Health inspection·December 15, 2022

F 0555 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Choice of Attending Physician Revised February 2021 stated in part, .3. The facility may not interfere with the process by which the resident chooses his or her physician. No other information was provided by the facility exit on 12/15/2022 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 2 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 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 0557 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on observation, interview and record review, the facility failed to ensure the resident's right to a dignified existence for one (Resident #39) of 14 residents reviewed for dignity in that: Residents Affected - Few Resident #39 was served nine minutes after the first person at his table was served and he was the last person served at his table after everyone else received their meal. This deficient practice could place all residents who eat in the dining room at risk of psychosocial harm, feeling disrespected or uncomfortable, decreased self-esteem, and impaired quality of life. Findings included: Record review of Resident #39's Face Sheet dated 12/15/2022 revealed Resident #39 was a sixty-eight-year-old Black or African American Male with an admission date of 9/13/2022 and diagnosis of: Cerebral Infarction, unspecified (called a stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it); Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness of one side of the body) following Cerebral Infarction affecting Right Dominant Side; Acute Respiratory Failure with hypoxia (deficiency in the amount of oxygen reaching the tissues.) and Unspecified Protein- Calorie Malnutrition. Record review of Resident #39's Care Plan dated 10/6/2022 revealed that Resident #139 was at risk for dehydration or potential fluid deficit and was at risk for nutritional changes. Record review of Resident #39's BIMS score of 6 which indicated severe impairment. Observation of breakfast in the dining room on 12/13/2022 beginning at 8:03 AM revealed the following: Resident trays were brought out on carts at 8:11 AM and four staff members began serving trays. Tables were being served incomplete with one meal served to one table and another meal served to another table. At 8:15 AM two residents at Resident #39's table had been served. Resident #39 began hollering for his food., RA stated, It's coming (Resident #39). LVN C said, What is wrong with (Resident #39)? Resident #39 said, Hey, come on man. At 8:19 AM Resident #39 pulled away from the table and confronted staff stating, Look, can I have my mother fucking meal. LVN C replied, they are making yours At 8:20 AM Resident #39 was served his meal. At 8:21 Resident #39 repeatedly called out for staff and received no response from staff. Interview with Resident #39 on 12/13/2022 at 8:52 AM revealed the following: Resident #39 stated he usually gets his tray with everyone else. Resident #39 did not want to say anything else and left the area. Interview with DFS on 12/13/2022 at 8:58 AM revealed the following: DFS has been in that position for a year. Residents sit at different tables every day and there is no assigned seating. Dietary staff do not know who is sitting at which table every day to have the trays come out according to tables so that one table is served completely before another is started to serve. Interview with DON on 12/15/2022 at 12:55 PM revealed the following: DON is an interim DON with a new DON starting on 12/28/2022. DON stated, I would be frustrated if my plate came out later than everyone else at the table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 3 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 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 0557 Review of facility policy titled Dignity Revised February 2021 stated in part, .1. Residents are treated with dignity and respect at all times 5. e. Provided with a dignified dining experience. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 4 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and a timeframe to meet a resident's medical and nursing needs for 2 (Residents #64 and #39) of 12 residents reviewed for person-centered care plans in that: 1. The facility failed to identify and address goals and interventions for Residents #39's tube feeding in the comprehensive person-centered care plan. 2. The facility failed to include or address any care interventions/personalized care in Resident #64's comprehensive care plan. This failure could affect residents in the facility by placing them at risk of not being provided necessary care and services and not having plans developed to address their needs. Findings included: 1.) Record review of Resident #39's Face sheet dated 09/13/22 documented a [AGE] year-old male with an admission date of 09/13/22. Diagnoses: stroke with right-sided paralysis and difficulty swallowing, concussion, a brain bleed, heart failure, muscle wasting, gastrostomy (a surgical opening into the stomach for the introduction of food via a tube), high blood pressure, acid reflux, lack of coordination, cocaine dependence, and hepatitis. Record review of Resident #39's physician orders dated 09/30/22 documented an order for an enteral feed every 8 hours as needed for decreased oral intake; give 2 cans with 50ml water flush pre- and post-bolus via g-tube after meals if less than 50% of the meal is consumed. Record review of Resident #39's physician orders dated 09/14/22 documented 1.) an order to check gastric residual volume (GRV) every 4 hours and hold feedings if residuals are > 250ml, return to the stomach, and recheck in 4 hours. If enteral feeding is held for high GRV for 3 consecutive checks, notify the physician for additional orders. 