Inspection·November 28, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Care Plan dated 3/03/2022 revealed Resident #1 uses psychotropic medications with interventions which included: Discuss with MD and family ongoing need for use of medication. Review behaviors/interventions and alternate therapies and their effectiveness per facility policy. Educate the resident/family/caregivers about risks, benefits, and side effects and/or toxic symptoms (of) medications. Residents Affected - Some Record review of Resident #1's Care Plan dated 03/03/2023 revealed the resident used antidepressant medication with interventions which included: educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of medications. Record review of Resident #1's Care Plan dated 11/15/2022 last revised on 4/12/2023 revealed the resident was on sedative/hypnotic therapy with interventions which included : administer sedative/hypnotic as ordered by physician. Record review of Resident #1's physician order Summary for November 2023 revealed physician orders for the following medications: -Ativan (lorazepam) (a class a medication known as benzodiazepines which affect the brain and are depressants that produce sedation and hypnosis) 1 mg , give 1 tablet three times a day for anxiety ordered on 3/01/2022. -Cymbalta delayed release (class of medication which affect the chemicals in the brain) 30 mg, give 1 capsule by mouth one time a day related to depression ordered on 1/06/2023. -Doxepin (tricyclic antidepressant a class a medication which affects the chemicals in the brain) 100 mg, give 1 capsule by mouth at bedtime for insomnia with an order date of 8/09/2023. -Haloperidol (an antipsychotic medication which affects the brain) 5 mg, give 1 tablet by mouth two times a day related to psychotic disorder with delusions due to known physiological condition with an order date of 5/31/2023 -Lithium Carbonate (a mood stabilizer used to treat schizophrenia, bipolar disorder and depression and affects the brain) 300 mg, give 1 capsule by mouth three times a day related to mood disorder due to known physiological condition order date 11/19/2023. -Melatonin (sedative that affects the brain) 5 mg, give two tablets by mouth at bedtime related to insomnia with an order date of 3/01/2022. -Zyprexa 10 mg (antipsychotic medication that affects the brain) 10 mg, give one tablet, two times a day related to mood disorder due to known physiological condition with order date of 3/01/2022. Record review of Resident #1's November 2023 MAR revealed the resident was administered the following medications in November: -Ativan 0.5 mg, give 1 tablet by mouth three times a day related to anxiety disorder with a start date of 10/09/2023. -Ativan 1.0 mg, give 1 tablet by mouth three times a day for anxiety with a start date of 11/21/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 2 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0552 -Cymbalta delayed release 30 mg, give one capsule by mouth, one time a day for depression. Level of Harm - Minimal harm or potential for actual harm -Doxepin 100 mg, give 1 capsule by mouth at bedtime related to insomnia. -Haloperidol 5 mg, give 1 tablet by mouth two times a day related to psychotic disorder with delusions. Residents Affected - Some -Lithium Carbonate 150 mg, give 1 capsule by mouth three times a day related to psychotic disorder with delusions with a start date of 6/08/23 -Lithium Carbonate 300 mg, give 1 capsule by mouth three times a day related to mood disorder with a start date of 11/19/23 -Melatonin 5 mg, give 2 tablets by mouth at bedtime related to insomnia -Zyprexa 10 mg, give 1 tablet by mouth two times a day related to mood disorder. Record review of Resident #1's medical record revealed no signed consents from an RP or guardian for the use of Ativan, Cymbalta, Doxepin, Lithium Carbonate, or Melatonin and no consents or form 3713 consents for the use of antipsychotic medications haloperidol or Zyprexa . During an interview on 11/27/2023 at 11:44 a.m. LVN C stated Resident #1 was not able to make decisions for himself because he had dementia and behaviors. She stated Resident #1 also did not have family to make decisions for him. She stated normally she would look in the medical record to see who the residents RP was. She stated because Resident #1 did not have a RP, they just notify the physician . 2. Record review of Resident #2's face sheet dated 11/22/2023 revealed an admission date of 6/26/23 with diagnoses which included: Huntington's Disease, anxiety disorder, and major depressive disorder. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated a moderate cognitive impairment. Record review of Resident #2's Care Plan dated 7/11/2023 revealed the resident used psychotropic medications with interventions which included: educate resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of medications. Record review of Resident #2's physician order summary for November 2023 revealed an order with a start date of 10/21/2023 for Zyprexa (antipsychotic medication that affects the brain) 2.5 mg, give one tablet by mouth in the evening related to anxiety disorder. Record review of Resident #2's medical record revealed there was no signed Form 3713 (antipsychotic consent) in the medical record. During an interview on 11/22/2023 at 10:59 a.m., Resident #2's family member stated she was aware Resident #2 was in a secured unit for elopement behaviors, but she was not aware Resident #2 had been placed an antipsychotic medication Zyprexa. The family member stated she had not been asked to sign any form or consent for Zyprexa. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 3 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0552 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/27/2023 at 3:09 p.m., LVN F stated Resident #2 did not have a consent for the use of antipsychotic medication Zyprexa in her medical record. She stated she never saw Form 3713 for the use of antipsychotics used at the facility. She stated they just had the old consent forms but there was not one for Zyprexa. LVN F stated consent for the use of antipsychotic medication was required before the medication was given to the resident . Residents Affected - Some During an interview on 11/28/2023 at 4:26 p.m., the MDS Coordinator stated Resident #2 had an elopement from the facility (date unknown). She stated after the elopement incident she notified Resident #2's physician and completed a medication review. She stated she received new orders for Zyprexa. The MDS Coordinator stated she spoke with Resident #2's family member on the phone and she was okay with the medication. The MDS Coordinator stated I think I got consent. She stated she did not get a signed Form 3714 consent for antipsychotics signed . She stated that was an ADON or DON responsibility. She stated a consent was needed prior to administering the medication but the consent could be obtained over the phone as a verbal consent. The MDS Coordinator stated Form 3713 was a process that had to be emailed or mailed to get a signature from the family and was a whole process she had not completed. During an interview on 11/28/2023 at 4:19 p.m., the DON stated she was new to the facility and had been working there for two weeks. She stated she had an expectation for residents to have consents prior to giving a new medication that required consent which also included obtaining consent for dosage changes. She stated Resident #1 did not have the required consents for his medication. She stated she found a binder with Form 3713's in the DON's office but Resident #1's and Resident #2's consents were not included. She stated obtaining medication consent for medications such as hypnotics, sedatives, antidepressants, and antipsychotics was important, so the family knew how the facility was treating the patient The DON stated Form 3713 (consent for antipsychotics) was important, so the staff understood the reactions to medications when explaining to the resident and the family . Record review of the facility's, undated, policy, titled Psychoactive Medication Procedure, Consent to Administer (undated) revealed: Psychoactive medication: A medication prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorders and used to exercise an effect on the central nervous system to influence and modify behavior, cognition or affective state when treating the symptoms of mental illness. The term includes the following categories: antipsychotics or neuroleptics, antidepressants, agents for the control of mania or depression, anti-anxiety agents, sedative, hypnotics or other sleep-promoting trugs and psychomotor stimulants. Consent: A person may not administer a psychoactive medication to a resident who does not consent to the prescription unless: 1. The resident is having a medication-related emergency or 2. The person authorized by law to consent on behalf of the resident has consented to the prescription. Consent to the prescription of psychoactive medication given by a resident, or by a authorized by law to consent on behalf of the resident is valid only if: 1. The consent is given voluntarily and without coercive or undue influence. 