Inspection·July 31, 2025

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of medications. Date Initiated: 02/20/2025 . The resident has a mood problem r/t schizophrenia, depression, has hallucinations and yells at things that are not there. Date Initiated: 02/20/2025 . A record review of Resident #2's physician's orders dated 7/31/2025 revealed the physician prescribed for Resident #2:- To receive trazodone 50mg 1 tablet twice a day for depression.- To receive divalproex 500mg 1 capsule twice a day for schizophrenia.- To receive ziprasidone 80mg 1 tablet twice a day for schizophrenia.- To receive haloperidol 5mg injection once for anxiety. A record review of Resident #2's medication administration record for the period from 7/1/2025 through 7/30/2025 revealed the nursing staff administered the following medications daily:- Trazodone 50mg.- Divalproex 500mg.- Ziprasidone 80mg.- Haloperidol 5mg injection, once on 7/16/2025. A record review of Resident #2's medical record for the period 2/1/2025 to 7/31/2025 revealed:Consent for antipsychotic or neuroleptic medication treatment dated 2/12/2025, revealed a consent for ziprasidone without any documentation for the section: In my clinical opinion: the probable clinically significant side effects and risks of the proposed treatment with antipsychotic or neuroleptic medications are indicated: or the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medication is indicated:- Consent for antipsychotic or neuroleptic medication treatment dated 2/12/2025, revealed a consent for divalproex without any documentation for the section: In my clinical opinion: the probable clinically significant side effects and risks of the proposed treatment with antipsychotic or neuroleptic medications are indicated: or the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medication is indicated: - Consent for antipsychotic or neuroleptic medication treatment dated 2/12/2025, revealed a consent for haloperidol without any documentation for the section: In my clinical opinion: the probable clinically significant side effects and risks of the proposed treatment with antipsychotic or neuroleptic medications are indicated: or the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medication is indicated: - Consent for antipsychotic or neuroleptic medication treatment dated 2/12/2025, revealed a consent for trazadone without any documentation for the section: In my clinical opinion: the probable clinically significant side effects and risks of the proposed treatment with antipsychotic or neuroleptic medications are indicated: or the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medication is indicated: A record review of Resident #2's Psychiatry Initial Evaluation dated 1/16/2025, revealed, chief complaint reason for this visit evaluation on patient with complex psychiatric issues that requires continued monitoring, evaluation, medication review and treatment. Plan of care and treatment discussed with nurses. Patient seen for comprehensive psychiatric evaluation for schizophrenia, anxiety, agitation, and insomnia. HPI [history of present illness] relating to this visit; [AGE] year-old female seen in the nursing home via tele visit. Staff assist with visit due to visit platform and memory issues. She is alert and oriented times 3. The patient is new to the facility and has a diagnosis of schizophrenia upon admission. She has been having behaviors and acting manic. She has been responding to internal stimuli. She has been arguing with herself according to staff and attempting to choke herself. During an observation and interview on 7/28/2025 at 11:00 AM Resident #2 resided in the secured memory care unit of the facility. An attempted interview with Resident #2 revealed she was calm but confused and could respond to her name. Further observation revealed LVN D attended to residents in the secured memory care unit. LVN D stated Resident #2 was alert to herself and received antipsychotic medications for example Geodon (ziprasidone). LVN D stated she was unaware if Resident #2 had an informed consent due to her representative had no contact with her or the facility, I have tried to call him . there is no answer. 2A record review of Resident #25's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 2 of 15 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 07/31/2025 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 Residents Affected - Some admission record dated 7/31/2025 revealed an admission date of 1/27/2025 with diagnoses which included dementia. A record review of Resident #25's quarterly MDS assessment dated [DATE] revealed Resident #25 was a [AGE] year-old female admitted for LTC related to dementia and was assessed with a BIMS score of 04 which indicated severe cognitive impairment. A record review of Resident #25's care plan dated 7/31/2025 revealed, I am at risk for injury from wandering in an un- safe environment R/T DX of (DEMENTIA) AEB [as evidenced by] impaired safety awareness. I am at risk for injury from others while residing in secure/ memory unit D/T altered cognition. Date Initiated: 04/29/2025 . A record review of Resident #25's physicians orders dated 7/31/2025 revealed the physician prescribed for Resident#25 to receive:- Divalproex 500mg twice a day for dementia.