2.) Enteral feed every shift flush tube with 30cc before and after feeding. 3.) Change the g-tube flush kit daily on the night shift. 4.) elevate the head of the bed at least 30 degrees every shift. 5.) give 5-10cc water between each medication. 6.) change enteral tubing and syringe every 24 hours. Record review of Resident #39's MDS dated [DATE] revealed a score of 6, indicating severe cognitive impairment. Record review of Resident #39's care plan dated 10/06/22 revealed no mention of enteral feedings, how to care for them, goals, or interventions. The care plan had: The resident is at risk for nutritional changes. Resident #39 is refusing his purred diet and is at risk for nutritional changes. An interview with the ADON A on 12/15/22 at 10:55 am revealed the MDS was responsible for entering data into the care plans of all the residents. An interview with the DON on 12/15/22 at 10:57 am revealed she was responsible for checking care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 5 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plans for accuracy. She said the tube feeding orders should be in the care plan and there was no excuse for them not to be. She said she would begin angel rounds with the department directors every morning to re-visit all care plans for accuracy. 2.) Record review of Resident #64's face sheet dated 11/12/22 revealed a [AGE] year-old male originally admitted on [DATE] with medical diagnoses of multiple strokes with subsequent paralysis on the left side, inability to speak, a feeding tube, diabetes, high blood pressure, acid reflux, major depression, and a tracheostomy (a surgically created hole through the front of the neck and into the windpipe to keep it open for breathing). Observation of Resident #64's oxygen machine on 12/13/22 at 02:25 pm revealed the settings to be at 100% oxygen and had 2 humidifiers. The suction machine was on a bedside table near the head of the bed. Resident #64 demonstrated how he could not reach the on/off switch. There was no signage on the door to indicate the use of oxygen in the room. Observation of Resident #64's texting device on 12/13/22 at 02:30 pm revealed a portable phone that was plugged into the wall opposite the foot of the bed and secured to an overbed table. Record review of Resident #64's physician orders dated 11/13/11 revealed: O2 setting 30% with 8L 02 continuously via trach collar every 12 hours for O2. Record review of Resident #64's physician orders dated 11/12/11 revealed: Trach care q shift and PRN every 12 hours for Trach Care AND every 12 hours as needed Record review of Resident #64's care plan dated 10/07/22 revealed: Resident #64 had a tracheostomy; suction as needed, oxygen settings: O2 via Trach, Suction as necessary. The resident has oxygen therapy r/t respiratory issues, oxygen settings: O2 via Trach Collar. Suction as needed. There was no mention of the texting device. There was no mention to assure the suction device was readily accessible. There was no mention to keep the door open. An interview with the ADON A on 12/15/22 at 10:55 am: She said she could not explain why there were 2 humidifiers. She said she did not see the order for the humidifiers or anything about humidifiers in the care plan. She said respiratory took care of it and they set it up. She said they came 1 day a week. She said the charge nurse cleans and does trach care when respiratory was not there. She said respiratory did in-services and the facility kept the sheets, but she did not know where the sheets were. She said she did not know if the in-services were based on their policy. She said she had not attended an in-service on trach care. She said the MDS nurse was responsible for entering data, and the DON was responsible for checking them for accuracy. An interview with the DON on 12/15/22 at 10:57 am revealed she was responsible for checking care plans for accuracy. She said the humidifier for the oxygen, the trach care, suctioning, and tube feeding orders should have all been in the care plan and there was no excuse for them not to be. She said she would begin angel rounds with the department directors every morning to re-visit all care plans for accuracy. An interview with the MDS on 12/15/22 at 11:00 am revealed that she was the only one entering the data for all residents, and she was behind. She said the data and updates were very important for person-centered care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 6 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with Resident #64's RP, Family W, on 12/13/22 at 02:34 revealed she did not think the inner cannula of his trach was being changed as often as it should have been. She said she was under the impression the inner cannula was to be changed every other day. She said Resident #64 had to turn the suction machine on every time he wanted to use it, which was near all the time, as he had copious secretions. She said he could not reach the suction machine to turn it on and they (respiratory) told her they could not leave it on all the time because the machine burns out. She said the respiratory therapist (who was not available for an interview during the survey) told them the suction device could no longer be left on the continuous mode because Resident #64 had already gone through 4 of them. She said that Resident #64 had panic attacks and he freaked out one time after 30 minutes of the door being closed-he texted her repeatedly until she was able to call the nurses' station to let them know he needed his door opened. She said his only means of communication was a device he can text on. It was set up on a bedside table and positioned in front of him. A record review of the facility policy titled oxygen administration, revised 10/2010 revealed, under preparation; 1.) Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2.) Review the resident's care plan to assess for any special needs of the resident., 3.) Assemble the equipment and supplies as needed. Under general guidelines; 1.) Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. Under equipment and supplies; 4.) No smoking/Oxygen in use signs. Aside from checking the water level in the humidifier(s), there was no mention of oxygen by way of tracheostomy. A record review of the facility policy titled tracheostomy care, revised 08/2013 revealed, under general guidelines; 4.) tracheostomy tubes should be changed as ordered and as needed (at least monthly) A record review of Resident #64's physician orders dated 11/12/22 revealed: trach care every shift and PRN; every 12 hours and every 12 hours as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 7 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one of nine residents reviewed for Activities of Daily Living. Residents Affected - Few The facility failed to keep Resident #292 clean and free of odor. This failure had the potential to affect residents by placing them at risk for poor personal hygiene odors and a decline in their quality of life. Findings include: Record review of Resident #292's face sheet dated 12/13/2022, revealed the resident was admitted to the facility on [DATE] under Hospice respite care with no diagnosis listed. Resident is documented as a sixty-nine-year-old, Black or African American female. Current Comprehensive Care Plan was not completed by facility due to recent admission. Current Minimum Data Set was not completed by facility due to recent admission. Record review of Physician Progress Note dated 12/09/2022 revealed resident #292's diagnosis as: Anoxic Brain Injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), History of Sudden Cardiac Arrest (the abrupt loss of heart function, breathing and consciousness), Chronic Pain Disorder (an illness that causes extreme pain in one area or dorsal wall of the body.), Anxiety Disorder (any of a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension.) Observation and interview on 12/13/2022 beginning at 3:42 PM with Resident #292's Family Member Y who stated, the family feels she is not changed or taken care of when the family isn't here. Her hands stink and are not cleaned. Underarms and hands are sour smelling. Observed Resident #292 in bed, with covers over her. Observation and interview on 12/14/2022 beginning at 9:57 AM with Resident #292's Family Member X who was observed sponge bathing resident #2. Family member #292 stated, every time I come to her room, I have to clean her and do her hair. Observed a dirty washcloth after wiping Resident #292's axilla area. Family Member X went on to state, Hospice says they come in every eight hours, but they only come when we call. Observation and interview on 12/14/2022 beginning at 1:49 PM with Family Member Y. Family Member Y voiced concerns regarding Resident #292 not being cleaned and the smell of her feet. Family Member Y pushed call light. Observation and interview on 12/14/22 beginning at 1:54 PM with CNA C who stated she was agency and, new to this client. CNA C stated she was going to give Resident #292 a bath. Strong malodor present to right foot area. Undated dressings were observed to both heels. CNA C departed the room stating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 8 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 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 she was going to check with the nurse. Upon returning to Resident 292's room, CNA C stated the dressings were preventative and that the wound care nurse would come and change them. CNA C proceeded to bathe Resident #292. Interview with ADON A on 12/14/2022 at 3:10 PM. This surveyor inquired why Resident #292 had malodorous feet and undated bandages on her heels if the resident had been bathed and ADON A replied, I can't go around and look at all of the residents and make sure they are bathed. She went on to state that it was unreasonable that residents would be bathed every shift. Interview with DON on 12/15/2022 at 12:55PM who stated, Facility is still responsible for bathing residents. after inquiring about Resident #292 and the Hospice arrangement for bathing residents under Hospice contract. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 9 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all drugs, medical devices, and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates in one of two medication rooms reviewed for expired items. The facility failed to store all drugs and biologicals in locked compartments for 1 of 5 medication carts reviewed for storage of drugs. 1. This deficient practice could place residents who receive medications from the medication room, at risk for not receiving the intended therapeutic benefit of their medications. 