Health inspection·November 23, 2022

F 0759 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #13's MAR on 11/21/22 at 8:00 AM and dates 11/1/2022-11/30/2022 revealed the Benicar (Olmesartan) tablet 20 mg 1 tablet, Cyanocobalamin- cobamamide tablet sublingual 5,000- 100 mcg and Lasix ( Furosemide) tablet 40 mg was scheduled for administration 8:00 AM and had been initialed as being administered daily from 11/1/22 through 11/21/22. Residents Affected - Some Resident #37 Record review of Resident # 37's admission record revealed she was an [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: vitamin deficiency, type 2 diabetes mellitus with hyperglycemia (high glucose in the blood). Record review of Resident #37's Physician's orders and Medication Administration Record dated 11/01/22 reflected an order for Glimepiride 2 mg once daily. This order had a start date of 08/08/22. Observation of MA A on 11/21/22 at 8:50 AM during medication administration, MA A administered Glimepiride 4 mg 1 tablet by mouth to Resident #37, instead of Glimepiride 2 mg as ordered by the doctor. Resident #17 Record review of Resident # 17's admission record revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses: allergic rhinitis and Alzheimer's disease (memory loss). Record review of Resident #17's Physician order summary report on 11/01/22 had Active Orders As Of: 07/21/2022 revealed the following orders: Flonase Allergy ( Fluticasone Propionate) spray suspension; once a day, 2 spray in each nostril every day and Allegra Allergy ( Fexofenadine) 60 mg 1 tablet twice a day for allergic rhinitis Order Status Active, and Order Date 07/21/2022 and Start Date 07/21/2022. Record review of Resident #17's Physician's orders and Medication Administration Record dated 11/01/22 reflected an order for Flonase Allergy (Fluticasone Propionate) spray suspension; once a day, 2 spray in each nostril every day and Allegra Allergy ( Fexofenadine) 60 mg 1 tablet twice a day for allergic rhinitis. Observation of MA A on 11/21/22 at 9:00 AM during medication administration, MA A administered Flonase Allergy (Fluticasone Propionate) spray suspension; 1 spray to each nostril and Allegra Allergy (Fexofenadine) 60 mg 1 tablet was not given to Resident #17. During an interview on 11/22/22 at 12:55 PM, MA A said she was working through a nurse agency and 11/21/22 was her first day in the facility. She sorry about the error. She said she was pulled from nurses' aides to pass medication. MA A said she sometime works as nurse. MA A said she was not used to facility medication carts and she was medication aide where works full time. MA A said staff should follow the physician's orders when giving medications and the staff were responsible for checking physician's order before administration. In an interview with the DON on 11/21/22 at 1:44 PM, she said the regular MA called off that morning (11/21/22) and that was why she asked the agency MA to help. The DON said her expectation was for the staff to make sure they administered the medications according to the orders and followed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 2 of 8 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 676164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bellville 106 N Baron Bellville, TX 77418 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 0759 physician orders. The DON stated MA A should be following the 5 rights of medication administration. Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator on 11/22/22 at 2:10 PM, he said he expects the nurses to give medication as ordered by the doctor. Residents Affected - Some Record review of the facility's policy for Administrating Oral Medications (revised date October 2010) revealed in part . Steps in the Procedure . 8. Check the medication dose. Re-check to confirm the proper dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 3 of 8 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 676164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bellville 106 N Baron Bellville, TX 77418 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of one medication room and, two of three medication carts ( 1medication room, A, B&C medication carts) reviewed for drug labeling and storage, in that: Medication cart for A Hall had 3 Fluticasone propionate nasal spray USP 50 mcg open with no date and Cetirizine Hydrochloride 5 mg 1 bottle. Medication cart for Hall B and C had 3 Fluticasone propionate nasal spray USP 50 mcg open with no date. Medication room cabinets had 2 bottles of Folic Acid expired, oral anti-diarrheal solution, and 4 Summer's Eve medicated Ph-Balanced expired. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: Observation of the medication room cabinet storage on [DATE] 10:20 AM revealed : 2 bottles of Folic Acid 800 mcg 100 tablets each expired 07/2022, oral anti-diarrheal solution expired 05/2022 and 4 Summer's Eve medicated Ph-Balanced douche expired 06/2022. Observation of the medication cart for Hall A on [DATE] at 10:27 AM revealed, 3 Fluticasone propionate nasal spray USP 50 mcg open with no date and Cetirizine Hydrochloride 5 mg 1 bottle expired 10/2022 Observation of the medication cart for Hall A and C on [DATE] at 10:27 AM revealed, 3 Fluticasone propionate nasal spray USP 50 mcg open with no date Interview with MA B on [DATE] at 10:44 AM, she said she only started working with the facility 10/2022. She said she did not know that Fluticasone propionate nasal spray was supposed to be dated after being open. MA B said Fluticasone propionate nasal sprays were already open before started working for the facility. Interview with the DON on [DATE] at 3:09 PM, she said was responsible for checking the medications for expired medication and she would be checking the medication more. DON said she will be checking the medication room and do a lot of in-services. Record review of the facility's policy titled Storage of Medications (Revised [DATE]) revealed in part .Policy Interpretation and Implementation statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Policy interpretation and implementation . 