Health inspection·August 15, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete care of the resident, she had not asked her to get out of bed. She said she had gotten her up to go shower on some days. She said the morning of 08/13/25 the resident did not ask to get up and she did not offer to get the resident up. She said she did not offer because the resident usually did not want to get up. During an interview on 08/13/25 at 2:52 p.m., LVN C said Resident #2 was usually gotten up three days a week. She said it was the CNAs responsibility to get the residents out of bed. She said Resident #2 did not refuse to get up very often. She said the CNAs were supposed to report to the nurses anytime a resident refused to get up. She said she did not know why CNA G did not offer to get Resident #2 up this morning, 08/13/25. She said residents need to get up out of the bed and off their bottoms. She said it also helped their spirits to get up.During an interview on 08/13/25 at 3:14 p.m., the DON said Resident #2 was gotten up out of bed every day. She said they got her up out of bed if she wanted to get up. She said Resident #2 did not like to get up. She said Resident #2 should have been gotten up daily if that was her preference. She said she would expect staff to get her up and offer to get her up daily. She said staff should never tell her they do not have time to get her up. She said residents not being gotten up out of bed could hurt their feelings.During an interview on 08/13/225 at 3:51 p.m., the Administrator said she would have expected for Resident #2 to have been gotten out of bed if she wanted to get out of bed. She said she expected staff to offer every day, and the resident then had the right to refuse. She said she saw Resident #2 up out of bed most days. She said a resident had the right to get up if they requested to get up. Record review of a Resident Rights facility policy last revised in February 2021 indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.self-determination.be supported by the facility in exercising his or her rights . Event ID: Facility ID: 675949 If continuation sheet Page 2 of 28 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 08/15/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to file a grievance report and investigate the grievances reported by a resident for 1 of 13 residents (Resident #1) reviewed for grievances. The facility failed to investigate Grievances/concerns when Resident #1 reported to the DON by emails on 7/05/25, 7/09/25, 7/12/25, 7/21/25, 7/22/25, 8/02/25, 8/03/25, 8/04/25, 8/07/25 and 8/08/25 related to not answering her call light timely, staff mistreatment, the lack of care she was receiving, and not being fed completely/timely.The facility failed to document Resident #1's grievances/concerns on the Grievance/Concerns log forms for the reported dates of 7/05/25, 7/09/25, 7/12/25, 7/21/25, 7/22/25, 8/02/25, 8/03/25, 8/04/25, 8/07/25 and 8/08/25.These failures could place residents at risk for abuse, neglect, and not having their needs met.Findings included:Record review of Resident #1's face sheet dated 8/12/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Amyotrophic Lateral Sclerosis (ALS) (a nervous system disease that causes muscle weakness and paralysis (unable to move) and impacts physical function, ability to talk and breathe), muscle weakness, lack of coordination, anxiety (feeling of worry, dread, and uneasiness), speech disturbances, dyspnea (difficulty breathing), pain and hypertension (high blood pressure).Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood but was able to understand others. The MDS indicated Resident #1 did not complete the BIMS because she was rarely/never understood. The MDS indicated Resident #1 had verbal behavioral symptoms directed toward others 1-3 days and rejected care daily. Resident #1 had impairment to upper and lower extremities. Resident #1 was dependent on staff for all ADLs. Resident #1 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS indicated ALS was Resident #1's primary diagnosis. Resident #1 had shortness of breath or trouble breathing when lying flat. Resident #1 had loss of liquids/solids from mouth when eating or drinking and had coughing or choking during meals or when swallowing medications. Record review of Resident #1's Care Plan revised on 8/14/25 indicated she had a diagnosis of ALS and used a communication device to communicate her needs and would also make gestures with her head and able to say some words with interventions including: allowing resident time to use the communication device to communicate needs; if unable to understand resident when she was speaking then ask her to use her communication device; make sure communication device was in place before and after care needs; make sure resident was positioned properly in bed, with the use of pillows if needed to ensure that she can eat, use her device, breathe easily, and be comfortable; make sure the dot that helps her operate her communication device was in place; offer emotional support as needed; and staff to speak calm, clearly, and slowly. The care plan revised on 4/09/25 indicated Resident #1 had the potential for a nutritional problem and was resistive to care with intervention to provide consistency in care to promote comfort with ADLs, maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Record review of Resident #1's emails sent to the DON indicated: On 7/05/25 at 5:24 PM, email with subject line emotional abuse, reported aide . just told me I am responsible for other residents being neglected because she is in my room so long in those exact words camera 7/5 right at 5:00 pm. On 7/09/25 at 5:52 AM, email with subject line aide treating me badly, reported aide snaps at me, like what do I want, tells me she is busy doing a round and in a loud and angry tone, and pushes pillow roughly and carelessly, when I make a noise that is hurting me, she says, I am doing what you asked Is there anything else, loud and angry tone 4:40 am I ask for the nurse so I can report what happened and she said she couldn't be in here alone and got (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 3 of 28 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 08/15/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some aide who stared me down with her arms crossed so nurse got another aide and I told her I didn't want the other aide reading the screen and what I was reporting was confidential and the aide stopped reading but the nurse . kept reading the screen out loud I typed don't read out loud confidential but she would not stop so I told them never mind I would report it another way she had already seen what I wrote about the aide she made it impossible for me to report to her this aide always behaves this way probably on camera. On 7/09/25 at 9:13 PM, email with subject line bed pan needed to get, reported I waited from 8:30-9 pm aide turned off call light and said all the aides were too busy when I would have to be pulled up making it impossible for me to use the bed pan said I would have to wait for an unknown time I need someone who knows me and keeps me safe . On 7/09/25 at 9:35 PM, email with subject line bed pan needed to get, reported new aide trying to tell me nobody can help and she has to do it alone unsafe! how will I get pulled up! I can't be left down in the bed I can't breathe well,! please call! keep turning light off. On 7/09/25 at 9:45 PM, email with subject line waiting over an hour, reported waiting an hour and fifteen for bed pan. On 7/12/25 at 4:04 PM, email with subject line need help eating, reported the aide left me at two and I wasn't done eating can the nurse or someone feed me for just like ten minutes I lose weight so quickly and I have no other way to get the calories back my food is just sitting here. On 7/21/25 at 4:13 PM, email with subject line need food, reported two staff walked out while feeding me without explanation ADON F came in to say I was picking who could help me and talked over everything I played on the tablet and told the aide to leave that was supposed to feed me and do bed pan and food and tray were taken I had said nothing about wanting one aide over the other ADON F told me she would get somebody to help me drink my shake because that is where most of my calories come from the aide had brought the tray in at 12:30 and left me at one I had only a few bites after everything was prepared ADON F made me sit and wait with my light on for a half hour because I was trying to speak with the tablet to defend myself instead of being silent and she wanted me to say yes I will eat now and nothing else when she came back in she said she would get someone to give me shake after shift change now she is saying I had lunch and her and the aides are busy helping other residents she told me my aide at lunch had to leave early so I didn't do anything wrong the shakes are 360 calories that I need to survive and I usually drink one at dinner so there is no way to make up for these lost calories because I can't feed myself. Resident #1 also referenced https://www.als.org/navigating-als/living-with-als/therapies-care/maintaining-adequate-nutrition-continuing-challenge in the email. On 7/22/25 at 1:47 PM, email with subject line Took lunch, reported second day in a row they took lunch while I was eating and had food all over my face and was aggressively harassed and scolded and threatened for an hour and filmed without my consent 11:45-1:45. On 8/2/25 at 6:07 PM, email with no subject line reported she pushed the pillow up next to my head so fat, I can't lift head and told me I have to type or she won't help me while I screamed and said over, over, over . she knows I can't type and me and {the Ombudsman's name} told her exactly why this is unsafe and why I can't do it during the care plan meeting . so she knows exactly what I am going through and does it anyway full well knowing I am suffering and it is abuse. On 8/02/25 at 6:18 PM, email with subject line Abusive, reported ADON F told me you have no staff because they all quit because of me and that she was going to quit because of me . and she said she wasn't allowed in my room and I asked based on what she said my emails this is gaslighting aka emotional abuse and now I have to sit in soiled clothing with my hand trapped under me and starve at dinner or I can get food and care while being emotionally abused. On 8/03/25 at 2:08 PM, email with subject line won't feed me lunch, reported four people in here watching me eat like I am in a jail nurse saying are you going to eat are you going to eat over and over and over while the cup is in my mouth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 4 of 28 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 08/15/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some aide and everyone left and wont feed me because I wasn't drinking right I guess need to eat she didn't put me on bed pan either she gets out of doing my care every time by telling everyone I won't cooperate when I am I have not been on the bed pan since six . On 8/03/25 at 2:32 PM, email with subject line help BED PAN LUNCH, reported LVN C lied to the police and probably you also about coming back in to see if I would eat they left and did not come in for two hours while my food sat here because I asked to be MOVED OVER this is not REFUSING TO EAT then they came back in both nurses to write down fake times they were in here two hours later asking me why I am not eating while food is getting prepared isn't asking three times if I want to eat I need bed pan and lunch urgently CNA L just came in and turned off light and left what is going on I need help!!. On 8/04/25 at 3:56 PM, email with subject line a request for safe practice, reported please tell CNA L do not roll me by herself I was on my side probably three inches from the edge nobody in front of me her pushing at my back to get the sheet under me from the opposite side of the bed bed in its highest position off the floor I am terrified when they do this with even two people because my head slides off the pillow and over the edge and my legs sometimes come off the bed and they don't notice and are not concerned and ignore me or shame me for trying to scream and say they will leave the room if I don't stop I told her do not roll me like that again and she said she would if she had to I said do not it's not safe and she got mad and said she just won't do my care then after that she did my last bed pan after dinner and did everything up to rolling and told me she was going to get help to roll me and just never came back and didn't answer my light while it was on for an hour up to shift change please tell her to not roll me by herself and that it is acceptable if a resident makes this kind of request and they should not be denied care because of it I told her I would wait until she found help but she just never came back I will die or have a very severe head injury if I fall off the bed I don't have the same bounce people with muscle have and my head hits first. On 8/07/25 at 12:36 PM, email with subject line of need help, reported the aide will not fix the