Inspection·February 17, 2024

F 0657 adapt/adjust to living indepedently). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #35's care plan dated 12/18/23, revealed a Focus: Restorative: Resident #35 has Right hand carrot [something to grip with a severe hand contracture] and left hand posey [something to grip to help prevent contractures] (Initiated: 8/18/23, Revised 8/18/23). Goal: Individualized assistance with right hand carrot [something to grip with a severe hand contracture] and left posey [something to grip to help prevent contractures] will be provided (Initiated: 8/18/23, Revised: 8/18/23, Target: 12/3/23). Interventions: Dependent upon trained staff with the application and/or removal of prosthetic device, brace or splint x 5 per week x2 hrs (Initiated: 8/18/23, Revised: 9/13/23). Requires assistance from trained staff with the application and/or removal of a prosthetic device, brace or splint 5 per week x2 hrs (Initiated: 8/18/23, Revised: 9/13/23). Focus: Resident #35 has a cognitive deficit r/t late effects of CVA (stroke), long/short term memory deficit, BIMS 00 (Initiated: 9/19/16, Revised: 6/21/23). Goal: Resident #35 will improve current level of cognitive function through the review date (Initiated: 9/19/16, Revised: 3/24/23, Target: 12/3/23). Interventions: Communicate with Resident #35's caregivers regarding my capabilities and needs (Initiated: 9/19/16, Revised: 9/22/17). Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status (Initiated: 9/19/16). Residents Affected - Few Record review of Resident #35's Physician Orders revealed the following order from MD A: -R hand carrot [something to grip with a severe hand contracture] and left hand posey daily [something to grip to help prevent contractures], one time a day for contracture management. Remove per schedule. Ordered on 8/18/23 at 8:00am and discontinued on 12/6/23 at 9:13am. Record review of Resident #35's Restorative Nursing Program flow sheet from January 2024 revealed Goal: Pt to wear R hand posey (something to grip to help prevent contractures) 2-4hrs x5 times a week, signed by the Rehab Director and the DON. In an observation and interview on 2/13/24 at 8:44am with Resident #35 she was lying on her back in bed. She had aphasia (unable to speak) and was unable to communicate. She did not have any splints or braces on her hands. In an observation on 2/14/24 at 10:03am with Resident #35, she was asleep on her back in bed. She had prevalon boots (heel protection boots) on and was on an air mattress, but no splints/braces were seen on her hands. Resident #30 Record review of Resident #30's undated face sheet revealed she was an [AGE] year-old female readmitted on [DATE] with an original admission date of 8/28/15. She had diagnoses of Alzheimer's disease, contracture of left hand, contracture of joint, muscle wasting and atrophy, contracture of right hand (tightening or shortening causing deformity), encephalopathy (condition that causes brain dysfunction), palliative care, dementia, need for assistance with personal care, dysphagia (trouble swallowing), cardiac arrest (heart stopped), history of falling, and speech and language deficits following cerebrovascular disease (conditions that affect blood flow and blood vessels in the brain). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 2 of 22 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 02/17/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #30's Quarterly MDS dated [DATE], revealed a BIMS was unable to be performed due to her condition. The MDS revealed she had impairment on one side of her upper and lower extremities, and she did not use a mobility device due to being bedbound. According to the MDS, she was dependent with all self-care activities, and with rolling left to right in bed, chair/bed to chair transfer, tub/shower transfers, and all other mobility activities were unable to be performed due to her condition. The MDS revealed the resident was on oxygen, received ST, OT, PT, but did not mention Restorative Nursing (nursing interventions that promotere resident's ability to adapt/adjust to living indepedently). Record review of Resident #30's care plan dated 12/20/23, revealed a Focus: Resident #30 has ADL self-care performance deficits r/t cognitive and mobility impairment (Initiated: 12/31/17, Revised: 4/12/23). Goal: Restorative: Resident #30 will maintain or increase to max assistance with feed finger foods while seated in wheelchair in feeder dining room through the review date (Initiated: 9/30/20, Revised: 11/10/23, Target: 1/10/24). Interventions: Personal hygiene/oral care: Place hand splints [splint worn to protect joints by positioning correctly] on both hands every morning, remove at bedtime (Initiated: 8/14/21). Focus: The resident has an alteration in musculoskeletal status right hand