Health inspection·November 16, 2023

F 0575 Level of Harm - Potential for minimal harm During an interview on 11/14/23 at 3:10 p.m., the Ombudsman stated she informed the administrator about four months ago that she was required to have the HHS phone number, the Ombudsman contact information, and the complaint statement posted on the wall. The Ombudsman stated it she informed the administrator that it was important for the residents and the resident's families to have access to the information. Residents Affected - Many During an interview on 11/15/23 at 3:43 p.m., the administrator stated she was responsible for ensuring the correct information was posted. The administrator stated they had recently painted and had not replaced the postings yet. When asked how she ensured the residents knew their rights, especially when it came to voicing concerns/grievances, she stated residents were given a copy upon admission, and she expected the AD to address resident rights in Resident Council meetings. The administrator stated she didn't feel like this was a failure since the AD and social worker handed out monthly circular (resident newsletter) with the resident rights attached. The administrator acknowledged the required postings that were not currently posted, stating it was due to the touch up painting. Requested a copy of the policy regarding required posting from the administrator, policy not provided. During an interview on 11/16/23 at 4:30 p.m., the social worker stated when resident was admitted they were given a copy of the resident rights but not information on how to contact the Ombudsman. The social worker stated when they went through the care plan cycle, they were given a copy of the resident rights and that she let them know just because they are in the facility, they still have rights. During an interview on 11/16/23 at 4:30 p.m., with the AD, she stated she usually placed a copy of the resident rights in the monthly circular on first of the month. The AD stated she sat with the residents who could not see and answered questions and explained the complaint process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 2 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #24's face sheet, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included sepsis due to Escherichia Coli (infection in the blood), hypertension (high blood pressure), and anxiety (feeling anxious). Residents Affected - Few Record review of Resident 24's quarterly MDS assessment, dated 10/24/23, indicated Resident #24 was understood and understood by others. Resident #24 had a BIMS score of 14 which indicated she was cognitively intact. Resident #24 required assistance with toileting, personal hygiene, dressing, bed mobility, bathing, and eating. The MDS indicated she was receiving an anticoagulant medication. Record review of Resident #24's comprehensive care plan, dated 10/19/23 did not indicate any problems or goals related to an anticoagulant medication. Record review of Resident #24's physician's orders dated 10/16/23 through 11/13/23 did not indicate any anticoagulant medication. During an interview and observation on 11/16/23 at 1:53 p.m., the MDS Coordinator said she was responsible for the completion of the MDS for the facility. She looked at Resident #24's quarterly MDS assessment dated [DATE] on section N and said she coded Resident #24 as taking an anticoagulant medication. The MDS Coordinator said it was coded incorrectly because Resident #24 did not take any anticoagulant medications. She said she coded it by mistake. She said it was important to code the MDS assessment correctly because it reflected their care. During an interview on 11/16/23 at 3:38 p.m., the DON said the MDS coordinator was responsible for completing the MDS. The DON stated she expected that assessments were reflected in the MDS accurately. During an interview on 11/16/23 at 4:04 p.m., the Administrator said the MDS coordinator was responsible for the completion of the MDS. She said she expected the MDS assessment for any resident to be completed thoroughly and correctly based on the resident assessment. Record review of facility's policy titled Resident Assessment Instrument dated 05/07/21, indicated, . comprehensive assessment of a resident's needs shall be made within fourteen (14 days of the resident's admission 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity 7. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information . Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 2 of 21 residents (Resident #59 and Resident #24) reviewed for MDS assessment accuracy. 1. The facility failed to accurately code Resident #59's diagnosis of schizophrenia (mental illness that causes delusions, or fixed beliefs that seem real, and hallucinations, or hearing voices that are not real) on his quarterly MDS assessment. 2. The facility inaccurately coded Resident #24 taking an anticoagulant medication on her quarterly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 3 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0641 MDS assessment dated [DATE]. Level of Harm - Minimal harm or potential for actual harm These failures could place residents at risk for not receiving care and services to meet their needs . Findings included: Residents Affected - Few 1.Record review of Resident #59's face sheet dated 11/15/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 59's diagnoses included paranoid schizophrenia. Record review of Resident #59's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated he had a BIMS score of 13 indicating his cognition was intact. The MDS assessment under active diagnosis did not indicate Resident #59 had schizophrenia. Record review of Resident #59's care plan dated 09/18/23, indicated he received antipsychotic medication related to schizophrenia with interventions to administer Zyprexa (an antipsychotic medication) as ordered. Record review of Resident #59's physician's order report dated 10/15/23-11/15/23, indicated he had an order for Zyprexa 5mg one tablet twice a day for paranoid schizophrenia with a start date of 08/16/23. Record review of Resident #59's nurse medication administration history dated 11/01/23-11/13/23, indicated he had been receiving Zyprexa 5mg twice a day. During an interview and observation on 11/16/23 at 2:17 PM, the MDS Coordinator said she was responsible for ensuring the MDS assessments were accurate and tried her best to ensure they were. The MDS Coordinator reviewed Resident #59's quarterly MDS assessment and said the diagnosis for schizophrenia was not marked, and it should have been as Resident #59 schizophrenia was being treated with Zyprexa. The MDS Coordinator said failure to accurately code Resident #59's schizophrenia diagnosis did not reflect an accurate assessment of Resident #59's active diagnoses. The MDS Coordinator said ADON D signed the MDS assessments for completion, but she did not review them for accuracy. During an interview on 11/16/23 at 2:29 PM, ADON D said she was responsible for signing the MDS for completion. ADON D said she sometimes reviewed the MDS assessments. ADON D said she was unsure as to why Resident #59's schizophrenia diagnosis was not marked and did not notice it was not marked. ADON D said Resident #59 had a diagnosis of schizophrenia and was taking Zyprexa for it. ADON D said Resident #59's schizophrenia diagnosis should have been checked as it was part of his profile, and his diagnosis was not complete. ADON D said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. During an interview on 11/16/23 at 2:44 PM, the DON said she expected the MDS assessments to be correct. The DON said if Resident #59 was receiving Zyprexa and they were treating the schizophrenia then he should have had schizophrenia checked as an active diagnosis. The DON said Resident #59 had no behaviors and was not at risk for having an inaccurate MDS assessment. The DON said the MDS coordinator was responsible for ensuring the MDS assessments were accurate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 4 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0641 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/16/23 at 3:16 PM, the Administrator said she expected the MDS assessments to be completed timely and accurately. The Administrator said Resident #59's MDS assessment should have had schizophrenia marked as an active diagnosis. The Administrator said the MDS coordinator was responsible for ensuring the MDS assessments were accurate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 5 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 2 residents (Resident #59) reviewed for resident assessments. Residents Affected - Few The facility failed to refer Resident #59 for PASRR review following new mental illness diagnoses for paranoid schizophrenia (mental illness that causes delusions, or fixed beliefs that seem real, and hallucinations, or hearing voices that are not real) and PTSD (post-traumatic stress disorder)(mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress anxiety, flashback and avoidance of similar situations). This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of Resident #59's face sheet dated 11/15/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 59's diagnoses included paranoid schizophrenia, post-traumatic stress disorder, congestive heart failure (heart can't pump blood well enough to meet the body's needs), chronic kidney disease (stage 4) (severe loss of kidney function) and essential hypertension (high blood pressure). Record review of Resident #59's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated he had a BIMS score of 13 indicating his cognition was intact. The MDS assessment indicated Resident #59 he required supervision with all ADLs. The MDS assessment indicated under active diagnoses Resident #59 had post-traumatic stress disorder checked. The diagnosis for schizophrenia was not checked. Record review of Resident #59's care plan dated 09/18/23, indicated he received antipsychotic medication related to schizophrenia with interventions to administer Zyprexa as ordered. Record review of Resident #59's physician's order report dated 10/15/23-11/15/23, indicated he had an order for Zyprexa (antipsychotic medication) 5 mg one tablet twice a day for paranoid schizophrenia with a start date of 08/16/23. Record review of Resident #59's nurse medication administration history dated 11/01/23-11/13/23, indicated he had been receiving Zyprexa 5mg twice a day. Record review of Resident #59's PASRR Level 1 Screening dated 05/29/23, indicated Resident #59 did not have a mental illness. During an interview on 11/15/23 at 03:22 PM, the MDS Coordinator said when Resident #59 admitted to the facility, he admitted from the hospital, and the diagnoses for PTSD and schizophrenia were not on the hospital records. The MDS Coordinator said they received the diagnoses for Resident #59's schizophrenia and PTSD from the VA after he had been admitted to the facility. The MDS Coordinator said she should have completed Form 1012 when she received Resident #59's mental diagnoses. The MDS Coordinator said she had not completed the form as it was overlooked. The MDS Coordinator said Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 6 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #59 was not at risk for missing any PASRR services as the VA was paying for his therapy if he qualified for it. The MDS Coordinator said she spoke with the PASRR nurse today, 11/15/23, and a new PASRR Level 1 was completed. During an interview on 11/16/23 at 2:44 PM, the Director of Clinical Services said a PASRR form 1012 should have been completed when they became aware of the new diagnoses of mental illness for Resident #59 so they could provide better care for him. The Director of Clinical Services said Resident #59 was not at risk for missing any PASRR service as the VA was providing all services to him. The Director of Clinical Services said the MDS Coordinator and social services were responsible for updating the PASRR and completing required documents after a new mental illness diagnosis. During an interview on 11/16/23 at 3:16 PM, the Administrator said she expected the PASRR form to be completed after new mental illness diagnosis. The Administrator said the MDS nurse was responsible for updating the PASRRs. The Administrator said Resident #59 had no risks for not updating his PASRR because he was receiving VA services. Record review of the facility's policy titled Antipsychotic Medication Use dated June 2020, indicated . Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indicated for use. The interdisciplinary team will: a. complete PASRR screening( preadmission screening for mentally ill and intellectual disabled individuals), if appropriate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 7 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 - Some 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 observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 4 of 21 (Residents #38, #29, #59 and #49) residents reviewed for care plans. 1. The facility failed to ensure Resident #38's comprehensive care plan addressed that she required Lasix (a diuretic medication used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease). 2. The facility failed to ensure Resident #29's left-hand contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) was care planned. 3. The facility failed to ensure Resident #59's diagnosis of PTSD (post-traumatic stress disorder - a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress anxiety, flashbacks, and avoidance of similar situations) was care planned. 