4. The consent is evidenced in the resident's clinical record by a signed form prescribed by the facility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 4 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents' mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's care plan indicated her risk for elopement or interventions following an actual elopement. This failure could place residents at risk of not receiving appropriate care to prevent elopement. Record review of Resident #2's face sheet dated 11/22/2023 revealed an admission date of 6/26/23 with diagnoses which included: Huntington's Disease (progressive degeneration of the nerve cells of the brain), anxiety disorder, and major depressive disorder. Record review of Resident #2's Care Plan dated 7/11/2023 revealed a plan of care had not been developed and was not included in the resident's plan of care to show her risk for elopement and actual elopement event. Record review of Resident #2's quarterly MDS, dated [DATE] revealed a BIMS score of 12, which indicated a moderate cognitive impairment. Record review of Resident #2's Elopement Risk assessment dated [DATE] revealed she was at risk for elopement. Record review of Resident #2's progress notes dated 10/21/2023 revealed: Resident #1 was not seen in her room or bathroom and athe screen of the window was pushed out.Resident #2 was found at a local store in town and was returned to the facility (within a short amount of time) with an abrasion to her leg (minor). During an interview on 11/28/2023 at 4:22 p.m., the MDS Coordinator stated Resident #2's care plan did not include elopement or risk for elopement. She stated elopement should have been care planned for Resident #2 after the elopement incident had occurred which would have included interventions for care. The MDS Coordinator stated she was responsible for updating Resident #2's care plan. She stated nursing staff could update care plans but the primary responsibility for the care plan fell on her. She stated she was aware of Resident #2's elopement because she had spoken to the resident's physician after the event occurred (date unknown) and completed a medication review with the physician. The MDS Coordinator stated a care plan that was updated to include the resident's current status was important because it was the plan of care especially for someone who did not know the resident . During an interview on 11/28/2023 at 6:11 p.m., the DON stated she expected care plans to be updated immediately and as soon as possible so it was timely, as necessary. The DON stated a care plan that addressed Resident #2's risk for elopement and actual elopement was important because it was the plan of care on how the facility had decided to care for the patient so they could live their lives (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 5 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 to the fullest extent. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's, undated, policy, titled Care Plans (undated) revealed: Purpose: 1. To identify resident real and potential needs 2. To set achievable short- and long-term outcome goals 3. To document interdisciplinary interventions to achieve stated goals 4. To evaluate, review, and revise goals and approaches. Procedure: 5. MDS/CP Nurse (Care Plan) and Care Plan Team members will utilize the RAP summary to identify triggered problems, real and potential. 5. Care Plans will be updated to reflect changes in resident needs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 6 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 7 residents (Resident's #1, #2, and #3) reviewed for activities. Residents Affected - Some The facility failed to ensure there were organized activities provided to residents of the secured unit. This failure could place residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status. The findings included: Record review of the November activity calendar posted on the hallway wall in the secured unit revealed: -11/21/2023- 9:30 a.m. Men's Group, 10:00 a.m. outdoor meditation, 2:30 p.m. snacks and music, 3:30 p.m. Popcorn Social -11/27/2023- 9:45 a.m. Monday Manicures, 10:45 a.m. crosswords and coffee, 2:30 p.m. snacks and music, 3:30 p.m. ring toss and jeopardy -11/28/2023-9:45 a.m. Men's Group, 10:45 a.m. crosswords and coffee, 2:00 p.m. snacks and music, 3:30 p.m. 25 cent Bingo. Record review of Resident #1's face sheet dated 11/21/2023 revealed an admission date of 3/29/2021 with readmission date of 9/17/2023 with diagnoses which included: Parkinson's disease, psychotic disorder with delusions due to known physiologic condition, mood disorder due to known physiological condition, post-traumatic stress disorder, social and emotional deficit following nontraumatic intracerebral hemorrhage . Record review of Resident #1's quarterly MDS dated [DATE] revealed the resident had a severe vision impairment and had BIMS of 1 which indicated the resident was severely cognitively impaired. Record review of Resident #1's Care Plan revealed: Locked/secured unit related to poor decision making related to personal safety, wandering, dementia with interventions which included: encourage activities of choice to alleviate boredom and reduce stress. Little or no activity involvement due to resident wishes not to participate with interventions which included: The resident needs a variety of activity types and location to maintain interests. Record review of Resident #1's care plan dated 11/16/2022 and last revised on 8/02/2023 revealed Resident #1 had a behavior problem with interventions which included: provide a program of activities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 7 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0679 that is of interest and accommodates resident status. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's face sheet dated 11/22/2023 revealed an admission date of 6/26/23 with diagnoses which included: Huntington's Disease, anxiety disorder, and major depressive disorder. Residents Affected - Some Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated a moderate cognitive impairment. Record review of Resident #2's admission assessment dated [DATE] revealed the resident indicated it was very important to have books, newspapers, and magazines to read, listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do favorite activities, go outside to get fresh air when the weather was good and to participate in religious services or practices. Record review of Resident #2's care plan dated 7/11/2023 revealed the resident had depression with interventions which included: assist the resident in developing a program of activities that were meaningful and of interest. Encourage and provide opportunities for exercise, physical activity. Record review of Resident #3's face sheet dated 11/21/2023 revealed an admission date of 1/29/2014 with a readmission date of 12/15/2022 revealed a [AGE] year-old with diagnoses which included: bipolar disorder (mental health condition that affects mood), anxiety disorder, schizophrenia (mental health disorder) and major depressive disorder. Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated the resident was cognitively intact. The MDS indicated Resident #3 indicated it was very important to her to be able to listen to music she liked and go outside to get fresh air when the weather was good and somewhat important to have books, newspapers, and magazines to read, to be around animals such as pets, to do things with groups of people, to do her favorite activities and to participate in religious services or practices. Record review of Resident #3's Care Plan dated 4/27/2022 and last revised on 7/18/2023 revealed Resident #3 resided in the locked/secured unit with interventions which included: Encourage activities of choice to alleviate boredom and reduce stress. The Care Plan also revealed the resident was independent for meeting emotional, intellectual, physical and social needs with interventions which included: Activity Director to discuss/monitor for preferences, provide for in-room activities as needed and/or required, remind/encourage resident to attend, assist with activities as needed. During an observation on 11/21/2023 at 11:20 a.m. revealed no activities in the secured unit. Two to three residents were observed wandering in the hallways. Residents #2 and #3 were observed pacing near the secured unit entrance. Resident #1 was seated on the floor of his room in the corner of the room. During an observation and interview on 11/21/2023 at 11:28 a.m., Resident #3 was observed pacing near the entrance to the secured unit. She stated her full name and was able to recall events. She stated there was nothing for her to do during the day in the secured unit. She stated there were no activities. She stated she got to go outside to smoke 5 times a day but that was it . During an observation on 11/21/2023 at 2:30 p.m., no activities were observed in the secured unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 8 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 11/21/2023 at 2:41 p.m. revealed there were no activities in the secured unit. CNA B stated Resident #1 was blind, frustrated, and bored. She stated staff tried to distract him by putting him in his wheelchair and wheeling him up and down the hallway but there was only so much they could do. She stated there were no activities in the secured unit. During an observation on 11/21/2023 at 2:45 p.m. revealed there was a scheduled snack with music but no activities had occurred . Resident #2 was observed walking and pacing in the hallway near the secured unit entrance. During an observation on 11/21/2023 at 3:40 p.m., there were no activities occurring in the secured unit. Resident #1 was moving/crawling around the floor in his room. He was calm but active. Resident #2 was observed walking and standing in the hallway. Resident #3 was observed lying o her bed in her room . During an interview on 11/21/2023 at 3:44 p.m., NA A stated Resident #2 and Resident #3 had pacing behaviors. She stated both of them liked to go outside to smoke. She stated the secured unit did not have any thing to distract the residents. She stated there were no activities in the secured unit. She stated they did not even have colors or markers for the residents. She stated the residents of the secured unit did not get to go out to the parties and there was no games or activities of any kind. She stated she did not want to get in trouble for speaking up about the activities but felt like the residents deserved more . During an observation and interview on 11/21/2023 at 5:32 p.m., Resident #1 was observed in his wheelchair in the hallway. During the interview his eyes were looking down towards the floor and he did not move his eyes or his gaze or appear to be able to see. He stated he was blind and could see about 60% and could hear about 50%. He stated he enjoyed drawing, reading, listening to music, and watching TV . He stated in the past he spent a lot of time watching TV. He stated he had a TBI (traumatic brain injury) and had short term memory problems. Resident #1 was not able to remember that he just finished eating dinner or that he took medications. Due to his cognitive status, he was unable to answered detailed interview questions . During an observation and interview on 11/21/2023 at 5:37 p.m., Resident #2 was observed walking in the secured unit. She did not answer interview questions and it was unclear if she understood or if she chose not to respond. During an observation on 11/27/2023 at 11:00 a.m. revealed there were no organized activities in the secured unit. There were no activities in the activity room in the secured unit. The activity closet did not have any activities in it. The cabinet in the activity room was empty . On top of the cabinet in the activity room was a bead [NAME] and several employee drinking mugs. Resident #3 was observed watching TV in her room while lying on her bed. Resident #1 was sitting on the floor of his room without any activities. Resident #2 was observed standing in the hallway. During an observation and interview on 11/27/2023 at 11:11 a.m. Resident #1 was observed crawling on the floor of his room. There was no music playing and no TV. Resident #1 stated he did not know what he was doing (while crawling on floor). He stated there was not much to do. He stated he used to like to watch TV but now did not know if he could see it now (because he was visually impaired ). During an observation on 11/28/2023 at 4:15 p.m. through 4:47 p.m. bingo was observed in the main dining room of the facility with many residents in attendance. None of the residents from the secured (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 9 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0679 unit were included in the activity . Level of Harm - Minimal harm or potential for actual harm During an observation on 11/28/2023 at 5:20 p.m., the Activity Director entered the secured unit to show the State Surveyor where she kept activities in the secured unit. There were a few coloring pages that were not organized in a drawer and some markers and a puzzle. Upon entry, Resident #3 ran up to the Activity Director in an excited manner and hugged the Activity Director. Resident #3 was smiling and appeared exited to see the Activity Director. Resident #3 said to the Activity Director she (AD) forgot to bring her (Resident #3) the cinnamon roll and coke she had promised. The Activity Director responded by saying she (AD) took her (Resident #3) the snack while she (Resident #3) was smoking. Resident #3 stated, No, you did not. You said you would, but you never came back. The Activity Director argued back and forth with Resident #3 before saying she would get the snack and bring it to her in a few minutes . Residents Affected - Some During an interview on 11/28/2023 at 4:22 p.m., LVN C stated she had never seen any activities in the secured unit. LVN C stated Resident #3 went outside to smoke for an activity and could sometimes go into the main area of the facility for activities, but the Activity Director never came into the secured unit with activities. LVN C stated she was not aware of any activity supplies in the secured unit. She stated there was a TV that was not typically on if the residents wanted to watch it. LVN C stated the main activity for residents in the secured unit was smoking. LVN C stated she did not know why activities were important but stated she thought the residents in the secured unit should have them. During an interview on 11/28/2023 at 5:23 p.m., the Activity Director stated she was supposed to have at least 5 activities a day in both the main area of the facility and in the secured unit and was required by law to have separate activity calendars for the secured unit . She was unable to locate the secured unit activity calendar when asked for a copy and was unsure what was posted on the wall of the secured unit. The Activity Director stated she did provide activities in the secured unit but had not been back to the secured unit for activities for the past two weeks because she had been busy. She stated she had dropped off some coloring pages a couple of times in the secured unit but did not participate with the residents in activities. She stated she did not go into the secured unit at all on this day (11/28/2023). The Activity Director stated she had just not been able to go into the secured unit because she could not leave the