pillow, she gets the nurse to do it, the nurse says let the aide do it, the aide is playing a game, so she doesn't have to feed me they both left this is every day now I have to eat super late because they do the bs with the pillow On 8/07/25 at 1:40 PM, email with subject line of not feeding me still, reported this is getting more and more ridiculous ADON F refusing to help me I have no lunch not one of them will push the pillow down a supervisor needs to step in where is ADON J where is ADM I did nothing wrong!! I have to eat!! they are just ignoring my light. On 8/08/25 at 12:25 AM, email with subject line of reporting unprofessional behavior reported today at noon during bed pan procedures I became physically uncomfortable and was frustrated trying to speak and did not have the tablet in front of me and made a noise that sounded like crying and the CNA K said {Resident #1's name} you need to tell us what you need and stop all the crying we are not running a daycare center here this is derogatory unprofessional and inflicts emotional pain on people I hope that you will please speak to this employee and let her know that she is not welcome to talk to me like that in the future another aide was present when this happened. During an observation and interview on 8/12/25 at 11:45 AM, Resident #1 was sitting up in bed and used a communication tablet on a stand in front of her that she used by having a metal like dot on her forehead that acted like a wireless mouse, and she was able to use slight head movements to type her conversations. Resident #1 said she was not able to do anything for herself and relied on the staff for all her care needs. Resident #1 said it was easier for her to type an email and send her concerns and/or complaints to the DON when she was not rushed and felt by sending an email to the DON, she would ensure her concerns and/or complaints would be given to someone that could help resolve the issues. Resident #1 said she had sent numerous emails to the DON about how staff were mistreating her, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 5 of 28 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 08/15/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the lack of care she was receiving, not allowing her time to complete her meals and/or late meals, not allowing her to time to communicate her needs, and not answering her call light timely. Resident #1 said she did not feel her concerns/complaints were being addressed because the issues continued almost daily. Resident #1 said she would like a system for resident complaints that took them seriously and resolved them quickly.During an interview on 8/15/25 at 2:46 PM, the SW said she had worked at the facility for two and a half years. The SW said if a staff member told her about a resident being upset about something, she would go talk to the resident to assess for depression. The SW said the nurses would tell her about resident grievances sometimes and then they would discuss the grievance in the morning meetings. The SW said she would document the resident's grievance on the Grievance/Concern Form, unless it was a simple fix then she would just get it fixed and did not put it on the form. The SW said she had the grievance forms and logs to help track the grievances. The SW said if there were more of any type of issues the grievance log could be used to trend any issues and to be able to discover any issues. The SW said she was not sure how things were being handled if there was not a grievance form completed or logged on the grievance log. The SW said she kept the grievance logs in her office. The SW said it would be frustrating for the resident if the facility was not addressing their grievances/complaints. During an interview on 8/15/25 at 3:47 PM, the DON said her process for grievance/complaints depended on what it was or what was sent to her. The DON said if it was something she could address quickly, then she did it right then. The DON said if the grievance/complaint was about abuse, she would forward it to the ADM. The DON said she had told Resident #1 to tell the nurse to call her if there was an issue, and she could talk to Resident #1 on speaker phone, but Resident #1 had not called her. The DON said her staff had called her, to talk to Resident #1. The DON said she did not put all grievances/complaints on the grievance forms. The DON said if it was something she could address and resolve quickly, then she did not put it on the form. The DON said if grievances/complaints were not being addressed timely, it could negatively affect the resident, but without knowing what the emails were about, she really did not know what to say about how Resident #1 could be affected.During an interview on 8/15/25 at 4:09 PM, the ADM said her process for grievances was to address them. The ADM said they had a formal grievance log. The ADM said the SW was mostly the one that documented the grievances/complaints on the log. The ADM said if it was something, she thinks there is a difference in needing a formal grievance versus addressing an immediate concern. The ADM said if she was aware of a resident saying staff were talking bad to her, then yes, it would need to go on a grievance form, if she was aware. The ADM said any staff member could take a grievance. The ADM said she could not recall if she had received any emails forwarded from the DON from Resident #1. The ADM said she could not fix something if she did not know about it. The ADM said if someone did file a formal grievance/complaint, then they do document it on the Grievance/Complaint form. The ADM said the residents had a right to have their grievances/complaints resolved. The ADM said she was ultimately responsible for ensuring the residents grievances/concerns were addressed, but any staff member could take a grievance/complaint.Record review of the facility's Grievance/Complaint Log from 7/2025 through 8/2025 revealed there were no grievances/complaints logged for Resident #1.Record review of the facility's policy titled Resident Rights, dated revised February 2021, indicated Employees shall treat all residents with kindness, respect, and dignity . federal and state laws guarantee certain basic rights to all residents of the facility . these rights include the resident's right to . u. voice grievances to the facility . without discriminations or reprisal and without fear of discrimination or reprisal . v. have the facility respond to his or her grievances .Record review of the facility's grievance policy titled Grievances/Complaints, Filing, dated revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 6 of 28 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 08/15/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete April 2017 reflected . Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or agency designated to hear grievances . the Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative . 1. Any resident . may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, . care that has not been furnished . 3. All grievances, complaints or recommendations stemming from resident . concerning issues of resident care in the facility would be considered . actions on such issues would be responded to in writing, including a rationale for the response . 8. Upon receipt of a grievance and/or complaint, the grievance officer would review and investigate the allegations and submit a written report of such findings to the Administrator within five working days of receiving the grievance and/or complaint . 10. The grievance officer, Administrator and staff would take immediate action to prevent further potential violations of resident rights while the alleged violation was being investigated . 11. The Administrator would review the findings with grievance officer to determine what corrective actions, if any, need to be taken . 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, would be informed (verbally and in writing) of the findings of the investigation and the actions that would be taken to correct any identified problems . 14. The results of all grievances files, investigated and reported would be maintained on file for a minimum of three years from the issuance of the grievance decision . Event ID: Facility ID: 675949 If continuation sheet Page 7 of 28 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 08/15/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 13 residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from abuse, as evidenced by video footage of multiple incidents where direct care staff had inappropriate interactions towards Resident #1, such as staff making inappropriate and disrespectful comments towards the Resident and failing to maintain the Resident's dignity by leaving the Resident exposed and in view of individuals who could have walked by, not allowing the Resident time to communicate her needs, not feeding resident timely, and not identifying when Resident #1's head was not in the appropriate position for using her communication device, ease of breathing and eating. An immediate jeopardy (IJ) was identified on 8/14/25 at 3:25 PM. The IJ template was provided to the facility on 8/14/25 at 3:43 PM. While the IJ was removed on 8/15/25 at 3:34 PM, the facility remained out of compliance at a scope of patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to complete in-service trainings with all staff and evaluate the effectiveness of the corrective systems.These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress.Findings included:Record review of Resident #1's face sheet dated 8/12/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Amyotrophic Lateral Sclerosis (ALS) (a nervous system disease that causes muscle weakness and paralysis (unable to move) and impacts physical function, ability to talk and breathe), muscle weakness, lack of coordination, anxiety (feeling of worry, dread, and uneasiness), speech disturbances, dyspnea (difficulty breathing), pain and hypertension (high blood pressure).Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood but was able understand others. The MDS indicated Resident #1 did not complete the BIMS because she was rarely/never understood). The MDS indicated Resident #1 had verbal behavioral symptoms directed toward others 1-3 days and rejected care daily. Resident #1 had impairment to upper and lower extremities. Resident #1 was dependent on staff for all ADLs. Resident #1 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS indicated ALS was Resident #1's primary diagnosis. Resident #1 had shortness of breath or trouble breathing when lying flat. Resident #1 had loss of liquids/solids from mouth when eating or drinking and had coughing or choking during meals or when swallowing medications.Record review of Resident #1's Care Plan revised on 8/14/25 indicated she had a diagnosis of ALS and used a communication device to communicate her needs and would also make gestures with her head and able to say some words with interventions including: allowing resident time to use the communication device to communicate needs; if unable to understand resident when she was speaking then ask her to use her communication device; make sure communication device was in place before and after care needs; make sure resident was positioned properly in bed, with the use of pillows if needed to ensure that she can eat, use her device, breathe easily, and be comfortable; make sure the dot that helps her operate her communication device was in place; offer emotional support as needed; and staff to speak calm, clearly, and slowly. The care plan revised on 4/09/25 indicated Resident #1 had the potential for a nutritional problem and was resistive to care with intervention to provide consistency in care to promote comfort with ADLs, maintain consistency in timing of ADLs, caregivers and routine, as much as possible. 