2. This deficient practice could affect residents who have medications in the Medication Cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. The findings were: 1. Observation of the medication room in the nursing station on 12/15/22 at 9:45 am revealed: 3 sets of IV tubing expired on 11/27/22, 21 expired IV start kits; 3 on 08/27/22, 3 on 04/15/22, 4 on 04/21/22, 5 on 09/17/22, 2 on 03/10/22, 2 on 04/12/22, 1 on 3/22/22, and 1 on 09/10/21. There were 13 expired IV catheters: 6 on 07/24/22, 1 on 06/26/22, 3 on 10/11/22, 1 on 08/05/21, 1 on 09/08/21, and 1 on 09/13/21. There was one 10ml pre-drawn sterile saline syringe that expired on 10/21/22. There was also a bag of medications belonging to Resident #75, who was admitted on [DATE]. In the bag, there were partial prescription bottles: atorvastatin (a cholesterol-lowering drug) with an expiration date of 12/01/22, an iron replacement expired 11/10/22, vitamin B-12, expired 08/12/22, and a skin cream expired 06/23/22. There was also a partial bottle of Hyaluronic Acid (used for skin and joints) that expired on 01/2022, and 2 sealed bottles of probiotics: one expired on 02/2022 and one expired on 08/2022. An interview with LVN D on 12/15/22 at 9:50 am said that expired supplies and medications could cause infection and adverse reactions, such as stomach upset, nausea, and/or diarrhea, or the medication may not work as intended. An interview with the ADON A on 12/15/22 at 9:55 am revealed that resident home medications they are admitted with were supposed to be sent home with the family and nursing staff was supposed to take care of that. She also said the pharmacist came once a month and should have caught it. She explained that expired medications, whether prescribed or over the counter, were supposed to go into destruction bins. She said no one was assigned to make sure it happened. She said nurses or the pharmacist were supposed to check for expired medications and had no explanation as to why Resident #75's expired medications had been in the med room cabinet since 09/13/21. 2. Observation on 12/13/22 02:55 PM revealed 200 hall medication cart was unlocked and unattended. This surveyor was able to open all drawers recognizing the cart being unlocked. Multiple medications in bulk bottles and blister packs were easily assessable for removable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 10 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 12/13/22 03:09 PM revelaed CMA A come out of room [ROOM NUMBER] and identified herself as being responsible for the unlocked medication cart. Medication cart was next to room [ROOM NUMBER]. Interview on 12/13/22 03:07 PM ADON walked by and asked this surveyor who's medication cart this belonged to. This surveyor stated, I have no idea who this medication cart belongs to. I found it unlocked and unattended. ADON asked this surveyor if she can lock the cart and ADON proceeded to lock the medication cart. Interview with CMA A at 12/13/22 03:10 PM Revealed, CMA A does not usually leave the medication cart unlocked and was unaware that medication cart was left unlocked. CMA A stated, medication carts should be locked at all times and stated it was important to keep medication cart locked at all times due to anyone being able to open it and get medications not prescribed to them. This surveyor asked when was the last time an in-service on medication storage took place and CMA stated, cannot remember. Interview on 12/14/22 at 02:45 PM with Interim DON revealed, in service is being conducted beginning on12/13/22 for staff who have medication cart access. Interim DON stated, it is important to keep medication cart locked as to reduce residents from having access, so medications are not taken by anyone other than who the medications are prescribed for. Interview on 12/13/22 at 03:18 PM with ADON revealed it is important to keep medication carts locked at all time because anyone can get inside the medication cart making the medications in the cart easily assessable to anyone that should not have access to. This surveyor requested the Policy on Medication Storage from ADON. Last In-service (training) on Medication Storage of Medications dated 06/02/22. CMA A is not listed as an attendee on in-service training. Policy on Storage of Medications dated November 2022: Line 6. states, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 11 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for four of four staff members serving food: CNA A, CNA B, RA, and LVN C, 1 of 1 kitchen and 2 of 2 nutrition rooms reviewed for cleanliness in that: 1. The facility failed to ensure that staff served food without placing their hands on residents eating and drinking surfaces for 14/14 resident's meals observed being served. 2. The overall cleanliness of the kitchen was poor, and the nutrition rooms had dirty dishes and shampoo in one of them and in the other, a leaking coffee pot, and personal items. This failure could place residents at serious risk for complications from food contamination, cross-contamination, and food-borne illnesses. The findings included: 1. Observation of breakfast in the dining room on 12/13/2022 beginning at 8:03 revealed the following: RA and CNA B handled glasses of juice from the top of the glass where residents would drink from. All staff members serving resident's meals (LVN C, CNA A, CNA B and RA) were observed with their thumbs in the resident's plates. An interview on 12/13/2022 at 8:37 AM 12/13/22 Interview with Medical Records who was present in the dining room during breakfast stated she was a part of the management team. Medical Records went on to state that the management, makes sure the trays come out on time, everyone has drinks, make sure everyone is getting fed, that there is a nurse and CNA, and management assist as needed. An interview on 12/13/2022 at 8:58 AM with DFS stated she had been at her current job for a year. DFS indicated there had not been any in-services on how to serve meals to residents. She also stated, staff should not be putting their fingers in the plates or grabbing the cups by the rims. An interview on 12/15/2022 at 12:55 PM with DON who stated, Residents should not be served meals by staff with thumbs in the plates. And indicated there was no reason why the staff had their thumbs in the plates. Record review of facility policy titled Food and Nutrition Services Revised October 2017 did not reveal a way to serve meals that did not include contaminating surfaces. 