4. The facility failed to ensure Resident #49's side rails were care planned. These failures could place residents at increased risk of not having their individual needs met and a decreased quality of life. The findings included: 1.Record review of Resident #38's face sheet, indicated she was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included acute embolism and thrombosis (both blood clots that reduce or block blood flow inside your blood vessels), Hypernatremia (a medical term used to describe having too much sodium in the blood), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar (glucose). Record review of Resident 38's quarterly MDS assessment, dated 10/18/23, indicated Resident #38 was rarely understood and rarely understood by others. Resident #38 was cognitively severely impaired in decision-making. Resident #38 required extensive assistance with toileting, personal hygiene, dressing, bed mobility, bathing, and eating. The MDS indicated she was receiving a diuretic medication. Record review of Resident #38's comprehensive care plan, dated 11/03/23 revealed no care plan related to the resident's Lasix medication. Record review of Resident #38's comprehensive care plan, after the surveyor intervention dated 11/14/23, indicated she had the potential for dehydration related to diuretic use. The intervention was for staff to administer Lasix as ordered, assist with hydration, assess for any changes in level of care, and report to the physician and family. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 8 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 Record review of Resident #38's physician's orders dated 10/12/23 indicated, Lasix (water pill) give 1 tablet daily for hypertension. Record review of Resident #38's medication administration (MAR) record dated 11/01/23 through 11/16/23 revealed Resident #38 received Lasix 20 mg as ordered. Residents Affected - Some During an interview on 11/14/23 at 3:31 p.m., the MDS coordinator said she was responsible for ensuring the care plans were updated. The MDS coordinator said the diagnoses and medication should have been listed on Resident #38's care plan and the omissions were an oversight. The MDS coordinator said staff may not be aware of how to properly care for Resident #38 because her diagnosis and/or medication were not listed on her plan of care. During an interview on 11/16/23 at 2:50 p.m., the ADON D said the MDS coordinator was responsible for the care plans and the DON was the overseer of care plans. The ADON said they had clinical meetings where they talked about changes. She said it was important to have a care plan for the care of each resident. She said the intent of the care plan was for staff to be able to meet the resident's needs. During an interview on 11/16/23 at 3:38 p.m., the DON said the MDS coordinator was responsible for ensuring care plans were updated with any changes. She said the MDS coordinator came to the morning meetings and had access to the resident's orders and the 24-hour report to update the resident's care plans as needed. The DON said care plans should be complete and accurate to ensure residents receive proper care. During an interview on 11/16/23 at 4:04 p.m., the Administrator said he expected all residents to have a care plan. She said she expected the care plan to be updated to reflect the resident's care. She said the MDS coordinator was responsible and the DON was the overseer of care plans. She said the care plans painted a picture of the resident's care. 2. Record review of Resident #29's face sheet dated 11/15/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #29 had diagnoses that included senile degeneration of the brain (memory loss), anxiety, depression, and high blood pressure. Record review of Resident #29's quarterly MDS assessment dated [DATE], indicated she rarely/never made herself understood or understood others. The MDS assessment indicated Resident #29 had a long-term and short-term memory problem and her cognition was severely impaired. The MDS assessment indicated Resident #29 required extensive assistance with bed mobility, toileting, and personal hygiene. Resident #29 was totally dependent on staff with dressing and bathing. The MDS assessment indicated Resident #29 had limited range of motion to lower extremity on both sides. Record review of Resident #29's comprehensive care plan dated 09/19/23, indicated Resident #29 had impaired mobility related to cerebral vascular accident (stroke) with interventions for Hoyer lift with 2 staff for all transfers and OT/PT screen and/or evaluation as needed. The care plan did not address Resident #29's left hand contracture. Record review of Resident #29's physician's order report dated 10/15/23-11/15/23, did not reveal any orders for her left-hand contracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 9 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 - Some Record review of Resident #29's hospice visit note dated 10/24/23 indicated under physical/musculoskeletal had contractures and location of contractures were left hip, right hip, left ankle, right ankle, left fingers, left foot, right foot. During an observation on 11/13/23 at 2:44 PM, Resident #29 was in bed and her left hand was contracted. Resident #29's middle finger, ring finger, and pinky fingers were in a closed position. There were no interventions in place to her left hand. Resident #29 was nonverbal. During an observation on 11/14/23 at 08:37 AM, Resident #29 was in bed and continued with no interventions in place for her left-hand contracture. During an observation and interview on 11/15/23 at 12:01 PM, Resident #29 was in bed. Her left hand continued with no interventions in place for her left-hand contracture. CNA L said Resident #29's left hand was contracted and kept in that position. CNA L did not respond when asked if Resident #29 had any interventions in place for her left-hand contracture. CNA M arrived in Resident #29's room and said Resident #29's left hand had been contracted for a long time. CNA M said they usually placed a carrot in her hand, but it must have been sent to laundry. During an interview on 11/16/23 at 09:08 AM, CNA K said Resident #29 always kept a hand towel rolled in her left hand and was unable to answer why she did not have it in place for the last 3 days. CNA K said it was important for Resident #29 to have an intervention in place to her left-hand contracture so her fingernails would be kept off her palm and not dig into it or cause bruises and to keep her left hand from contracting more. During an interview on 11/16/23 at 09:12 AM, LVN H said Resident #29 has had her left hand contracted and was unsure if there was anything in place for her contracture. LVN H said they were not doing anything for her contracture. LVN H said it was important to have interventions in place to keep Resident #29's hand from contracting more. LVN H said the nurses, aides, ADON and hospice were responsible for ensuring something was put in place for Resident #29's contracture. LVN H said Resident #29 should have had her contracture care planned with interventions in place. LVN H said charge nurses do not care plan and the MDS, ADON, and DON were responsible for care planning. During an interview on 11/16/23 at 09:25 AM, ADON E said in the past, the staff was applying a wash rag to Resident #29's left hand, but she usually removed it. ADON E said the nurses were responsible for ensuring the interventions for Resident #29 were in place. ADON E said she remembered Resident #29 had something in place to her left hand on Monday and Tuesday, and she must have taken it off. ADON E said the hospice nurse and herself were responsible for ensuring Resident #29 had an intervention in place for her left-hand contracture. ADON E said Resident #29 should have had her contracture care planned to ensure she was properly taken care of. ADON E said the MDS coordinator was responsible for the care plans. During an interview on 11/16/23 at 02:44 PM, the DON said she expected contractures to be prevented. The DON said Resident #29's left hand contracture should have been care planned so they could properly care for it. The DON said Resident #29's contracture will not contract anymore than it is as she has had it for a long time. The DON said the MDS coordinator was responsible for care plans, and care plans were updated during the morning meetings. During an interview on 11/16/23 at 3:16 PM, the Administrator said she expected residents who had contractures to have interventions in place for their contracture whether it was a hand roll in place (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 10 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 - Some or therapy. The Administrator said Resident #29 should have had a hand roll in place for her left-hand contracture along with an order or the hand roll. The Administrator said Resident #29's contracture should have been included in her care plan. The Administrator said her nurses would have known if a resident had a contracture. The Administrator said new staff would not have known if Resident #29 had a contracture unless they put their eye on her. The Administrator said the MDS Coordinator was responsible for the care plans. 3. Record review of Resident #59's face sheet dated 11/15/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 59's diagnoses include paranoid schizophrenia (mental illness that causes delusions, or fixed beliefs that seem real, and hallucinations, or hearing voices that are not real), post-traumatic stress disorder, congestive heart failure (your heart can't pump blood well enough to meet the body's needs), chronic kidney disease (stage 4) (severe loss of kidney function) and essential hypertension (high blood pressure). Record review of Resident #59's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated he had a BIMS score of 13 indicating his cognition was intact. The MDS assessment indicated Resident #59 required supervision with all ADLs. The MDS assessment indicated under active diagnoses Resident #59 had post-traumatic stress disorder. Record review of Resident #59's care plan dated 09/18/23, did not indicate Resident #59 had a diagnosis of PTSD. During an observation and interview 11/14/23 at 8:59 AM, Resident #59 was not in his room. LVN F said Resident #59 was sent to the hospital that morning for a procedure. LVN F said he was not sure when Resident #59 would return to the facility. During an observation and interview on 11/15/23 at 9:02 AM, Resident #59 was not in his room. The DON said Resident #59 had not returned from the hospital. During an interview on 11/16/23 at 9:56 AM, Resident #59's family member said Resident #59 had been diagnosed with PTSD more than 40 years ago. The family member said he was not sure if Resident #59 had any triggers because he was not raised by him. During an observation on 11/16/23 at 9:02 AM, Resident #59 was not in his room. Resident #59 was still hospitalized . During an attempted interview on 11/16/23 at 10:01 AM, Resident #59 did not answer the phone. During an attempted interview on 11/16/23 at 1:11 PM, Resident #59 did not answer the phone. During an interview on 11/15/23 at 3:22 PM , the MDS Coordinator said she was responsible for the comprehensive care plans. The MDS Coordinator said Resident #59's mental diagnoses should have been care planned and she said she was unsure of why Resident #59 had PTSD. The MDS Coordinator said since Resident #59 did not have his diagnosis of PTSD care planned, then staff would not know if he had any triggers and to how to treat him. During an interview on 11/16/23 at 09:08 AM, CNA K said she was not aware Resident #59 had a diagnosis of PTSD or if he had any triggers. CNA K said Resident #59 was always upbeat and never showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 11 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 anything that would indicate he had a mental illness. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/16/23 at 09:12 AM, LVN H said she was aware of Resident #59's diagnosis of PTSD. LVN H said she was unaware if Resident #59 had any triggers. LVN H said it was important for Resident #59's diagnosis of PTSD to be included in his care plan to ensure the staff were aware he had a diagnosis of PTSD, and so the staff were aware of any triggers he had and what to do for him. Residents Affected - Some During an interview on 11/16/23 at 09:25 AM, ADON E she was aware Resident #59 had a diagnosis of PTSD since he admitted to the facility. ADON E said she was unsure of Resident #59's triggers but they tried to keep his room quiet. ADON E said Resident #59 should have had his diagnosis of PTSD care planned, and his care plan should have included any triggers to his PTSD so that they would be able to treat him properly. ADON E said the MDS coordinator was responsible for the comprehensive care plans. During an interview on 11/16/23 at 2:44 PM, the DON said all of Resident #59's diagnoses should have been care planned so they would have a better plan of care for him. The DON said Resident #59 did not have any behaviors. The DON said the MDS coordinator was responsible for the comprehensive care plans being accurate. The DON said the comprehensive care plans were updated in the morning meeting. During an interview on 11/16/23 at 3:16 PM, the Administrator said she expected Resident #59's diagnosis of PTSD to only be care planned if he had any identifiable triggers. The Administrator said there was no risk to Resident #59. The Administrator said the MDS coordinator was responsible for ensuring the comprehensive care plans included the residents' diagnoses. The Administrator said the care plans were updated as needed during their morning meetings. 