1. Record review of video footage dated 2/26/25 beginning at 4:40 PM, started with Resident #1 sitting up in bed looking at her communication device. CNA A and CNA D enter Resident #1's room. CNA A said, Is she typing something. CNA D looks at the communication device (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 8 of 28 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 08/15/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and said Girl, I don't know. CNA A then moves the communication device to the end of the bed, out of the reach of Resident #1. Then CNA A and CNA D without telling or asking, began to pull Resident #1's panties down and Resident #1 began to move her legs and make verbal noises. CNA D said we gonna get you on the bed pan. CNA A said, Don't act up, this gonna be the 2nd time and you on your period. Resident #1 was making vocal noises and grimacing and CNA A and CNA D were carrying on a conversation between themselves. CNA A and CNA D placed the bed pan under Resident #1 and left her lower half of her body fully exposed and the mini blinds open. Resident #1's room was directly in front of the entrance where vehicles entered the parking lot. CNA D kept turning and looking out the window. Both CNA A and D were standing over Resident #1's bed and began to laugh and CNA A said I got to get out of here and both aides left out of the camera view with Resident #1 still fully exposed on a bed pan. CNA D returns and goes and looks out the window. CNA A can be heard talking to the roommate. Then CNA D performs peri care, they both redressed her, and then left the room. 2. Record review of video footage dated 2/26/25 beginning at 4:50 PM, started with Resident #1 in bed, her head was leaning onto her left shoulder, she can be heard moaning loudly and then began screaming. CNA E had entered the room and can be seen sitting down in a chair barely in site of the camera and said {Resident #1's name}, I literally just walked in the room and I don't know why your screaming, then gets up, walks toward her and said I'm listening, but I cannot hear you or do what you need me to do with all that screaming. Resident #1 then began making verbal noises and not screaming. CNA E then walked to the opposite side of the bed and asked Resident #1 What do you want, what do you want, then adjusted her leg, covers, as resident was making verbal noises. CNA E said, I can't understand you with all that screaming you're doing. Resident was not screaming. Then CNA E walked back to other side of bed and adjusted Resident #1's head on pillows and sits her more upright. CNA E then asks Resident #1 What else can I do for you, what else, move what as Resident #1 continued to make verbal noises and then CNA E said I can't do that by myself and you'll have to wait, I can only move you left and right, then asks resident move what, move it out, then she moved Resident #1's communication device out some and then said to Resident #1, Please and Thank you, Please and Thank you.3. Record review of video footage dated 3/01/25 beginning at 4:50 PM, started with Resident #1 sitting up in bed. CNA A told Resident #1, Tell the truth, cause I'm not doing this with you today and I'm your aide while standing at the end side of the bed with her arms folded I moved you up then and you started screaming, this is why it's hard for us to take care of you. Resident #1 was saying something using her device, but CNA A was speaking over her and unable to hear what Resident #1 was saying. CNA A then said, I'm sick of you, I don't care about that camera, kick me out of here, I wish and walked out of the camera view. CNA A then returned and moved Resident #1's communication device to the end of the bed and placed Resident #1 on a bed pan and left lower half of her body exposed and then stood over resident while she used the bed pan. CNA A then removed the bed pan and cleaned Resident #1's peri area. CNA A pulled the resident toward her and allowed Resident #1's head to hang over the edge of bed against her body and Resident #1 began to scream. Then CNA A repositioned Resident #1 and resident was making verbal noises, and CNA A said {Resident #1's name} you gonna quit hollering at me, or I'm going to leave. Resident #1 continued to make verbal noises and appeared to use her foot to point at her communication device at the end of the bed. CNA A adjusted the pillows. CNA A then No, we not going to keep going back forward, I've already moved your head 3 times. CNA A then moved the communication device back in front of the Resident #1 and told her to type what she needed.4. Record review of video footage dated 3/13/25 beginning at 8:33 PM, started with Resident #1 sitting up in bed making moaning/crying sounds and her communication device was at the end of the bed out of her reach. CNA E (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 9 of 28 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 08/15/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some was standing at the end of the bed and told Resident #1 to focus on her breathing and Resident #1 begun to scream. ADON F entered the room at 8:34 PM and said {Resident #1's name} they cannot lift you by your arms, it was unsafe for you and unsafe for them, the staff could not pull her up without a transfer sheet and Resident #1 was making verbal crying noises and ADON F said {Resident #1's name} if you don't listen they would walk out until she calmed down enough. ADON F told CNA E to walk out. The communication device was still at the end of the bed and ADON F moved the device back in front of the resident and told her to use her communication board. The Resident #1's head had fallen down on her left shoulder and chin on her chest, and she began to scream, and her left leg began to shake. ADON F said {Resident #1's name}, use your communication board. Then ADON F walked up and pulled Resident #1's pillow down and around by one corner, which caused her head to go further down and pulled the top part of her head further over and she began to scream. ADON F told Resident #1 multiple times to use her communication board and said, I'm going to walk away until you can use your communication board. Resident #1 began to scream louder. There was no way for her to use the communication device with her head in the position it was in. Then ADON F repositioned her head, but her head kept falling back over. ADON F then placed the touch pad call light over Resident #1's lap and told her to call her when she can use her communication board. Resident #1 is only able to use a touch pad if the pad was placed under her hand, because she cannot raise her arm to place her hand. Resident #1's head was laying over toward her left shoulder with the corner of the pillow between her head and shoulder. Resident #1 began to scream louder when ADON F left the room. ADON F did return and repositioned her head again and said, I keep putting your head up and you keep pushing it down and told resident again multiple times to use her communication board. ADON F told Resident #1 we aren't going to keep going over the same things, I've already discussed it with you, we aren't going to keep going over the same things over, over, and over again.5. Record review of video footage dated 5/22/25 beginning at 7:05 AM, started with CNA B was at Resident #1's bedside and Resident #1's communication device was at the end of the bed. CNA B used her left hand to push resident's right shoulder away from her as CNA B pushed a blue pad under the resident, Resident #1 began to holler. CNA B then let resident turn back onto her back and then reached over Resident #1 and grabbed the draw sheet and pulled Resident #1 toward her. Resident #1's left leg began to vigorously shake, and her voice was shaky, and CNA B continued to pull the blue pad out of the other side. Resident #1 was hollering and kicking her legs. CNA B did not speak a word to Resident #1 during the interaction.6. Record review of video footage dated 5/22/25 beginning at 7:06 AM, started with Resident #1 lying in bed with head of the bed elevated. Resident #1's communication device and touch pad call light were at the end of her bed and not in reach. Resident #1's doorbell rang, and CNA B entered the room. CNA B moved the communication device to in front of resident and placed her hand on the touch pad call light. CNA B did not speak to Resident #1 during the interaction. 7. Record review of video footage dated 8/03/25 beginning at 6:42 AM, started with Resident #1 sitting up in bed and said with the communication device, I need you to stop what you are doing to CNA G who was at the end of the bed. CNA G interrupted and said {Resident #1's name} if you're done, let me know so I can go, I have a lot to do today and I can't sit in here and go up and down, up and down, side to side while making hand gestures. Resident #1 said Oh, Oh with her communication device. CNA G then adjusted Resident #1's pillow and said I will let the nurse do your pillow, can't keep doing your pillow every thirty minutes as she was walking out of the room. 8. Record review of video footage dated 8/03/25 beginning at 8:10 AM, started with Resident #1 sitting up in bed. CNA G brought breakfast tray into Resident #1's room and said I'm here to feed you. Resident #1 said with her communication device need top corners pushed down (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 10 of 28 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 08/15/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some around my head and CNA G said {Resident #1's name} I'm here to feed you, OK and started asking what she wanted to eat, and Resident #1 said get the nurse and as CNA G walked away, she said O, Okay, that's a refusal. Then LVN C was at Resident #1's bedside 8:15 AM and asked, what's wrong {Resident #1's name}. Resident #1 said with her communication device, I need pillow supporting head, before I can eat and LVN C said, it is supporting your head, got it fixed just right and Resident #1 shakes her head. LVN C asked, how is it not right and then pushed the pillow down behind her back and said, alright, it's tucked as good as it's going to tuck and asked Resident #1 you ready to eat now? LVN C and another staff member started to grab the draw sheet to reposition Resident #1 and Resident #1 started making noises and shaking her head no. LVN C said if you want me to move you over, I have to use your sheet, I'm not going to pull on you and Resident #1 continued to shake her head no. LVN C said alright {Resident #1's name} then we are not moving over, cause I'm not going to pull on you. LVN C then repositioned Resident #1 and said alright, your shoulders are over, you're ready to start eating. Resident #1 said need pillow tucked and LVN C tucked her pillow behind her back. Resident #1 was asking them to move her arm over and LVN C said, I don't know what that means. Resident #1 was looking at her device and appeared to be trying to communicate something and at 8:22 AM, LVN C said OK, let's leave and told Resident #1 when you are ready to eat, we will come back and left the room. Resident #1 sounded the alarm on her communication device at 8:22 AM and someone out of the view of the camera told her to shut the alarm off. At 8:35 AM, the housekeeper came into the room to clean. Resident #1's meal tray continued to sit on the bedside table. At 8:51 AM, CNA G was at the bedside and said, I'll go tell them, OK and left the room. At 9:04 AM, RN H entered the room and said yes, ma'am, how can I help you. Resident #1 told RN H using her communication device, they need to come feed me, they need to come feed me and RN H said, yes ma'am, they are getting all the other . CNA G returned to the room at 9:53 AM and asked {Resident #1's name} are you ready to eat now. Resident #1 asked CNA G to see if she had some yogurt. Then at 9:55 AM, a police officer entered Resident #1's room with LVN C and asked what he could do for her. Resident #1 told the officer that they put my breakfast in here two hours ago, but they won't feed it to me and I'm not able to feed myself. LVN C said {Resident #1's name} you know we have been in here multiple times trying to feed you. Resident #1 said it was two hours . it needed to be warmed and LVN C said okay, we'll warm it, it's not a problem, we have a microwave, are you going to eat it if we warm it. At 9:58 AM, LVN C and CNA G then begin taking items off the breakfast tray that had been sitting on the bedside table since 8:10 AM asking which items she wanted warmed. The police officer said, they are going to warm it up and they were going to feed you. At 10:00 CNA G said I have to go get a cup to mix it (holding a plastic bag with a white substance in it, later identified as thickener) and then she returned and said it was not in her scope to mix it and would have to take it to dietary to have them mix it and that was the way it had to be, so her food or whatever you want your thickener in, I'll have to take it to them, so they can do it. CNA G asked Resident #1 how do you want your coffee and Resident #1 said I'll take as it is and CNA G said OK, I'll be back and left the room at 10:04 AM. Then at 10:04 AM, LVN C entered the room and placed items on the bedside table and left without speaking to Resident #1. At 10:17 AM, CNA G returned and said OK, they mixed it and Resident #1 said head up and CNA G raised the head of the bed. At 10:19 AM, CNA G sat down in a chair at bedside and at 10:21 AM, Resident #1 said using her communication device will you move me over, move me forward away from the bed first, then over and then back. CNA G then asked resident #1, you want to be moved over, you want moved over here. At 10:22 AM, LVN C entered the room and said, what's wrong now {Resident #1's name} and CNA G said, it's everything but eating, I don't know. LVN C said {Resident #1's name} what's wrong. CNA G (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 11 of 28 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 08/15/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some then pulls resident over toward her as she was telling LVN C that Resident #1 wanted to be pulled over and LVN C said, I already pulled her over and CNA G said, I know. LVN C said, are you ready to eat now {Resident #1's name}. CNA G tells LVN C in front of Resident #1, it takes two hours, it takes a while to feed her, so it doesn't really matter how long it takes to feed anyone else, then asked Resident #1 so you