- Lorazepam 1mg twice a day for anxiety. A record review of Resident #25's medical record for the period 1/28/2025 to 7/31/2025 revealed:- Consent for antipsychotic or neuroleptic medication treatment dated 5/25/2025, revealed a verbal consent for divalproex without a second nurse to witness and sign the consent.- Consent for antipsychotic or neuroleptic medication treatment dated 1/28/2025, revealed a verbal consent for lorazepam without a second nurse to witness and sign the consent.- A Medical Power, Authorization and Directive dated 12/19/2019, (Resident #25) appoint (Resident #25's Representative) as my agent to make any and all health care decisions for me . limitations on the decision making authority of my agent are as follows: NONE. During an interview on 7/30/2025 at 1:10 PM Resident #25's Representative stated he visited Resident #25 often, at least twice a week. Resident #25's Representative stated he could not recall if he ever gave a verbal consent for Resident #25's medications but did recall he often communicated with the nurses and they may have communicated details about her medications. He said, I don't know much about my sweeties medications, but if she needs them I want her to have them. During an interview on 7/30/2025 at 1:20 PM LVN A stated Resident #25's representative was Resident #25's legal representative. LVN A stated Resident #25 received divalproex and lorazepam for dementia and anxiety. LVN A stated the DON was responsible for documenting consents. LVN A stated she had reviewed the consent documents for Resident #25's lorazepam and divalproex and recognized the verbal consents were only signed by the DON. LVN A stated she believed a verbal consent should be witnessed and signed by 2 nurses. 3A record review of Resident #59's admission record dated 7/30/2025 revealed an admission date of 7/24/2024 with diagnoses which included schizophrenia. A record review of Resident #59's quarterly MDS assessment dated [DATE] revealed Resident #59 was a [AGE] year-old male admitted for LTC related to his needs for safety related to his hallucinations and difficulties coping with realities. Resident #59 was assessed with a BIMS score of 04 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #59's care plan dated 7/30/2025 revealed, Resident's family expresses the desire to have the resident stay in facility long term. POA- (power of attorney) Resident #59's Representative) Date Initiated: 08/06/2024 . Resident resides in a locked/secured unit related to poor decision making related to personal safety, wandering, dementia Date Initiated: 08/06/2024 . The resident has impaired cognitive function/dementia or impaired thought processes r/t Vascular Dementia, schizophrenia, Date Initiated: 08/06/2024 . The resident uses psychotropic medications r/t Behavior management Date Initiated: 08/06/2024. A record review of Resident #59's physicians orders dated 7/30/2025 revealed the physician prescribed for Resident #59 to receive:Risperidone 1mg 1 tablet twice daily. A record review of Resident #59's medical record for the period 7/24/2024 to 7/31/2025 revealed:- Consent for antipsychotic or neuroleptic medication treatment dated 2/08/2025, revealed a verbal consent for divalproex without a second nurse to witness and sign the consent. During an interview on 7/29/2025 at 10:00 AM Resident #59's Representative stated she could not visit Resident #59 due to her lack of transportation and limited physical abilities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 3 of 15 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 07/31/2025 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #59's Representative stated she often spoke to Resident #59 and the nursing staff on the telephone. Resident #59's Representative stated she did not recall giving a verbal consent for the medication divalproex but did want Resident #59 to receive medications the physician prescribed. During an interview on 7/30/2025 at 3:40 PM LVN MDS stated:- Resident #2 had a signed consent for trazodone, haloperidol, divalproex, and ziprasidone; however, the consents were blank for any risks vs benefits documentation. LVN stated Resident #2 was confused but still could score 11 out of 15 on a BIMS score which indicated mildly impaired cognition. LVN stated Resident #2 may not be able to recall her medications, their benefits, nor potential risks.- Resident #25 and Resident #59 had verbal consents signed by the DON without a second nurse to witness the verbal consent. During an interview on 7/30/2025 at 4:10 PM the ADON stated:- The ADON stated she reviewed the consents for Resident #2 and concluded the consents did not document any benefits vs risk for the medication.