4.Record review of Resident # 49's face sheet dated 11/15/23, revealed an [AGE] year-old male with diagnoses of chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems), Gastro-esophageal reflux disease without esophagitis (type of GERD that does not involve inflammation of the esophagus), Generalized anxiety disorder (worrying constantly and can't control the worrying). Record review of Resident # 49's MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #49 had a BIMS score of 7 which indicated her cognition was severely impaired. Record review of Resident # 49's care plan dated 11/9/2023, 23 did not indicate the use of side rails. During an observation on 11/13/23 at 10:18 a.m., Resident # 49 was lying in bed with both side rails up. During an observation on 11/14/23 at 3:20 p.m., Resident # 49 was lying in bed with both side rails up. During an interview on 11/16/2023 at 9:45 a.m., the ADON stated she could not answer why the side rails were not care planned. The ADON stated it was important for the care plan to be accurate for the resident's continuation of care. The ADON stated the care plan was the resident's profile. The ADON stated care plans were monitored every morning during their stand-up meetings to go over orders. The ADON stated there was no harm to the resident because all the staff knew he had side rails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 12 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 During an interview on 11/16/2023 at 2:30 p.m., the DON stated the resident was on hospice. The DON stated in her opinion hospice ordered the bed and the order just got passed them. The DON stated the MDS coordinator at the time was responsible for ensuring the care plan was correct. The DON stated the care plans were monitored during mornings where they went over checks and balances and added new orders. The DON stated there was no risk to the resident. Residents Affected - Some During an interview on 11/16/2023 at 3:17 p.m., the Administrator stated side rails were something normally care planned. The Administrator stated she did not have answer as to why the side rails were not care planned, the order and consent were there. The Administrator stated it was the nursing team's responsibility to ensure the care plan was correct. The Administrator stated they reviewed care plans and discussed what's needed to be care planned in the morning meeting. The Administrator stated the side rails not being care planned were not a risk to the resident if they had an order. Record reviews the facility's policy titled Comprehensive Care Planning dated 4/19/2021, indicated . The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and the right to refuse treatment . Record review of the facility's policy titled Functional Impairment- Clinical Protocol dated June 2020, indicated . 1. Upon admission to the facility, at any time a significant change if condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's physical condition and functional status .The physician and staff will evaluate the residents for complications secondary to functional decline, and/or immobility, such as .f. muscle atrophy/contractures 6. The Physician and staff will review the results of the implications of these evaluations and use them to guide subsequent care planning FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 13 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who was unable to carryout activities of daily living received services to maintain grooming and personal hygiene for 2 of 6 residents (Resident #'s 26 and 117) reviewed for quality of life. Residents Affected - Few The facility failed to provide Residents #26 and #117 with a routine shower and shave. These failures could place residents at risk for and a decreased quality of life. Findings included: 1) Record review of a face sheet dated 11/16/2023 indicated Resident #26 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of incontinence and stroke with hemiplegia (paralysis of one side of the body). Record review of the Quarterly MDS dated [DATE] indicated Resident #26 was usually understood and understands others. The MDS indicated Resident #26's BIMS score was 10, indicating he had moderately impaired cognition. The MDS in the section of Behaviors failed to indicate Resident #26 rejected care. The MDS in section Functional Status indicated Resident #26 required total assistance of one staff with personal hygiene, and bathing. Record review of a comprehensive care plan dated 6/03/2022 indicated Resident #26 had a self-care deficit. The goal of the care plan was Resident #26 would be clean, odor free, well groomed, and appropriately dressed. Interventions of the comprehensive care plan included showers per schedule and as needed, and staff will assist with grooming needs, and shaving as needed. Record review of Resident #26's Point of Care ADL Category Report dated 11/01/0223 - 11/15/2023 indicated there were no baths documented for Resident #26 for 11/10/2023 - 11/15/2023. During an observation and interview on 11/13/2023 at 10:17 a.m., Resident #26 said he had not been showered since Friday on 11/10/2023 and he was unshaved his facial hair was ¼ inches long. Resident #26 said he was unsure why he had not had a shower. During an observation and interview on 11/15/2023 at 3:30 p.m., Resident #26 said he had not had his shower yet this week. During an observation and interview on 11/16/2023 at 2:20 p.m., Resident #26 said he still had not been showered since Friday 11/10/2023 and he continued to be unshaved. 2) Record review of a face sheet dated 11/16/2023 indicated Resident #117 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia, urinary tract infections, and stroke with hemiplegia (paralysis of one side of the body). Record review of a Quarterly MDS dated [DATE] indicated Resident #117 was usually understood and usually understood others. The MDS indicated Resident #117 was unable to complete the BIMS and had a memory problem. The MDS indicated in section Behaviors Resident #117 had not demonstrated any refusal of care behaviors. The MDS indicated Resident #117 requires substantial/maximum assistance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 14 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0677 personal hygiene and bathing. Level of Harm - Minimal harm or potential for actual harm Record review of the comprehensive care plan dated 11/04/2023 did not to indicate Resident #117 required assistance with his ADLs. Residents Affected - Few Record review of a Point of Care ADL Category Report dated 11/01/0223 - 11/15/2023 indicated there were no baths documented for Resident #117 for 11/10/2023 - 11/15/2023. During an observation on 11/14/2023 at 9:00 a.m., Resident #117 was sitting in his room, he was unshaven with his facial hair ¼ inches long and smelled of urine. He was not interviewable. During an interview on 11/16/2023 at 2:24 p.m., CNA A said she was assigned to Resident #'s 26 and 117. CNA A said the shower schedule was Monday, Wednesday, and Friday A bed on day shift and B bed on evening shift. CNA A said she was an agency staff member but had been coming to this facility over the last 3 years, at least 1-2 days per week. CNA A said although she was assigned to Resident #'s 26 and 117 that day, she was not usually assigned to these residents. During an interview on 11/16/2023 at 2:29 p.m., CNA B said she was not assigned to Resident #'s 26 and 117. CNA B said she was also an agency CNA but works often. CNA B said when she reviewed the bathing print out sheets for Resident #'s 26 and 117. She the section bathing and type indicated which bath type the resident received. CNA B said Resident #'s 26 and 117 had no baths documented for the week of 11/10/2023 - 11/15/2023. CNA B said there was enough CNAs to ensure bathing was completed. During an interview on 11/16/2023 at 2:33 p.m., LVN C said she was the nurse assigned to Residents #26 and #117. LVN C said she expected the residents to receive their showers according to the shower schedule. LVN C said the shower schedule was Monday, Wednesday, Friday with A bed on day shift and B bed on evening shift. LVN C said both Resident #'s 26 and 117 were B-bed evening shift. LVN C said she would intervene if she had known Resident #'s 26 and 117 were not bathed or shaved. LVN C said the CNAs were responsible for the bathing task and the nurse for ensuring the bathing was completed. During an interview on 11/16/2023 at 3:02 p.m., ADON D said she expected the residents to receive their baths according to the bathing schedule. ADON D said CNAs were responsible for bathing the residents. ADON D said she found it hard to believe Resident #'s 26 and 17 had not received their scheduled baths. ADON D said she was responsible for monitoring bathing by monitoring the documentation. ADON D said she must have missed the missing documentation for bathing on Residents #26 and #117. During an interview on 11/16/2023 at 3:19 p.m., the DON said she expected Residents #26 and #117 were bathed if they chose to be bathed. The DON said the nurses were responsible for monitoring the provision of showers/baths. The DON said if Resident #'s 26 and 117 had not been bathed someone could have smelled the body odor. The DON said the lack of bathing could affect a resident's self-esteem. During an interview on 11/16/2023 at 3:40 p.m., the Administrator said she expected the showers to be provided according to their bath schedules or as they requested. The Administrator reviewed the shower documentation for Resident #'s 26 and 117 and indicated the lack of documented bathing was a documentation error most likely. The Administrator was made aware of Resident #26's and 117's unkempt appearance and verbally indicating a lack of bathing. The Administrator said she could see a need to improve on documentation. Record review of a Shower/Tub Bath policy and procedure dated August 16,2023 indicated the purpose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 15 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. Documentation: The follow information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. The name and title of individuals who assisted the resident with the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason (s) why and the intervention taken. Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath. Event ID: Facility ID: 675949 If continuation sheet Page 16 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 6 residents (Resident #4) reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #4's low air loss mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. These failures could place residents at risk for deterioration of wound. Findings included: Record review of a face sheet dated 11/15/2023 indicated Resident #4 was an [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of fracture to left femur (upper leg bone), dementia, pressure ulcer right buttock, unstageable, and pressure ulcer to left buttock stage 2. Record review of an Annual MDS assessment dated [DATE] indicated Resident #4 was usually understood, and usually understands others. The MDS indicated Resident #4's BIMS score was 4 indicating severe impairment of cognition. Record review of the MDS indicated Resident #4 required extensive assistance of one staff member with bed mobility. The Skin Conditions (determination of pressure ulcer/injury risk) section was not marked regarding Resident #4 having a pressure ulcer/injury, a scar over bony prominence, or non-removable dressing/device. The areas regarding a formal assessment and clinical assessment were marked as a risk. The MDS indicted in Risk of Pressure Ulcers/Injuries section that Resident #4 was at risk. The MDS indicated in the section M0210 Unhealed Pressure Ulcers/ Injuries no was marked indicating Resident #4 did not have one or more unhealed pressure ulcers/injuries. The MDS indicated Resident #4 had moisture associated skin damage. Record review of the comprehensive care plan dated 10/25/2023 indicated Resident #4 had a non-pressure wound to the right upper buttock but was resolved on 11/01/2023. The comprehensive care plan dated 8/19/2022 indicated Resident #4 was at risk for pressure ulcers due to immobility, and incontinence. The care plan indicated Resident #4's low air loss mattress was implemented on 11/03/2023. Record review of the comprehensive acute care plan dated 10/18/2023 indicated Resident #4 had one or more pressure ulcers to the right buttock-DTI (deep tissue injury) and the wound was surgically excisional debridement (tissue removed with a scalpel, cutting away tissue) was completed with a post stage 3 wound. The goal of the care plan was the wound to the right buttock would heal without complications by cleansing right buttock with normal saline and applying Silvadene daily and as needed and use a pressure relieving appliances as ordered. Record review of the active physician orders indicated on 11/15/2023 Resident #4 had a physician's order to cleanse stage 3 to right buttocks with normal saline and apply Silvadene cover with dressing daily and as needed. Record review of Resident #4's Skin Condition Reports indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 17 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/04/2023, Resident #4 had a non-pressure related skin conditions. The section of the assessment for pressure related skin condition side detail indicated no pressure injury. The assessment was blank otherwise. 10/10/2023 Resident #4 had no non-pressure related skin conditions; the section of the assessment for pressure related skin condition report indicated Resident #4 had no pressure related skin conditions. The assessment was blank otherwise. 10/16/2023 Resident #4 had no non-pressure related skin conditions; the section of the assessment for pressure related skin condition report indicated see wound management report. The assessment was blank otherwise. 10/25/2023 Resident #4 had no non-pressure related skin conditions; the section of the assessment for pressure related skin condition report indicated see wound management report. The assessment was blank otherwise. 11/01/2023 Resident #4 had no non-pressure related skin conditions; the section of the assessment for pressure related skin condition report indicated see wound management report. The assessment was blank otherwise. 11/08/2023 Resident #4 had no non-pressure related skin conditions; the section of the assessment for pressure related skin condition report indicated see wound management report. The assessment was blank otherwise. Record review of Wound Evaluation and Management Summary indicated: 10/04/2023 Resident #4 had a wound to his right buttock. Focused wound #8 was a non-pressure (wound not caused from pressure) wound of the right buttock partial thickness (confined to the skin layers) measuring 2 x 2.5 x not measurable centimeters. The assessment indicated the surface area was 5.00 centimeters squared with no exudate (drainage), with a dried scab. Focused wound #9 indicated Resident #4 had a non-pressure wound of the left buttock (resolved on 10/04/2023). 