contracture in all fingers. Finger extension brace [splint worn for contracture management in the fingers] given to decrease contracture. To be worn 16 hours of the day (Initiated: 9/30/20, Revised: 1/12/24). Goal: The resident will be free of complications r/t contracture management through review date (Initiated: 9/30/20, Revised: 11/10/23, Target: 1/10/24). Interventions: Follow facility protocol, PT treatment plan, MD orders, for contracture management, report abnormalities to care team (Initiated: 9/30/20, Revised: 5/5/21). The care plan did not mention the continuous oxygen she was on. Record review of Resident #30's medical record revealed the following Physician Orders from MD B: -O2 @ 2L/min via NC continuous to maintain O2 sats > 92%, every shift. Ordered on 8/9/23 at 6:00pm. -Apply right and left hand posey [something to grip to help prevent contractures], one time a day for contracture management. Apply at 8:00am and remove at 8:00pm. Ordered 8/18/23 at 7:29am. Record review of Resident #30's Physician Orders revealed there were no orders for the hand splints or the finger extension brace. Record review of Resident #30's January and February 2024 MAR/TAR's revealed no record of the hand splints or finger extension brace. However, it did reveal documentation of the resident using O2 @ 2L via NC. In an observation on 2/14/24 at 10:09am, Resident #30 was asleep on her back in bed. She had oxygen via NC and left and right hand posey's on. A finger extension was not observed, neither were the hand splints. Interview with the MDS Coordinator on 2/16/24 at 2:10pm, she said she had only been working at the facility for 2 weeks. She said the IDT met once a week and they would update the care plans at that time. She said it was a team effort to update the care plans and not one person specifically was responsible for updating them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 3 of 22 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 02/17/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the DON on 2/16/24 at 2:15pm, she said the IDT met once a week and it was a team effort to update the care plans at that time. She said they discuss the residents at the meeting and update the care plan accordingly. She said the Director of Rehab and herself were responsible for updating the care plans relating to the Restorative Therapy. Interview with the Director of Rehab on 2/16/24 at 2:50pm, she said she started in October 2023 and when she first started, she walked the building with the OT and evaluated the residents to see who were on Restorative Therapy and who needed it. She said she wrote orders for the Restorative Therapy devices and the DON reviewed them and signed off on them. She said she also gave a copy to the ADON, and she would update the computer. She was unsure if the ADON was creating an order for it or not. She also said she attended the IDT meeting and discussed which residents were on Restorative Therapy and then the ADON would update the care plans accordingly, she never touched the care plans. She would re-evaluate residents every 3mths for therapy. Record review of the facility's policy and procedure on Care Plans, Comprehensive Person-Centered (revised March 2022) read in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 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. 2. The comprehensive, person-centered care plan is delivered within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes, b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .c. includes the resident's stated goals upon admission and desired outcomes, d. builds on the resident's strengths, and e. reflects currently recognized standards of practice for problem areas and conditions .10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition, b. when the desired outcome is not met, c. when the resident has been readmitted to the facility from a hospital stay, and d. at least quarterly, in conjunction with the required quarterly MDS assessment . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 4 of 22 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 02/17/2024 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 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 remained as free of accident hazards as is possible for 3 of 7 residents' rooms (Resident #84, Resident #80, and Resident #33) reviewed for accidents. -The facility failed to maintain water temperatures at a safe temperature level in Resident #84, Resident #80, and Resident #33's bathrooms. This failure could place residents at risk of injuries and burns. Findings include: Resident #84 Record review of Resident #84's face sheet revealed a [AGE] year-old male admitted on [DATE]. His diagnosis included convulsions (a medical event in which nerve cell activity in the brain is disrupted, causing