ready now, you ready. At 10:54 AM, Resident #1 started making crying noises while CNA G was feeding her and CNA G went and got LVN C. As LVN C entered the room, Resident #1 said with her communication device, I just want a drink, I just want a drink, I just want a drink LVN C said, she's been trying to give you a drink since 7:30 this morning, then elevated her voice and said alright, so why aren't you taking a drink. Resident #1 continued repeating I just want a drink and LVN C said alright Resident #1 that's enough. CNA G said I tried to give her a drink. Resident #1 told LVN C to look at it, look at it and LVN C said, Well you keep sending it back. Then Resident #1 said with her communication device clumps out, clumps out, referring to the drink that requires thickening. LVN C took the drink and brought another back. Resident #1 completed breakfast and breakfast tray removed at 11:43 AM.9. Record review of video footage dated 8/13/25 beginning at 6:40 AM, started with Resident #1 lying in bed with head of the bed elevated, can be heard moaning, then she turned on the alarm on her communication device. At 6:44 AM, LVN C was standing at Resident #1's bedside and said, She has already done that, they fluffed your pillow, both girls have already done that. Resident #1 said through her communication device Push down top and left too. LVN C said No, we are not readjusting your pillow again, she's already done it ten times. Resident #1 says again, Push down top and left too. LVN C said Nope, {Resident #1's name}, and walks out of the camera view. Resident #1 says Push down top and left too and repeats Push down top and left too. LVN C returns to camera view and said in a louder voice I'm going to do it one time {Resident #1's name} and that's all I'm going to do it, what do you want then adjusts the pillow and said, alright it's pushed down and leaves the room. During an observation and interview on 8/12/25 at 11:45 AM, Resident #1 was sitting up in bed and used a communication tablet on a stand in front of her that she used by having a metal like dot on her forehead that acted like a wireless mouse, and she was able to use slight head movements to type her conversations. The communication tablet also allowed for Resident #1 to turn the typed words to be read aloud by the device if she chose to. Resident #1 said it was easier for her to type an email and send her concerns and/or complaints to the DON when she was not rushed and felt by sending an email to the DON, she would ensure her concerns and/or complaints would be given to someone that could help resolve the issues. Resident #1 said she had sent numerous emails to the DON about how staff were mistreating her, the lack of care she was receiving, not allowing her time to complete her meals and/or late meals, not allowing her to time to communicate her needs, and not answering her call light timely. Resident #1 said she did not feel her concerns/complaints were being addressed because the issues continued almost daily. Resident #1 said the problems were complex because there was so much lying and characterizing her as a bad patient, which leads to her poor care and helped staff justify their behavior. Resident #1 said she felt some staff intentionally treated her bad, so they would not have to care for her, so they are getting rewarded for abusing me and she felt like the staff intentionally ignored her at times because they know she took longer than the other residents. Resident #1 said often when staff do come in to assist her with the bed pan or other care, they are rough and talk rudely and made it very apparent they did not want to be providing her care. Resident #1 said she had little to no movement of her body but was able to push the touch pad call light for assistance when needed if it was placed under her hand. Resident #1 said the staff did not take the time to let her explain what she needed due to it took her a while to type out her needs on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 12 of 28 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 08/15/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the tablet. Resident #1 said staff would also come in and turn her light off and then tell her she would have to wait until they finished their rounds on the other residents before they could get her on the bedpan. She said her bladder and bowels were one of the few things she had control over, and she felt that the staff should provide her care when she needed it, so it did not put her in a hardship to be holding it until they finished their rounds. Resident #1 said it was emotionally and physically hard on her. Resident #1 said she often hollers or screams when staff would not give her time to communicate on her tablet, she needed to have her pillow adjusted to position her head so she communicate on her communication device, be able to breathe comfortably, and be able to eat without aspirating (inhaling food into lungs) and she knew once they left her room it would be a long time before they returned. Resident #1 said often times while being fed, she would still be trying to swallow one bite of food and the staff were trying to feed her another bite and when she could not take a bite right then, the staff would say she was refusing to eat and took her food, and she was still hungry. Resident #1 said they would not give her time to respond and let them know she was still hungry and rushed out. Resident #1 said her muscles in her mouth, tongue, and throat were weak and it took her a long time to maneuver the food in her mouth and to be able to swallow it, and they have to often take her food back and re-blend it because it had clumps in it and her food had to be the consistency of baby food. Resident #1 said it did take a long time to feed her, but it was not something she could help or change because of her disease. Resident #1 said at times her head would fall over and she did not have the ability to pick her head up and it makes it difficult to breathe and all she could do was scream in hopes someone would come help her. Resident #1 said when she was not given time to respond on her tablet, the only thing she could do was make hollering type noises and it was very frustrating to her and caused her a lot of anxiety when the staff did not take the time to listen to her needs. During an interview on 8/13/25 beginning at 4:00 PM, Resident #1 said when staff bring her meals in, then moved her communication board where she could not type, then say she refused to eat made her feel powerless to get help and confused about why nobody used common sense, because obviously she wanted and needed to eat, and defeated in realizing it was the staff's intention to misunderstand her. Resident #1 said when staff said things such as: not going to keep going over the same thing over and over, I'm sick of you and don't care about that camera, kick me out of here, you gonna holler at me, I'm gonna leave, Don't act up, I literally just walked in here, don't know why you screaming, staff indicating she should say please and thank you, it made her mad and she wanted to tell them not to talk to her like that and to get out of her room, but she could not because she could not talk and had to accept their help. Resident #1 said she could not do anything, so anger builds up and caused her depression. Resident #1 said when staff keep asking her what do you want, what do you want and did not give her time to communicate on her device or staff chose not to take the time to read her communication device, it made her feel exhausted. Resident #1 said she did not have a hearing problem. Resident #1 said typing was not super easy and it took up long periods of mental and physical effort and she did not know who or if the staff would listen. Resident #1 said she becomes very scared when she realized they do not want to know what she needed or wanted. Resident #1 said some of the staff she trusted and knew they would do what she needed without her having to tell them, but there was not many she trusted left. Resident #1 said when staff enter her room and do not speak to her or do not tell her what they were going to do prior to touching her, was frightening and she absolutely had not way to stop them from whatever it was they were going to do and just hoping they would take a no from the tablet as an answer, and it was especially scary when they just sent new staff she had not ever met in to answer her call light. Resident #1 said when staff come (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 13 of 28 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 08/15/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some into her room and just move her communication device to the end of the bed without letting her communicate her needs, scared her because they were intending to do whatever they wanted. Resident #1 said it was humiliating to be put on a bed pan, not covered, and left fully exposed with the window blinds open and sometimes staff would leave her room while she was on the bed pan and leave the door open to be seen by any member of the public walking by. Resident #1 said it made her feel angry when staff stood over her talking and laughing while she was on the bed pan, because they had no regard for the fact that she needed their close attention when she was in such a vulnerable position. Resident #1 said she did not want them staring at her while she went to the bathroom, but she needed them to hear her if she needed help. Resident #1 said when one staff member rolled her from side to side using the draw sheet, this is just one of the many ways they tortured me with the sheet, I am being handled like an object and it was isolating, when nobody acknowledges your humanness, you are alone. Resident #1 said continuous issues with her care has caused her to feel dehumanized and not treated as a person, and it had affected her well-being, self-worth, and self-esteem. Resident #1 said staff talk bad to her non-stop, and she does not feel her complaints were taken seriously and resolved. Resident #1 said she just wanted to be able to trust the staff and be treated with respect and kindness and be helped if not. During an interview on 8/13/25 at 11:46 AM, MA K said she had worked at the facility for about a year on the 6 AM-6 PM shift. MA K said they were sometimes a little short staffed, but the staff did the best they could. MA K said they were short staffed because staff have gotten fired due to Resident #1. MA K said she helped feed Resident #1 when she could, to help. MA K said it was time consuming. MA K said Resident #1 normally provided her own food. MA K said Resident #1 would tell you how to do it all and it took Resident #1 time to type it out. MA K said Resident #1 would type what she wanted and if staff did it wrong then she would start screaming and kicking. MA K said she thought Resident #1 wants some things a specific way because it was probably one of the only things Resident #1 could still control. MA K said the resident would be upset if staff did not communicate what they were doing to them prior to providing care. MA K said it was the resident's home. MA K said she would be upset if staff left her fully exposed while on a bed pan and window blinds opened. MA K said it would be a dignity issue. MA K said she would not be happy if she could not communicate her needs, but Resident #1 would usually answer yes or no questions either verbally or by head movements. MA K said if Resident #1 was not allowed time to communicate her needs, the staff would not know what she needed or wanted to say. MA K said it would probably make Resident #1 feel unsafe. MA K said she had not received any training on taking care of a resident with ALS. MA K said she was sure it would affect Resident #1's quality of life and made her feel less than a human if not provided privacy during incontinent care, not allowed time to communicate her needs, and not letting her know what care was going to be provided, and not speaking to her; and they were there to ensure Resident #1's needs were met.During an interview on 8/13/25 at 12:15 PM, CNA J said she had worked at the facility since April 2025 on the 6 AM-2 PM shift. CNA J said they had approximately 3 people on 400 hall that required 2-person assistance. CNA J said she felt she was able to meet the care needs of the residents. CNA J said it would make her feel very uncomfortable if staff did not speak to her and just started providing care. CNA J said it would make her feel uncomfortable, ashamed, and embarrassed if staff did not cover her or close the window blinds while on a bed pan. CNA J said Resident #1 at times wanted to be covered and at other times did not want to be covered and told them no. CNA J said if staff moved Resident #1's communication device out of her reach and did not give her time to communicate, then how was Resident #1 supposed to let her needs known if unable to communicate needs and it would make her angry. CNA J said she would be mad if her momma was done that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 14 of 28 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 