Health inspection·January 26, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 01/24/2024 at 2:45 PM, the ADON stated Resident #28 would use the CPAP himself when he wanted to. She stated she did not know if the CPAP was part of the resident's care plan and she did not have anything to do with the care plan. In an interview on 01/25/2024 at 3:05 PM, the Regional Consulting Nurse stated Resident #28 did not have a care conference and that it did not meet regulations. She stated she would double check if there was a paper copy of a care conference. She stated care conferences were usually done 2 weeks after admission and with each MDS, usually every 3 months. She stated the care plan should include use of CPAP and the purpose of the care plan was to provide information on how to care for the resident. She stated it should be resident centered d/t every resident would have different needs . In a telephone interview on 01/25/2024 at 4:20 PM, the Regional MDS Nurse had been the MDS nurse for the facility for the past 2 months. She stated a person-centered care plan involved a meeting with the IDT team to review care with family/RP/Resident to meet the resident's needs and concerns. She stated it was important to make sure the resident was getting needs met for continuity of care when a resident comes from a hospital or from home. She stated if a resident was using Bipap/CPAP this should be included in the care plan so different team members could identify respiratory issues that needed to be addressed. She stated this would help provide an accurate picture of the resident's needs and the team would discuss and make sure it was addressed in the MAR. She stated if there were any current issues, the nurse or CNA would discuss with the DON then the DON would make necessary changes to the plan of care. In an interview on 01/26/2024 at 10:56 AM, the Regional Consulting Nurse stated Resident #28's care plan had not been updated d/t changes in staffing and the absence of the MDS nurse at the time. She stated the Regional MDS had been working on care plans and the facility was doing the best they could. She stated this was the root cause of the problem with the care plans not being updated. She stated there was no evidence of a care conference for Resident #28 and that a care conference was part of the Comprehensive Care Plan. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised on December 2016, read in part: .Policy Interpretation and Implementation - 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; .l. Identify the professional services that are responsible for each element of care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 2 of 19 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 01/26/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 residents (Resident #28) reviewed for Quality of Care in that: Residents Affected - Few -Nurse Aide F provided services outside the scope of practice of a NA by administering a topical medication to Resident #28's wound. -the ADON delegated outside the scope of nursing practice by allowing Nurse Aide F to administer a topical medication to Resident #28's wound. This failure could place residents at risk of inappropriate medication administration, infection and decline in health. Record review of Resident #28's face sheet dated 01/23/2024 revealed a [AGE] year-old male admitted [DATE]. His diagnoses included stroke, need for assistance with personal care, difficulty with speech, acute respiratory disease, Pneumonia (inflammatory condition of the lung), urinary tract infection, shortness of breath (difficulty breathing), COPD, hemiplegia (paralysis to one side of the body), obesity, diabetes, HTN and osteoarthritis (a type of joint disease). Record review of Resident #28's quarterly MDS dated [DATE] revealed he had a BIMS score of 6 out of 15 indicating severe cognitive impairment. He had limited range of motion d/t impairment on both sides of his lower extremities. He was dependent on staff or required substantial assistance with ADLs. He had moisture associated skin damage, required nonsurgical dressings and applications of ointments/medications. Record review of Resident #28'scare plan did not address skin injuries/wounds and interventions. The care plan was last reviewed/revised on 12/04/2023. Record review of Resident #28's Wound Evaluation and Management Summary dated 01/23/2024 by the Wound Physician revealed a non-pressure wound of the right buttock to be an abrasion that was 1.0 x 0.7 x 0.1 cm in size. The wound had light serosanguinous exudate (a type of wound drainage secreted by an open wound). The dressing treatment plan was to use Silver Sulfadiazine cream twice daily and discontinue the use of a gauze dressing. Record review of Resident #28's physician orders for the nurse medication flow sheet revealed a prescription order for silver sulfadiazine cream, 1 %, amount: thick layer; topical, twice a day; 7:00 AM 7:00 PM, 7:00 PM - 7:00 AM. Start date was 11/14/2023. Observation and interview on 01/24/2024 at 12:45 PM, Resident #28 stated he needed a brief change. Nurse Aide F performed peri care. Resident #28 self-turned to his right side and Nurse Aide F wiped the resident's buttocks with disposable wipes around a small dressing over an area on the right buttocks that was loose. Nurse Aide F removed the dressing. Nurse Aide F