- Resident #25 and #59 had verbal consents documented without a second nurse to witness the verbal consents.The ADON stated the DON was responsible for obtaining informed consents for Residents. The ADON stated the training and expectations was for nurses to obtain consent for medications prior to their administration and the consent should have documentation for patient Resident education for benefits vs risk for the proposed medications. The ADON stated in a situation where the resident's representative gave consent verbally the expectation was for nursing staff to have 2 nurses witness the verbal consent and sign the consent. During an interview on 7/31/2025 at 3:30 PM the DON stated he was responsible for informed consents for residents who received antipsychotic, antidepression, and neuroleptic medications. The DON stated if a consent was given verbally there was no need for 2 nurses to witness and sign the consent. The DON stated the benefits, and the potential risks of the proposed medication was discussed with residents and their representative but may not have been documented on the consent forms. The DON stated he was responsible to ensure the consents were obtained and documented. During a joint interview on 7/31/2025 at 5:00 PM the Regional Clinical Nurse and the Administrator stated the facility policy and expectation was for nurses to obtain informed consent prior to any administration of antipsychotics, neuroleptics, and or antidepressant medications. The Regional Clinical Nurse stated informed consent included a resident's education with understanding of the proposed benefits and potential risks of the intended treatments and or medications. The Regional Clinical Nurse stated in the case where a verbal consent was obtained the facility policy and procedure would be for the nursing staff to have a second nurse witness the consent and sign the document. The Regional Clinical Nurse stated the potential risk to residents could be lack of informed consent for the therapies they received. A policy was requested, and the Administrator stated the facility followed HHSC guidelines A record review of the United States of America's National Library of Medicine, undated website titled, Informed consent adultshttps://medlineplus.gov/ency/patientinstructions/000445.htmaccessed 7/31/2025 revealed, You have the right to help decide what medical care you want to receive. By law, your health care providers must explain your health condition and treatment choices to you. What Should Occur During the Informed Consent Process?When asking for your informed consent, your provider must explain:Your health problem and the reason for the treatmentWhat happens during the treatmentThe risks of the treatment and how likely they are to occurHow likely the treatment is to workIf treatment is necessary now or if it can wait and the consequences of waitingOther options for treating your health problemRisks or possible side effects that may happen later onYou should have enough information to make a decision about your treatment. Your provider should also make sure you understand the information. One way a provider may do this is by asking you to repeat the information back in your own words (this is called teaching back). Event ID: Facility ID: 675931 If continuation sheet Page 4 of 15 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 07/31/2025 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 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 2 of 8 residents (Residents #3 and #79) reviewed for care plans. The facility failed to invite and include the input of Resident #3 and Resident #79 and/or residents' representative as members of the interdisciplinary team in Care Plan Conference meetings. This failure could place residents at risk of not receiving the interventions, treatments, and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident and/or the residents' representative in Care Plan Conference meetings. The findings included: Record review of Resident #3's face sheet, dated 7/31/25 revealed a [AGE] year-old female admitted [DATE] with diagnosis including anemia (a deficiency of red blood cells), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), Poly osteoarthritis (a condition where five or more joints are affected by inflammation, pain, stiffness), pre-Diabetes (a condition where blood sugar level is higher than what is considered health, but not high enough to be Type 2 Diabetes), Hypertension (high blood pressure). No diagnosis of dementia was present on Resident #3's face sheet. Record review of Resident #3's BIMS assessment, dated 7/16/25, reflected Resident #3 had a BIMS score of 15 indicating intact cognition. Record review of Resident #3's Electronic and Paper health Record revealed that a care plan meeting for Resident #3 was held on 2/6/25 and neither the resident nor her representative was included in the meeting. During an interview on 7/30/25 at 10:00 a.m., Resident #3 stated she had not been invited to any Care Plan conference meeting since she admitted to this facility. Resident #3 stated she was familiar with Care Plan meetings because she attended them in the past at a previous facility. Record review of Resident #79's face sheet, dated 7/30/25 revealed a [AGE] year-old female admitted [DATE] with diagnosis including Osteoporosis (a condition in which bones become weak and brittle), cerebral infarction (a condition where a part of the brain id damaged due to a blockage of blood flow), insomnia (a sleep disorder), anxiety, major depressive disorder, dysphagia (difficulty swallowing), dementia (a group of