muscles to involuntarily contract and spasm), Wernicke's encephalopathy (a disorder that primarily affects the memory system in the brain), heart disease, and depression. Record review of Resident #84's admission MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. He required supervision with toileting hygiene. In an observation and interview on 2/13/24 at 9:43 a.m. with Resident #84, his bathroom sink water was hot to touch and this Surveyor removed fingers from the water after approximately 2 seconds. Resident #84 said he used the restroom and sink. He said it was hard to find the warm water and it was either cold or really hot. In an observation and interview on 2/13/24 at 2:08 p.m. of Resident #84's bathroom, the Maintenance Director took the sink water's temperature using his thermometer and the temperature ranged from 128°F to 130.4°F. The Maintenance Director said the water was hot and said it was not like that last week. Resident #84 said the window between the hot and cold water was very narrow. Resident #80 Record review of Resident #80's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnosis included heart failure, syncope (fainting or passing out) and collapse, lack of coordination, and need for assistance with personal care. Record review of Resident #80's quarterly MDS assessment dated [DATE] revealed a BIMS score was 5 out of 15 which indicated severe cognitive impairment. She required partial to moderate assistance with toileting hygiene. In an observation and interview on 2/13/24 at 1:38 p.m. with Resident #80, her bathroom sink water was hot to touch. Resident #80 said she used the restroom and sink, and said the water was ok. In an observation on 2/13/24 at 2:11 p.m. of Resident #80's bathroom, the Maintenance Director took (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 5 of 22 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 02/17/2024 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 0689 the sink water's temperature with his thermometer and the temperature was 128.1°F. Level of Harm - Minimal harm or potential for actual harm Resident #33 Residents Affected - Some Record review of Resident #33's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnosis included hemiplegia (paralysis on one side) and hemiparesis (partial paralysis on one side) following cerebral infarction (stroke), need for personal care, anemia (low number of red blood cells), depression, and diabetes. Record review of Resident #33's admission MDS assessment dated [DATE] revealed a BIMS score was 15 out of 15 which indicated no cognitive impairment. She required substantial to maximal assistance with toileting hygiene. In an observation and interview on 2/13/24 at 9:23 a.m. with Resident #33, her bathroom sink water was hot to touch and this Surveyor removed fingers from the water after approximately 2 seconds. Resident #33 said she could not walk and did not use her restroom. Interview on 2/13/24 at 2:01 p.m. with the Maintenance Director, he said he started working at the facility 2 weeks ago. He said he tested water temperatures on each hall once per week. He said he conducted one week of testing since starting. He said water temperatures should be between 102°F - 110°F. In an observation on 2/13/24 at 2:12 p.m. of Resident #33's bathroom, the Maintenance Director took the sink water's temperature with his thermometer and the temperature was 128°F. Interview on 2/13/24 at 2:20 p.m. the Maintenance Director said he was responsible for checking water temperatures. He said he checked the temperatures one week and they were good. He said he was unsure how the water temperatures rose. He said he liked to keep the water temperatures between 102°F and 120°F and if the water was too hot the residents could burn their hands. He said he would adjust the hot water heater. In an observation on 2/13/24 at 2:38 p.m. of the hot water heaters revealed Tank #1's temperature was 124°F and operating set point was 120°F. Tank #2's temperature was 133°F and operating set point was 133°F. In an observation and interview on 2/13/24 at 2:43 p.m. with CNA G, she said the resident bathroom water did not get too hot. She entered Resident #33's bathroom and turned the hot water on. CNA G touched the water and said it was hot, hot, too hot. She said she had to pull her hand back a little from the water. She said the water temperature had not been like that. Interview on 2/13/24 at 3:59 p.m. with the Administrator, she said the upper water limit was 120°F. She said she did not know how the temperature got out of range and she had not given her key to the hot water tank room to anyone. She said the Maintenance Director monitored the water temperatures and was responsible for ensuring the temperatures were in range. She said the Maintenance Director had temperature logs