10/11/2023 Resident #4 had a non-pressure wound #8 of the right buttocks was resolved on (10/11/2023). The assessment had no other wounds listed for treatment. 10/18/2023 Resident #4 had a new wound stage 2 pressure wound #11 of the left buttock partial thickness measuring 1 x 1 x 0.1 cm wound with light serous (clear t yellow fluid that leaks out of a wound) drainage. The etiology (the cause) was pressure. The assessment indicated Resident #4 had a new pressure wound #12 an unstageable DTI of the right buttock partial thickness measuring 8.5 x 2.2 x 0.1 centimeters with a surface area of 18.70 centimeters squared wit light serous drainage with 100 % dermis tissue the etiology was pressure, and the stage was DTI unstageable. The treatment plan included silver sulfadiazine apply once daily for 30 days, recommendation of off-loading, and group 2 mattress. The note indicated Resident #4 had sharp selective debridement (surgical removement of tissue using a scalpel) to remove devitalized epidermis and/or dermis. The recommendations were off-loading the wound; reposition per facility protocol, and group 2 mattress. 10/25/2023 Resident #4's wound #11 was resolved to the left buttock on 10/25/2023. The wound #12 was a stage 2 pressure wound of the right buttock with partial thickness measuring 3.5 x 2.2 x 0.1 cm with 7.70 centimeters squared surface area with light serous drainage with etiology pressure, with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 18 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few improved due to decrease surface area. The recommendations were off-loading the wound; reposition per facility protocol, and group 2 mattress. 11/01/2023 Resident # 4's wound #12 to the right buttock was unstageable deep tissue injury and full thickness wound. The wound measured 4.0 x 2.4 x 0.1 centimeters. The surface area of the wound measured 9.60 centimeters squared. The wound had 30% slough (dead tissue), with 70% viable tissue, and the wound was at goal. The note indicated the wound required surgical excisional debridement to remove necrotic tissue and establish the margins of viable tissue. The recommendations were off-loading the wound; reposition per facility protocol, and group 2 mattress. 11/08/2023 Resident #4's wound #12 to the right buttock was a full thickness, pressure wound measuring 1.4 x 0.8 x 0.1 centimeters with 1.12 centimeters squared surface area, with light serous drainage, and 100% slough to the wound bed. The wound progress was at goal. The note indicated Resident #4's right buttock full thickness wound was debrided using surgical excisional debridement to remove necrotic tissue and establish the margins of viable tissue. The recommendations were off-loading the wound; reposition per facility protocol, and group 2 mattress. 11/15/2023 Resident #4's wound #12 to the right buttock was a full thickness wound. The etiology was from pressure, the wound measured 1.3 x 3.2 x 0.1 centimeters with a surface area of 4.16 centimeters squared with cluster wound (open ulceration) measuring 0.83 centimeters squared with light serous drainage. The wound was 20% granulation tissue and 80 % skin with the wound considered healing evidenced by decreased wound surface area. The treatment continued as silver sulfadiazine apply once daily x 30 days with gauze island dressing. Recommendations of off-load wound, reposition per protocol, and group-2 mattress. Record review of Resident #4's current weight listed in the computer system was 136 pounds on 11/10/2023. During an observation on 11/13/2023 at 10:02 a.m., Resident #4 was resting in bed. Resident #4 had a low air loss mattress with the mattress setting on 350 pounds. Resident #4 was not interviewable. Resident #4 was thin and frail, not of the 350 pound weight range. During an observation on 11/14/2023 at 8:11 a.m., Resident #4 was eating breakfast. Resident #4's low air loss mattress was set to 350 pounds. During an observation on 11/14/2023 at 11:21 a.m., Resident #4's low air loss mattress was set to 350 pounds. During an observation and interview on 11/15/2023 at 9:15 a.m., LVN F was providing Resident #4's wound care. LVN F said Resident #4 had a new wound measuring 2 x 1.5 centimeters to the coccyx area. LVN F said the wound was not present yesterday when he completed the wound care for Resident #4. LVN F said the wound physician would round today and he would make him aware. LVN F was made aware to evaluate the low air loss mattress setting. LVN F said the mattress was set at 350 pounds. LVN F said Resident #4's weight was not 350 pounds. LVN F said the setting at 350 pounds could prevent a wound from healing. LVN F said he was responsible for monitoring the low air loss mattress setting. During an interview on 11/15/2023 at 11:11 a.m., the wound consultant physician indicated, 11/15/2023, there was a small open area to the right buttock. The physician indicated the low air loss mattress set on 350 pounds could aggravate (make worse or more serious) the healing process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 19 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/16/2023 at 2:56 p.m., ADON E said she checked Resident #4's mattress on Monday 11/13/2023. ADON E said Resident #4's mattress should have been set on the correct weight setting. ADON E said Resident #4's weight was not 350 pounds and agreed his weight was 133 pounds after he was reweighed 11/16/2023. ADON E said the nurses had not signed off a physician's order or a nursing order to validate the mattress was set on the correct settings. The ADON E said she monitored the low air loss mattress settings by going room to room and she expected the nurses to do the same. The ADON E said pressure injuries were caused from pressure, but she denied having a low air loss mattress set at 350 pounds and the resident's weight was 133 had no bearing on the effectiveness of the mattress. The ADON E said if there was too little air, then she could see the problem with effectiveness of the mattress for wound healing. During an interview on 11/16/2023 at 3:15 p.m., the DON said pressure injuries were caused from direct pressure. The DON said she expected the low air loss mattress to be set correctly for healing and comfort. The DON said the nurses were responsible for monitoring the low air loss mattress settings. The DON said she personally did not feel a weight setting not set to his weight would cause any more harm. The DON said she exchanged the mattress today for a comfort setting mattress. During an interview on 11/16/2023 at 3:55 p.m., the Administrator said she expected the low air loss mattress to be set according to comfort and weight. The Administrator said the weight setting dial was used for adjusting for comfort. The Administrator said the nurses were responsible for monitoring the low air loss mattresses. The Administrator said the low air loss mattress was set for comfort and had no risk to the healing of Resident #4's wounds. Record review of an email dated 11/15/2023 at 10:44 a.m., indicated the supplier of the low air loss mattress wrote the DON indicating the low air loss mattress replacement system provided both alternating pressure and low air loss to optimize pressure redistribution, shear/friction reduction, and microclimate control designed to prevent, treat, and heal pressure ulcers in the home or long-term care setting. The control unit offers 10-minute cycles when alternating and can also be used to static mode adjustable patient weight settings to allow for optimal immersion and patient comfort. Record review of a Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 6/2020 indicated 1. The nursing staff will evaluate and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 20 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 6 residents reviewed for quality of care. (Resident #29) The facility did not provide interventions for Resident #29's left hand contracture. This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being. Findings included: Record review of Resident #29's face sheet dated 11/15/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #29 had diagnoses that included senile degeneration of the brain (memory loss), anxiety, depression, and high blood pressure. Record review of Resident #29's quarterly MDS assessment dated [DATE], indicated she rarely/never made herself understood or understood others. The MDS assessment indicated Resident #29 had long-term and short-term memory problem and her cognition was severely impaired. The MDS assessment indicated Resident #29 required extensive assistance with bed mobility, toileting, and personal hygiene. Resident #29 was totally dependent on staff with dressing and bathing. The MDS assessment indicated Resident #29 had limited range of motion to lower extremity on both sides. Record review of Resident #29's comprehensive care plan dated 09/19/23, indicated Resident #29 had impaired mobility related to cerebral vascular accident (stroke) with interventions for Hoyer lift with 2 staff for all transfers and OT/PT screen and/or evaluation as needed. The care plan did not address Resident #29's left hand contracture. Record review of Resident #29's physician's order report dated 10/15/23-11/15/23, did not reveal any orders for her left-hand contracture. Record review of Resident #29's hospice visit note dated 10/24/23, indicated under physical/musculoskeletal she had contractures, and the location of the contractures were left hip, right hip, left ankle, right ankle, left fingers, left foot, right foot. During an observation on 11/13/23 at 2:44 PM, Resident #29 was in bed and her left hand was contracted. Resident #29's middle finger, ring finger, and pinky fingers were in a closed position. There were no interventions in place to her left hand. Resident #29 was nonverbal. During an observation on 11/14/23 at 08:37 AM, Resident #29 was in bed and continued with no interventions in place for her left-hand contracture. During an observation and interview on 11/15/23 at 12:01 PM, Resident #29 was in bed. Her left hand continued with no interventions in place for her left-hand contracture. CNA L said Resident #29's left hand was contracted and kept in that position. CNA L did not respond when asked if Resident #29 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 21 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had any interventions in place for her left-hand contracture. CNA M arrived in Resident #29's room and said Resident #29's left hand had been contracted for a long time. CNA M said they usually placed a carrot in her hand, but it must have been sent to laundry. During an interview on 11/16/23 at 09:08 AM, CNA K said Resident #29 always kept a hand towel rolled in her left hand and was unable to answer why she did not have it in place for the last 3 days. CNA K said it was important for Resident #29 to have an intervention in place to her left-hand contracture so her fingernails would be kept off her palm and not dig into it or cause bruises and to keep her left hand from contracting more. During an interview on 11/16/23 at 09:12 AM, LVN H said Resident #29 has had her left hand contracted and was unsure if there was anything in place for her contracture. LVN H said they were not doing anything for her contracture. LVN H said it was important to have interventions in place to keep Resident #29's hand from contracting more. LVN H said the nurses, aides, ADON and hospice were responsible for ensuring something was put in place for Resident #29's contracture. During an interview on 11/16/23 at 09:25 AM, ADON E said in the past, the staff was applying a wash rag to Resident #29's left hand, but she usually removed it. ADON E said the nurses were responsible for ensuring the interventions for Resident #29 were in place. ADON E said she remembered Resident #29 had something in place to her left hand on Monday and Tuesday, and she must have taken it off. ADON E said the hospice nurse and herself were responsible for ensuring Resident #29 had an intervention in place for her left-hand contracture. During an interview on 11/16/23 at 02:44 PM, the DON said she expected contractures to be prevented. The DON said Resident #29's contracture will not contract any more than it is as she has had it for a long time. The DON said the nursing staff was responsible for ensuring residents with contractures had interventions in place. During an interview on 11/16/23 at 3:16 PM, the Administrator said she expected residents who had contractures to have interventions in place for their contractures whether it was a hand roll in place or therapy. The Administrator said Resident #29 should have had a hand roll in place for her left-hand contracture along with an order for the hand roll. The Administrator said her nurses would know if a resident had a contracture. The Administrator said new staff would not know if Resident #29 had a contracture unless they put their eye on her. The Administrator said the nursing staff was responsible for ensuring Resident #29 had interventions in place for her contracture. Record review of the facility's policy titled Functional Impairment- Clinical Protocol dated June 2020, indicated . 1. Upon admission to the facility, at any time a significant change if condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's physical condition and functional status .The physician and staff will evaluate the residents for complications secondary to functional decline, and/or immobility, such as .f. muscle atrophy/contractures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 22 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0692 Provide enough food/fluids to maintain a resident's health. 