08/15/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete way. CNA J said it would affect Resident #1's quality of life if she was unable to communicate her needs. CNA J said not being allowed time to communicate needs, providing care without telling the resident what you were going to do, not speaking to the resident during care, would make the resident feel less of a human, and if not able to communicate then you would not get anywhere. CNA J said she had not received any training related to caring for a resident with ALS, just what she had learned working with Resident #1. CNA J said she had not had any in-services related to caring for Resident #1. CNA J denied ever telling Resident #1 to stop crying that they were not running a daycare center. During an interview on 8/13/25 at 12:52 PM, CNA G said she had worked at the facility for about 2 months on the 6 AM-2 PM shift. CNA G said they had 7-8 residents on the 400 hall that required 2-person assistance. CNA G said she felt she was able to meet the needs of the residents sometimes. CNA G said if she had Resident #1 then it was hard to care for the other residents when Resident #1 took 2-2.5 hours to feed twice on her shift sometimes. CNA G said usually no one provided care to her other residents when she was feeding Resident #1, and then she had to come out when she was done feeding Resident #1 and work hard to get her other residents' care completed before the end of her shift. CNA G said one of her other residents pushed their call light while she was feeding Resident #1, then someone may go check them, but usually no one checked on her other residents until she was able to go back when she was done. CNA G said she would feel tortured or abused if staff just walked in and started providing care without speaking. CNA G said she would feel exposed if left on a bed pan fully exposed with the window blinds open to the street. CNA G said it would be a dignity issue. CNA G said if staff did not allow Resident #1 time Event ID: Facility ID: 675949 If continuation sheet Page 15 of 28 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 08/15/2025 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 0675 Honor each resident's preferences, choices, values and beliefs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review; it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1 of 13 residents reviewed for Quality of Life. (Resident #1)The facility failed to provide an environment which supported and enhanced the Resident #1's quality of life, as evidenced by video footage of multiple incidents where direct care staff had inappropriate interactions towards Resident #1, such as staff making inappropriate and disrespectful comments towards the Resident and failing to maintain the Resident's dignity by leaving the Resident exposed and in view of individuals who could have walked by, not allowing the Resident time to communicate her needs, not feeding resident timely, and not identifying when Resident #1's head was not in the appropriate position for using her communication device, ease of breathing and eating. An immediate jeopardy (IJ) was identified on 8/14/25 at 3:25 PM. The IJ template was provided to the facility on 8/14/25 at 3:43 PM. While the IJ was removed on 8/15/25 at 3:34 PM, the facility remained out of compliance at a scope of patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to complete in-service trainings with all staff and evaluate the effectiveness of the corrective systems.The facility's failures could place dependent residents requiring assistance at risk for increased anxiety and depression, weight loss, poor self-esteem and poor self-worth. Findings included:Record review of Resident #1's face sheet dated 8/12/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Amyotrophic Lateral Sclerosis (ALS) (a nervous system disease that causes muscle weakness and paralysis (unable to move) and impacts physical function, ability to talk and breathe), muscle weakness, lack of coordination, anxiety (feeling of worry, dread, and uneasiness), speech disturbances, dyspnea (difficulty breathing), pain and hypertension (high blood pressure).Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood but was able understand others. The MDS indicated Resident #1 did not complete the BIMS because she was rarely/never understood). The MDS indicated Resident #1 had verbal behavioral symptoms directed toward others 1-3 days and rejected care daily. Resident #1 had impairment to upper and lower extremities. Resident #1 was dependent on staff for all ADLs. Resident #1 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS indicated ALS was Resident #1's primary diagnosis. Resident #1 had shortness of breath or trouble breathing when lying flat. Resident #1 had loss of liquids/solids from mouth when eating or drinking and had coughing or choking during meals or when swallowing medications. Record review of Resident #1's Care Plan revised on 8/14/25 indicated she had a diagnosis of ALS and used a communication device to communicate her needs and would also make gestures with her head and able to say some words with interventions including: allowing resident time to use the communication device to communicate needs; if unable to understand resident when she was speaking then ask her to use her communication device; make sure communication device was in place before and after care needs; make sure resident was positioned properly in bed, with the use of pillows if needed to ensure that she can eat, use her device, breathe easily, and be comfortable; make sure the dot that helps her operate her communication device was in place; offer emotional support as needed; and staff to speak calm, clearly, and slowly. The care plan revised on 4/09/25 indicated Resident #1 had the potential for a nutritional problem and was resistive to care with intervention to provide consistency in care to promote comfort with ADLs, maintain consistency in timing of ADLs, caregivers and routine, as much as Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 16 of 28 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 08/15/2025 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 0675 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some possible. 1. Record review of video footage dated 2/26/25 beginning at 4:40 PM, started with Resident #1 sitting up in bed looking at her communication device. CNA A and CNA D enter Resident #1's room. CNA A said, Is she typing something. CNA D looks at the communication device and said Girl, I don't know. CNA A then moves the communication device to the end of the bed, out of the reach of Resident #1. Then CNA A and CNA D without telling or asking, began to pull Resident #1's panties down and Resident #1 began to move her legs and make verbal noises. CNA D said we gonna get you on the bed pan. CNA A said, Don't act up, this gonna be the 2nd time and you on your period. Resident #1 was making vocal noises and grimacing and CNA A and CNA D were carrying on a conversation between themselves. CNA A and CNA D placed the bed pan under Resident #1 and left her lower half of her body fully exposed and the mini blinds open. Resident #1's room was directly in front of the entrance where vehicles entered the parking lot. CNA D kept turning and looking out the window. Both CNA A and D were standing over Resident #1's bed and began to laugh and CNA A said I got to get out of here and both aides left out of the camera view with Resident #1 still fully exposed on a bed pan. CNA D returns and goes and looks out the window. CNA A can be heard talking to the roommate. Then CNA D performs peri care, they both redressed her, and then left the room. 2. Record review of video footage dated 2/26/25 beginning at 4:50 PM, started with Resident #1 in bed, her head was leaning onto her left shoulder, she can be heard moaning loudly and then began screaming. CNA E had entered the room and can be seen sitting down in a chair barely in site of the camera and said {Resident #1's name}, I literally just walked in the room and I don't know why your screaming, then gets up, walks toward her and said I'm listening, but I cannot hear you or do what you need me to do with all that screaming. Resident #1 then began making verbal noises and not screaming. CNA E then walked to the opposite side of the bed and asked Resident #1 What do you want, what do you want, then adjusted her leg, covers, as resident was making verbal noises. CNA E said, I can't understand you with all that screaming you're doing. Resident was not screaming. Then CNA E walked back to other side of bed and adjusted Resident #1's head on pillows and sits her more upright. CNA E then asks Resident #1 What else can I do for you, what else, move what as Resident #1 continued to make verbal noises and then CNA E said I can't do that by myself and you'll have to wait, I can only move you left and right, then asks resident move what, move it out, then she moved Resident #1's communication device out some and then said to Resident #1, Please and Thank you, Please and Thank you. 3. Record review of video footage dated 3/01/25 beginning at 4:50 PM, started with Resident #1 sitting up in bed. CNA A told Resident #1, Tell the truth, cause I'm not doing this with you today and I'm your aide while standing at the end side of the bed with her arms folded I moved you up then and you started screaming, this is why it's hard for us to take care of you. Resident #1 was saying something using her device, but CNA A was speaking over her and unable to hear what Resident #1 was saying. CNA A then said, I'm sick of you, I don't care about that camera, kick me out of here, I wish and walked out of the camera view. CNA A then returned and moved Resident #1's communication device to the end of the bed and placed Resident #1 on a bed pan and left lower half of her body exposed and then stood over resident while she used the bed pan. CNA A then removed the bed pan and cleaned Resident #1's peri area. CNA A pulled the resident toward her and allowed Resident #1's head to hang over the edge of bed against her body and Resident #1 began to scream. Then CNA A repositioned Resident #1 and resident was making verbal noises, and CNA A said {Resident #1's name} you gonna quit hollering at me, or I'm going to leave. Resident #1 continued to make verbal noises and appeared to use her foot to point at her communication device at the end of the bed. CNA A adjusted the pillows. CNA A then No, we not going to keep going back forward, I've already moved your head 3 times. CNA A then moved the communication device back in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 17 of 28 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 08/15/2025 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 0675 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some front of the Resident #1 and told her to type what she needed. 4. Record review of video footage dated 3/13/25 beginning at 8:33 PM, started with Resident #1 sitting up in bed making moaning/crying sounds and her communication device was at the end of the bed out of her reach. CNA E was standing at the end of the bed and told Resident #1 to focus on her breathing and Resident #1 begun to scream. ADON F entered the room at 8:34 PM and said {Resident #1's name} they cannot lift you by your arms, it was unsafe for you and unsafe for them, the staff could not pull her up without a transfer sheet and Resident #1 was making verbal crying noises and ADON F said {Resident #1's name} if you don't listen they would walk out until she calmed down enough. ADON F told CNA E to walk out. The communication device was still at the end of the bed and ADON F moved the device back in front of the resident and told her to use her communication board. The Resident #1's head had fallen down on her left shoulder and chin on her chest, and she began to scream, and her left leg began to shake. ADON F said {Resident #1's name}, use your communication board. Then ADON F walked up and pulled Resident #1's pillow down and around by one corner, which caused her head to go further down and pulled the top part of her head further over and she began to scream. ADON F told Resident #1 multiple times to use her communication board and said, I'm going to walk away until you can use your communication board. Resident #1 began to scream louder. There was no way for her to use the communication device with her head in the position it was in. Then ADON F repositioned her head, but her head kept falling back over. ADON F then placed the touch pad call light over Resident #1's lap and told her to call her when she can use her communication board. Resident #1 is only able to use a touch pad if the pad was placed under her hand, because she cannot raise her arm to place her hand. Resident #1's head was laying over toward her left shoulder with the corner of the pillow between her head and shoulder. Resident #1 began to scream louder when ADON F left the room. ADON F did return and repositioned her head again and said, I keep putting your head up and you keep pushing it down and told resident again multiple times to use her communication board. ADON F told Resident #1 we aren't going to keep going over the same things, I've already discussed it with you, we aren't going to keep going over the same things over, over, and over again. 