on 10/02/23 at 10:56 AM with LVN A, she revealed she did not have any documentation in front of her and the situation regarding Resident #1's medications was a long time ago, but she would try her best to remember what happened on 09/04/23. LVN A said she did administer Resident #1 hydrocodone on 09/04/23 during her 2:00 PM-10:00 PM shift and documented the administration on the resident's narcotic count sheet. LVN A said Resident #1 had an order for hydrocodone which was for one tablet every six hours. LVN A said most people had an order for two tablets of hydrocodone every four hours so she got confused and accidentally administered Resident #1 too many hydrocodone pills because she had popped an extra pill each time. LVN A said Resident #1 was on hospice and had a lot of pain and was complaining of pain on 09/04/23 which was why she administered the hydrocodone to her. LVN A said she did document on the narcotic count sheet that the medication was administered at times when she was not working (referring to the 8:00 AM and 12:00 PM administrations). LVN A said that she documented it that way because she had administered too many pills to Resident #1 and should have been following the physician's order for just one tablet of the hydrocodone. LVN A said she also gave Resident #1 two pills of Ativan that day but could not remember why or what doctor's order she was following to administer it. LVN A said Resident #1 did not experience any adverse effects to the additional medications. LVN A said she did not take the medications for herself or administer them to any other residents. LVN A said she succumbed to the pressure and knew it was wrong to inaccurately document the wrong times of the medication administration. LVN A said she recognized her mistake and she should have asked another nurse to come and waste the medication and only administer Resident #1 what she was ordered by the doctor. LVN A said she administered Resident #1 hydrocodone and lorazepam on 09/04/23 during her 2:00 PM-10:00 PM shift and documented the administration on the resident's narcotic count sheet only. LVN A said she did not notate the medication administration on Resident #1's MAR because she forgot even though she knew she was supposed to do that. In an interview on 10/02/23 at 3:36 PM with the DON, she revealed she expected staff to document on the resident's controlled drug sheet and on the resident's MAR when a medication was administered. In an interview on 10/02/23 at 3:36 PM with the DON, she revealed all staff knew to document any medications administered on the resident's EMAR. Review of the facility's Oral Medication Administration policy, dated September 2018, reflected: .9. Chart medication administration on the MAR (or eMAR) immediately following each resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 6 of 7 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 675905 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Grapevine 1500 Autumn Drive Grapevine, TX 76051 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 0842 medication administration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 7 of 7