stated he needed to get a nurse because of the wound. Nurse Aide F removed his gloves and sanitized his hands just outside of the room. Nurse Aide F returned with gloved hands and white cream in a medicine cup. Nurse Aide F stated the ADON gave it to him to put on the wound for now. Nurse Aide F said it was cream that was typically put on the area. Nurse Aide F did not say what the name of the cream was when asked. Nurse Aide F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 3 of 19 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 01/26/2024 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 0684 applied the cream over the open area. Nurse Aide F completed the peri care procedure. Level of Harm - Minimal harm or potential for actual harm In an interview on 01/25/2024 at 10:30 AM the ADON stated she gave the cream to Nurse Aide F to apply over Resident #28's wound. The ADON stated it was Silvadene cream (Silver Sulfadiazine) and that only nurses were allowed to administer. The ADON stated it was wrong to have given it to the NA to administer and it should not have happened. The ADON stated she was trying to do so many things at that time. The ADON stated she would fix it and make sure it did not happen again. Residents Affected - Few In an interview on 01/25/2024 at 10:40 AM, the Regional Consulting Nurse stated it was not ok for an aide to administer the Silvadene cream because it was a medication ordered by the MD and nurse aides cannot assess wounds. She stated nurse aides were taught not to put anything over open areas. She stated if the skin was broken it required an assessment. She stated the cream would not have hurt the resident, but it was out of the scope of practice for a nurse aide, and it was out of the scope of practice for the nurse to delegate the task to a NA. She stated it was a deficient practice. Record review of the facility policy titled Administering Medications, revised December 2012, read in part: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so . Record review of the facility policy titled Administering Topical Medications, revised October 2010 read in part: Purpose - The purpose of this procedure is to provide guidelines for the safe administration of topical medications. Preparation: 1. Verify that there is a physician's medication order for this procedure .General Guidelines: 1. Follow the medication administration guidelines in the policy entitled Administering Medications Steps in the Procedure .15. Assess the area for broken skin, drainage, debris, rashes, allergic reaction, or signs of infection .17. Clean the skin. Remove old medication residue, debris, scales, dried blood, etc. If necessary, saturate a gauze pad with solvent and wipe .to remove paste, cream or ointment from the area . Record review of the facility's undated Job Description for Certified Nursing Assistant read in part: Summary: Provide direct nursing care to the residents according to established policies and procedures and to ensure that the highest degree of quality care is maintained at all times . Record review of the facility's undated Job Description for LVN, Licensed Vocational Nurse read in part: Summary: The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day to day nursing activities of your assigned unit. Such supervision must be in accordance with current Federal, State, and local standards, guidelines and regulations that govern the Long-term care facility as well as our established policies and procedures, and as may be direct by the Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 4 of 19 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 01/26/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the environment was free of accidents hazards for 4 (Resident #20, Resident #25, Resident #26, Resident #30 ) of 5 residents, reviewed for accidents hazards This failure placed residents at risk of injury for accidents or hazard. Findings included: Record review of Resident #25's orders revealed Resident #25 was admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (chronic shortness of breath and cough), muscle wasting and atrophy (loss of muscle), cough, unsteadiness on feet, colostomy status (opening for the large intestine in the stomach). Record review of Resident # 25's MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. Resident #25 required supervision with eating, oral hygiene, and showering/bathing. Resident #25 was independent with upper body dressing, lower body dressing, personal hygiene, and used a wheelchair and walker for ambulating. Record review of Resident #25's Care Plan dated 7/25/2023 revealed . Resident #25 smokes .I will not suffer from unsafe smoking practices through the next review date .instruct resident about the facility policy on smoking, locations, times and safety concerns .notify charge nurse immediately if it suspected resident has violated facility smoking policy . Record review of Resident #25's Smoking assessment dated [DATE] revealed in part . Smoking materials carries matches/lighter, general awareness and orientation-including ability to understand the facility safe smoking policy-0-No Problem . In an interview on 1/24/2024 at 8:56am with Resident #25 she said she kept her lighters in her room. She said her lighters were in her drawer and pointed at her drawer. Resident #25 said she did not keep her lighters