other part of the building because she was busy. She became emotional during the interview and stated she was given a very limited budget to work with and she could not take supplies to the secured unit because they would disappear, and she would not see them again. The Activity Director stated when she was hired for the position, the Administrator told to her she needed to go into the secured unit. She stated it was the law for her to go back there. The Activity Director stated on Wednesday of last week (11/22/20023) the Administrator reiterated to her she had to go back into the secured unit. The Activity Director stated she knew it was her fault she did not go into the secured unit with activities, but she felt overwhelmed. She stated she informed the Administrator she was overwhelmed. The Activity Director stated she was new to the position of Activity Director. She stated she was working at the facility as a CNA and at the end of October 2023 the previous Activity Director left, and she was hired in the position. She stated she had never worked as an Activity Director before but felt confident she could do the position as she had worked with the elderly since 2008. She stated she had not yet signed up for the Activity Director classes but it was in the process of signing up. She stated she had an associate degree in applied sciences. The Activity Director stated the Administrator informed her when she was hired, she would have to complete the Activity Director courses which started in January 2024. The Activity Director stated Resident #3's family had communicated with her that she needed additional activities and they asked if Resident #3 could help her. She stated Resident #3 could come out of the secured unit for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 10 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some activities if she was supervised and liked to play Bingo. The Activity Director stated she did not invite Resident #3 out of the unit to play Bingo today. The Activity Director stated Resident #3 enjoys helping her with tasks, but she has to keep an eye on her, and she can't always do it. She stated Resident #3 liked to talk and discuss make up but again stated she could not watch her 24/7. The Activity Director stated Resident #2 wanders but also liked helping her with activities. She stated all Resident #1 liked was music. The Activity Director stated she had not gone into the secured unit to play music for him. The Activity Director originally stated she provided 1:1 activity to the residents of the secured unit but was unable to produce documentation. She then stated the previous Activity Director did not tell her she needed to provide 1:1 activities to residents who could otherwise not participate, and she did not know she needed to document those interactions. The Activity Director stated she had a cart for nail polish she used on some of the residents to polish their nails. She stated she did not take the nail cart into the secured unit. When asked why it was important for residents in the secured unit to participate in activities, she stated because it was the law. During an interview on 11/28/2023 at 6:11 p.m., the DON stated she expected the Activity Director to be present in the secured unit daily. She stated other staff could assist with activities, but she expected the Activity Director to initiate and/or direct activities and follow up. The DON stated it was important for quality of life that there were things to do in the secured unit other than stare at each other. The DON stated she (DON) was new to the facility and was not involved with the training of the Activity Director. She stated it was the Administrator who was responsible. The DON stated she did not want residents in the secured unit out in the main areas because unless it was a significant event like a Christmas activity or music, and the facility had the staff to supervise each resident. The DON stated Resident #1 would benefit from outdoor activities and activities using his hands. She stated Resident #2 was discharged to another facility (11/28/23). She stated Resident #3 spoke with her family frequently, had access to a phone, went on smoking breaks frequently and the Activity Director could find out Resident #3's personal preferences. During an interview on 11/28/2023 at 6:28 p.m., the Administrator stated she had been trying to find someone par-time to help the Activity Director. The Administrator stated she told the Activity Director she had to have at least 5 activities a day and have a calendar of activities. The Administrator stated she had several conversations with the Activity Director. She stated she told her she could not change the activities that were on the calendar and gave her some ideas. She stated she also discussed the secured unit with the Activity Director including the need for 5 activities a day. The Administrator stated the Activity Director was on a learning curve because she had never done it before , but the residents really liked her, and she was vivacious. The Administrator stated the Activity Director just had not been able to pull it all together with the secured unit. The Administrator stated she saw the residents color and the Activity Director took smokers outside once a day. The Administrator stated she was not monitoring the Activity Directors activities in the secured unit. The Administrator stated the job market for staff (in a rural area) was so limited and they had to do a lot to bring in the staff. Record review of the facility's, undated, policy titled Activities (undated) revealed the facility provided an ongoing program of resident activities. The activity program is designed to meet the interests and physical, mental, and psychosocial well-being of each resident in accordance with the resident's comprehensive assessment. The facility provides group and individual activities for all residents who are able to participate. All residents, particularly bedfast and those residents unable to participate in group activities will be visited by the Activity Director and/or a volunteer. A monthly calendar is posted at the beginning of each month in an area that is accessible and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 11 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0679 frequented by the residents. A balance of recreational activities including physical, social, religious, arts and crafts, diversional and intellectual, will be planned. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 12 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 4 residents (Resident #2 and #4) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #2 did not elope from the facility on 10/21/2023. 2. The facility failed to ensure Resident #4 did not elope from the facility on 8/27/2023 These failures could place residents at risk for elopement and could result in injury or a decline in health. The findings included: 1. Record review of Resident #2's face sheet dated 11/22/2023 revealed an admission date of 6/26/23 with diagnoses which included: Huntington's Disease, anxiety disorder, and major depressive disorder. Record review of Resident #2's care plan dated 7/11/2023 revealed the resident did not have a plan of care to include her risk for elopement or actual elopement on 10/21/2023. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 12, which indicated a moderate cognitive impairment and no wandering behaviors. Record review of Resident #2's Elopement Risk assessment dated [DATE] revealed the resident was at risk for elopement with a score of 13. The assessment indicated a score of 10 or more put the resident at risk for elopement. The assessment indicated the IDT team had determined no elopement precautions were necessary at the time of the assessment. Record review of a facility's self-report dated 10/28/2023 revealed on 10/21/2023 at 10:30 a.m., Resident #2 had eloped from the building out of a window. She was located at 11:00 a.m. on the same day at a local store down the road. Resident #2 was assessed for injuries and was noted with a minor abrasion to her right leg. Resident #2 stated she was not in any pain and no treatment was provided. Resident #2's family member and physician were notified, and she was placed on every 15-minute checks to prevent (another) elopement and ensure her safety. The report indicated staff were in-serviced on resident abuse and the facility elopement policy. Record review of Resident #2's progress notes dated 10/21/2023 revealed the psych MD was notified of Resident #2's attempt to leave the facility and medications were reviewed. A new order for Zyprexa was ordered. Record review of Resident #2's medical record revealed a new Elopement Risk Assessment was not completed after her actual elopement on 10/21/2023 . Record review of Resident #2's care plan revealed the resident did not have a plan of care to include her risk for elopement or actual elopement on 10/21/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 13 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm During an observation on 11/21/2023 at 11:20 a.m. revealed Residents #2 pacing near the secured unit entrance but was not trying to exit. During an observation on 11/21/2023 at 2:45 p.m. Resident #2 was observed walking and pacing in the hallway near the secured unit entrance. Residents Affected - Some During an observation/interview on 11/21/2023 at 5:37 p.m., Resident #2 was observed walking in the secured unit. She did not answer interview questions and it was unclear if she understood or if she chose not to respond. During an interview on 11/22/2023 at 10:59 a.m., Resident #2's family member stated she was notified Resident #2 had eloped from the facility. The family member stated this was not the first time it had happened. She stated she did not remember when Resident #2 got out of the facility or where exactly she was found. She stated Resident #2 was a drug abuser and there was concern she would get out of the facility to seek drugs. She stated the Administrator had called her and had a conversation with her after she recently got out of the facility and stated she thought Resident #2 would be happier closer to her family. The family member stated Resident #2 would always say she was looking for family when she got out of the facility. The family member stated she was in agreement to move Resident #2 closer to her and had found a facility that was closer. During an interview on 11/27/2023 at 11:22 a.m., CNA L stated Resident #2 had eloped from the facility in October 2023. She stated Resident #2 pushed out a window and climbed through. CNA L stated it was close to a mealtime and staff were unable to locate the resident. She stated she was trained to look everywhere inside and outside. She stated since Resident #2 could not be located on the premises the department heads went to look for her. CNA L stated Resident #2 was located at a store which she confirmed on a map was 0.6 of a mile from the facility. CNA L stated Resident #2 was a fast walker and had walked there looking for her daughter. CNA L stated when she came back, she did not see any injuries. CNA L stated she was trained to check on the residents every 2 hours but if they go missing to notify the charge nurse and then start searching. CNA L stated she was given an in-service on elopement the same day as the incident (unknown date) by the MDS Coordinator . During an interview on 11/27/2023 at 3:09 p.m., LVN F stated she was the charge nurse on the day Resident #2 opened a window, kicked out the screen and left. She stated she had just seen Resident #2 15-30 minutes prior to the incident. She stated she was sitting on her bed. LVN F stated she later went by the room again and noticed the door was closed, which was unusual. She stated she went into the room to see what was going on. LVN F stated she saw the window open, and the screen pushed out. LVN F stated she notified the Administrator (former) and staff searched the building but could not find the resident. LVN F stated several staff went into the community and found her at a local store and brought her back. LVN F stated when Resident #2 came back to the facility she completed an assessment. She stated she noted a few scratches on her leg that were not deep and did not require medical care. LVN F stated Resident #2 told her she had fallen but there were no other injuries, and she was not complaining of pain. She stated she washed the scratches and notified the physician and family. LVN F stated the Administrator spoke with family about moving the resident to another facility. She stated to her knowledge it was the first elopement. LVN F stated Resident #2's physician said to keep an eye on the resident but did not give any new orders. LVN F stated keep an eye on her meant every 15minute checks. LVN F stated Resident #2 did not make any other attempts but was placed in the secured unit after the incident. During an interview on 11/28/2023 at 4:09 p.m., the Administrator stated Resident #2 had a previous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 14 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some history of eloping from the building (unknown dates) The Administrator stated Resident #2 had a high BIMS score and knowingly made the decision to exit the building saying she was going home (to another city). The Administrator stated Resident #2 was a known drug abuser. She stated she had multiple conversations with Resident #2 where she had voiced understanding of her requirement and need to stay in the facility. She stated she had also had conversations with the RP about Resident #2's elopement and spoken desire to be with family and made a plan for the resident's safety which included a facility discharge. The Administrator stated she had issued a 30-day discharge to Resident #2 and the family for safety reasons. Record review of a facility in-service dated 10/21/2023, revealed 26 staff were in-serviced on the facility abuse policy and facility elopement policy which included the right to leave, and procedures for missing residents. 2. Record review of Resident #4' s face sheet dated 11/28/2023 revealed an admission date of 11/20/2017 with readmission date of 1/17/2020 with diagnoses which included: schizophrenia, major depressive disorder, and anxiety disorder . Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9, which indicated a moderate cognitive impairment and no wandering behaviors. Record review of Resident #4's Elopement Risk assessment dated [DATE] revealed he was at risk for elopement with a score of 18. The assessment indicated a score of 10 or more indicated the resident was at risk for elopement. Record review of the facility self-report dated 9/05/2023 revealed on 8/27/2023 at 11:00 p.m., Resident #4 eloped from the facility. Resident #4 exhibited exit-seeking behaviors in the evening and LVN K noticed Resident #4 was watching the exit doors which she had re-redirected him away from on several occasion. The report indicated at approximately 11:00 p.m. LVN K did not notice Resident #4 sitting at the dining room table, a high traffic area where she had left him. She directed all staff in the building to begin searching for Resident #4. On 8/27/2023 at 11:40 p.m., Resident #4 was assessed and found to have no injuries after he was found off facility property down the road and brought back to the facility. The investigative summary revealed through video Resident #4 was seen watching CNA staff take wheelchairs outside to wash. Resident #4 found the opportunity and went out the dining room door that had not closed properly. He walked approximately 1/8 mile from the facility. The report indicated staff were in-serviced on being mindful of making certain the doors closed completely behind them and to make sure the door magnet latches, and they double checked it by pulling or pushing on the door after they opened/closed them. This self-report was signed by a previous Administrator. Record review of Resident #4's progress notes revealed staff documented his elopement in the medical record and indicated Resident #4 was brought back to the facility, placed on the secured unit as an intervention until he acute change of condition of exit seeking was resolved with every 15-minute checks. The progress note indicated Resident #4 was examined for any injury and was free from injury with notifications to RP and physician. Record review of Resident #4's Care Plan dated 9/26/2023 revealed the resident was a wanderer and was at risk for elopement with interventions which included: Distract resident from wandering by offering pleasant diversions structured activities, food, conversation, television, book. Identify pattern of wandering, intervene as appropriate, provide structured activities: toileting, walking inside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 15 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 and outside, reorientation strategies including which included signs, pictures and memory boxes. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/28/2023 at 3:23 p.m., LVN C stated Resident #4 would walk around the facility but was not exit seeking at this time. LVN C stated she had received training on elopement and behaviors and was trained to approach and speak calmly to the resident, redirect the resident, attempt to solve their problems or issues and ask the residents to follow her away from the exits. LVN C stated if a resident was missing the staff were trained to check their rooms and bathrooms and knowing their habits their frequented areas. She stated they then searched common areas, the inside of the building and then the exterior of the facility and asked other staff for assistance. She stated they notified the RP, the DON and the Administrator and if unable to locate the resident they would notify the policefor assistance . Residents Affected - Some During an interview on 11/28/2023 at 6:11 p.m., the DON stated she was new to the facility and had only worked there for 2 weeks. She stated she had no knowledge of either elopement. She stated her expectations if a resident was exit seeking was to place the resident on either 1:1 observation or every 15 minute monitoring. She stated it was important to see the resident and know their location if they were exit seeking. The DON stated a resident who eloped should be evaluated for the secured unit with the family, and the physician during an IDT meeting. The DON stated if a resident went missing, staff should search inside, outside and the facility perimeter, find out when and where they were last seen, notify the DON/Administrator and local authorities if the resident could not be located. The DON stated once the resident was back at the facility, the nurse should assess for change of condition, injuries or stress. During an attempted interview on 11/28/2023 at 3:08 p.m. attempts were made by phone and text message for LVN K but no return calls were received. During an interview on 11/28/2023 at 3:23 p.m. with LVN C, Resident #2 and Resident #4's current charge nurse, stated she had not observed any exit seeking behavior for Resident #2 or Resident #4. She stated the residents walked around but were not exit seeking. LVN C stated she was trained to speak calmly, redirect the resident, attempt to problem solve any issues and ask them to follow her away from the exit. She stated she was trained to look for the resident, know the residents habits, check rest rooms, common areas and ask other staff with assistance in locating the resident by looking both inside and outside the facility. She stated she was trained to notify the RP, MD, DON and Administrator and notify the police if the resident could not be quickly located. Record review of the facility's, undated, policy titled Elopement Policy and Procedures: Time is of the essence when it is suspected that a resident is missing .Once resident is found, the Executive Director or Designee will: notify the family, complete a physical examination to determine if medical attention is necessary, document event in the resident's medical record, notify the residents physician of the event, initiate an incident report, investigate the incident .Executive Director and/or Licensed Nurse will: Assess the resident for further elopement risk FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 16 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 of 4 residents (Resident #1) reviewed for medically related social services. Residents Affected - Few The facility failed to ensure a Social Worker assisted Resident #1 in obtaining a legal guardian to look after his best interest and make medically related medical decisions for the resident. This deficient practice could place residents at risk of unmet needs due to insufficient medically related social services. The findings included: Record review of Resident 1's face sheet dated 11/21/2023 revealed an admission date of 3/29/2021 with readmission date of 9/17/2023 with diagnoses which included: Parkinson's disease, psychotic disorder with delusions due to known physiologic condition, mood disorder due to known physiological condition, post-traumatic stress disorder, social and emotional deficit following nontraumatic intracerebral hemorrhage. Record review of Resident #1's face sheet dated 11/21/2023 revealed There were no contacts listed for Responsible Party, next of kin, emergency contact, family members or legal guardianship. The facility listed Resident #1 as self in the contacts list . Record review of Resident #1's quarterly MDS dated [DATE] revealed the resident had a severe vision impairment and had BIMS of 1 which indicated the resident was severely cognitively impaired. Record review of Resident #1's Care Plan revealed: Locked/secured unit related to poor decision making related to personal safety, wandering, dementia with interventions which included: Record review of Resident #1's Care Plan dated 3/03/2022 revealed Resident #1 used psychotropic medications with interventions which included: Discuss with MD and family ongoing need for use of medication. Review behaviors/interventions and alternate therapies and their effectiveness per facility policy. Educate the resident/family/caregivers about risks, benefits and side effects and/or toxic symptoms (of) medications. Record review of Resident #1's physician order Summary for November 2023 revealed physician orders for the following medications: -Ativan (lorazepam) (a class a medication known as benzodiazepines which affect the brain and are depressants that produce sedation and hypnosis) 1 mg , give 1 tablet three times a day for anxiety ordered on 3/01/2022. -Cymbalta delayed release (class of medication which affect the chemicals in the brain) 30 mg, give 1 capsule by mouth one time a day related to depression ordered on 1/06/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 17 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Doxepin (tricyclic antidepressant a class a medication which affects the chemicals in the brain) 100 mg, give 1 capsule by mouth at bedtime for insomnia with an order date of 8/09/2023. -Haloperidol (an antipsychotic medication which affects the brain) 5 mg, give 1 tablet by mouth two times a day related to psychotic disorder with delusions due to known physiological condition with an order date of 5/31/2023 -Lithium Carbonate (a mood stabilizer used to treat schizophrenia, bipolar disorder and depression and affects the brain) 300 mg, give 1 capsule by mouth three times a day related to mood disorder due to known physiological condition order date 11/19/2023. -Melatonin (sedative that affects the brain) 5 mg, give two tablets by mouth at bedtime related to insomnia with an order date of 3/01/2022. -Zyprexa 10 mg (antipsychotic medication that affects the brain) 10 mg, give one tablet, two times a day related to mood disorder due to known physiological condition with order date of 3/01/2022. Record review of Resident #1's medical record revealed no signed consents from an RP or guardian for the use of Ativan, Cymbalta, Doxepin, Lithium Carbonate, or Melatonin and no consents or form 3713 consents for the use of antipsychotic medications haloperidol or Zyprexa . During an interview on 11/27/2023 at 11:44 a.m., LVN C stated Resident #1 was not able to make decisions for himself because he had dementia and behaviors. She stated Resident #1 also did not have family to make decisions for him. She stated normally she would look in the medical record to see who the residents RP was. She stated because Resident #1 did not have a RP they notified the physician who made decisions for the resident . During an