4. Facility should ensure that medications and biologicals that: (1) have an expired on the label; (2) have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 4 of 8 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 676164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bellville 106 N Baron Bellville, TX 77418 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm been retained longer than recommended by manufacturer or supplier guidelines, or (3) have been contaminated or deteriorated , are stored separate from other medications until destroyed or returned to the pharmacy or supplier . One Med Room & 2 Med Carts. Residents Affected - Some FACILITY Medication Storage and Labeling FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 5 of 8 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 676164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bellville 106 N Baron Bellville, TX 77418 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of four staff (MA A) and three of ten residents (Resident #13, #38 and #17) reviewed for infection control, in that Residents Affected - Few MA A failed to sanitize a wrist blood pressure cuff between uses on Residents #13, #38 and #17. This failure could place residents at risk for spread of infection through cross-contamination of pathogens and illness. Findings included: Resident #13 Record review of the face sheet for Resident #13 reflected she was an [AGE] year old female, who was admitted to the facility on [DATE] with the following diagnoses: essential (Primary) hypertension (high blood pressure), vitamin deficiency, and vitamin B12 deficiency anemia due to intrinsic factor deficiency and age-related osteoporosis without current pathological fracture. Record review of the quarterly MDS for Resident #13 dated 10/13/22 reflected a BIMS score of 15, indicating no cognitive impairment. Record review of the care plan for Resident #13 dated 09/19/22 reflected the following: The resident has hypertension. The resident will remain free of complications related to hypertension through review date. Avoid taking the blood pressure reading after physical activity or emotion distress. Monitor for and document any edema. Notify MD. Monitor/document abnormalities for urinary output. Report significant changes to the MD. Record review of the physician orders for Resident #13 dated 09/19/22 reflected the following: Benicar (Olmesartan) tablet 20 mg once a day for Hypertension Hold if SBP<100 and HR<60. Observation on 11/21/22 at 8:44 AM revealed MA A preparing medications for administration on a medication cart and using the computer keyboard on the cart. MA A left her medication preparation to take blood pressure/pulse rate for Resident #13. MA A attached wrist cuff without cleaning/ wiping it with sanitizer. Resident #38 Record review of the face sheet for Resident #38 reflected 90 -year-old male admitted to the facility on [DATE] with diagnoses of dementia, hypertension (high blood pressure), and anemia ( low blood volume). Record review of the quarterly MDS for Resident #38 dated 08/24/22 reflected a BIMS score of 10, indicating a moderate cognitive impairment. Record review of the care plan for Resident #38 dated 07/29/22 reflected the following: The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 6 of 8 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 676164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bellville 106 N Baron Bellville, TX 77418 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident has hypertension (HTN) related to Smoking, use/side effects of medication. The resident will remain free of complications related to hypertension through review date. Give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Monitor for and document any edema. Notify MD. Monitor/document/report PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing (Dyspnea). Record review of the physician orders for Resident #38 dated 12/01/21 reflected the following: Losartan Potassium tablet 50 mg. Give one tablet by mouth. Hold if SBP<100 and HR<60. Observation on 11/21/22 at 9:13 AM revealed MA A preparing medications for administration on a medication cart and using the computer keyboard on the cart. MA A left of her medication preparation to take blood pressure/pulse rate for Resident #38. MA A attached to a wrist cuff without cleaning/ wiping it w ith sanitizer. Resident #17 Record review of Resident # 17's admission record revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses: allergic rhinitis and Alzheimer's disease (memory loss). Record review of the quarterly MDS for Resident #17 dated 10/13/22 reflected a BIMS score of 06, indicating severe cognitive impairment. Observation on 11/21/22 at 9:30 AM revealed MA A preparing medications for administration on a medication cart and using the computer keyboard on the cart. MA A left of her medication preparation to take blood pressure/pulse rate monitor for Resident #17, MA A attached to a wrist cuff without cleaning/ wiping it with sanitizer. During an interview and observation on 11/22/22 at 9:34 AM, MA A stated she was supposed to disinfect the wrist cuff monitor between resident uses. She stated she should have used bleach wipes that should have been on her medication cart. She stated that not sanitizing the wrist cuff monitor or the residents' hands could result in them getting sick with infection. During an interview on 11/22/22 at 2:57 p.m., the DON/IP stated she was responsible for most of the staff training, especially around infection control. She stated she taught, in-serviced, watched, and critiqued her staff regularly. She stated they did specialized teaching all week recently for Infection Control. She stated she monitored for compliance what people do by walking the halls and watching them. She stated she had a monitoring schedule. When asked what the schedule was, she stated it was really all the time. She stated she trained staff to sanitize the blood pressure/heart rate monitors using bleach wipes before and after each resident use, every time. She stated she expected them to let the equipment sit and dry for two full minutes. She stated she had done in-servicing and teaching specifically about that issue. She stated the potential consequences of not sanitizing the machines were cross contamination and exposure to infection. She stated that applied to every piece of equipment they used on residents. She stated she derived her guidance from the facility's infection control policy. She stated she did skills checkoffs with MA A because she was an agency nurse and was pulled off the floor. During an interview on 11/22/22 at 3:29 p.m., the ADM stated his expectation was that staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 7 of 8 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 676164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bellville 106 N Baron Bellville, TX 77418 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm followed the infection control protocol, which was to sanitize equipment between each resident use. He stated he ensured that happened by ensuring the nurse management did in-servicing and made observations of staff performance. Policy and procedure requested on 11/22/22 from DON and none provided before exit. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 8 of 8