at the nurse's station. Record review of Resident # 30 's orders revealed resident was admitted [DATE] with diagnoses of major depressive disorder (persistent sadness), chronic obstructive pulmonary disease, pressure ulcer of the right buttock stage 3 (wound from pressure), pressure ulcer of the left buttock stage 3, venous insufficiency (blood pooling in the veins), nicotine dependence, cigarettes, with withdrawal, other specified diseases of pancreas, morbid (severe) obesity due to excess calories. Record review of Resident #30's MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating Resident #30 was moderately cognitively impaired. Resident #30's required extensive assistance with toileting and bathing, substantial/maximal assist with lower body dressing, putting on footwear, personal hygiene and set up with eating. Resident required a wheelchair for ambulation. Record review of Resident #30's Care Plan revealed in part . Encourage resident to keep all smoking material at nurses' station after smoke break. Education provided to family and resident . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 5 of 19 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 01/26/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident #30's Smoking assessment dated [DATE] read in part . Carries Matches/Lighter, inappropriately provides smoking materials to others .severe problem .General awareness and orientation including ability to understand the facility safe smoking policy-0-No Problem . In an interview on 1/24/2024 at 9:00am with Resident #30 he said he kept his own lighter in his room. Resident #30 said he kept the lighters in his bedside table. Observation on 1/24/2024 at 9:00am of Resident #30 bag with lighter revealed resident had a white bag in bed with him. Record review of Resident #26 orders revealed resident was admitted [DATE] with a diagnosis of other lack of coordination, Muscle wasting and atrophy, Difficulty walking, Unspecified atrial fibrillation (abnormal heart rhythm), Nicotine dependence, unspecified, uncomplicated, Adult failure to thrive (decline). Record review of Resident #26 MDS dated [DATE] revealed a BIMS score of 11 out of 15 indication the resident was moderately cognitively impaired. Resident was set up or cleanup for oral hygiene, toileting, showering, putting on taking off footwear, and personal hygiene. Resident was independent with upper and lower body dressing. Resident ambulated with a wheelchair. Record review of Resident #26's Care Plan dated 5/10/2023 revealed . Resident #26 is a smoker .I will not suffer injury from unsafe smoking practices through the next review date .instruct resident about the facility policy on smoking, locations, times, safety concerns .Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Record review of Resident #26's Smoking assessment dated [DATE] revealed in part . Capability to follow facility safe smoking policy-0-No problem . In an interview on 1/24/2024 at 9:05am with Resident #26 he said he had his own lighter. He said the facility did not keep lighters. He said his lighter was in his bedside drawer. Record review of Resident #20 Orders revealed resident was admitted [DATE] with diagnoses of Type 2 diabetes mellitus with diabetic nephropathy (problem with sugar regulation that affects the kidneys), Other secondary hypertension (high blood pressure), Mild intellectual disabilities (limitation to mental ability), Hypertension (high blood pressure), Hyperlipidemia High blood fats). Record review of Resident #20's MDS dated [DATE] revealed a BIMS score of 14 indicating the resident was cognitively intact. Resident was Supervision or touching assistance with personal hygiene, putting on/taking off footwear, set up or clean up with oral hygiene, toileting hygiene, showering/bathing, and independent with eating, upper and lower body dressing. Resident was ambulatory. Record review of Resident #20's Care Plan dated 12/12/2023 revealed in part . Resident has hypertension and is an occasional smoker .remind resident that cigarettes and lighter are to be kept at the nurse's station . Record review of Resident #20's Smoking assessment dated [DATE] revealed in part . Clinical Judgement-Resident is not capable of even supervised smoking. Smoking will result in danger to self and others .False. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 6 of 19 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 01/26/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 1/24/2024 at 9:10am with Resident #20 he said he gets his lighters from the store. He said his family buys them for him. He said he keeps his lighters in the drawer in the bedside table and pulled out 2 lighters and shoed them to the surveyor. Record review of Resident # 12's Orders dated 12/25/2023-1/25/2023 revealed a [AGE] year old male admitted to the facility 10/14/2022. His diagnoses were Cerebral Infarction (Brain cells do not get enough blood), Acute on chronic diastolic congestive heart failure (Heart cannot pump enough blood to meet the bodies need), Dysphagia (Difficulty speaking), Hemiplegia and hemiparesis following cerebral vascular disease affecting left non-dominant side (Paralysis on left side). Record review of Resident #12's MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating Resident #12 was moderately cognitively impaired. He required