interview on 11/27/2023 at 3:56 p.m., LVN I stated Resident #1 had behaviors which included frustration, agitation and acting out. She stated Resident #1 seemed unaware of his behaviors and when asked he would say he did not know why he was doing it. LVN I stated staff had to anticipate his needs. LVN I stated Resident #1 could answer yes or no questions but she stated she did not know if he could make decisions for himself. She stated if he had a low BIMS score or had dementia, he would not be able to give consent for anything. LVN I stated Staff G tried to get guardianship for Resident #1 before she left but did not know what happened. During an interview on 11/27/2023 at 4:19 p.m., the DON stated Resident #1 did not have a RP on file. She stated she would want more testing to determine if he was competent to make decisions for himself but did not know who was responsible for this testing. The DON stated generally a dementia diagnoses meant that a resident could not make decisions for themselves. She stated the Social Worker was normally someone who assisted with guardianship. The DON stated the facility had a part-time Social Worker (SW J ). During an interview on 11/27/2023 at 4:32 p.m., SW J stated she was working at the facility part time weekends which began on 11/11/2023. She stated she determined if a resident was able to make decisions for themselves by looking at their BIMS. She stated an individual with an intact to moderate impairment could typically make their own decisions. She stated a moderate impairment was dependent on the resident's personal status. SW J stated Resident #1 had a severe cognitive impairment. She stated she would consider Resident #1 as definitely impaired. She stated he should not sign his own consents because of his mental capacity. SW J stated the facility should get an outside guardian for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 18 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0745 Level of Harm - Minimal harm or potential for actual harm Resident #1 and there were ways to go about getting one with the state. SW J stated this was her first time working at a place where the residents had such severe disorders. She stated she knew there were guardianship resources but had not started any guardianship process for Resident # 1. She started she had just started working with the facility and she had another full-time job and had notified the Administrator she could only work PRN (as needed, part time basis ). Residents Affected - Few During an interview on 11/27/2023 at 4:59 p.m., Staff G (otherwise known as the facility SW) stated she was working in social services at the facility. She stated she was not licensed as a Social Worker and would not graduate from college with her bachelor's degree until May 2024. She stated she was working under another SW at another facility. She stated she could not remember the name of the Social Worker she was working under or the name of the facility in which she was affiliated. Staff G stated Resident #1 did not have family or RP. She stated the facility nurses and physician made decisions on what was best for the resident in leu of an RP because Resident #1 did not have anybody. Staff G stated she did not seek out a guardian for Resident #1. She stated the SW she was working with (unknown name, unknow affiliation) told her to call APS (Adult Protective Services). Staff G stated APS said no to guardianship because Resident #1 was already in a nursing home facility. Staff G stated she spoke to the owner of the facility, and he told her to contact the State about guardianship. She stated since she had already called APS for referral, and they said no there was nothing else for her to do. Staff G stated she did not reach out to anyone else and did not contact the State Ombudsman because the facility did not have one. Staff G stated the facility knew she was not licensed as a Social Worker. She stated she told the previous Administrator and DON during her interview she was not licensed, and they said okay. She stated the facility did not offer her any other guidance or resources to do her job. Staff G declined to be further interviewed and disconnected the call. During an interview on 11/27/2023 at 5:43 p.m., SW H stated she was a licensed Social Worker at a sister facility in a different city than the facility. She stated she was available for questions and advice if the facility got into a bind and did not know what to do but she was not the SW for the facility. SW H stated in the past 6 months no one at the facility had reached out to her or asked for advice. She stated she was not providing oversight to Staff G and was not her supervisor. She stated if a resident did not have a family or RP and had a low BIMS score, depending on the county in which they resided, the facility would need to put a call into a company that provided professional guardianship. She stated it was a process that involved a judge. SW H stated no one at the facility had reached out to her or asked for assistance with obtaining guardianship for any resident. She stated she could not speak for Staff G except to say she was in training and in school and not a licensed SW and should have spoken to the facility Administrator about guardianship. During an interview on 11/28/2023 at 12:25 p.m., the Administrator stated Staff G was already on staff when she came on board (as Administrator). She stated she was told by the company she was working under the other SW (SW H at the sister facility). The Administrator stated Staff G was functioning as a Social Worker at the facility even though she was not licensed as a Social Worker. The Administrator stated she was not aware Resident #1 did not have a RP, family, or guardian. She stated guardianship for Resident #1 had not been discussed prior to surveyor intervention. During an interview on 11/28/2023 at 6:28 p.m., the Administrator stated the facility did not have a policy for a resident without a RP or guardianship. Record review of the facility's, undated, policy, titled Social Services revealed: The facility provides medically related social services. The social service program is designed to assist each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 19 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0745 This includes assisting resident in maintaining or improving their abilities to manage their everyday physical, mental, and psychosocial needs. 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: 675931 If continuation sheet Page 20 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 4 staff (Staff C) reviewed for staff qualifications . Residents Affected - Some The facility failed to ensure Staff G completed the appropriate educational requirements of a bachelor's degree in social work and was appropriately licensed to practice social work in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly trained and supervised. The findings included: Record review of Staff G's personnel file revealed: date of hire 9/19/2022 with position hired listed as Social Worker signed by the HR Director. There was no signed job description and no license to practice as a Social Worker in the State of Texas. During an interview on 11/27/2023 at 4:59 p.m., Staff G stated she was working in social services as the Social Services Director at the facility but had not completed her training and did not graduate with her bachelor's degree until May of 2024. Staff G stated she had worked at the facility for a little over a year under a SW at another facility. She stated she no longer worked at the facility . Staff G stated she could not remember the name of the SW she worked under or the name of the facility in which she was affiliated. Staff G stated she sent the SW an email on Fridays just to keep in touch or to communicate any questions . Staff G stated the last time she worked at the facility was the last week of October 2023. She stated she left for personal reasons. Staff G stated she provided BIMS assessments, completed PASRR stuff, worked on crisis intervention through the local authority. She stated if a resident was depressed/suicidal she would send them out to a local hospital and do crisis intervention. She