2. An interview with the DFS during the initial tour of the kitchen on 12/13/22 at 11:05 am revealed: The ice machine had fuzzy black and pink spots along the inside edge of the ice chute, a white chalky substance around the seals of the hatch, on the hatch, and around the legs of the ice machine on the floor. The handle on the paper towel dispenser was covered in dust. The oven doors were kept closed with tightly folded paper towels. The handles of the ovens had a thick, sticky substance all over them. The underside of the shelf above the steamer table had an abundance of a dark brown substance on it. The front of the stand-up ovens had a dark brown substance, both sticky and dried, in long drip marks, indicating it had been there a long time. Several containers of spices had the lids (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 12 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 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 - Some open to the air. A large container of rice had the lid askew enough to be open to the air. The DFS said they had a cleaning log, and they (the staff) were sticking to it. She did not reply to the findings of filth. She said the oven had been broken for 6-8 months, but it was not essential because they had stand-up ovens. An interview with the DFS during the initial tour of the kitchen on 12/13/22 at 11:05 am revealed: The ice machine had fuzzy black and pink spots along the inside edge of the ice chute, a white chalky substance around the seals of the hatch, on the hatch, and around the legs of the ice machine on the floor. The handle on the paper towel dispenser was covered in dust. The oven doors were kept closed with tightly folded paper towels. The handles of the ovens had a thick, sticky substance all over them. The underside of the shelf above the steamer table had an abundance of a dark brown substance on it. The front of the stand-up ovens had a dark brown substance, both sticky and dried, in long drip marks, indicating it had been there a long time. Several containers of spices had the lids open to the air. A large container of rice had the lid askew enough to be open to the air. The DFS said they had a cleaning log, and they (the staff) were sticking to it. She did not reply to the findings of filth. She said the oven had been broken for 6-8 months, but it was not essential because they had stand-up ovens. Observation of nutrition room [ROOM NUMBER] at nursing station 2 (behind hall 500) on 12/14/22 at 10:55 am revealed a half-empty 8 oz. bottle of shampoo and a stack of dirty dishes consisting of a cup, a dessert cup, and a fork and a spoon in the cabinet above the sink. Observation of nutrition room [ROOM NUMBER] at nursing station 1 (behind hall 100) on 12/14/22 at 11:05 am revealed a coffee pot under the sink that presumably had leaked with resultant dark and light brown stains beneath it which had run and splattered into the cabinet. There was one area where there was also a black and green substance, suspicious of mold. There was an open and cold-feeling soda in the cabinet above the sink. There was no date or name on it. Beside it, there was a personal glass with a lid and straw that also had no name or date. There was a small plastic cup upside down over the straw. Interview with LVN E on 12/14/22 at 11:10 am said the brown stuff under the sink, stemming from beneath a coffeemaker, looked like old, dried coffee, and the black & green stuff was fuzzy and looked like mold. She said the small cup over the straw that was in the cup, in the cabinet, was probably to keep the gnats out of it. Interview with DFS on 12/14/2022 at 01:54 pm she provided cleaning logs which she said were dated 9/1/22-present. December and November logs were missing initials to indicate the cleaning was done, per DFS. She also said she had been short-staffed for a while and had no response to why the cleaning logs had the ice machine exterior to be wiped down weekly, but not the inside, and stated, there was no check-off for emptying and cleaning the interior of the ice machine. She said she did not know where or how to refer to the manufacturer's instructions/recommendations. A record review of 22 pages of daily kitchen checklists received from the DM revealed 6 of the pages were not dated, with 19 of 42 days showing not cleaned at all, 4 pages with Nov marked on them (no dates), with 9 of 28 days showing not cleaned at all, one with Dec marked on it (no dates), with 3 of 7 days showing not cleaned at all, 1 dated 10/31/21-11/06/22 (there was a column for each day of the week on the checklists) .in all, the pages were jumbled, containing some weeks from 2021 checklists, and others misdated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 13 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with ADM on 12/15/22 at 12:28 pm: she said the process for repairs was if the maintenance supervisor could not fix something, the vendor was called, or it got replaced. She said the oven had been repaired before and it was currently having issues again. She said she was made aware of the cleaning logs yesterday and had been talking with the