total assistance with bathing and partial/moderate assistance with toileting, lower body dressing, putting on footwear and personal hygiene. He required supervision with upper body dressing and eating. Record review of Resident #12's Care Plan dated 4/6/2023 revealed in part Resident #12 is a smoker . I will not suffer injury from unsafe smoking practices .Resident can smoke unsupervised .The resident can light own cigarette. Record review of Resident #12's Smoking assessment dated [DATE] read in part . moderate problem with Careless with smoking materials-Drops cigarette/cigar butts or matches on floor, furniture, self, or others; burns fingertips; smokes near oxygen, Smokes Cigarettes/Cigar Butts from Ash Trays, and with his Capability to Follow Safe Smoking Policy. He had a severe problem begging for and/or stealing smoking materials. On 1/24/2024 at 7:30am Surveyor observed empty smoke box in the medication room. In an interview on 1/23/2024 at 7:30am with Nurse Aid F he said he had worked at the facility since 2017. He said they had an in service on smoking before in the past but could not remember the date. He said the residents were supposed to stay in the smoking area when they smoked. He said the lighters were supposed to be at the nursing station. He said the families brought the lighters in to the residents. He said the residents felt like they could carry their own lighters. He said he had removed some personally and said there were some residents he would leave a lighter with. He said staff were not always with the residents when they smoked. In an interview on 1/23/2024 at 7:46am with CNA R, the activities director, she said she had worked at the facility since November 2023. She said they had no one observing the smokers. She said the residents had their own lighters in their rooms with them. She said they had only one resident that wandered in the building. In an interview on 1/25/2024 at 7:25am with Nurse Aid I she said she had worked at the facility for 2 years and 5 months. She said lighters were supposed to be kept at the nurse's station. She said she did not hand lighters to the residents. She said the residents were keeping their own smoking paraphernalia. She said 6 months ago an aide was supposed to always go out with the residents but that stopped. She said if lighters were kept in rooms residents could get them and they could cause an explosion or catch themselves on fire. In an interview on 1/25/2024 at 7:30am with CMA H she said the residents go outside to the smoking area. She said the residents are mostly independent. She said there was usually someone with them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 7 of 19 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 01/26/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She said they had a smoke box in the medication room they were supposed to be using for residents to put their lighters in. She said if the residents had lighters in their rooms there could be a tragedy. In an interview on 1/26/2024 at 10:30am with the ADON she said she did a smoking assessment on everyone that came into the building. She said they did a recent smoking assessment for the new smoking policy. She said lighters in resident rooms were a fire hazard. She said another resident could wander into the room who was cognitively impaired and cause a fire and for this reason lighters were not allowed in rooms. She said resident lighters were supposed to be kept at the nurses station in the smoke box and lighters were to be taken up by nursing staff at the end of each smoke break. Record review of facilities policy titled, Smoking Policy-Residents dated October 2022 read in part . Lighters, including matches, are prohibited to be kept in patients' rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 8 of 19 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 01/26/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care for 1 of 6 residents (Residents #28) reviewed for care consistent with professional standards, in that: Residents Affected - Few The facility failed to clean Resident #28's CPAP (a machine used to keep breathing airway open) mask, nasal pillow and tubing daily. The facility failed to change Resident #28's CPAP tubing monthly. These failures could place residents at risk of respiratory infection, decline in health and hospitalization. Findings include: Record review of Resident #28's face sheet dated 01/23/2024 revealed a [AGE] year-old male admitted [DATE]. His diagnoses included stroke, need for assistance with personal care, difficulty with speech, acute respiratory disease, Pneumonia (inflammatory condition of the lung), urinary tract infection, shortness of breath (difficulty breathing), COPD, hemiplegia (paralysis to one side of the body), obesity, diabetes, HTN and osteoarthritis (a type of joint disease-causing pain and stiffness). Record review of Resident #28's quarterly MDS dated [DATE] revealed he had a BIMS score of 6 out of 15 indicating severe cognitive impairment. He had limited range of motion d/t impairment on both sides of his lower extremities. He was dependent on staff or required substantial assistance with ADLs. He had shortness of breath when lying flat and when sitting at rest. He required oxygen therapy and non-invasive mechanical ventilator. Record review of Resident #28's physician