stated she also sent out referral packets for discharges. She denied doing any counseling of residents. She stated she did conduct a men's discussion ground where they talked about their feelings and about family and nursing home care. She stated she also worked on facility grievances. Staff G stated she did let facility management know she was not licensed as a Social Worker. She stated a former Administrator and former DON interviewed her. She stated both left within a week of when she was hired. Staff G stated during the interview she told them she was in school, and they said okay and did not receive any further direction. She stated she was not given any guidance or resources for her job. She stated she declined to be further interviewed at this point and ended the phone call. During an interview on 11/27/2023 at 5:43 p.m., SW H stated she was a licensed SW at a sister facility in another city and acted as a liaison to this facility. She stated she did not go in person to the facility but was available for questions or advice if they got into a bind and did not know what to do. SW H stated she was not a SW for the facility. She stated within the last 6 months no one from the facility asked her for advice. SW H stated she was available for consult only to Staff G, but she was not providing any oversight to her or her work. SW H stated Staff G was a student who had not yet entered into her internship for social work. SW H stated she had sent a text to Staff G offering preceptorship to her, so she would have been directly involved with her including consulting and education, but Staff G declined. SW H stated Staff G stated her school did not want her preceptorship to be at a place where she worked. SW H stated Staff G stated she needed to move forward in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 21 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some different way. SW H stated this text conversation occurred in September 2023. SW H stated she was not reviewing or proving oversight to any of Staff G's work. SW H stated she was unsure what her contract was with the facility, but as a student she should not be signing off on MDS's and could not sign her name as a licensed Social Worker or sign anything as a Social Worker. SW H stated Staff G could write progress notes but only if she signed them as an intern, not as a social worker. The notes should have her name followed by the word intern. SW H stated it was her understanding Staff G was not signing off on anything. SW H stated she was not Staff G's supervisor and did not review her notes or work. She stated it would have been up to the Administrator to supervise Staff G. SW G stated she was only on retainer to answer questions. During an interview on 11/28/2023 at 10:15 a.m., the HR Director stated Staff G was in the facility Social Worker role working under SW H a SW at a sister facility. The HR Director stated she was aware Staff G was not licensed as a Social Worker. She stated it was really hard to get a Social Worker out there (rural area). The HR Director stated Staff G had explained she was a student and was to graduate in May 2024. She stated SW H would get with Staff G two times a month and was being paid from the facility budget to consult with Staff G. The HR Director stated Staff G was to call SW H with any questions and she thought they communicated through emails. The HR Director stated she did not see any of the emails and did not monitor or review them. The HR Director stated her understanding of what Staff G could do in the role was she was not allowed to sign any papers or documentation and her role was limited. The HR Director stated Staff G was hired to assist with Medicaid/Medicare applications and if one of the residents acted up, she would talk with the resident. The HR Director stated Staff G was a part of the care plan meetings with the residents, helped with smoking assessments, and helped residents obtain ID's. The HR Director stated she made the name badge for Staff G and it stated Staff G's name, Social Worker. The HR Director stated Staff G was presenting as a Social Worker. She stated Staff G never said she could not present that way. The HR Director stated Staff G gave her the name of the school she was attending and told her she would be graduating but left the facility to work at a local school. The HR Director stated she did not verify her references or school attendance . She stated that would have been an Administrator responsibility. The HR Director stated she did not interview Staff G for the Social Worker role. She stated a former Administrator interviewed her on her own and told her that was who the facility was hiring. The HR Director stated she could not remember who the Administrator was, just that it was not the current one. The HR Director stated if there was no signed position description in Staff G's personnel file then she probably did not sign one. During an interview on 11/28/2023 at 12:25 p.m., the Administrator stated Staff G was already on staff when she came on board (as Administrator). She stated she was told by the company she was working under the other SW (SW H at the sister facility). The Administrator stated Staff G told her she did not have a degree and had just started her internship as a student. She stated everyone knew she did not have a degree and it had been discussed with her. The Administrator stated Staff G had quit. The Administrator stated Staff G was functioning as a Social Worker at the facility even though she was not licensed as a Social Worker. The Administrator stated she was not aware Staff G did not have any oversight from SW H at the sister facility . The Administrator stated she had never called or verified Staff G was officially enrolled in college as a student of social work. She stated she was just told by Staff G she was working on a preceptor ship through her school and was enrolled in an online college. The Administrator stated Staff G was very good with the residents. The Administrator stated because of their rural location they did not get many qualified candidates for the Social Worker position . During an interview on 11/28/2023 at 1:38 p.m., facility owner E stated he was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 22 of 23 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hiring the Administrator and the Administrator was responsible for hiring support staff for the facility. He stated he did not participate in hiring Staff G for Social Services. He stated he was aware Staff G was not licensed as a Social Worker to practice social work. He stated Staff G was supposed to be writing progress notes and communicate concerns to a Social Worker at a sister facility (SW H) to collaborate with her. He stated Staff G was supposed to interact with residents and any social services need were to be discussed with the facility Administrator. Owner E stated the Administrator should be involved with direction. He stated technically the facility should have a licensed SW part time, or an unlicensed SW designee could participate with oversight with a licensed SW. Owner E stated oversight of Staff G was an in-house leadership task to be supervised by SW H from the sister facility and the Administrator. He stated they should be communicating during morning meetings. Record review of Staff G's, undated, resume revealed: Seeking an position [sic] in social services to continue working with and enabling people to achieve the best possible levels of personal and social well-being. She listed her education as enrolled in a Bachelor of Social Work program. Record review of the facility's, undated, policy, titled Social Service Director revealed: The social service program is directed by either a full-time qualified social worker or a qualified social worker is contracted with to provide social services at a sufficient amount of time to meet the needs of the residents. The qualified social worker will be licensed by the Texas State Board of Social Work Examiners and have a bachelor's degree in social work and one year of supervised social work experience in a health care setting working directly with individuals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 23 of 23