Inspection·July 19, 2024

F 0580 Level of Harm - Immediate jeopardy to resident health or safety back in bed. At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to oncoming nurse to monitor resident discomfort if worsens to report to NP/MD. Record review of Resident #1's x-ray report, dated 06/16/24, reflected: Residents Affected - Few .EXAM: Pelvis and left hip HISTORY: Pain .FINDINGS: There is a fracture involving the proximal left femur centered within the intertrochanteric space. There does appear to be approximately a centimeter of shortening as well as a few degrees of varus angulation. There is no dislocations. A significant joint effusion is not seen. Mild symmetric osteoarthritis is seen . IMPRESSION: 1. Proximal left femur fracture . Record review of Resident #1's hospital records, dated 06/16/24, reflected Resident #1 had been diagnosed with an acute fracture of the left proximal femur (hip fracture). Record review of the facility's Provider Investigation Report, dated 06/17/24, reflected the following: .This resident is a 60 yo (year old) female who resides on the secured unit. The resident ambulates independently on the unit. This resident also ambulates in a wheelchair. This resident has dementia, osteoarthritis, and vitamin D deficiency. The weekend RN supervisor informed this admin that x-rays were ordered due to a resident possible leg fracture .On-coming aide notified charge nurse that during peri care resident was favoring her left leg. Charge nurse stated that resident is non-verbal and that she would monitor resident throughout her shift. Charge nurse indicated that resident slept through the night. Facility received x-rays, indicating possible fracture . Observation on 07/02/24 at 10:00 AM of Resident #1 revealed she was in a low bed with her eyes closed. After knocking, the resident's name was called out, but Resident #1 barely opened her eye, closed them right away and did not speak. Interview on 07/02/24 at 10:54 AM CNA B stated she was making her rounds on, 06/15/24, around 7:45 PM. She went in to change Resident #1 and when she started peri care, Resident #1 yelled out like she was in pain, so she went to get LVN A. At that time both the CNA B and LVN A tried to assist the resident to a standing position and Resident #1 yelled again. and They noted something was wrong, and it appeared like her left foot was hurting so she was put back in bed. Resident #1 was not able to speak therefore could not tell them what was wrong. CNA B said it was not normal for Resident #1 to yell out when she was being changed. CNA B further stated she worked from 7:00 PM to 7:00 AM and during the night she continued to monitor Resident #1. and during her brief change, the resident did not groan or appear to be in pain the remainder of her shift. Record review of LVN A's undated handwritten and signed statement reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 2 of 14 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 07/19/2024 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 0580 To whom it may concern, Level of Harm - Immediate jeopardy to resident health or safety Cc: [Resident #1] Residents Affected - Few Upon my shift on June 15th, this writer [LVN A] noted patient sitting on w/c but seems sleepy (eyes closed). Notified nurse aide to lay patient in bed. During rounds for incontinent care with nurse aide, noted facial grimacing when touching pt on left leg but since patient is non-verbal, assessed pt left extremities no bruises noted, or any other skin issues. Layed [laid] pt comfortably in bed, while continuous monitoring, pt slept all night long. This writer reported oncoming nurse to monitor if patient persist with pain to touch to notify MD. Review of LVN A's undated typed and signed statement on 07/02/24 reflected the following: To whom it may concern, Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed., At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3: 00 AM ] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to on coming nurse to monitor resident discomfort if worsens to report to NP/MD. Record review of LVN A's personnel file on 07/02/24 reflected the signature on LVN A's handwritten statement matched the signatures on her new hire paperwork. Interview on 07/02/24 at 2:25 PM LVN A stated she arrived to work around 6:00 PM on, 06/15/24, and Resident #1 was in her wheelchair and appeared to look tired, so she asked an aide to lay her down in bed. Later that evening, CNA B told her the resident was having some discomfort while she was trying to change her brief, so she went into Resident #1's room to assess the resident. LVN A denied trying to make the resident stand up and said Resident #1 indeed looked to have some discomfort, but it was not pain. LVN A described the discomfort as someone that was tired and did not want to be touched and again denied the discomfort as pain . LVN A said she continued to monitor the resident throughout the night and there were no concerns as Resident #1 has slept comfortably the whole night. LVN A was asked about her handwritten statement where she had documented facial grimacing when the resident's left leg was touched and LVN A denied writing a statement. LVN A further stated the only thing she wrote was her narrative in the progress notes of Resident #1's clinical record and again denied she wrote a statement of the incident. LVN A