conditions characterized by impairment, memory loss, judgement), ataxia (impaired balance or coordination). Record review of Resident #79's MDS dated [DATE] revealed a BIMS assessment score of 14 indicating intact cognition. Record review of Resident #79's electronic and Paper health record revealed that care plan meetings for Resident #79 were held on 12/12/24 and 2/20/25 and neither the resident nor her representative was included in the meetings. During an interview on 7/30/25 at 10:15 a.m., Resident #79 stated she was informed of care plan meeting but had not attended or participated in a Care Plan conference meeting since she admitted to this facility. During an interview on 7/31/25 at 2:15 p.m., the MDS Nurse stated she notified family member by mail or email (if available) of Care Plan meetings date and time. The MDS Nurse stated she met with the residents but did not have them sign on attendance or indicate that they were present for review meetings. The MDS Nurse stated failure to include residents in their plan of care could result in them not being fully aware of their medications, treatments and rights. During an interview on 7/31/25 at 2:44 p.m., the DON stated it was important for residents and/or representative to participate in the plan of care meeting if they desire. The DON stated adverse effect of resident's or their representative no attending and participating in review meeting would be that decisions could be made that the resident and/or representative were not aware of. During an interview on 7/31/25 at 4:30 p.m., the ADM stated his expectation was that residents and/or their representative were informed of and participate in quarterly care plan meetings. Review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 5 of 15 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 07/31/2025 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 0553 Level of Harm - Minimal harm or potential for actual harm facility policy titled Care Plans, Comprehensive Person-Centered, Revised March 2022, revealed 5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences; and 6. If the participation of the resident and his/her resident representative is not practicable, an explanation is documents in the resident's medical record. the explanation should include what steps were taken to include the resident or representative in the process. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 6 of 15 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 07/31/2025 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to inform each Medicaid-eligible resident, in writing, when the resident becomes eligible for Medicaid of those other items and services that the facility offers and for which the resident may be charged for 2 of 2 (Residents #1 and #16) residents reviewed in that: 1. Resident #1 did not provide the cost of Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. 2. Resident #16 did not provide the cost of Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). This failure could affect residents who use skilled services and could place them at risk of not being aware of changes to provided services. The Findings were: 1. Record review of Resident #1's admission Record dated 7/31/2025 reflected she [AGE] years old, was admitted on [DATE], re-admitted on [DATE] and was on Medicare/Medicaid services. Record review of Resident #1's Quarterly MDS dated [DATE] reflected she was Medicare and/or Medicaid certified, and her BIMS score was 9/15 (Moderate Cognitive impairment). Record review of Resident #1's SNF Beneficiary Protection Notification Review start date was 7/4/2025 and revealed the last day of service was 7/16/2025. The Skilled Nursing Facility Advance Beneficiary Notice of NON-Coverage) SNF-ABN) began on 7/16/2025 for Occupational Therapy and Daily Skilled Nursing Care was X'd, and the estimated cost to resident was blank. 2. Record review of Resident #16's admission Record dated 7/30/2025 reflected he was [AGE] years old, was admitted on [DATE], re-admitted on [DATE] and was on Medicare/Medicaid services. Record review of Resident #16's Quarterly MDS dated [DATE] reflected he was on Medicare and/or Medicaid certified, and her BIMS score was 9/15 (Moderate Cognitive impairment). Record review of Resident #1's SNF Beneficiary Protection Notification Review start date was 5/12/2025 and revealed the last day of service was 5/29/2025. The Skilled Nursing Facility Advance Beneficiary Notice of NON-Coverage) SNF-ABN) began on 5/29/2025 for Occupational Therapy and Daily Skilled Nursing Care was X'd , and the estimated cost to resident was blank. Interview on 7/30/2025 at 12:24 PM with MDS nurse stated she was not sure the cost and did not review with Residents #1 and #16. Interview on 7/31/2025 at 2:50 PM with the DON stated the MDS nurse was responsible for ABN letters. Interview on 7/31/2025 at 6:00 PM with the ADM stated he was not aware of this and stated they follow the Federal requirements, when asked for policy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 7 of 15 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 07/31/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, interviews and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, for 4 of 4 shower rooms in that: 1. The 100-hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. 