Health inspection·February 22, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diversion was reported. The alleged perpetrator was unknown. Four staff members were named as witnesses. The allegation reflected, Blister pack of 30 Norco (a narcotic pain reliever) along with all documentation missing from medication cart for a single resident (Resident #1). The charge nurse that had been on duty when Norco was received noticed that the blister pack of Norco and documentation was missing when she came back for her shift next day. The report reflected on injury or harm to the resident. The facility notified the police, the medical director, their family, and regional corporate nurse. The resident had no knowledge of the drug diversion. The statements were obtained, and staff were drug tested. The investigation findings confirmed the drug diversion. Review of the pharmacy packing slip dated 12/19/23 reflected 30 hydrocodone/APAP tablets 10-235mg, were delivered to the facility. Review of the business card left by the responding police officer reflected, CASE NO: P23100075 DATE: 12/21/23. During an interview on 2/22/24 at 1:00 PM, the DON stated they did not identify a perpetrator or find the missing medications. She stated, Maybe the medication had been accidently discarded, but that would not have accounted for the missing paperwork. During a phone interview on 2/22/24 at 3:35 with the local police department, the officer stated the case number he provided was not a case number. The call was transferred to the narcotics division, but the call went unanswered. During an interview on 2/22/24 at 3:58 PM, the DON stated after the medication was noticed to be missing, the narcotic drawer was recounted by two staff. The other medication cart was counted, then the nurse's switched carts, and recounted again. She stated they looked at each bubble-pack in both medication carts incase the medication was accidently put in the cart and not the locked drawer. She stated they notified the regional nurse, called the police, and notified family. She stated the pharmacist came to check the facility. She stated the resident had not missed any doses of the medication, there was no adverse effect for the resident. She stated that neither the medications nor the count sheet was ever located. She stated the nurses and medication aides were drug tested and all the results were negative . During an interview on 2/22/24 at 4:12 PM with ADON A, she stated she received 30 Norco tablets from the pharmacy on the night of 12/19/23. She matched the paper to the bubble pack confirming the number of pills delivered. She placed the medication in the narcotics drawer on the medication cart and locked the medication cart. She stated she counted the narcotics drawer at the end of her shift. The next day when she returned to work, she stated she was counting the narcotics with the off going nurse when she noticed the Norco, she received the night before was not in the narcotic drawer. She stated they looked in the other medication cart but could not locate the medication. She stated they notified the DON at that time. She stated she was drug-tested . During an interview on 2/22/24 at 4:23 PM, the ADM stated he was notified when the medication went missing. He stated they investigated and looked for the medication. He stated the police were notified and came to the facility, but they were there for less than five minutes. He stated the staff who had access to the medication all wrote statements and were drug tested. He stated they were not able to identify a perpetrator . Review of the facility policy Identifying Exploitation, Theft, and Misappropriation of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675946 If continuation sheet Page 2 of 3 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 675946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Temple East 1511 Marlandwood Rd Temple, TX 76502 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 0602 Level of Harm - Minimal harm or potential for actual harm Property dated April 2021 reflected in part, 1. Exploitation, theft, and misappropriation of resident property are strictly prohibited. 4. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 5. Examples of misappropriation of resident property include: f. drug diversion (taking the resident's medication). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675946 If continuation sheet Page 3 of 3