5. Record review of video footage dated 5/22/25 beginning at 7:05 AM, started with CNA B was at Resident #1's bedside and Resident #1's communication device was at the end of the bed. CNA B used her left hand to push resident's right shoulder away from her as CNA B pushed a blue pad under the resident, Resident #1 began to holler. CNA B then let resident turn back onto her back and then reached over Resident #1 and grabbed the draw sheet and pulled Resident #1 toward her. Resident #1's left leg began to vigorously shake, and her voice was shaky, and CNA B continued to pull the blue pad out of the other side. Resident #1 was hollering and kicking her legs. CNA B did not speak a word to Resident #1 during the interaction. 6. Record review of video footage dated 5/22/25 beginning at 7:06 AM, started with Resident #1 lying in bed with head of the bed elevated. Resident #1's communication device and touch pad call light were at the end of her bed and not in reach. Resident #1's doorbell rang, and CNA B entered the room. CNA B moved the communication device to in front of resident and placed her hand on the touch pad call light. CNA B did not speak to Resident #1 during the interaction. 7. Record review of video footage dated 8/03/25 beginning at 6:42 AM, started with Resident #1 sitting up in bed and said with the communication device, I need you to stop what you are doing to CNA G who was at the end of the bed. CNA G interrupted and said {Resident #1's name} if you're done, let me know so I can go, I have a lot to do today and I can't sit in here and go up and down, up and down, side to side while making hand gestures. Resident #1 said Oh, Oh with her communication device. CNA G then adjusted Resident #1's pillow and said I will let the nurse do your pillow, can't keep doing your pillow every thirty minutes as she was walking out of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 18 of 28 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 08/15/2025 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 0675 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the room. 8. Record review of video footage dated 8/03/25 beginning at 8:10 AM, started with Resident #1 sitting up in bed. CNA G brought breakfast tray into Resident #1's room and said I'm here to feed you. Resident #1 said with her communication device need top corners pushed down around my head and CNA G said {Resident #1's name} I'm here to feed you, OK and started asking what she wanted to eat, and Resident #1 said get the nurse and as CNA G walked away, she said O, Okay, that's a refusal. Then LVN C was at Resident #1's bedside 8:15 AM and asked, what's wrong {Resident #1's name}. Resident #1 said with her communication device, I need pillow supporting head, before I can eat and LVN C said, it is supporting your head, got it fixed just right and Resident #1 shakes her head. LVN C asked, how is it not right and then pushed the pillow down behind her back and said, alright, it's tucked as good as it's going to tuck and asked Resident #1 you ready to eat now? LVN C and another staff member started to grab the draw sheet to reposition Resident #1 and Resident #1 started making noises and shaking her head no. LVN C said if you want me to move you over, I have to use your sheet, I'm not going to pull on you and Resident #1 continued to shake her head no. LVN C said alright {Resident #1's name} then we are not moving over, cause I'm not going to pull on you. LVN C then repositioned Resident #1 and said alright, your shoulders are over, you're ready to start eating. Resident #1 said need pillow tucked and LVN C tucked her pillow behind her back. Resident #1 was asking them to move her arm over and LVN C said, I don't know what that means. Resident #1 was looking at her device and appeared to be trying to communicate something and at 8:22 AM, LVN C said OK, let's leave and told Resident #1 when you are ready to eat, we will come back and left the room. Resident #1 sounded the alarm on her communication device at 8:22 AM and someone out of the view of the camera told her to shut the alarm off. At 8:35 AM, the housekeeper came into the room to clean. Resident #1's meal tray continued to sit on the bedside table. At 8:51 AM, CNA G was at the bedside and said, I'll go tell them, OK and left the room. At 9:04 AM, RN H entered the room and said yes, ma'am, how can I help you. Resident #1 told RN H using her communication device, they need to come feed me, they need to come feed me and RN H said, yes ma'am, they are getting all the other . CNA G returned to the room at 9:53 AM and asked {Resident #1's name} are you ready to eat now. Resident #1 asked CNA G to see if she had some yogurt. Then at 9:55 AM, a police officer entered Resident #1's room with LVN C and asked what he could do for her. Resident #1 told the officer that they put my breakfast in here two hours ago, but they won't feed it to me and I'm not able to feed myself. LVN C said {Resident #1's name} you know we have been in here multiple times trying to feed you. Resident #1 said it was two hours . it needed to be warmed and LVN C said okay, we'll warm it, it's not a problem, we have a microwave, are you going to eat it if we warm it. At 9:58 AM, LVN C and CNA G then begin taking items off the breakfast tray that had been sitting on the bedside table since 8:10 AM asking which items she wanted warmed. The police officer said, they are going to warm it up and they were going to feed you. At 10:00 CNA G said I have to go get a cup to mix it (holding a plastic bag with a white substance in it, later identified as thickener) and then she returned and said it was not in her scope to mix it and would have to take it to dietary to have them mix it and that was the way it had to be, so her food or whatever you want your thickener in, I'll have to take it to them, so they can do it. CNA G asked Resident #1 how do you want your coffee and Resident #1 said I'll take as it is and CNA G said OK, I'll be back and left the room at 10:04 AM. Then at 10:04 AM, LVN C entered the room and placed items on the bedside table and left without speaking to Resident #1. At 10:17 AM, CNA G returned and said OK, they mixed it and Resident #1 said head up and CNA G raised the head of the bed. At 10:19 AM, CNA G sat down in a chair at bedside and at 10:21 AM, Resident #1 said using her communication device will you move me over, move me forward away from the bed first, then over and then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 19 of 28 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 08/15/2025 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 0675 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some back. CNA G then asked resident #1, you want to be moved over, you want moved over here. At 10:22 AM, LVN C entered the room and said, what's wrong now {Resident #1's name} and CNA G said, it's everything but eating, I don't know. LVN C said {Resident #1's name} what's wrong. CNA G then pulls resident over toward her as she was telling LVN C that Resident #1 wanted to be pulled over and LVN C said, I already pulled her over and CNA G said, I know. LVN C said, are you ready to eat now {Resident #1's name}. CNA G tells LVN C in front of Resident #1, it takes two hours, it takes a while to feed her, so it doesn't really matter how long it takes to feed anyone else, then asked Resident #1 so you ready now, you ready. At 10:54 AM, Resident #1 started making crying noises while CNA G was feeding her and CNA G went and got LVN C. As LVN C entered the room, Resident #1 said with her communication device, I just want a drink, I just want a drink, I just want a drink LVN C said, she's been trying to give you a drink since 7:30 this morning, then elevated her voice and said alright, so why aren't you taking a drink. Resident #1 continued repeating I just want a drink and LVN C said alright Resident #1 that's enough. CNA G said I tried to give her a drink. Resident #1 told LVN C to look at it, look at it and LVN C said, Well you keep sending it back. Then Resident #1 said with her communication device clumps out, clumps out, referring to the drink that requires thickening. LVN C took the drink and brought another back. Resident #1 completed breakfast and breakfast tray removed at 11:43 AM. 9. Record review of video footage dated 8/13/25 beginning at 6:40 AM, started with Resident #1 lying in bed with head of the bed elevated, can be heard moaning, then she turned on the alarm on her communication device. At 6:44 AM, LVN C was standing at Resident #1's bedside and said, She has already done that, they fluffed your pillow, both girls have already done that. Resident #1 said through her communication device Push down top and left too. LVN C said No, we are not readjusting your pillow again, she's already done it ten times. Resident #1 says again, Push down top and left too. LVN C said Nope, {Resident #1's name}, and walks out of the camera view. Resident #1 says Push down top and left too and repeats Push down top and left too. LVN C returns to camera view and said in a louder voice I'm going to do it one time {Resident #1's name} and that's all I'm going to do it, what do you want then adjusts the pillow and said, alright it's pushed down and leaves the room. During an observation and interview on 8/12/25 at 11:45 AM, Resident #1 was sitting up in bed and used a communication tablet on a stand in front of her that she used by having a metal like dot on her forehead that acted like a wireless mouse, and she was able to use slight head movements to type her conversations. The communication tablet also allowed for Resident #1 to turn the typed words to be read aloud by the device if she chose to. Resident #1 said it was easier for her to type an email and send her concerns and/or complaints to the DON when she was not rushed and felt by sending an email to the DON, she would ensure her concerns and/or complaints would be given to someone that could help resolve the issues. Resident #1 said she had sent numerous emails to the DON about how staff were mistreating her, the lack of care she was receiving, not allowing her time to complete her meals and/or late meals, not allowing her to time to communicate her needs, and not answering her call light timely. Resident #1 said she did not feel her concerns/complaints were being addressed because the issues continued almost daily. Resident #1 said the problems were complex because there was so much lying and characterizing her as a bad patient, which leads to her poor care and helped staff justify their behavior. Resident #1 said she felt some staff intentionally treated her bad, so they would not have to care for her, so they are getting rewarded for abusing me and she felt like the staff intentionally ignored her at times because they know she took longer than the other residents. Resident #1 said often when staff do come in to assist her with the bed pan or other care, they are rough and talk rudely and made it very apparent they did not want to be providing her care. Resident #1 said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 20 of 28 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 08/15/2025 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 0675 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some she had little to no movement of her body but was able to push the touch pad call light for assistance when needed if it was placed under her hand. Resident #1 said the staff did not take the time to let her explain what she needed due to it took her a while to type out her needs on the tablet. Resident #1 said staff would also come in and turn her light off and then tell her she would have to wait until they finished their rounds on the other residents before they could get her on the bedpan. She said her bladder and bowels were one of the few things she had control over, and she felt that the staff should provide her care when she needed it, so it did not put her in a hardship to be holding it until they finished their rounds. Resident #1 said it was emotionally and physically hard on her. Resident #1 said she often hollers or screams when staff would not give her time to communicate on her tablet, she needed to have her pillow adjusted to position her head so she communicate on her communication device, be able to breathe comfortably, and be able to eat without aspirating (inhaling food into lungs) and she knew once they left her room it would be a long time before they returned. Resident #1 said often times while being fed, she would still be trying to swallow one bite of food and the staff were trying to feed her another bite and when she could not take a bite right then, the staff would say she was refusing to eat and took her food, and she was still hungry. Resident #1 said they would not give her time to respond and let them know she was still hungry and rushed out. Resident #1 said her muscles in her mouth, tongue, and throat were weak and it took her a long time