also said she did not contact the doctor because Resident #1 was not in pain and the resident had slept comfortably all night. Interview on 07/02/24 at 1:40 PM RN C stated when she arrived at the facility on, 06/16/24 at 6:00 AM, Resident #1 was in bed sleeping. She got report from the night nurse, LVN A, that Resident #1 was having pain to her left leg. RN C went in to assess the resident in her room and Resident #1 did not appear well, was not her normal self, and when she tried to move her left leg, the resident expressed pain through facial grimacing. RN C called the doctor and ordered an x-ray of the resident's leg, and the results came back positive for a hip fracture, so she was sent out to the hospital. Interview on 07/02/24 at 1:54 PM ADON stated she was not informed of all the details with Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 3 of 14 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 07/19/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #1. The ADON said she only assisted in gathering a few statements from the staff and the Administrator had conducted the investigation with Resident #1's incident. Interview on 07/02/24 at 2:43 PM Administrator stated she had been made aware of Resident #1's hip fracture and she began an investigation of the incident. The Administrator was made aware LVN A denied writing a statement., and she was shown the handwritten statement that was part of the provider investigation report and shown the matching signatures. The Administrator said she had provided the wrong statement. The Administrator said had found LVN A's handwritten statement under her door and because corporate preferred their statements to be typed out, the [NAME] President of Clinical Operations had gotten LVN A's other statement. The Administrator further stated she would provide the LVN A's typed statement and that was the correct one. The Administrator could not explain why there were two statements where one addressed Resident #1 was having pain and the other statement did not. Interview on 07/02/24 at 3:19 PM with the [NAME] President of Clinical Operations revealed she was not aware LVN A had written a statement. and the facility did not have a DON at the time, so she called LVN A into the facility and had her type up a statement. The [NAME] President of Clinical Operations said LVN A further stated LVN A had been suspended and educated on pain management and resident assessment after the incident with Resident #1 because they felt like LVN A could have assessed the resident better and wanted to make sure she knew how to fully assess a resident and contact the doctor if needed. Record review of the facility's Change in Resident's Status or Condition policy, revised February 2021, reflected the following: Policy Statement: Our promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .b. discovery of injuries of an unknown source; .i. specific instruction to notify the physician of changes in the resident's condition. This was determined to be an Immediate Jeopardy (IJ) on 07/19/24 at 8:44 AM. The Administrator, the DON and ADON were notified. The Administrator was provided with the IJ template on 07/19/24 at 8:50 AM. The following Plan of Removal submitted by the facility was accepted on 07/19/24 at 2:37 PM: Problem: Facility failed to immediately consult with the resident's physician when there was a change in the resident's condition, when Resident #1 had a change of condition on 06/15/24 and did not receive timely treatment. - The following in-services were initiated by - started on 7/2/2024 and completed on 7/5/2024 COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 4 of 14 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 07/19/2024 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 0580 Licensed Nurses: Level of Harm - Immediate jeopardy to resident health or safety - Promptly and accurately assessing a resident when change of condition has been identified / reported. Education started on 7/2/2024 and completed on 7/5/2024. Residents Affected - Few - Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner. Education started on 7/2/2024 and completed on 7/5/2024. -Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form. Education started 7/2/2024 and completed on 7/5/2024. Non-licensed nursing staff: - Reporting changes in a resident's condition to a nurse immediately. Education started 6/16/2024 and completed on 7/5/2024. - If the nurse does not assess timely, the DON/Designee must be notified. Education started 6/16/2024 and completed 7/5/2024. The Administrator, DON and ADON were in-serviced .regarding .ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement. An ADHOC QAPI meeting was conducted on 7/8/2024 regarding this plan and monitoring. The Medical Director .was notified of this plan and monitoring on 7/2/2024. Monitoring -The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely. -The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was report to them that a resident had a change of condition. -The QAPI committee will review the findings and make any needed changes. Monitoring of the facility's Plan of Removal included the following: Record review of the facility's Incident by Incident type reflected Resident #2, Resident #3, Resident #4, Resident #5 had unwitnessed falls and nursing staff documented, assessed the residents, and reported to the Interim DON, family, and physician. Record review of Admit/Discharge Report, from 06/16/24 through 07/19/24, reflected Resident #6, Resident #7, Resident #8, Resident #9 were discharged to the hospital due to change in condition. Residents were assessed and nursing staff documented change in condition using SBAR and notified the Interim DON, family, and physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 5 of 14 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 07/19/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of the facility's Change in Condition Evaluation - SBAR (Situation, Background, Assessment, and Recommendation), undated, reflected the form addressed signs and symptoms identified, start date, review findings and provider notifications, mental status evaluation, functional status evaluation, vital signs evaluation, provider notification and feedback, behavioral status evaluation, respiratory status evaluation, cardiovascular status evaluation, abdominal/GI status evaluation, genitourinary status evaluation, skin status evaluation, pain status evaluation, neurological status evaluation, general background evaluation and available laboratory test/diagnostic procedures and resident representative notification. Record review of the facility's Record of In-service Education, dated 06/16/24, reflected training for abuse, neglect policy - who was coordinator; resident rights; pain policy; and timely notification. In-services reflected all staff completed the trainings. The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/25/24, reflected the training participant would be able to verbalize and demonstrate proper transfer techniques in order to safely provide patient care handling, transfers included sit to stand, stand - pivot, squat- pivot, slide board, and mechanical lift. The in-services were conducted and signed by CNAs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/26/24, reflected the Administrator, the Interim DON and ADON were in-serviced on all staff applicable to receive training to use online resources or in person training to ensure all trained staff have attested to receiving education. Record review of the facility's Record of In-service Education, dated 07/02/24, reflected training for what was change of condition, what to do when a change of condition happens, who to notify, orders to receive, full head to toe assessment, assess for pain, medicate as ordered and continue to assess and to follow through any new orders. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 07/03/24, reflected training regarding how to identify pain and what to do. The training record reflected: .pain may be late on set and resident may not be able to verbalize, job is to assess pain and treat timely, once treated - [you] have to assess for effectiveness, continue to monito if not effective new orders may be needed. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Monthly QA Meeting reflected the meeting was completed on 07/08/24. Interviews conducted on 07/19/24 from 2:40 PM through 5:45 PM with the Administrator, the Interim DON, ADON, LVN A, RN D, RN E, RN F, LVN G, LVN M, RN O, LVN Q, who worked the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM verbally revealed nurses were able to verify education was provided to them. Nursing staff were able to accurately summarize what was change of condition, what to do when a change of condition occurred, who to notify, orders to receive, completing a full head-to-toe assessment, assessing for pain, medicating as ordered and continuing to assess, following through any new orders, documenting, and completing the SBAR. The Interim DON and ADON stated they would be responsible for monitor all kiosk (dashboard) alert a minimum of 4 times per week to ensure any potential change of condition had been addressed timely and continue education on change of condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 6 of 14 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 07/19/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interviews conducted on 07/19/24 from 3:48 PM through 5:45 PM with CNA B, CNA H, CNA I, CNA J, CNA K, CNA L, CNA N, CNA P, CNA R, CNA S, and CNA T who work the shifts of 6:00 AM- 6:00 PM- 6:00 PM 6:00 AM verbally revealed staff were able to verify education was provided to them, staff were able to accurately summarize what was change of condition, how to identify pain and who to notify. The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/19/2024 at 5:50 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 675905 If continuation sheet Page 7 of 14 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 07/19/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. Residents Affected - Few LVN A failed to ensure Resident #1 was provided with timely treatment when the resident had a changed of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which revealed the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment. An Immediate Jeopardy (IJ) situation was identified on 0719/24. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delay in needed treatment and care. Findings included: Record review of Resident #1's MDS assessment, dated 06/24/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, vitamin D deficiency, hypocalcemia (calcium deficiency), and cognitive communication deficit. Resident #1 had long and short- term memory impairment and decision making was severely impaired. Resident #1 had unclear speech rarely understood/understands. The MDS further reflected the resident was in a manual wheelchair and dependent for all ADLs. Record review of Resident #1's care plan, revised 07/29/21, reflected she had a communication problem related to dementia. Interventions included to monitor and document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. Record review of Resident #1's progress notes, dated 06/15/24, documented by LVN A reflected: Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed. At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to oncoming nurse to monitor resident discomfort if worsens to report to NP/MD . Record review of Resident #1's x-ray report, dated 06/16/24, reflected: .EXAM: Pelvis and left hip HISTORY: Pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 8 of 14 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 07/19/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety .FINDINGS: There is a fracture involving the proximal left femur centered within the intertrochanteric space. There does appear to be approximately a centimeter of shortening as well as a few degrees of varus angulation. There is no dislocations. A significant joint effusion is not seen. Mild symmetric osteoarthritis is seen . IMPRESSION: Residents Affected - Few 1. Proximal left femur fracture . Record review of Resident #1's hospital records, dated 06/16/24, reflected Resident #1 had been diagnosed with an acute fracture of the left proximal femur (hip fracture). Record review of the facility's Provider Investigation Report, dated 06/17/24, reflected the following: .This resident is a 60 yo (year old) female who resides on the secured unit. The resident ambulates independently on the unit. This resident also ambulates in a wheelchair. This resident has dementia, osteoarthritis, and vitamin D deficiency. The weekend RN supervisor informed this admin that x-rays were ordered due to a resident possible leg fracture .On-coming aide notified charge nurse that during peri care resident was favoring her left leg. Charge nurse stated that resident is non-verbal and that she would monitor resident throughout her shift. Charge nurse indicated that resident slept through the night. Facility received x-rays, indicating possible fracture . Observation on 07/02/24 at 10:00 AM of Resident #1 revealed she was in a low bed with her eyes closed. After knocking, the resident's name was called out, but Resident #1 barely opened her eye, closed them right away and did not speak. Interview on 07/02/24 at 10:54 AM CNA B stated she was making her rounds on, 06/15/24, around 7:45 PM. She went in to change Resident #1 and when she started peri care, Resident #1 yelled out like she was in pain, so she went to get LVN A. At that time both the CNA B and LVN A tried to assist the resident to a standing position and Resident #1 yelled again. and They noted something was wrong, and it appeared like her left foot was hurting so she was put back in bed. Resident #1 was not able to speak therefore could not tell them what was wrong. CNA B said it was not normal for Resident #1 to yell out when she was being changed. CNA B further stated she worked from 7:00 PM to 7:00 AM and during the night she continued to monitor Resident #1. and during her brief change, the resident did not groan or appear to be in pain the remainder of her shift. Record review of LVN A's undated handwritten and signed statement reflected the following: To whom it may concern, Cc: [Resident #1] Upon my shift on June 15th, this writer [LVN A] noted patient sitting on w/c but seems sleepy (eyes closed). Notified nurse aide to lay patient in bed. During rounds for incontinent care with nurse aide, noted facial grimacing when touching pt on left leg but since patient is non-verbal, assessed pt left extremities no bruises noted, or any other skin issues. Layed [laid] pt comfortably in bed, while continuous monitoring, pt slept all night long. This writer reported oncoming nurse to monitor if patient persist with pain to touch to notify MD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 9 of 14 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 07/19/2024 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 0684 Review of LVN A's undated typed and signed statement on 07/02/24 reflected the following: Level of Harm - Immediate jeopardy to resident health or safety To whom it may concern Residents Affected - Few Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed., At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to on coming nurse to monitor resident discomfort if worsens to report to NP/MD. Record review of LVN A's personnel file on 07/02/24 reflected the signature on LVN A's handwritten statement matched the signatures on her new hire paperwork. Interview on 07/02/24 at 2:25 PM LVN A stated she arrived to work around 6:00 PM on, 06/15/24, and Resident #1 was in her wheelchair and appeared to look tired, so she asked an aide to lay her down in bed. Later that evening, CNA B told her the resident was having some discomfort while she was trying to change her brief, so she went into Resident #1's room to assess the resident. LVN A denied trying to make the resident stand up and said Resident #1 indeed looked to have some discomfort, but it was not pain. LVN A described