2. The 300-hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. The 300-hall shower had brown substance on the one of the shower stalls and shower a grate was full of hair. 3. The secure hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. 4. The 400-hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. These failures could place residents at risk of a diminished quality of life due to an unsafe environment. The Findings were: Observation/Interview on 7/29/2025 at 11:45 AM with Resident #16 stated the 100-hall shower was dirty and needed to be refurbished. Observation on 7/29/25 at 11:50 AM in the 100-hall shower room with the DON and Corporate nurse had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. Interview on 7/29/2025 at 11:51 Am with the DON and Corporate nurse stated he will have staff clean the 100-hall shower room. Interview on 7/29/25 at 11:52 to 12:15 PM the Laundry/Housekeeping Supervisor and the Maintenance Supervisor confirmed the following on the shower halls:1. The 100-hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance.2. The 300-hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. The 300-hall shower had brown substance on the one of the shower stalls and shower a grate was full of hair.3. The secure hall shower room had black substance along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance.4. The 400-hall shower room had mold along the edges of the shower room; the baseboards were loose; tiles were cracked and had a dirty appearance. Interview on 7/29/25 at 12:12 PM the Maintenance Supervisor confirmed the shower rooms needed to be cleaned and repaired. The Maintenance Supervisor had been working at the facility for a few years. Then Maintenance Supervisor stated no documentation of deep cleaning for showers, but the housekeepers do clean the showers. The Maintenance Supervisor stated the nursing cleans the feces and both housekeeping and nursing can clean the shower grates. The Maintenance Supervisor and Laundry/housekeeping Supervisor stated they would look for a policy on cleaning the shower rooms. Observation of Hall 100 revealed the shower walls had black substance, and the tiles are cracked. Observation on Hall 200/300/Secure unit/400 hall, shower walls had mold and the tiles are cracked Observation on 300 halls had brown substance on the shower floor and the shower grate was full of hair. Interview on 7/31/2025 at 2:46 PM the DON stated the shower rooms could affect residents could be a risk for the grout he did not see. The DON stated for the brown substance and hair in grate the resident could be apprehensive to take showers. The DON stated the housekeeping staff was responsible for cleaning the showers and the nursing staff would be responsible for cleaning the brown substance and shower grate. Record review of a checklist for housekeeping staff to follow, was last dated 6/29/25. This housekeeping list did not include the resident showers. Record review of policy, Homelike Environment dated 2/2021 was documented Resident are provided with safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximize, t the extent possible, the characteristics of the facility that reflect a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 8 of 15 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 07/31/2025 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 0584 [personalized, homelike setting. These characteristics include a. clean, sanitary and orderly environment. 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 9 of 15 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 07/31/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from chemical restraints with adequate monitoring for 1 of 8 residents reviewed for abuse, neglect and exploitation. The facility failed to ensure Resident #79 had monitoring for antidepressant medication (Paroxetine). These failures could place resident at risk for adverse drug reactions (unintended, harmful events attributed to the use of medication. The findings included: Record review of Resident #79's face sheet, dated 7/30/25 revealed a [AGE] year-old female admitted [DATE] with diagnoses including Osteoporosis (a condition in which bones become weak and brittle), cerebral infarction (a condition where a part of the brain id damaged due to a blockage of blood flow), insomnia (a sleep disorder), anxiety, major depressive disorder, dysphagia (difficulty swallowing), dementia (a group of conditions characterized by impairment, memory loss, judgement), ataxia (impaired balance or coordination). Record review of Resident #79's MDS dated [DATE] revealed a BIMS assessment score of 14 indicating intact cognition. Record review of Resident #79's medication administration record dated 3/1/25-3/31/25 indicated a new order for Paroxetine HCl Tablet 10MG. give 1 tablet by mouth at bedtime related to major Depressive Disorder, recurrent unspecified (F33.9) -Start Date- 03/24/2025. The medication administration record did not indicate assessment or monitoring for a new medication or monitoring for adverse reactions. Record