and checked hot water heaters if the water was beyond the temperature. She said there were no complaints from staff or residents regarding hot water temperatures and no residents were affected. She said some residents had fragile skin and may not be able to handle the temperature. She said she did not want anyone to get injured and it could be a safety risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 6 of 22 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 02/17/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Interview on 2/14/24 at 11:08 a.m. with the Maintenance Director, he said he adjusted the hot water tanks to an operating temperature of 111°F yesterday 2/13/24. In an observation on 2/14/24 at 11:10 a.m. of Resident #33's bathroom sink revealed the hot water was warm and no longer hot to touch. Residents Affected - Some Record review of the facility's Logbook Documentation dated 2/13/24 revealed the water temperatures were marked done on time by the Maintenance Director on 2/9/24. Water temperatures were tested on each hallway and resulted the following on 2/9/24: 100 hall -107°F, 200 hall - 108°F, 300 hall 106°F, 400 hall - 109°F, 500 hall - 107°F, 600 hall - 105°F, 700 hall - 109°F, and 800 hall - 105°F. Record review of the facility's policy Water Temperatures, Safety of dated December 2009 read in part, .Tap water in the facility shall be kept within a temperature range to prevent scalding of residents . 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120°F or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 7 of 22 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 02/17/2024 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 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 observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 1 Resident (#56) reviewed for oxygen in that: Residents Affected - Few -Resident #56's oxygen was administered at 3 Liters Per Minute instead of 2 Liters Per Minute via nasal cannula as ordered by the physician. This deficient practice could affect Resident #56 who received oxygen continuously and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. Findings include: Record review of Resident #56's face sheet revealed that Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Pneumonia (an infection of the lungs that may be caused by bacteria, viruses, or fungi)-unspecified Organism; Acute respiratory Failure with hypoxia; and Emphysema (a lung condition that causes shortness of breath)-unspecified, pleural effusion in other conditions classified elsewhere. Record review of Resident #56's December 2023 Consolidated Physician's Orders revealed an order for oxygen continuous at 2 Liters Per Minute (LPM) per nasal cannula with a start date of 12/16/2023. Observation on 02/13/24 at 09:21 AM revealed Resident #56's O2 rate was at 3 liters. Observation on 02/13/2024 at 4:01 PM revealed Resident #56's O2 rate was at 3 liters. Interview on 02/13/2024 at 4:02 PM with the ADON B, she said the nurse in charge should check the Oxygen level on every shift. The ADON looked at the oxygen and confirmed the oxygen tank was set at 3 LPM instead of 2 LPM as ordered by the physician. In a phone interview on 02/15/24 at 08:41 AM, LVN H said that she should check the Oxygen level before signing off on it as administered, but she misread it or did not pay closer attention and signed off for 2 liters. She said that the nurses had to check the O2 every shift. She said she was aware of the consequences of administering more Oxygen than required to a resident. She said the resident could become dependent on more Oxygen than needed. A review of Resident #56's Care plan dated 12/16/2023 read, The resident has oxygen therapy as ordered and PRN r/t CHF H. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Review of the undated facility oxygen administration procedures stated, Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 8 of 22 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 02/17/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (CR #1) reviewed for dialysis. Residents Affected - Few The facility failed to ensure CR #1 received hemodialysis since she admitted to the facility on [DATE]. CR #1 missed dialysis on Saturday 2/10/24 and Tuesday 2/13/24. CR #1 was sent to the hospital on 2/14/24 with signs of altered mental status, increased confusion, and lethargy. The facility failed to document monitoring of CR #1's dialysis port (access site used when blood is transported from the body for cleaning) The facility failed to obtain a signed contract with CR #1's dialysis center. An immediate jeopardy (IJ) was identified on 2/16/24 at 12:26 p.m. While the IJ was removed on 2/17/24 at 12:43 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of missing vital treatments and experiencing worsening