DFS already. She said she would have them do an action plan to address a more cohesive and effective cleaning operation. She said there was enough dietary staff, and they currently only needed 1 aide. She said the kitchen would be doing a deep clean, and that she had already spoken to the kitchen about it. Event ID: Facility ID: 676314 If continuation sheet Page 14 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 36 resident (Resident #292) reviewed for hospice services, in that: The facility did not have Resident #2's most recent Hospice Plan of Care, Hospice Consent and Election Form, Physician Certification of Terminal Illness, names, and contact information for hospice personnel involved in hospice care of resident, documentation by specific interdisciplinary hospice staff providing services to the resident, and hospice medication information specific to each resident or a signed Hospice Contract with the Hospice company providing Hospice Services for Resident #292. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings include: Record review of Resident #292's face sheet dated 12/13/2022, revealed the resident was admitted to the facility on [DATE] under Hospice respite care with no diagnosis listed. Resident is documented as a sixty-nine-year-old, black or African American female. Current Care Plan was not completed by facility due to recent admission Current Minimum Data Set was not completed by facility due to recent admission MDS unavailable due to recent admission. Record review of Physician Progress Note dated 12/09/2022 revealed resident #292's diagnosis as: Anoxic Brain Injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), History of Sudden Cardiac Arrest (the abrupt loss of heart function, breathing and consciousness), Chronic Pain Disorder (an illness that causes extreme pain in one area or dorsal wall of the body.), Anxiety Disorder (any of a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension.) Record review of Resident #292's electronic medical record revealed the following information was not in the resident's record: - Most recent hospice Plan of Care - Hospice Consent and Election Form - Physician Certification of Terminal Illness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 15 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 - Names and contact information for hospice personnel involved in hospice care of the resident Level of Harm - Minimal harm or potential for actual harm - Documentation by specific interdisciplinary hospice staff providing services to the resident - Hospice medication information specific to the resident Residents Affected - Few Record review of a Hospice Certification and Plan of Care for Resident #292 for Certification period 12/1/2022 - 2/28/2023 provided by the DON on 12/15/2022 at 2:10 PM revealed the following: no resident specific orders or goals. Plan of Care read in part Hospice RN to evaluate patient and develop a nursing plan of care. Medical Social Worker to evaluate social, emotional and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care; Chaplain to evaluate patient/family/caregiver and develop a plan of care. Contract review did not reveal a contract with the company that was supplying Hospice Services to Resident #292. Observation on 12/14/2022 at 10:16 AM and 3:02 PM revealed Resident #292's hospice binder could not be located at the nurses' station. Interview on 12/14/22 at 11:30 AM with administrator who stated hospice company had changed names and that she would look into date of hospice name change and new contract signed and find the updated contract. Administrator also stated there was no reason that the contract was not signed. Interview on 12/14/2022 at 3:02 PM with LVN A, at the same time of the observation, LVN A confirmed Resident 2 did not have a hospice binder at the nurse's station with the required documentation. LVN A stated, there isn't one here, I will call them. Interview with DON on 12/15/2022 at 12:53 PM who confirmed that Resident #2 did not have a hospice binder at the nurse's station with the required documentation. DON stated, The facility should coordinate with the Hospice to ensure the resident is properly cared for. Record review of the facility's policy titled, Hospice Program Revised July 2017 revealed the following in part, .5. Hospice providers who contract with this facility: a. must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency 6. The agreement with the hospice provider will be signed by the facility representative and a representative from the hospice agency before hospice services are furnished to any resident 12. Coordination of Care: d. Obtaining the following from the hospice: (1) The most recent hospice plan of care specific to each resident; (2) Hospice election form; (3) Physician certification and recertification of the terminal illness specific to each resident; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 16 of 17 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 676314 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Orem 3730 W. Orem Drive Houston, TX 77045 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 (4) Names and contact information for hospice personnel involved in hospice care of each resident; Level of Harm - Minimal harm or potential for actual harm (5) Instructions on how to access the hospice's 24 hour on-call system; (6) Hospice medication information specific to each resident; and Residents Affected - Few (7) Hospice physician and attending physician (if any) orders specific to each resident 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 17 of 17