order report dated 12/24/2023 to 01/24/2024 revealed an order to change CPAP tubing on the first day every month, order start date 10/31/2023. Monitor CPAP every 2 hours while in use for function and compliance, order start date 10/31/2023. CPAP in place at HS, once a day; 7:00 AM - 7:00 PM. Resident may use CPAP during day as needed. Further review of the general flow sheet section of the physician order report did not include orders on when to change CPAP face mask or to use distilled water only in the humidifier chamber. Record review of Resident #28's general administration history dated 11/01/2023 to 11/30/2023 revealed the CPAP tubing was documented as changed on 11/01/20203. Record review of Resident #28's general administration history dated 12/01/2023 to 12/31/2023 revealed the CPAP tubing was documented as changed on 12/01/20203. Record review of Resident #28's general administration history dated 01/01/2024 to 01/26/2024 revealed the CPAP tubing was documented as changed on 01/01/20204. Observation and interview on 01/24/2024 at 11:45 AM, Resident #28's head gear and tubing for the CPAP was hanging between the mattress and siderail. The head gear was touching the floor. The inside of the tubing had areas of brownish, tan discoloration. The humidifier chamber was dry. The outside of the machine was dusty and dirty. The resident applied the CPAP onto his nose, adjusted the head (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 9 of 19 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 01/26/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gear and lowered the head of the bed. Resident #28 stated he would use the CPAP whenever he is flat in bed. He stated he owned the CPAP and the tubing was about 6 months old. He stated no one at the facility had ever changed it out or cleaned it and they would use tap water and not distilled water. The equipment was not dated. Interview on 01/24/2024 at 2:45 PM the ADON stated the tubing for Resident #28's CPAP was dirty, needed to be changed and there was no water in the humidifier chamber. The ADON stated the outside of the machine could use cleaning and the tubing had no date. She stated nurses were responsible to clean the CPAP machine, tubing and mask. The ADON stated they should be cleaned daily and by the night shift. The ADON stated the risk to the resident would be lung infection. The ADON stated it should be stored in a plastic bag, but the resident wanted it kept at his bedside with him. The ADON stated the previous DON was supposed to order the parts and that they should be dated. The ADON stated she did not know when the former DON placed the order and did not know where the invoice would be located. The ADON stated she would place an order for parts. Interview on 01/25/2024 at 12:05 PM, the Regional Nurse Consultant stated Resident #28 should have orders for changing tubing for CPAP monthly and the machine should be wiped down weekly and PRN. She stated the facility had standing orders for CPAP and was unsure who did the ordering for supplies. She stated it did not matter whether the CPAP was owned by the resident or not, the facility was responsible to take care of it. Interview on 01/26/2024 at 10:34 AM, the ADON stated there were no CPAP supplies for Resident #28 since his admission in October 2023. Interview on 01/26/2024 at 12:27 PM the Regional Nurse Consultant stated it was upsetting to her that nurses signed off that the CPAP tubing was changed out monthly when it was not done. She stated she did not know why this happened. She stated she expected the nurse's to have brought it up to management's attention so the supplies could get ordered. She stated she did not recognize the names of the nurses who signed the documentation, and they could have been Agency nurses. She stated moving forward she will be asking the current facility nurses about the tubing and will conduct staff inservices . Record review of the facility policy for CPAP/BiPAP Support, revised March 2015, read in part: Purpose .1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety General Guidelines for Cleaning, 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device 4. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. 5. Humidifier (if used): a. Use clean, distilled water only in the humidifier chamber. b. clean humidifier weekly and air dry. c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. 6. Filter cleaning .7. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. 8. Headgear(strap): Wash with warm water and mild detergent as needed. Allow to air dry Record review of the facility's policy titled Infection Control Guidelines for All Nursing Procedures, revised August 2012 read in part: Purpose - To provide guidelines for general infection control while caring for residents General Guidelines - 1. Standard Precautions will be used in the care of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 10 of 19 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 01/26/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether they contain visible blood, non-intact skin, and /or mucous membranes .6. In addition to these general guidelines, refer to procedures for any specific infection control precautions that may be warranted. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 11 of 19 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 01/26/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview, and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day 7 days a week from 11/1/2023 to 11/30/2023 for a total of 30 days, 12/1/2023 to 12/31/2023 for a total of 31 days and 1/1/2024 to 1/23/2024 for a total of 23 days, reviewed for RN coverage. The facility had no DON from 7/25/2023 to 9/26/2023 and from 12/26/2023 to 1/26/2024. These failures placed the residents at risk for not having decisions made that would have required and RN to make in the management of the resident's healthcare needs and in managing and monitoring of the direct care staff. The findings included: Record review of employee files r evealed employment dates of the two previous DON's as: DON A 8/31/2022 to 7/25/2023 DON B 9/6/2023 to 12/26/2023 Record review of facility time stamps revealed facility had no RN coverage: 11/1/2023 to 11/30/2023. 12/1/2023 to 12/31/2023. 1/1/2024 to 1/23/2024. Record review on 1/26/2024 revealed facility census was 38 . In an interview on 1/26/2024 at 8:30am with the Regional Nurse Consultant she said an RN has a higher level of education than an LVN or a Medication Technician. She said the difficulties at the facility were because it was set in a rural area. When asked if they would increase the pay, she said they only paid a little less than other facilities. When asked if they increased the pay would nurses be willing to drive the 16 miles from the larger town she did not answer. She said state laws mandate registered nurses because of the level of experience and knowledge they have. She said when they did not have registered nurses a resident might not be assessed properly. She said the DON had acted as a charge nurse part of the time but did not the other part of the time. She said she had no proof of what days the DON did charge. She said they did not have a policy on nurse staffing because it was not federally mandated, and they only had policies on federal mandates. On 1/26/2024 at 8:30am policy on nurse staffing was requested and not provided. Record review of facilities job description Registered Nurse, no date said in part . The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities of your assigned unit. Such supervision must be in accordance with current Federal, State and local standards, guidelines and regulations that govern the long term care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 12 of 19 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 01/26/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm facility, as well as our established policies and procedures .ensure that the nursing services policies and procedures manual is followed by nursing personnel .interpret the departments policies and procedures to employees, residents, visitors, government agencies, etc. ensure that nursing personnel are following their prospective job descriptions. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 13 of 19 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 01/26/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, record review and interview, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 of 4 dietary support staff Dietary Aide W, [NAME] S, [NAME] R, and Dietary Aide T reviewed for competencies. The facility failed to ensure [NAME] S, [NAME] R, Dietary Aide T, and Dietary Aide W had a current Food Handling Certificate while working in the facility kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. The findings included: Record review of Dietary Aide W's personnel file information revealed Dietary Aide W was a part-time aide, with a hire date of 12/23/23. No documentation of a food handler's certificate was found in Dietary Aide W's personnel information provided to surveyor. Observation on 1/23/2023 at 11:30 AM revealed [NAME] S was ladling food onto plates and placing the plates on trays with the assistance of [NAME] R. Dietary Aide T was pouring tea and water into cups for resident's lunch meal revealing they were working in the kitchen handling food and beverages. Review of the staff list and the kitchen staff schedule for January 2024, provided by the Administrator on 1/24/24, revealed [NAME] S was a full-time cook with a hire date of 11/29/2023, [NAME] R was a part-time cook with a hire date of 11/30/23, and Dietary Aide T was a full-time aide with a hire date of 12/12/2023. The personnel files, requested on 1/25/24, were not made available to the surveyor to review prior to exit. During an interview on 1/25/24 at 2:05 PM, the Administrator revealed the previous Dietary Manager's last day of employment was 1/5/24 and a replacement has not been hired. The Dietary Manager would be the person responsible for ensuring kitchen staff had Food Handling Certificates and it was not known if the certifications had been completed. During an interview on 1/26/24 at 9:50 AM with the Administrator, the Regional Nurse Consultant, and the Regional Director of Operations, it was revealed that the kitchen staff did not complete the food handling training and did not have certification. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. Record review of the Texas Food Establishment Rules of the Texas Administrative Code, Title 25, Part 1, Chapter 228, Subchapter B, dated August 2021, indicated the Certified Food Protection Manager and Food Handler Requirements: .