to maneuver the food in her mouth and to be able to swallow it, and they have to often take her food back and re-blend it because it had clumps in it and her food had to be the consistency of baby food. Resident #1 said it did take a long time to feed her, but it was not something she could help or change because of her disease. Resident #1 said at times her head would fall over and she did not have the ability to pick her head up and it makes it difficult to breathe and all she could do was scream in hopes someone would come help her. Resident #1 said when she was not given time to respond on her tablet, the only thing she could do was make hollering type noises and it was very frustrating to her and caused her a lot of anxiety when the staff did not take the time to listen to her needs. During an interview on 8/13/25 beginning at 4:00 PM, Resident #1 said when staff bring her meals in, then moved her communication board where she could not type, then say she refused to eat made her feel powerless to get help and confused about why nobody used common sense, because obviously she wanted and needed to eat, and defeated in realizing it was the staff's intention to misunderstand her. Resident #1 said when staff said things such as: not going to keep going over the same thing over and over, I'm sick of you and don't care about that camera, kick me out of here, you gonna holler at me, I'm gonna leave, Don't act up, I literally just walked in here, don't know why you screaming, staff indicating she should say please and thank you, it made her mad and she wanted to tell them not to talk to her like that and to get out of her room, but she could not because she could not talk and had to accept their help. Resident #1 said she could not do anything, so anger builds up and caused her depression. Resident #1 said when staff keep asking her what do you want, what do you want and did not give her time to communicate on her device or staff chose not to take the time to read her communication device, it made her feel exhausted. Resident #1 said she did not have a hearing problem. Resident #1 said typing was not super easy and it took up long periods of mental and physical effort and she did not know who or if the staff would listen. Resident #1 said she becomes very scared when she realized they do not want to know what she needed or wanted. Resident #1 said some of the staff she trusted and knew they would do what she needed without her having to tell them, but there was not many she trusted left. Resident #1 said when staff enter her room and do not speak to her or do not tell her what they were going to do prior to touching her, was frightening and she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 21 of 28 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 08/15/2025 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 0675 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some absolutely had not way to stop them from whatever it was they were going to do and just hoping they would take a no from the tablet as an answer, and it was especially scary when they just sent new staff she had not ever met in to answer her call light. Resident #1 said when staff come into her room and just move her communication device to the end of the bed without letting her communicate her needs, scared her because they were intending to do whatever they wanted. Resident #1 said it was humiliating to be put on a bed pan, not covered, and left fully exposed with the window blinds open and sometimes staff would leave her room while she was on the bed pan and leave the door open to be seen by any member of the public walking by. Resident #1 said it made her feel angry when staff stood over her talking and laughing while she was on the bed pan, because they had no regard for the fact that she needed their close attention when she was in such a vulnerable position. Resident #1 said she did not want them staring at her while she went to the bathroom, but she needed them to hear her if she needed help. Resident #1 said when one staff member rolled her from side to side using the draw sheet, this is just one of the many ways they tortured me with the sheet, I am being handled like an object and it was isolating, when nobody acknowledges your humanness, you are alone. Resident #1 said continuous issues with her care has caused her to feel dehumanized and not treated as a person, and it had affected her well-being, self-worth, and self-esteem. Resident #1 said staff talk bad to her non-stop, and she does not feel her complaints were taken seriously and resolved. Resident #1 said she just wanted to be able to trust the staff and be treated with respect and kindness and be helped if not. During an interview on 8/13/25 at 11:46 AM, MA K said she had worked at the facility for about a year on the 6 AM-6 PM shift. MA K said they were sometimes a little short staffed, but the staff did the best they could. MA K said they were short staffed because staff have gotten fired due to Resident #1. MA K said she helped feed Resident #1 when she could, to help. MA K said it was time consuming. MA K said Resident #1 normally provided her own food. MA K said Resident #1 would tell you how to do it all and it took Resident #1 time to type it out. MA K said Resident #1 would type what she wanted and if staff did it wrong then she would start screaming and kicking. MA K said she thought Resident #1 wants some things a specific way because it was probably one of the only things Resident #1 could still control. MA K said the resident would be upset if staff did not communicate what they were doing to them prior to providing care. MA K said it was the resident's home. MA K said she would be upset if staff left her fully exposed while on a bed pan and window blinds opened. MA K said it would be a dignity issue. MA K said she would not be happy if she could not communicate her needs, but Resident #1 would usually answer yes or no questions either verbally or by head movements. MA K said if Resident #1 was not allowed time to communicate her needs, the staff would not know what she needed or wanted to say. MA K said it would probably make Resident #1 feel unsafe. MA K said she had not received any training on taking care of a resident with ALS. MA K said she was sure it would affect Resident #1's quality of life and made her feel less than a human if not provided privacy during incontinent care, not allowed time to communicate her needs, and not letting her know what care was going to be provided, and not speaking to her; and they were there to ensure Resident #1's needs were met.During an interview on 8/13/25 at 12:15 PM, CNA J said she had worked at the facility since April 2025 on the 6 AM-2 PM shift. CNA J said they had approximately 3 people on 400 hall that required 2-person assistance. CNA J said she felt she was able to meet the care needs of the residents. CNA J said it would make her feel very uncomfortable if staff did not speak to her and just started providing care. CNA J said it would make her feel uncomfortable, ashamed, and embarrassed if staff did not cover her or close the window blinds while on a bed pan. CNA J said Resident #1 at times wanted to be covered and at other times did not want to be covered and told them no. CNA J (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 22 of 28 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 08/15/2025 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 0675 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete said if staff moved Resident #1's communication device out of her reach and did not give her time to communicate, then how was Resident #1 supposed to let her needs known if unable to communicate needs and it would make her angry. CNA J said she would be mad if her momma was done that way. CNA J said it would affect Resident #1's quality of life if she was unable to communicate her needs. CNA J said not being allowed time to communicate needs, providing care without telling the resident what you were going to do, not speaking to the resident during care, would make the resident feel less of a human, and if not able to communicate then you would not get anywhere. CNA J said she had not received any training related to caring for a resident with ALS, just what she had learned working with Resident #1. CNA J said she had not had any in-services related to caring for Resident #1. CNA J denied ever telling Resident #1 to stop crying that they were not running a daycare center. During an interview on 8/13/25 at 12:52 PM, CNA G said she had worked at the facility for about 2 months on the 6 AM-2 PM shift. CNA G said they had 7-8 residents on the 400 hall that required 2-person assistance. CNA G said she felt she was able to meet the needs of the residents sometimes. CNA G said if she had Resident #1 then it was hard to care for the other residents when Resident #1 took 2-2.5 hours to feed twice on her shift sometimes. CNA G said usually no one provided care to her other residents when she was feeding Resident #1, and then she had to come out when she was done feeding Resident #1 and work hard to get her other residents' care completed before the end of her shift. CNA G said one of her other residents pushed their call light while she was feeding Resident #1, then someone may go check them, but usually no one checked on her other residents until she was able Event ID: Facility ID: 675949 If continuation sheet Page 23 of 28 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 08/15/2025 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 interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADLs. (Resident #2)The facility failed to provide Resident #2 with her scheduled showers.This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.Record review of a face sheet dated 08/12/25 revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included hemiplegia and hemiparesis affecting the left side (medical conditions that cause weakness or paralysis on one side of the body), generalized muscle weakness, vitamin deficiency, and recurrent depressive disorder (a disorder characterized by repeated episodes of major depression, separated by periods of remission).Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS indicated Resident #2 had a BIMs of 06 which indicated she had severe cognitive impairment. The MDS indicated Resident #2 required substantial to maximal assistance with showers or baths.Record review of Care Plan last revised 07/30/25 indicated Resident #2 had decreased mobility related to left sided hemiplegia, age related debility, and generalized weakness. There was an intervention indicating Resident #2 required extensive to total assistance of two staff members with toileting, personal hygiene, dressing, and bathing.Record review of ADL - Bathing documentation for Resident #2 from 07/16/25 - 08/12/25 revealed Resident #2 was scheduled for a full-body bath or shower on Mondays, Wednesday, and Fridays. The ADL - Bathing documentation revealed no documentation for a bath or a shower on Monday - 07/21/25, Wednesday - 07/23/25, Friday - 08/01/25, and Monday - 08/06/25.Record review of Progress notes for Resident #2 from 07/16/25 - 08/12/25 revealed no documentation of Resident #2 refusing to be bathed.During an interview on 08/12/25 at 9:56 a.m., a family member of Resident #2 said she had not always gotten her baths until they came to the facility to visit Resident #2. The family member said Resident #2 was supposed to be bathed on Mondays, Wednesdays, and Fridays. The family member said Resident #2 was not getting her baths without their intervention.During an interview on 08/13/25 at 1:16 p.m., Resident #2 said she did not always get her showers. She said the only time she had refused showers was when it was cold. She said other than that she wanted her showers.During an interview on 08/13/25 at 11:27 a.m., CNA G said baths and showers were charted in the residents' electronic medical record. She said residents were bathed three times a week. She said Resident #2's baths were being done on the 2 p.m. to 10 p.m. shift and they had just asked the day shift to do her baths because it was not getting done. She said she was not sure if she had missed baths or not because the 2 p.m. to 10 p.m. shift was supposed to be doing them.During an interview on 08/13/25 at 11:36 a.m., LVN C said CNAs documented baths in the ADL charting in each residents' electronic medical record every shift. She said she had not known Resident #2 to have missed her baths except when she had refused. She said any refusals should have been charted in the nurses' progress notes. She said it was also in the CNAs charting. She said when a resident refused the CNAs were supposed to tell the nurses. She said she did not remember Resident #2 refusing her bath recently. She said a resident missing baths could cause skin breakdown and cause them to have an odor.During an interview on 08/12/25 at 11:05 a.m., the DON said the CNAs charted baths/showers in each residents' electronic medical record. She said she felt that Resident #2 had received her baths even though they were not documented. She said if a bath was refused, she expected the refusal to be charted in the nurse's notes. She said she expected the CNAs to tell the nurse if a resident refused. She said Resident #2 could be stubborn. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 24 of 28 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 08/15/2025 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 She said Resident #2 has been being bathed on day shift for a while. She said residents not getting their bath could cause them to not be clean and make them smell. She said it could cause dignity issues.During an interview on 08/13/25 at 3:51 p.m., the Administrator said nursing staff were responsible for bathing the residents. She said the aides then documented the bath in the ADL charting in the resident's electronic medical record. She said she would have expected for baths to be given to Resident #2 as scheduled and then to have been documented. She said any refusals should also be charted in their medical records. She said residents not receiving a bath could make a resident feel less confident and would depend on how many days that were missed.Record review of an Activities of Daily Living (ADL) facility policy dated 2001 indicated, .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living.Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Unavoidable decline may occur if he or she.refuses care and treatment to restore or maintain functional abilities.the refusal and information are documented in the resident's clinical record . Event ID: Facility ID: 675949 If continuation sheet Page 25 of 28 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 08/15/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was provided that accommodated the preferences of 1 of 7 residents reviewed for preferences. (Resident #2) The facility did not honor Resident #2's food preferences after she made a request to the Dietary Manager on 08/04/25 that her meat be chopped. This failure could place residents at risk for dissatisfaction, poor intake, and/or weight loss.Record review of a face sheet dated 08/12/25 revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included hemiplegia and hemiparesis affecting the left side (medical conditions that cause weakness or paralysis on one side of the body), generalized muscle weakness, vitamin deficiency, and recurrent depressive disorder (a disorder characterized by repeated episodes of major depression, separated by periods of remission). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS indicated Resident #2 had a BIMs of 06 which indicated she had severe cognitive impairment. The MDS indicated Resident #2 required supervision or touching assistance with eating. Record review of Care Plan last revised 07/30/25 indicated Resident #2 had decreased mobility related to left sided hemiplegia, age related debility, and generalized weakness. There was an intervention indicating Resident #2 required set up for meals with one staff assist with feeding as needed. Record review of an Order Summary dated 08/12/25 for Resident #2 indicated an order for a regular diet. The orders did not indicate an order for chopped meats or mechanical soft diet. Record review of a Dietary Profile dated 08/04/25 at 3:46 p.m., indicated Resident #2's current diet was a regular diet. The current texture of her food was regular. Section H: Eating/Chewing/Swallowing Concerns indicated a referral to Speech Therapy was made. There was a comment that indicated, Resident states she is having trouble with chewing meats. Section N: Comments indicated, Resident asked for meats to be cut up for meals. Notified Therapy to follow up with eval (evaluation). Record review of an email thread between the Dietary Manager and the Rehabilitation Director dated 08/07/25 indicated at 2:50 p.m. the Dietary Manager wrote, Talked with her (Resident #2) this morning. Said she is having a little trouble chewing her meat. Said if it is cut up she can eat it better. The Rehabilitation Director responded at 2:59 p.m., Ok. I think nursing can downgrade to chopped meat but I will clarify! Thanks. The Dietary Manager responded at 3:01 p.m., They can. Just didn't know if you guys needed to see her first. Record review of a Dietary Slip for Resident #2 indicated on 08/13/25 at breakfast she was served a regular diet with regular texture. The slip indicated the meal included sausage. The notes at the bottom of the slip did not indicate the resident preferred her meats to be chopped. During an interview on 08/12/25 at 9:56 a.m. a family member of Resident #2 said staff were supposed to be chopping up Resident #2's meats. The family member said staff had not been chopping her meats. The family member said Resident #2 was having difficulty chewing meats unless they were chopped for her.During an observation on 08/13/25 at 8:53 a.m., Resident #2 was asleep in bed with breakfast tray in front of her. The tray consisted of scrambled eggs, sausage, toast, milk and coffee. The meal ticket on the tray did not indicate the resident requested cut up meats. The sausage was not cut up. During an observation on 08/13/25 at 9:10 a.m., Resident #2 was asleep in bed with her breakfast tray in front of her. The sausage on her plate was not cut up. During an interview on 08/13/25 at 10:00 a.m., the Rehabilitation Director said Resident #2 was not on speech therapy at this time. She said the Dietary Manager did email concerning the dietary note on 08/07/25. She said she recommended him notifying nursing staff to down grade her diet, until she was screened by speech therapy. She said Resident #2 was scheduled to be screened on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675949 If continuation sheet Page 26 of 28 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 08/15/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 08/13/25. She said she had an email saying she was having trouble eating her meats. She said the kitchen would be responsible for cutting up her meats or even the aides. She said if the Dietary Manager told nursing, they should have downgraded her diet to chopped meats or cut it up for her until she was screened. She said cutting up the meat would be a nursing decision.During an interview on 08/13/25 at 10:25 a.m., the Dietary Manager said on 08/04/25 he went in Resident 2's room to talk to her about food preferences. He said the resident told him she was having difficulty chewing her meats. He said she never said she was having difficulty swallowing, only chewing. He said he notified therapy because they would have to do an evaluation. He said he probably should have let the DON know also. He said if the order had been changed, it would have been the dietary staff's responsibility to chop up her meats. He said he was not going to make the changes until he had an order. He said if therapy had deemed it necessary to change the dietary order to chopped meats, then dietary staff would be chopping her meats. He said if her order was for a regular diet at this time then she was being served a regular diet. He said he was not sure if the aides were assisting the resident with cutting up her meats. During an interview on 08/13/25 at 11:27 a.m., CNA G said she has carried meal trays to Resident #2. She said the resident had never complained to her about having difficulty chewing her meat. She said she had not been cutting up meat for Resident #2. She said the resident ate just fine to her.During an interview on 08/13/25 at 11:36 a.m., LVN C said Resident #2 had never complained to her about having difficulty chewing and had not had any difficulty swallowing. She said today (08/13/25) was the first time she had heard that Resident #2 wanted her meat chopped for her. She said Resident #2's family had brought her fried chicken and other meats.During an interview on 08/13/25 at 1:06 p.m., a family member said Resident #2 needed chopped meats. They family member said they could observe on camera that her meats were not being chopped. The family member said Resident #2 was physically unable to chop her own meat because she was paralyzed on the left side. During an interview on 08/13/25 at 1:16 p.m., Resident #2 said she did not remember talking to the Dietary Manager about chopping her meats. She said she could not cut her own meat because of her left arm. She said she had difficulty chewing meat. She said it would help her if staff would chop her meats. During an interview on 08/12/25 at 11:05 a.m., the DON said this was the first she had heard of Resident #2 requesting for her meats to be chopped for her. She said if nursing had been notified, they would have chopped her meats for her. She said she expected dietary staff or the aides to chop the meats for her. She said Resident #2's meat not being chopped might cause her to not be able to eat it. During an interview on 08/13/25 at 3:51 p.m., the Administrator said she felt nursing staff were responsible for cutting up the meat for Resident #2. She said when they set up a tray sometimes, they do cut up the meat. She said staff told her that sometimes Resident #2 preferred for her meat to be left whole. She said she felt dietary staff should chop the meat if there was an order for the meat to be chopped. She said she did not feel like it was fair for her to be cited since Resident #2's preferences change meal by meal.Record review of an Accommodation of Needs facility policy dated March 2021 indicated, .The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other resident would be endangered . Event ID: Facility ID: 675949 If continuation sheet Page 27 of 28 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 08/15/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually, to include the resident population, diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population, and other pertinent information for 1 of 1 facility.The facility failed to include Resident #1's diagnosis of Amyotrophic Lateral Sclerosis (ALS) (a nervous system disease that causes muscle weakness and paralysis (unable to move) and impacts physical function, ability to talk and breathe).These failures could affect residents by not having the necessary resources to ensure appropriate care was provided. Findings included:Record review of the facility assessment dated [DATE] did not address Amyotrophic Lateral Sclerosis (ALS).Record review of Resident #1's face sheet dated 8/12/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included ALS, muscle weakness, lack of coordination, anxiety (feeling of worry, dread, and uneasiness), speech disturbances, dyspnea (difficulty breathing), pain and hypertension (high blood pressure).Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood but was able understand others. The MDS indicated Resident #1 did not complete the BIMS because she was rarely/never understood). The MDS indicated Resident #1 had verbal behavioral symptoms directed toward others 1-3 days and rejected care daily. Resident #1 had impairment to upper and lower extremities. Resident #1 was dependent on staff for all ADLs. Resident #1 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS indicated ALS was Resident #1's primary diagnosis. Resident #1 had shortness of breath or trouble breathing when lying flat. Resident #1 had loss of liquids/solids from mouth when eating or drinking and had coughing or choking during meals or when swallowing medications. Record review of Resident #1's Care Plan indicated she had a diagnosis of ALS and used a communication device to communicate her needs and would also make gestures with her head and able to say some words with interventions including: allowing resident time to use the communication device to communicate needs; if unable to understand resident when she was speaking then ask her to use her communication device; make sure communication device was in place before and after care needs; make sure resident was positioned properly in bed, with the use of pillows if needed to ensure that she can eat, use her device, breathe easily, and be comfortable; make sure the dot that helps her operate her communication device was in place; offer emotional support as needed; and staff to speak calm, clearly, and slowly. Requested a policy on Facility Assessment on 8/14/25 at 8:58 AM.On 8/14/25 at 10:00 AM, the ADM said they did not have a policy related to the Facility Assessment.During an interview on 8/15/2024 at 4:09 PM, the ADM stated she was responsible for completing and updating the facility assessment. The ADM said they update their facility assessment at least every year. The ADM said the purpose of the facility assessment was to give a summary of the types of residents they cared for and to stay in compliance. The ADM said they staff based on caring for all the residents and did not base their staffing on what was in the facility assessment. The ADM said the facility assessment captured most of the disease processes of the population, but all the diagnoses were not captured on the facility assessment, because there would be thousands of diagnoses. The ADM said the facility assessment being updated did not affect the care of the residents. Event ID: Facility ID: 675949 If continuation sheet Page 28 of 28