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 ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 2 of 5 residents (Residents #4 and #38) reviewed for hydration. Residents Affected - Few 1. The facility failed to ensure Resident #4 received adequate nutrition for wound healing. 2. The facility failed to ensure Resident #38 received adequate hydration. These failures could place residents at risk for dehydration, electrolyte imbalance, slow healing of pressure injuries, and continued poor skin health. Findings included: 1. Record review of a face sheet dated 11/15/2023 indicated Resident #4 was an [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of fracture to left femur (upper leg bone), dementia, pressure ulcer right buttock, unstageable, and pressure ulcer to left buttock stage 2. Record review of an Annual MDS dated [DATE] indicated Resident #4 was usually understood, and usually understands others. The MDS indicated Resident #4's BIMS score was 4 indicating severe impairment of cognition. The MDS indicated Resident #4 required set up or clean up assistance with eating. The MDS indicated Resident #4 was 6 ft 4 inches tall and his weight was 148 pounds, and he received a therapeutic diet. The MDS in section additional diagnoses were vitamin deficiency, and abnormal gait and mobility. The MDS in the section of Skin Conditions (determination of pressure ulcer/injury risk) the area was not marked regarding Resident #4 had a pressure ulcer/injury, a scar over bony prominence, or non-removable dressing/device. The areas regarding a formal assessment and clinical assessment were marked as a risk. The MDS indicted in M0150 Risk of Pressure Ulcers/Injuries indicated Resident #4 was at risk. The MDS indicated in the section M0210Pressure Ulcers/Injuries no was marked indicating Resident #4 did not have one or more unhealed pressure ulcers/injuries. The MDS indicated Resident #4 had moisture associated skin damage. Record review of a dietician evaluation dated August 2023 indicated Resident #4 was insidiously (gradual, subtle way, but with harmful effects) losing weight. Record review of the comprehensive care plan dated 5/19/2023 indicated Resident #4 had a risk for altered nutrition and received a regular no added salt diet. The goal of the care plan was to meet his nutritional needs and hydration. The interventions included no salt on the tray diet with thin liquids, monitor the meal intake, offer extra fluids, provide 8 ounces of water with each meal tray, hydration and snacks pass daily, monitor weight as recommended, monitor skin status, monitor labs, monitor food preferences, and provide supplemental foods as recommended by dietician. Record review of the active physician orders indicated on 11/15/2023 Resident #4 had a physician's order for a multivitamin one daily ordered on 8/29/2023; regular diet with no salt on tray on 10/26/2023; Fortified foods ordered on 8/24/2022; milk with all meals ordered on 9/07/2023; pro stat supplement 30 milliliters po twice daily; and house supplement 2.0 120 milliliters by mouth three times daily ordered on 10/23/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 23 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0692 Record review of Resident #4's Skin Condition Reports indicated: Level of Harm - Minimal harm or potential for actual harm 10/04/2023 indicated Resident #4 had a non-pressure related skin conditions; the section of the assessment for pressure related skin condition side detail indicated no pressure injury. The assessment was blank otherwise. Residents Affected - Few 10/10/2023 indicated Resident #4 had no non-pressure related skin conditions; the section of the assessment for pressure related skin condition report indicated Resident #4 had no pressure related skin conditions. The assessment was blank otherwise. 10/16/2023 indicated Resident #4 had no non-pressure related skin conditions; the section of the assessment for pressure related skin condition report indicated see wound management report. The assessment was blank otherwise. 10/25/2023 indicated Resident #4 had no non-pressure related skin conditions; the section of the assessment for pressure related skin condition report indicated see wound management report. The assessment was blank otherwise. 11/01/2023 indicated Resident #4 had no non-pressure related skin conditions; the section of the assessment for pressure related skin condition report indicated see wound management report. The assessment was blank otherwise. 11/08/2023 indicated Resident #4 had no non-pressure related skin conditions; the section of the assessment for pressure related skin condition report indicated see wound management report. The assessment was blank otherwise. Record review of Wound Evaluation and Management Summary indicated: 10/04/2023 indicated Resident #4 had a wound to his right buttock. Focused wound #8 was a non-pressure wound of the right buttock partial thickness measuring 2 x 2.5 x not measurable centimeters. The assessment indicated the surface area was 5.00 centimeters squared with no exudate (drainage) scab. Focused wound #9 indicated Resident #4 had a non-pressure wound of the left buttock (resolved on 10/04/2023). 10/11/2023 indicated Resident #4 had a non-pressure wound #8 of the right buttocks was resolved on (10/11/2023). The assessment had no other wounds listed for treatment. 10/18/2023 indicated Resident #4 had a new wound stage 2 pressure wound #11 of the left buttock partial thickness measuring 1 x 1 x 0.1 cm wound with light serous (clear/yellow fluid) drainage. The etiology (cause) was pressure. The assessment indicated Resident #4 had a new pressure wound #12 an unstageable DTI (deep tissue injury) of the right buttock partial thickness measuring 8.5 x 2.2 x 0.1 centimeters with a surface area of 18.70 centimeters squared wit light serous drainage with 100 % dermis tissue the etiology was pressure, and the stage was DTI unstageable. The treatment plan included silver sulfadiazine apply once daily for 30 days, recommendation of off-loading, and group 2 mattress. The note indicated Resident #4 had sharp selective debridement to remove devitalized epidermis (surgically removing the layer of skin with a scalpel) and/or dermis. The recommendations were off-loading the wound; reposition per facility protocol, and group 2 mattress. 10/25/2023 indicated Resident #4's wound #11 was resolved to the left buttock on 10/25/2023. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 24 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wound #12 was a stage 2 pressure wound of the right buttock with partial thickness measuring 3.5 x 2.2 x 0.1 cm with 7.70 centimeters squared surface area with light serous drainage with etiology pressure, with improved due to decrease surface area. The recommendations were off-loading the wound; reposition per facility protocol, and group 2 mattress. 11/01/2023 indicated Resident # 4's wound #12 to the right buttock was unstageable deep tissue injury and full thickness wound. The wound measured 4.0 x 2.4 x 0.1 centimeters. The surface area of the wound measured 9.60 centimeters squared. The wound had 30% slough (dead tissue), with 70% viable tissue, and the wound was at goal. The note indicated the wound required surgical excisional debridement to remove necrotic tissue and establish the margins of viable tissue. The recommendations were off-loading the wound; reposition per facility protocol, and group 2 mattress. 11/08/2023 indicted Resident #4's wound #12 to the right buttock was a full thickness, pressure wound measuring 1.4 x 0.8 x 0.1 centimeters with 1.12 centimeters squared surface area, with light serous drainage, and 100% slough to the wound bed. The wound progress was at goal. The note indicated Resident #4's right buttock full thickness wound was debrided using surgical excisional debridement to remove necrotic tissue and establish the margins of viable tissue. The recommendations were off-loading the wound; reposition per facility protocol, and group 2 mattress. 11/15/2023 indicated Resident #4's wound #12 to the right buttock was a full thickness wound. The etiology was from pressure, the wound measured 1.3 x 3.2 x 0.1 centimeters with a surface area of 4.16 centimeters squared with cluster wound (open ulceration) measuring 0.83 centimeters squared with light serous drainage. The wound was 20% granulation tissue and 80 % skin with the wound considered healing evidenced by decreased wound surface area. The treatment continued as silver sulfadiazine apply once daily x 30 days with gauze island dressing. Recommendations of off-load wound, reposition per protocol, and group-2 mattress. Record review of Resident #4's weights revealed: 11/15/2023 was 133.0 pounds (after surveyor intervention) 11/10/2023 was 136.0 pounds 10/10/2023 was 136.0 pounds 9/08/2023 was 142.0 pounds 8/10/2023 was 142.0 pounds 7/10/2023 was 148.0 pounds 6/09/2023 weight 150.0 pounds Resident #4 had a 11.33 % weight loss since June 2023. During an observation on 11/13/2023 at 12:20 p.m., Resident #4 had a sloppy joe on a bun, potato chips, and tea. Resident #4's lunch tray had no dessert, milk, or any items indicating fortified. Resident #4's tray card read to have milk with each meal. The tray card failed to indicate the fortified foods required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 25 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 11/14/2023 at 12:11 p.m., Resident #4 had baked fish, mashed potatoes, carrots, chocolate cake, bread, and tea. The lunch tray did not have milk on the tray. Resident #4's tray card read to have milk with each meal. The tray card failed to indicate the fortified foods required. During an interview on 11/15/2023 at 10:12 a.m., the DM said the fortified foods were usually in soup or a pudding. The DM said the sloppy joe meal had no fortified foods on the tray. The DM said the meal on 11/13/20232 had fortified soup served. The DM said the lunch 11/15/2023 would have fortified pudding. Record review of a fortified foods list provided by the DM on 11/15/2023 indicated Resident #4 was not on the list to receive fortified foods. During an observation on 11/15/2023 at 12:05 p.m., Resident #4 had ravioli, green beans, mashed potatoes, pineapple cobbler, tea, sliced bread. There was no milk or any items indicating fortified foods. Resident #4's tray card read to have milk with each meal. The tray card failed to indicate the fortified foods required. During an observation and interview on 11/15/2023 at 1:40 p.m., Resident #4's weight obtained after surveyor intervention via a mechanical lift scale indicated his current weight was 133 pounds. Resident #4's weight was verified by ADON E and she validated Resident #4 had lost 3 pounds since 11/10/2023. During a phone interview with the dietician on 11/16/2023 at 11:27 a.m., the dietician said the recommended milk and fortified foods was to increase the opportunity for more calories; therefore extra nutrition. During an interview on 11/15/2023 at 1:44 p.m., the DM said she was not aware of Resident #4 required milk with each meal or the physician ordered fortified foods. The DM said Resident #4 was at risk for weight loss and his wounds not healing by not having his physician ordered fortified foods, and milk. The DM said she should have received a communication form for the fortified foods. During an interview on 11/15/2023 at 2:54 p.m., ADON E said she expected Resident #4 to get the fortified foods and milk on his trays as ordered. ADON E said without the fortified foods and/or milk Resident #4 could have weight loss, continued skin breakdown, and could alter the wound healing process. ADON E said the nurses were responsible for ensuring the trays had the food items on the ticket. During an interview on 11/15/2023 at 3:15 p.m., the DON said she expected the physician orders to be followed by providing Resident #4 his milk and fortified foods on his trays. The DON said when those items were not on Resident #4's trays he was not receiving the extra calories, and therefore could lose weight. The DON said this was monitored by a weekly diet roster audit with the DM. The DON did not provide the surveyor with a diet roster. During an interview on 11/15/2023 at 3:50 p.m., the Administrator said she expected the dietician recommendations to be followed. The Administrator said Resident #4 was at risk for further weight loss. The Administrator said the dietary staff were responsible for ensuring the residents received the ordered food items. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 26 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2.Record review of Resident #38's face sheet, indicated she was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included acute embolism (DVT) and thrombosis (both blood clots that reduce or block blood flow inside your blood vessels), Hypernatremia (a medical term used to describe having too much sodium in the blood), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar (glucose). Record review of Resident 38's quarterly MDS assessment, dated 10/18/23, indicated Resident #38 was rarely understood and rarely understood by others. Resident #38 was cognitively severely impaired in decision-making. Resident #38 required extensive assistance with toileting, personal hygiene, dressing, bed mobility, bathing, and eating. The MDS indicated she was receiving a diuretic (water pill) medication. Record review of Resident #38's comprehensive care plan, dated 11/03/23, revealed Resident #38's needed assistance with her daily routine. Interventions were for staff to assist with fluids. Record review of Resident #38's physician's orders dated 10/12/23 indicated, Lasix (water pill) give 1 tablet daily for hypertension. Record review of Resident #38's physician's orders dated 10/25/23 indicated a regular mechanical soft diet and discontinued regular diet. Record review of Resident #38's physician's orders dated 10/26/23 indicated, encourage fluids. Record review of Resident #38's Comprehensive Metabolic (a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working) lab work dated 10/27/23 showed electrolyte imbalance with a sodium (NA) level of 151 which could indicate a sign of dehydration, which may be caused by not drinking enough, diarrhea, or certain medicines called diuretics (water pills) and blood urea nitrogen (BUN) levels of 70 which suggest impaired kidney function. Record review of Resident #38's, October 2023 ADL report, category: eating, fluid intake in ml indicated: *10/13/23 documented 360ml *10/14/23 through 10/22/23 no documentation of fluid intake *10/23/23 documented 120ml *10/24/23 documented 240ml *10/25/23 through 10/27/23 no documentation of fluid intake Record review of Resident #38's progress notes from 10/12/23 through 10/27/23 did not reveal any refusal of drinking liquids. Record review of Resident #38's hospital records dated 10/27/23 revealed she had a diagnosis of hypernatremia and DVT. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 27 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/14/23 at 9:30 a.m., LVN N said they offered fluids to Resident #38. She said Resident #38 was not a big drinker but she did drink. She said they did not document the amount she drank, but they did offer her drinks each time they went into the room with food and medication. She said Resident #38 was not a big eater but she did consume about 25-50% of each meal with a lot of coaching from staff. LVN N said she was the nurse who received Resident #38's Comprehensive Metabolic profile (CMP) back from the lab and notified the NP and the family. The NP gave orders to send Resident #38 to the hospital. She said Resident #38 had a diagnosis of hypernatremia, DVT, and UTI (urinary tract infection) while in the hospital. During an interview on 11/14/23 at 11:01 a.m., the NP said she had visited Resident #38 on admission and then again on 10/25/23. She said Resident #38 had advanced dementia and required a lot of assistance with care. She said dementia sometimes caused residents not to eat or drink at times but she had seen staff offering fluids. She said the facility notified her on 10/25/23 of Resident #38 pocketing food and she gave an order to change her diet and for speech therapy to do an evaluation. She said she had also ordered labs during that visit. The NP said the facility notified her of the lab results and because the NA and BUN levels were high, she had the facility to send Resident #38 to the emergency room. The NP said during her visit on 10/25/23 with Resident #38, she did not see any signs of distress or signs or symptoms of dehydration. She said she had no concerns about her care. During an interview on 11/15/23 at 3:28 p.m., LVN C said they encouraged fluids for Resident #38 but did not document the amount she drank on a day-to-day basis. She said Resident #38 drank fluids well most of the time. She said the CNAs were good about notifying her if a resident did not eat or drink during her shift. During a phone interview on 11/16/23 at 11:20 a.m., the dietician said she had not seen Resident #38. She said she had reviewed Resident #38's electronic chart on 10/23/23 but did not see her related to an incomplete height, weight, and no MNA (malnutrition screening) completed. She said the facility was responsible for completing but they could not complete without the height and weight being inputted into the electronic record. She said she had Resident #38 on her list to see next week on rounds. She said she had not received any consultants on Resident #38. During a phone interview on 11/16/23 at 11:27 a.m., the Medical Director said he did not know Resident #38. He said his NP came to the facility, made rounds, and notified him of any concerns if needed. He said that given the information from the surveyor about her labs being within range on her CMP on 10/13/23 and out of range on 10/27/23 with a BUN level of 70 and a sodium level of 152, it could be a nutrition, or hydration issue to cause her BUN to be elevated. He also said it could be age-related and cognition or any other comorbidity to have caused her hospitalization but without knowing all the details he could not say. He said his NP came and did an assessment then she would know more about Resident #38 and her overall health. During an interview on 11/16/23 at 3:38 p.m., the DON said the nurses were responsible for ensuring residents receive nutrition and hydration. She said they do an assessment every shift and they look at the resident's skin, mucous membrane, vital signs, weight loss, signs and symptoms of dark urine, and nutrition. She said if they noted any skin concerns, they would notify their wound consultant, and if they noted any nutrition concerns, they would notify the dietician. She said she had instructed her staff to offer fluids to Resident #38 and they were. She said they did not have to document fluids unless they had a doctor's order. The corporate nurse who was also in the room during the interview looked at the ADL documentation for Resident #38 and verified her ADL sheet had inconsistencies of documentation on nutrition and hydration in the electronic records. The DON said Resident #38 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 28 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0692 was receiving her nutrition and hydration. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/16/23 at 4:04 p.m., the Administrator said the nursing staff should have been documenting in the ADL documentation, how the resident had eaten or drank. She said the clinical team should have monitored during clinical meetings. The Administrator said it was important to monitor and ensure residents were receiving proper nutrition and hydration. Residents Affected - Few Record review of a Diets, Nutrition, and Hydration policy dated April 18, 2022, indicated The policy diet and hydration orders for newly admitted residents and changes to existing diets or fluids will be written as reflected in the facility diet manual. The facility will provide each resident with three meals daily and a nourishing snack at bedtime. Each meal will be provided according to physician orders, facility diet manual, and menu spread sheet. House supplements: the physician, practitioner, or dietician may choose to order house supplements to provide residents with additional calories and protein. The term house supplement will cover all items listed in the supplement rotation guide, this allows for rotating of various supplements and foods, so that residents do not become dissatisfied with the same shake day after day. The physician order should state frequency of the supplement. All procedure for supplements should be followed. One serving will be provided per ordered supplement. Hydration: The dietary manager, with the assistance of the dietician, will calculate daily fluid requirements for all residents with risk factors indicating a concern with fluid intake. Each resident should receive at least two to three 8 ounces to 12 ounces beverages for each meal; including residents who have orders for thickened liquids, unless contraindicated by diet or fluid orders. Each resident will be offered and have access to beverages between meals. The director of food and nutrition services will obtain the residents beverage preference on admission and not e preferred beverages on the tray care. During meal service in the dining room staff will have a variety of beverages to residents encouraging them to take at least 2 beverages of choice and will offer refills as needed or desired. Increased fluid needs may occur if the resident is suffering from one of the following: .dehydration .infections .urinary tract infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 29 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.Record review of a face sheet dated 11/15/2023 indicated Resident #4 was an [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of fracture to left femur (upper leg bone), dementia, pressure ulcer right buttock, unstageable, and pressure ulcer to left buttock stage 2. Residents Affected - Some Record review of an Annual MDS dated [DATE] indicated Resident #4 was usually understood, and usually understands others. The MDS indicated Resident #4's BIMS score was 4 indicating severe impairment of cognition. Record review of Resident #4's physician progress notes indicated Resident #4's visits were completed by a nurse practitioner on 9/12/2023, 9/28/2023, 10/12/2023, and 10/26/2023, and not his physician. During an interview on 11/16/2023 at 2:48 p.m., ADON E said when the physician came, he would provide a list of the residents he would see. ADON E said there was not a negative impact on the residents due to missing their physician visits on their admission and/or annual assessments. During an interview on 11/16/2023 at 3:15 p.m., the DON said she expected the residents to have their visits by their physician. The DON said all residents had been seen by the nurse practitioner. The DON said if a resident had not been seen by their physician, they could not receive their prescriptions. The DON said she was responsible for ensuring the residents were seen by their physician. During an interview on 11/16/2023 at 3:47 p.m., the Administrator said she expected the physician to make their visits. The Administrator said leadership was responsible for monitoring the physician-required visits. The Administrator said the admissions were discussed in the morning meetings. The Administrator said the nurse practitioner was an extension of the physician, therefore there was not risk for the resident. During a phone interview on 11/16/23 at 4:15 PM, the medical director said he became the medical director at the end of September 2023 for this facility. He said he made rounds in October and November. He said the facility was responsible for sending him a list of residents who needed to be seen. He said from the list he would break it down by using the alphabet. He said right off hand he could not say who he saw when making rounds. He said he had not completed documentation on any resident he visited in October or November. He stated he should have all documentation available and given to the facility for all visits. He stated he would start documenting all visits and getting all documentation to the facility. He said he would send over a list of residents he reviewed. He said he was aware all new admits should be seen within the first 30 days and all other residents should be seen every 60 days. Record review of a Physician Services policy dated May 7, 2021, indicated the medical care of each resident was under the supervision of a licensed physician. 3. The physician will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate; intervals; and ensure adequate alternative coverage. Based on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 4 of 21 residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 30 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0712 (Resident #'s 38, 59, 31 and 4) reviewed for physician services. Level of Harm - Minimal harm or potential for actual harm The facility failed to ensure Resident #38, Resident #59, Resident #31, and Resident #4 were seen by a physician within the first 30 days of their admission to the facility. Residents Affected - Some These failures could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status. The findings included: 1.Record review of Resident #38's face sheet, indicated she was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included acute embolism and thrombosis (both blood clots that reduce or block blood flow inside your blood vessels), Hypernatremia (a medical term used to describe having too much sodium in the blood), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar (glucose). Record review of Resident 38's quarterly MDS assessment, dated 10/18/23, indicated Resident #38 was rarely understood and rarely understood by others. Resident #38 was cognitively severely impaired in decision-making. Resident #38 required extensive assistance with toileting, personal hygiene, dressing, bed mobility, bathing, and eating. Record review of Resident 38's Face Sheet indicated the medical director was her primary physician. Record review of the electronic health records for Resident #38, did not reveal any documented evidence of physician progress notes for the physician's visit dated from 10/12/23 through 11/16/23. 