the discomfort as someone that was tired and did not want to be touched and again denied the discomfort as pain. LVN A said she continued to monitor the resident throughout the night and there were no concerns as Resident #1 has slept comfortably the whole night. LVN A was asked about her handwritten statement where she had documented facial grimacing when the resident's left leg was touched and LVN A denied writing a statement. LVN A further stated the only thing she wrote was her narrative in the progress notes of Resident #1's clinical record and again denied she wrote a statement of the incident. LVN A also said she did not contact the doctor because Resident #1 was not in pain and the resident had slept comfortably all night. Interview on 07/02/24 at 1:40 PM with RN C revealed when she arrived to the facility on, 06/16/24 at 6:00 AM, Resident #1 was in bed sleeping. She got report from the night nurse, LVN A, that Resident #1 was having pain to her left leg. RN C went in to assess the resident in her room and Resident #1 did not appear well, was not her normal self, and when she tried to move her left leg, the resident expressed pain through facial grimacing. RN C called the doctor and ordered an x-ray of the resident's leg, and the results came back positive for a hip fracture, so she was sent out to the hospital. Interview on 07/02/24 at 1:54 PM with the ADON revealed she was not informed of all the details with Resident #1. The ADON said she only assisted in gathering a few statements from the staff and the Administrator had conducted the investigation with Resident #1's incident. Interview on 07/02/24 at 2:43 PM with the Administrator revealed she had been made aware of Resident #1's hip fracture and she began an investigation of the incident. The Administrator was made aware LVN A denied writing a statement., and she was shown the handwritten statement that was part of the provider investigation report and shown the matching signatures. and The Administrator said she had provided the wrong statement. The Administrator said had found LVN A's handwritten statement under her door and because corporate preferred their statements to be typed out, the [NAME] President of Clinical Operations had gotten LVN A's other statement. The Administrator further stated she would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 10 of 14 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 07/19/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few provide LVN A's typed statement and that was the correct one. The Administrator could not explain why there were two statements where one addressed Resident #1 was having pain and the other statement did not. Interview on 07/02/24 at 3:19 PM with the [NAME] President of Clinical Operations revealed she was not aware LVN A had written a statement. and the facility did not have a DON at the time, so she called LVN A into the facility and had her type up a statement. The [NAME] President of Clinical Operations said LVN A further stated LVN A had been suspended and educated on pain management and resident assessment after the incident with Resident #1 because they felt like LVN A could have assessed the resident better and wanted to make sure she knew how to fully assess a resident and contact the doctor if needed. Record review of the facility's Change in Resident's Status or Condition policy, revised February 2021, reflected the following: Policy Statement: Our promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .b. discovery of injuries of an unknown source; .i. specific instruction to notify the physician of changes in the resident's condition. This was determined to be an Immediate Jeopardy (IJ) on 07/19/24 at 8:44 AM. The Administrator, the DON and ADON were notified. The Administrator was provided with the IJ template on 07/19/24 at 8:50 AM. The following Plan of Removal submitted by the facility was accepted on 07/19/24 at 2:37 PM: Problem: Facility failed to immediately consult with the resident's physician when there was a change in the resident's condition, when Resident #1 had a change of condition on 06/15/24 and did not receive timely treatment. - The following in-services were initiated by - started on 7/2/2024 and completed on 7/5/2024 COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged. Licensed Nurses: - Promptly and accurately assessing a resident when change of condition has been identified / reported. Education started on 7/2/2024 and completed on 7/5/2024. - Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner. Education started on 7/2/2024 and completed on 7/5/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 11 of 14 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 07/19/2024 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 0684 -Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form. Education started 7/2/2024 and completed on 7/5/2024. Level of Harm - Immediate jeopardy to resident health or safety Non-licensed nursing staff: Residents Affected - Few - Reporting changes in a resident's condition to a nurse immediately. Education started 6/16/2024 and completed on 7/5/2024. - If the nurse does not assess timely, the DON/Designee must be notified. Education started 6/16/2024 and completed 7/5/2024. The Administrator, DON and ADON were in-serviced .regarding .ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement. An ADHOC QAPI meeting was conducted on 7/8/2024 regarding this plan and monitoring. The Medical Director .was notified of this plan and monitoring on 7/2/2024. Monitoring -The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely. -The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was report to them that a resident had a change of condition. -The QAPI committee will review the findings and make any needed changes. Monitoring of the facility's Plan of Removal included the following: Record review of the facility's Incident by Incident type reflected Resident #2, Resident #3, Resident #4, Resident #5 had unwitnessed falls and nursing staff documented, assessed the residents, and reported to the Interim DON, family, and physician. Record review of Admit/Discharge Report, from 06/16/24 through 07/19/24, reflected Resident #6, Resident #7, Resident #8, Resident #9 were discharged to the hospital due to change in condition. Residents were assessed and nursing staff documented change in condition using SBAR and notified the Interim DON, family, and physician. Record review of the facility's Change in Condition Evaluation - SBAR (Situation, Background, Assessment, and Recommendation), undated, reflected the form addressed signs and symptoms identified, start date, review findings and provider notifications, mental status evaluation, functional status evaluation, vital signs evaluation, provider notification and feedback, behavioral status evaluation, respiratory status evaluation, cardiovascular status evaluation, abdominal/GI status evaluation, genitourinary status evaluation, skin status evaluation, pain status evaluation, neurological status evaluation, general background evaluation and available laboratory test/diagnostic procedures and resident representative notification. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 12 of 14 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 07/19/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of the facility's Record of In-service Education, dated 06/16/24, reflected training for abuse, neglect policy - who is coordinator; resident rights; pain policy; and timely notification. In-services reflected all staff completed the trainings. The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/25/24, reflected the training participant would be able to verbalize and demonstrate proper transfer techniques in order to safely provide patient care handling, transfers included sit to stand, stand - pivot, squat- pivot, slide board, and mechanical lift. The in-services were conducted and signed by CNAs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/26/24, reflected the Administrator, the Interim DON and ADON were in-serviced on all staff applicable to receive training to use online resources or in person training to ensure all trained staff have attested to receiving education. Record review of the facility's Record of In-service Education, dated 07/02/24, reflected training for what was change of condition, what to do when a change of condition happens, who to notify, orders to receive, full head to toe assessment, assess for pain, medicate as ordered and continue to assess and to follow through any new orders. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 07/03/24, reflected training regarding: how to identify pain and what to do. The training record reflected: .pain may be late on set and resident may not be able to verbalize, job is to assess pain and treat timely, once treated - [you] have to assess for effectiveness, continue to monito if not effective new orders may be needed. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Monthly QA Meeting reflected the meeting was completed on 07/08/24. Interviews conducted on 07/19/24 from 2:40 PM through 5:45 PM with the Administrator, the Interim DON, ADON, LVN A, RN D, RN E, RN F, LVN G, LVN M, RN O, LVN Q, who worked the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM revealed nurses were able to verify education was provided to them. Nursing staff were able to accurately summarize what was change of condition, what to do when a change of condition occurred, who to notify, orders to receive, completing a full head-to-toe assessment, assessing for pain, medicating as ordered and continuing to assess, following through any new orders, documenting, and completing the SBAR. The Interim DON and ADON stated they would be responsible for monitor all kiosk (dashboard) alert a minimum of 4 times per week to ensure any potential change of condition had been addressed timely and continue education on change of condition. Interviews conducted on 07/19/24 from 3:48 PM through 5:45 PM with CNA B, CNA H, CNA I, CNA J, CNA K, CNA L, CNA N, CNA P, CNA R, CNA S, and CNA T who work the shifts of 6:00 AM- 6:00 PM- 6:00 PM 6:00 AM revealed staff were able to verify education was provided to them, staff were able to accurately summarize what was change of condition, how to identify pain and who to notify. The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/19/2024 at 5:50 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 13 of 14 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 07/19/2024 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 0684 effectiveness of the corrective systems that were put into place. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675905 If continuation sheet Page 14 of 14