review of Resident #79's progress notes dated 3/24/25-3/31/25 did not reflect assessment or monitoring or assessment for adverse reactions to new medication. Record review of Resident #79's care plan indicated: Focus: The resident uses antidepressant medication related to Depression Date initiated: 01/15/25. Goal: The resident will be free from .adverse reactions related to antidepressant therapy. Interventions: Administer AINTIDEPRESSANT medications as ordered by physicians. Antidepressant medication Paroxetine was started on 3/24/25 and was not identified in the Care Plan. During an interview on 7/31/25 at 2:30 p.m., LVN D stated she would monitor residents with a new medication for at least 3 days for adverse side effects. LVN D stated that residents who were not monitored may not be assessed for potential allergic reactions, respiratory distress or other complications. During an interview on 7/31/25 at 3:30 p.m., the DON stated that he expected new medications to be monitored for 72 hours on initial on-set for adverse side effects. The DON stated failure to monitor side effects could cause potential harm to residents. Facility policy on Medication Administration and Monitoring for new medications was requested on 7/30/25 and 7/31/25 but was not received prior to survey exit. During an interview with the DON on 7/31/25 at 5:45 p.m., the DON stated that the facility followed HHSC standards and protocol for medication administration. According to Guidance 483.45(d) Unnecessary Drugs and (c)(3) and (e) Psychotropic Drugs .Proper medication .without adequate monitoring-ma increase the risk of a broad range of adverse consequences such as medication interactions, depression, confusion, immobility, falls, hip fractures, and death. Event ID: Facility ID: 675931 If continuation sheet Page 10 of 15 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 07/31/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 3 residents reviewed for indwelling urinary catheter care. The facility placed Resident #70's indwelling urinary catheter urine collection bag higher than Resident #70 bladder while in his wheelchair. This failure could place residents at risk for harm by urinary tract infections.The findings are: A record review of Resident #70's admission record dated 7/31/2025 revealed an admission date of 7/6/2022 with diagnoses which included retention of urine and obstructive and reflux uropathy (a blockage in the urethra that makes it difficult or impossible to urinate. It can also cause pain and infections.) A record review of Resident #70's annual MDS assessment dated [DATE] revealed Resident #70 was an [AGE] year-old male admitted for LTC related to vascular dementia (a type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and difficulties with reasoning, planning, and memory.) Resident #70 was assessed with a BIMS score of 00 out of a possible 15 which indicated severe cognitive impairment. Resident #70 was assessed with the need for an indwelling urinary catheter. A record review of Resident #70's physician's orders dated 7/31/2025 revealed the physician prescribed for Resident #70 to have an indwelling suprapubic urinary catheter (a type of urinary catheter. It empties the bladder through an incision in the belly instead of a tube in the urethra.) A record review of Resident #70's care plan dated 7/31/2025 revealed, The resident has a Suprapubic Catheter due to Obstructive and Reflux Uropathy. He is at risk for infections. Date Initiated: 07/20/2022 . CATHETER: The resident has 16 FR/ 30 cc bulb suprapubic. Position catheter bag and tubing below the level of the bladder . During an observation on 7/28/2025 at 10:20 AM revealed Resident #70 was in his wheelchair with his indwelling urinary catheter urine collection bag tied to the back of his wheelchair. Further observation revealed the urinary collection bag was tied at the level of the resident's mid lower back and above the bladder. During an observation and interview on 7/28/2025 at 10:24 AM CNA B stated Resident #70's urinary catheter urine collection bag was tied to Resident #70's wheelchair back about the level of his lower back. CNA B stated the level was too high. Observation revealed CNA B untied the urine collection bag and attempted to retie the bag to the lowest bar on the wheelchair which was below Resident #70's buttocks. During an interview on 7/28/2025 at 10:30 AM LVN A stated she was the charge nurse for Resident #70. LVN A stated Resident #70 should have his urinary catheter urine collection bag secured below the level of his bladder to facilitate the urine flow from his bladder to his collection bag. LVN A stated Resident #70 had a history of urinary tract infections and having the collection bag higher than the level of the bladder could reduce the urine flow from the bladder to the bag and could contribute to possible future urinary tract infections. During an interview on 7/30/2025 at 5:00 PM the DON stated residents who have a need for urinary catheters should have their urine collection bags below the bladder to ensure free flow of urine and prevent catheter associated urinary tract infections. During an interview on 7/31/2025 at 5:00 PM the Administrator stated he concurred with the DON's guidance and oversight concerning indwelling urinary catheters. A policy addressing the care and maintenance of urinary catheters was requested and the Administrator stated the facility followed professional standards and HHSC[KS8] guidelines. A record review of the United States of America's Centers for Disease Prevention and Control's website:Summary of Recommendations | Infection Control | CDCAccessed 7/31/2025, titled Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) revealed, . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 11 of 15 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 07/31/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Proper Techniques for Urinary Catheter Maintenance: . Keep the collecting bag below the level of the bladder at all times. A record review of Lippincott Nursing Procedures. [NAME] & [NAME], 2023, revealed, Indwelling Catheter Care - . Keep the catheter and drainage tubing free from kinks to allow the free flow of urine, and keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI [catheter associated urinary tract infections. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 12 of 15 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 07/31/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on record reviews and interviews the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility's reviewed for resources necessary to care for residents competently during both day-to-day operations and emergencies. The facility admitted 79 residents without conducting and documenting a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. This failure could place residents at risk for not receiving competent care during day-to-day operations and emergencies.The findings included: A record review of the facility census dated 7/28/2025 revealed 79 residents resided at the facility. During an interview on 7/31/2025 at 5:00 PM the administrator stated the facility had an assessment of their capabilities and resources however the document resided on the previous administrator's personal computer and efforts to secure the assessment had been unsuccessful. The Administrator stated he had not developed a facility wide assessment since March 1, 2025, when the new ownership became responsible for the facility. A policy was requested to address the facility assessment requirements. The Administrator stated the facility followed HHSC guidelines. As of 8/5/2025 a policy regarding the expectations and requirements for a facility wide assessment has not been received. Event ID: Facility ID: 675931 If continuation sheet Page 13 of 15 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 07/31/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, for 1 of 1 facility's reviewed for maintenance and operation of essential equipment. The facility failed to maintain operational 1 of the 3 commercial clothes dryers. These failures could place residents at risk for neglect and not having their hygiene needs met.The findings included. During an observation and interview on 7/28/2025 at 3:25 PM revealed the facility's laundry department had 3 commercial clothes dryers. 1 of the 3 dryers was not operational. The Housekeeping director stated the dryer had not been functioning for longer than 3 months and needed to be replaced. During an interview on 7/31/2025 at 5:00 PM the Administrator stated the facility was awaiting the ownership corporation to address the replacement of the commercial clothes dryer. A policy to address essential equipment maintenance was requested. The Administrator stated the facility follows HHSC guidelines. As of 8/5/2025 a policy for maintenance of essential equipment has not been provided. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 14 of 15 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 07/31/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 of 4 shower rooms. The 100 hall-shower room had 3-4 roaches scattering, when the light was turned on. This failure could result in illness and/or psychosocial harm for residents living in areas with insects. The Findings were: Observation and interview on 7/29/25 at 11:45AM with Resident #16 said the Shower room in 100-hall was dirty and needed to be refurbished. Observation of the 100-hall shower room revealed 3 or 4 live roaches scattering when light was turned on. Observation\interview on 7/29/25 at 11:50 AM with the Laundry/Housekeeping Supervisor/Maintenance Supervisor confirmed the scattered roaches in the 100- hall shower room. The ]Laundry/Housekeeping Supervisor stated they will clean the shower room and call pest control. The Maintenance Supervisor stated the pest control company comes once a month. Interview on 7/31/2025 at 2:50 PM the DON and Corporate nurse stated, he will have staff clean the shower rooms and call pest control. Record review of Pest control log had the Pest control every month. The treated for pest, Bugs no documentation of what type of bugs Record review of the policy for , Pest Control, dated May 2008, stated Our facility shall maintain an effective pest control program. 1. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675931 If continuation sheet Page 15 of 15