2. Record review of Resident #59's face sheet dated 11/15/23, indicated a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 59's diagnoses include paranoid schizophrenia (mental illness that causes delusions, or fixed beliefs that seem real, and hallucinations, or hearing voices that are not real), post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress anxiety, flashback, and avoidance of similar situations), congestive heart failure (your heart can't pump blood well enough to meet the body's needs), chronic kidney disease (stage 4) (severe loss of kidney function) and essential hypertension (high blood pressure). Record review of Resident #59's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated he had a BIMS score of 13 indicating his cognition was intact. The MDS assessment indicated Resident #59 required supervision with all ADLs. Record review of Resident #59's physician's order report dated 10/15/23-11/15/23, indicated he had an order to admit to [the facility name] under the care of the [medical director's name] for long-term care with a start date of 06/06/23. Record review of Resident #59's EMR on 11/16/23 at 4:34 PM, did not reveal a physician's progress note for Resident #59 since he was admitted to the facility on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 31 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have adequate monitoring in place for side effects associated with the use of psychotropic medications and documented in the clinical record for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #13). The facility failed to adequately monitor Resident #13's behaviors regarding his psychotropic medications, including valium (an antianxiety medication), buspirone (antianxiety medication), and paroxetine (an antidepressant medication). These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Record review of Resident #13's face sheet dated 11/16/23 indicated that he was a [AGE] year-old male who originally admitted on [DATE] and re-admitted [DATE] with the diagnoses of Alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), chronic kidney disease (longstanding disease of the kidney resulting in kidney failure), and anxiety (mental health disorder characterized by worry or fear enough to interrupt daily activities). Record review of Resident #13's quarterly MDS assessment dated [DATE] indicated he had BIMS score of 3 which indicated he had severely impaired cognition. The MDS indicated that he required substantial to maximal assistance with bathing ad personal hygiene, partial to moderate assistance with dressing, bed mobility, and transfers, and setup and cleanup assistance with eating. The MDS indicated Resident #13 was taking an antianxiety medication during the last 7 day look back period. Record review of Resident #13's care plan last revised 10/23/23 indicated he received an antidepressant medication with the approaches to include the medication administered per medical director orders, monitor/assess for the effectiveness of the drug, monitor for side effects, and monitor resident's mood and response to the medication. The care plan also indicated, last revised on 11/02/23, Resident #13 received an antianxiety medication with the approaches to include the medication administered per medical director orders, monitor for the effectiveness and adverse consequences of the drug, monitor resident's mood and response to the medication, and quantitatively and objectively document the resident's behavior/mood. Record review of Resident #13's physician order report dated 10/16/23-11/16/23 indicated he had the following orders: 1. Paroxetine HCL 30mg tablet 1 oral once a day at 8:00am for anxiety disorder with a start date of 01/12/23. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 32 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Valium (diazepam) 2mg tab oral once a day on Tuesday Thursday and Saturday at 4:00pm for anxiety disorder with a start date of 03/31/23. 3. Buspirone (buspar) 30mg tab 1 oral twice a day at 8:00am and 5:00pm for anxiety with a start date of 05/02/23. Record review of Resident #13's medication administration history dated 11/01/23-11/13/23 indicated he began taking buspirone on 05/02/23, valium on 03/31/23 and paroxetine on 01/14/23. The medication administration history record did not indicate any behavior monitoring for the administration of valium, buspirone, or paroxetine. During an interview on 11/16/23 at 02:42 PM ADON D said the behavior monitoring should have been in place when the order for the psychotropic medications were written. She said she was responsible for placing the order for monitoring in the system. The ADON D said usually if she failed to input the order for monitoring, the MDS nurse would catch it. She said herself, ADON E, and the MDS nurse monitor orders daily in the morning meeting and she guessed they just missed the order not being there. The ADON D said she did not feel it was a risk to Resident #13 because he did not have any behaviors. During an interview on 11/16/23 at 03:04 PM ADON E said anytime that psychotropic medications were ordered the nurse inputting the order was responsible for inputting the order for behavior monitoring. She said herself and ADON D were responsible for ensuring the order was in the system. ADON E said she did not see where there was a risk to Resident #13 with the monitoring not being in place. During an interview on 11/16/23 at 03:33 PM the DON said she expected the monitoring for the psychotropic medications to be in place. She said the order for behavior monitoring should have been input when the order for the medications and the side effect monitoring was input. The DON said the charge nurses were responsible for inputting the behavior monitoring and the ADONs were responsible for following up to make sure orders were placed correctly daily. She said she did not think there was a risk to Resident #13 because there was no documentation of behaviors in the nurse's notes. During an interview on 11/16/23 at 03:54 PM the Administrator said she expected the order for monitoring side effects and behavior monitoring to be in place for the antianxiety and antidepressant medications. She said the charge nurses were responsible for putting the monitoring in place. The Administrator said the ADONs and DON should have been monitoring the orders daily in the morning meeting to ensure orders were in place. The Administrator said she did not feel there was a risk to Resident #13 with monitoring not being in place. She said it would have been documented in the nurse's notes if the resident had a behavior. Record review of the facility policy for Antipsychotic Medication use dated 6/2020 indicated: Policy Statement Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 33 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0758 Level of Harm - Minimal harm or potential for actual harm 12. All antipsychotic medications will be used within the dosage guidelines listed in F758, or clinical justification will be documented for dosages that exceed the listed guidelines for more than 48 hours . 16. The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including psychotropic medications . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 34 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (300/400 Hall nurse cart) reviewed for cleanliness. The facility failed to ensure the Medication Cart #1 (300/400 nurse medication cart) was free from a dried, tacky substance in the 3rd large drawer, and #4 and #5 small drawers. This failure could result in residents not receiving an accurate dose of medication as not being maintained at their best therapeutic level. Findings included: During an observation on 11/15/2023 at 3:30 p.m., ADON E assisted the surveyor with reviewing the Medication Cart #1 (300/400 nurse medication cart). During the review the 3rd large drawer, and the 4th and 5th small drawers had a brown colored material which was dry but tacky feeling. The ADON said the nurses were responsible for ensuring the medication cart was clean. The ADON said the substance could contaminate the medications stored in these drawers. During an interview on 11/16/2023 at 3:21 p.m., the DON said the nurses were responsible for ensuring the medication cart was clean. The DON said the pharmacist comes and performs audits on the carts but has not had any issues with the cleanliness of the medication carts. The DON indicated there was not a failure with the sticky substance in the drawers with medications. During an interview on 11/16/2023 at 3:44 p.m., the Administrator said she expected the medication carts to be clean. The Administrator said the nurses were responsible for ensuring the medication carts were clean. The Administrator said she could not see the substance causing any harm to the resident. A policy was requested at this time. The policy was not received upon exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 35 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 2 residents (Resident #42 and Resident #20) reviewed for hospice services. The facility failed to maintain Resident #42 and Resident #20's hospice binder. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: 1.Record review of Resident #42's face sheet, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease {COPD}( a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar (glucose). Record review of Resident 42's quarterly MDS assessment, dated 11/02/23, indicated Resident #42 was understood and understood by others. Resident #42 BIMS score was a 13 indicating she was cognitively intact. Resident #42 required extensive assistance with toileting, personal hygiene, dressing, max assistance with bathing, and set up for eating. The MDS indicated she was receiving hospice service. Record review of Resident #42's comprehensive care plan, dated 11/08/23, revealed Resident #42's was admitted to hospice for a diagnosis of COPD. The intervention was staff would notify the hospice of any changes, the staff would coordinate with the hospice, staff would follow all hospice physician orders. Record review of Resident #42's physician's orders dated 04/12/23 indicated, admitted to hospice with a diagnosis of COPD. Record review of Resident #42's hospice binder, accessed on 11/15/23, revealed the last IDT meeting was 09/07/23, and the last plan of care (POC) was 09/10/23-11/08/23. 2. Record review of Resident #20's face sheet, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which congestive heart failure, or heart failure, (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), hypertension (high blood pressure), and anxiety (feeling anxious). Record review of Resident 20's annual MDS assessment, dated 10/01/23, indicated Resident #20 was usually understood and usually understood by others. Resident #20 was cognitively severely impaired in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 36 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few decision-making. Resident #20 required assistance with toileting, personal hygiene, dressing, bed mobility, bathing, and set up for eating. The MDS indicated she was receiving hospice service. Record review of Resident #20's comprehensive care plan, dated 10/13/23, revealed Resident #20's was admitted to hospice service related to heart failure. The intervention was staff would notify the hospice of any changes, the staff would coordinate with the hospice, staff would follow all hospice physician orders. Record review of Resident #20's physician's orders dated 09/30/22 indicated, admit to hospice. Record review of Resident #20's hospice binder, accessed on 11/15/23, revealed no updated medication list, the last IDT meeting was 09/07/23, and the last POC was 08/05/23-10/03/23. During an interview on 11/15/23 at 3:23 p.m., LVN F said the hospice binder was for the convenience of medication, to call in case of emergency, change in history, refills, and diets. He said the medication administration record (MARS) should be correlated together for continuity of care. He said the hospice nurses should have kept the hospice binder updated. During an interview on 11/15/23 at 3:37 p.m., ADON B said she was responsible for ensuring the hospice books were updated. ADON B said the facility should have a binder for all residents who were on hospice. She said the binders should contain when they were admitted to hospice, why they were admitted to hospice (such as diagnosis), code status (full code or do not resuscitate (DNR), a list of medications provided by hospice, progress notes, and their plan of care. She said it was important to have hospice charts updated for continuity of care. She said she did not see an updated IDT meeting or POC in the hospice binder and the most updated IDT meeting was 09/07/23 for Resident #42 and Resident #20. She said the last POC was dated 9/10/23-11/08/23 for Resident #42 and 08/05/23-10/03/23 for Resident #20. During a phone interview on 11/16/23 at 11:08 a.m., the hospice nurse said she was the nurse caring for Resident #42 and Resident #20. She said she was responsible for updating both resident's hospice books. She said they had their last IDT meeting on 11/02/23. She said she had the most recent POC and IDT meetings in her car because she had forgotten to bring them in on her last visit. She said the IDT meeting notes and the POC should be placed on the hospice chart as soon as possible after the meetings. to correlate care. She said without providing the facility with the most recent IDT meeting or plan of care could cause poor coordination of care. During an interview on 11/16/23 at 3:38 p.m., the DON said the hospice nurse should have made sure the hospice binder was up to date. She said they need to have the POC certification and IDT meeting in the binder for continuation of care and to prevent care from being missed. During an interview on 11/16/23 at 4:04 p.m., the Administrator said the hospice provides the books and keeps everything updated. She said hospice was supposed to bring the certifications, POC, and IDT meetings and keep the book updated. The Administrator said the clinical manager was responsible for ensuring the books were updated. She said the books should reflect the care being given. Record review of the facility's policy on Hospice Program, dated 6/2020, revealed Our facility contract for Hospice service for residents who wish to participate in such programs. Hospice providers who contract with this facility or held responsible for meeting the same professional standards and timeliness of service as contracted individuals or agency associated with the facility. When a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 37 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0849 Level of Harm - Minimal harm or potential for actual harm resident participates in the Hospice program, a coordinated plan of care between the facility, Hospice agency, and the resident or family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 38 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 21 residents (Resident #13, Resident #31, and Resident #39) reviewed for infection control practices and transmission-based precautions. Residents Affected - Some The facility failed to follow their policy for testing residents and staff following a COVID-19 outbreak in the facility after Resident #13 and Resident #31 tested positive for COVID-19. The facility failed to ensure LVN G performed hand hygiene and glove change while providing wound care for Resident #39. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1.Record review of Resident #31's face sheet dated 11/16/23 indicated he was a [AGE] year-old male who originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of chronic congestive heart failure (chronic condition that causes the heart not to pump as well as it should), depression (disorder that causes persistent feeling of sadness and loss of interest), and age-related physical debility (the state of being weak in health or overall body). Record review of Resident #31's quarterly MDS assessment dated [DATE] indicated he had a BIMS of 4 which indicated he had severe cognitive impairment. The MDS also indicated he required supervision for bed mobility, transfers, dressing, bathing, toileting, and eating. Record review of Resident #31's physician order report dated 10/16/23 indicated he was placed under isolation for COVID-19 with a start date of 10/05/23. Record review of the facility preventive health report dated 10/03/23-10/09/23 indicated Resident #31 tested positive for COVID on 10/03/23. Record review of the facility preventive health report dated 10/03/23-10/09/23 indicated that no further testing of residents was performed after 10/09/23. 2. Record review of Resident #13's face sheet dated 11/16/23 indicated that he was a [AGE] year-old male who originally admitted on [DATE] and re-admitted [DATE] with the diagnoses of Alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), chronic kidney disease (longstanding disease of the kidney resulting in kidney failure), and anxiety (mental health disorder characterized by worry or fear enough to interrupt daily activities). Record review of Resident #13's quarterly MDS assessment dated [DATE] indicated he had BIMS score of 3 which indicated he had severely impaired cognition. The MDS indicated that he required substantial to maximal assistance with bathing ad personal hygiene, partial to moderate assistance with dressing, bed mobility, and transfers, and setup and cleanup assistance with eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 39 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #13's physician order report dated 10/16/23-11/16/23 indicated he had COVID and was placed under isolation with a start date of 10/05/23 and end date of 10/16/23. Record review of Resident #13's care plan dated 10/03/23 indicated he was at risk for psychosocial well being related to the diagnosis of COVID-19 with interventions to follow facility, CDC, and CMS guidelines for COVID-19 infection control protocols. Record review of the facility preventive health report dated 10/03/23-10/09/23 indicated Resident #13 tested positive for COVID on 10/03/23. Record review of the facility preventive health report dated 10/03/23-10/09/23 indicated that no further testing of residents was performed after 10/09/23. Record review of the facility employee testing dated 10/03/23-10/09/23 indicated there were no positive covid tests for staff and there was no further testing performed after 10/09/23. During an interview on 11/16/23 at 1:35 PM ADON E, the infection preventionist, said she was responsible for COVID testing. She said Resident #13 and Resident #31 tested positive on 10/03/23 and they were placed in isolation. ADON E said the facility began the broad-based approach to testing. She said the facility staff and all the residents were tested on [DATE], 10/05/23, and 10/09/23 and no other positives tests were found so they stopped testing per the facility policy. The ADON E said the policy she had was the same policy provided to the surveyor. She said she was unsure of the testing needing to be completed for at least 14 days. The ADON E said at least 14 days meant they should have tested through 14 days of the positive test, but she would see what else related to testing she could find. She said she did not feel it was a risk to residents or staff because no one had tested positive. During an interview on 11/16/23 at 3:14 PM the DON said ADON E was the infection preventionist and was responsible for COVID and outbreak testing. She said she did assist her with the outbreak by completing testing of the facility staff. The DON said the facility policy that she provided to the surveyor said for broad based approach the staff and residents should have been tested on the initial day of 10/03/23, day 3 which was 10/05/23, and then on day 5 which was 10/09/23. She said with the facility staff and residents having 2 negative tests, the facility no longer had to complete testing. The DON said she guessed the interpretation of the facility policy is different because she did not understand it to be required to test up through 14 days. The DON said there was no risk to residents nor staff because if they had someone that became symptomatic, the facility would have retested. 3.Record review of Resident #39's face sheet, dated 11/15/2023, revealed Resident # 39 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of acute and chronic combined systolic congestive and diastolic congestive heart failure ( occurs when either disease or defect causes the heart muscle to lose the ability to pump blood efficiently), Non-pressure chronic ulcer of buttock with unspecified severity(Admission) ( Diseases of the skin and subcutaneous tissue), and unspecified dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Record review of Resident # 39's quarterly MDS assessment, dated 9/15/2023, indicated Resident #39 had a BIMS score of 10, indicating Resident #39 moderately impaired cognition. The MDS revealed Resident #39 had no behaviors or rejection of care during the look-back period. The MDS revealed Resident #39 required substantial/ maximal assistance for dressing, toilet use, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 40 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #39's comprehensive care plan, last revised on 7/12/2023, indicated Resident #39 requires extensive assistance with bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Care plan revealed Resident #39 has a stage 3 pressure ulcer to left buttock and an unstageable pressure ulcer to the left heel. During an observation on 11/15/2023 at 9:30 a.m., LVN G provided wound care for Resident #39. During wound care LVN G performed hand hygiene, put on gloves, removed dressing from left heel cleaned wound, changed gloves, applied new dressing. LVN G was not observed performing hand hygiene before donning clean gloves. LVN G then removed gloves performed hand hygiene, put on gloves removed Residents #39's brief, removed dressing to left buttock and cleaned wound. LVN G removed her dirty gloves and donned clean gloves applied a new dressing, cleaned buttock, removed solid brief, and applied a new brief. LVN G was not observed performing hand hygiene during glove change. LVN G performed hand hygiene when finished with wound care. During an interview on 11/16/2023 at 9:45 a.m., the ADON stated you are supposed to use hand hygiene when you enter the room, apply gloves, take off dirty dressing, take off dirty gloves, use hand sanitizer, clean gloves to apply dressing, take off gloves, sanitize, and discard dirty stuff in red bag. The ADON stated it was important to use proper hand hygiene to keep down infection. The ADON stated they in-service the nursing staff on infection. The ADON stated the harm to the resident was it could cause cross-contamination or infection. During an interview on 11/16/2023 at 1:45 p.m., LVN G stated she was supposed to use hand hygiene after every glove change. LVN G stated it was important to use hand hygiene to keep down the spread of germs and so there was no cross-contamination. LVN G stated the harm to the resident was it could spread to others, or she could get a UTI. LVN G stated everything should be done cleanly so there was no spread of infection. During an interview on 11/16/2023 at 2:30 p.m., the DON stated she expects the nurses to use hand hygiene during wound care. The DON stated hand hygiene was important so they would have clean hands when they put on gloves. The DON stated she ensured staff was performing hand hygiene by doing check offs, but stated you can tell if wounds are treated correctly by healing and infection. The DON stated there was a minimal risk to the residents for infection. During an interview on 11/16/2023 at 3:17 p.m., the administrator stated she expects the nurses to use hand hygiene during wound care. The administrator stated it was important to use hand hygiene for infection control measures. The administrator stated she ensured staff was performing hand hygiene by education on hand hygiene. The administrator stated not using hand hygiene could harm the resident because it was part of sanitation and infection control. Record review of the facility Covid-19 Response plan dated 10/1/2022 indicated: The facility's goal is to protect our residents and staff from infectious diseases, and to maintain the highest level of care practicable by means of assessment and screening of residents, employees, and visitors . Broad-Based Approach If a facility does not have expertise, resources, or ability to identify all close contacts, they should investigate thee outbreak at a facility-wide or group-level . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 41 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0880 Level of Harm - Minimal harm or potential for actual harm All staff and residents that tested negative should be retested every 3-7days until testing identifies no new cases of COVID-19 infection amongst staff or residents are identified for a period of at least 14 days . Record review of the site following was accessed on 11/16/23 at 04:23 PM and it indicated at least meant no less than. Residents Affected - Some AT LEAST | English meaning - Cambridge Dictionary Record review of the facility's undated policy titled Handwashing/Hand Hygiene, indicated all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of the healthcare-associated infection .before and after dressing change FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 42 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 5 of 21 employees (Speech Therapist, Occupational Therapist, Physical Therapist, CNA K, and CNA M) reviewed for required trainings. Residents Affected - Few The facility failed to ensure the Speech Therapist, the Occupational Therapist, and the Physical Therapist received restraint training annually. The facility failed to ensure CNA K, CNA M, the Speech Therapist, and the Physical Therapist received HIV training annually. These failures could place residents at risk for the inappropriate use of restraints and exposure to HIV. Findings included: Record review of the employee files indicated the following: *Speech Therapist (hire date 11/08/21), *Occupational Therapist (hire date 10/01/21), *Physical Therapist (hire date 08/12/22), *CNA K (hire date 09/14/18), *CNA M (hire date 03/04/20). During an interview on 11/16/23 at 11:00 AM the Administrator said staff that received the training were printed on the list of employees as they provided one on one with the staff who did not attend the in-service. The Administrator said she did not have the employees sign anything after the one-on-one in-service was provided. The Administrator said she printed an employee list and that was her check and balances for ensuring all employees received the training. The Administrator said the staff listed on the employee list received the training. Record review of the facility's in-service titled Restraint Reduction, GDR, sleep disorders, abuse prevention, and burnout dated 07/06/23, did not indicate signatures for the Speech Therapist, Occupational Therapist, or the Physical Therapist to prove they had attended the in-service. There was not an Active Employee List dated 07/06/23 provided with the in-service for restraint training. Record review of the facility's in-service titled HIV, TB, and Pain dated 09/20/23, did not indicate signatures for CNA K, CNA M, or the Speech Therapist to prove they had attended the in-service. Record review of the facility's Active Employee List dated 09/20/23 indicated there were no staff signatures to indicate an employee received one-on-one training. There was no evidence to indicate the staff received the education provided regarding HIV . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 43 of 44 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 675949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503 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 0940 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/16/23 at 02:44 PM, the DON said the Administrator and herself provided the monthly in-services. The DON said she expected the staff to read the in-service and sign it. The DON said if the staff did not sign the in-service, then they just didn't sign. The DON said they have preached enough on the topics that the staff are able to speak about them so there were no risks for the residents. The DON said she could not identify if the staff had received trainings since the in-services were not signed . Residents Affected - Few During an interview on 11/16/23 at 3:16 PM, the Administrator said she expected her staff to receive their trainings, and the staff received the required trainings. The Administrator said there were no risks to the residents as the staff received their education. The Administrator said management was responsible for providing the in-services. The Administrator said there were no other in-services to provide other than the ones already provided. Record review of the facility's policy titled Training and Training Records dated October 1, 2022, indicated All Employees will participate in a training program designed to educate and update staff on Company policies, state, and Federal Regulations at least annually. 1. The facility will provide training at least annually to all staff as required by company policy, state, and federal regulations 4. Training records will include the following information: a. The dates of the training sessions b. The contents or a summary of the training c. The names and qualifications of the persons conducting the training d. The names and job titles of all persons attending the training sessions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 44 of 44