(d) All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment. This requirement does not apply to temporary food establishments. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 14 of 19 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 01/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure bulk foods were stored in a manner to prevent contamination. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. The facility failed to ensure refrigerators maintained a temperature at or below 41 degrees Fahrenheit. These failures could place residents at risk for food contamination and foodborne illness. Findings included: 1/23/24 Entered kitchen for initial observation. 8:55 Am Refrigerator #1 had a temperature of 51 degrees. 8:55 AM Refrigerator #2 had no thermometer. 9:02 AM observation of Freezer #2 revealed it contained: 1 cardboard box of food not labeled, sealed, or dated;. 1 plastic bag of bacon not labeled, sealed, or dated;. 1 plastic bag of tomato-based sauce not labeled or dated;. 1 plastic bag of chicken strips not labeled or dated. 9:57 AM observation of Refrigerator #1 revealed it contained: 1 plastic bag of bacon not labeled, sealed, or dated;. 1 plastic package of sausages not labeled, sealed, or dated. 9:59 AM observation of the Dry storage area revealed it contained: 1 brown paper bag of potato slices not sealed or dated;. 1 brown paper bag of sugar not sealed or dated;. 1 carton of sprinkles not sealed;. 3 dented cans of chunk light tuna in water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 15 of 19 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 01/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 1/23/24 at 9:30 AM Interview attempts with kitchen staff were unsuccessful due to non-English speaking staff on duty. Interview on 1/23/24 at 11:39 AM with the Dietary Manager from a sister facility who was in the kitchen to assist the kitchen staff. The Dietary Manager reported she had been at this facility for first time last week. She was asked to help out after the Kitchen Manager quit on 1/5/24; no replacement Kitchen Manager had been hired yet. The Dietary Manager ordered food and had started working on sorting out the dry food storage area, which she reported had been disorganized when she arrived. Reviewed earlier findings with Dietary Manager of temperature of refrigerator #1 and missing thermometer on refrigerator #2. She was unable to provide any information about refrigerator temperatures. Also reviewed items in the refrigerator, freezer, and storage area that were not sealed, dated, or labeled. The Dietary Manager said that all food items should be labeled and dated and opened food items should be sealed. The Dietary Manager said it was kitchen staff responsibility to seal and label food items and she did not know who failed to seal and label to the food items. A record review of the facility's policy titled Food Receiving and Storage H5MAPL0335 dated December 2008 reflected the following: Policy Interpretation and Implementation 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 8. Refrigerated foods must be stored at or below 40?F unless otherwise specified by law. 11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 16 of 19 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 01/26/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 13 Residents (Resident #27, #22 and #20) reviewed for environment. The facility failed to properly clean/maintain resident #27, #22 and #20's rooms in a sanitary manner. This failure could place residents at risk of unsanitary conditions, psychosocial decline, spread infections which could result in a decline in health. Findings included: Record review of resident #27's face sheet dated 1/25/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, chronic kidney disease, dementia, Cellulitis (infection involving the skin of the lower limbs) and history of diarrhea. Record review of Resident #27's quarterly MDS dated [DATE] revealed he had a BIMS score of 1 out of 15 indicating severe cognitive impairment. He required partial/moderate assistance with toileting, and he was frequently incontinent of bowel and bladder. Record review of Resident #22's face sheet dated 1/24/2024 revealed a [AGE] year-old female admitted to the facility 06/16/2022. Her diagnoses included pervasive developmental disorder (a group of conditions that affect average development such as social and communication skills), restlessness and agitation, psychotic disorders, and heart failure. Record review of Resident #22's quarterly MDS dated [DATE] revealed a BIMS score of 9 out of 15 indicating moderate cognitive impairment. She required supervision for all ADLs. She was always continent of bowel and bladder. Record review of Resident #20's quarterly MDS dated [DATE] revealed a male whose date of birth was 09/17/1986 and was admitted to the facility on [DATE]. He had a BIMS score of 14 out of 15 indicating intact cognition. He required setup or clean-up assistance with toileting hygiene, and he was always continent of bowel and bladder. He had no functional limitations in range of motion. His active diagnoses included hypertension, diabetes, mild intellectual disabilities, morbid obesity. An observation on 01/23/2024 at 10:05 AM of Resident #20's bathroom revealed dirty walls with brown substance splattered on the walls above the garbage can and below the paper towel dispenser. An observation on 01/23/2024 at 10:20 AM of Resident #27's room revealed the doorknob to the bathroom was smeared with sticky semi dry brown unknown substance. During an interview on 01/23/2024 at 2:35 PM LVN N stated Resident #27 had a history of refusing to get cleaned up and at times there would be feces all over the place. LVN N stated the staff probably missed the brown substance on the doorknob. LVN N stated that housekeeping was responsible to clean the room and that she would get the housekeeper to clean the doorknob. LVN N stated it should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 17 of 19 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 01/26/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cleaned d/t infection control. LVN N stated it was also the responsibility of all staff to clean up when needed. She stated she would make sure all nursing staff and housekeeping were re-educated. During an interview on 01/23/2024 at 2:40 PM, Housekeeper K stated he cleaned Resident #27's room before lunch and that he cleaned everything including the dresser and the bathroom. He stated he did not clean the bathroom doorknob because he did not see the brown smears. An observation on 01/24/2024 at 10:32 AM of Resident #22's room revealed the trash can next to the resident's bed had no liner, it contained trash and had multiple dried splatters of brown unknown substance on the inside and on the rim of the trash can. During an observation and interview on 01/24/2024 at 11:30 AM the ADON looked at the garbage can next to Resident #22's bed and stated it should not look like that with all those brown spots and that she would not like it if it were her room. The ADON stated the risks would be infection. The ADON stated if it was feces, it could be E-coli (bacterial infection in the intestines) and that would be cross-contamination. The ADON stated the housekeepers were responsible to make sure the trash cans were clean and had liners. Resident #20's bathroom still had dirty walls, splattered with brown substance and the ADON stated it should not be dirty. The ADON stated the housekeepers were responsible to keep these areas clean. During an interview on 01/24/2024 at 11:35 AM, the Maintenance Director stated he was responsible for overseeing Housekeeping and stated Resident #22's trash can should have a liner. He stated the brown splatters could be food that was thrown into the trash can. He stated the housekeepers were responsible to keep the trash can clean and that he would be talking with them about it. He stated he expects the housekeepers to disinfect high touch surfaces including all doorknobs. He stated he heard about the brown substance on the bathroom doorknob in Resident #27's room and did not know why that happened. He stated that there have been occasions when feces were all over the walls, chair, and curtains in Resident #27's room. He stated he will conduct an in-service for housekeeping staff on infection control and make sure they wipe everything down including the bathroom walls in Resident #20's room. During an interview on 1/25/2024 at 11:55 AM, the Regional Consulting Nurse stated housekeeping was responsible for keeping resident rooms clean, trash cans clean and doorknobs clean. She stated there were assigned rounds every morning and if something was obvious and needed attention, she expected the staff to take out the trash, if it was feces on those surfaces, it should be wiped off. She expected high touch surfaces including doorknobs to be wiped clean to prevent viruses. Moving forward she stated staff should be making more frequent rounds on Resident #27 and will put a better plan for Housekeeping to check his room more often. Record review of the facility policy titled Quality of Life - Homelike Environment, revised April 2014 read in part: Policy Statement, residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extend possible. Policy Interpretation and Implementation .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order . Record review of the facility's undated Job Description, LVN, Licensed Vocational Nurse, read in part: .The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day to nursing activities of your assigned unit Safety and Sanitation .Ensure that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676164 If continuation sheet Page 18 of 19 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 01/26/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete all work services areas on your unit are maintained in a clean and sanitary manner, such as nurses' stations, medicine preparation rooms, etc .Participate in the development, implementation and maintenance of the infection control and universal precautions to assure that a sanitary environment is maintained at all times and that aseptic and isolation techniques are followed by personnel . Record review of the facility's undated Job Description, Certified Nursing Assistant, read in part: Summary: Provide direct nursing care to the residents according to established policies and procedures and to ensure that the highest degree of quality care is maintained at all times .Safety and Sanitation .Ensure that all rooms on your assignment are maintained in a clean and sanitary manner . Event ID: Facility ID: 676164 If continuation sheet Page 19 of 19