kidney damage, serious health side effects, and hospitalization. Findings include: Record review of CR#1's face sheet dated 2/15/24 revealed a [AGE] year-old female admitted on [DATE] and discharged to an acute care hospital on 2/14/24. Her diagnoses included end stage renal disease, unspecified kidney failure, heart failure, and mild cognitive impairment. Record review of CR #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. She required supervision to maximal assistance with ADLs. Record review of CR #1's baseline care plan dated 2/14/24 revealed she was alert, cognitively intact, and required dialysis. Record review of CR #1's Hospital record dated 2/1/24 revealed Hemodialysis was completed on 2/3/24 and 2/6/24. She had a right upper arm arteriovenous graft (a synthetic access point into the body's circulatory system to perform dialysis) present on admission to the hospital (on 2/1/24). She had a tunneled hemodialysis catheter in the left internal jugular vein (a thin, plastic tube inserted under the skin for dialysis) placed on 11/29/23. Record review of CR #1's Hospital Progress Note dated 2/6/24 revealed CR #1 was a [AGE] year-old with known history of ESRD on Tuesday, Thursday, Saturday hemodialysis schedule. Assessment and Plan: 5. ESRD on hemodialysis - TTS schedule. Record review of Email Correspondence dated 2/8/24 at 4:14 p.m. from CR #1's dialysis center to the admission Coordinator read in part, .I am needing the following information to request a contract (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 9 of 22 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 02/17/2024 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few between our facilities from our legal department . Once I receive this, I can request a contract draft from my legal department. Once they send it to me, I will send back to you for review and if everything is good your Administrator can sign and once returned to me, I will need my RVP to sign and then I will send you a completed signed copy . Record review of Email Correspondence dated 2/8/24 at 4:22 p.m. from the Admissions Coordinator to CR #1's dialysis center revealed the requested information for the contract was completed and returned. The email read, . Can you include me in the email when you send it please. And can (CR #1) start dialysis or until contract has been signed? . There were no further emails. Record review of CR #1's Clinical admission dated 2/9/24 revealed hemodialysis was not selected. There was no documentation regarding her dialysis port. Record review of the facility's 24-Hour Summary Report dated 2/9/24 - 2/10/24 and 2/10/24 - 2/11/24 revealed handwritten notes that CR #1 had hemodialysis on T-Th-S. The note was written by LVN B. Record review of CR #1's History and Physical dated 2/10/24 by NP A read in part, .initial assessment status post hospitalization for pneumonia, respiratory failure, acute on chronic HF, ESRD . Diagnosis, Assessment and Plan: End stage renal disease: HD per nephro . Dependence on renal dialysis: continue with HD per nephro . Record review of CR #1's skilled evaluation dated 2/11/24 by LVN M revealed hemodialysis was selected. There was no documentation about her dialysis port. Record review of CR #1's skilled evaluation dated 2/12/24 by LVN Z revealed hemodialysis was selected. There was no documentation about her dialysis port. Record review of CR #1's Progress Note dated 2/12/24 by MD B read in part, .Patient seen today - she is stable and not in distress . She is also tolerating dialysis . diagnosis, assessment, and plan: . dependence on renal dialysis: continue with HD . Record review of the facility's 24-Hour Summary dated 2/12/24 - 2/13/24 revealed handwritten notes that CR #1 had hemodialysis on T-Th-S. The note also read, Monitor . (family member) concerned about her being asleep all the time. Record review of CR #'1's Progress Note dated 2/13/24 by NP B read in part, .patient in bed alert, awake, talking . Chest: dialysis port . Diagnosis, Assessment, and Plan . End stage renal disease: HD three times per week t/th/sat . Record review of CR #1's Physician Orders for February 2024 revealed: 1.Dialysis days T-Th-Sat do not arrive later than 6:45 a.m. by w/c, order date 2/14/24. 2.Dialysis address: . chair time 6:30 a.m. please do not arrive any later than 6:45 a.m., order date 2/14/24. 3.Dialysis - left subclavian port notify MD/NP for any unusual/unexpected findings every shift, order date 2/14/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 10 of 22 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 02/17/2024 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Record review of CR #1's Medication Administration Record for February 2024 revealed there was no documentation of dialysis or port monitoring between 2/9/24 - 2/14/24. In an observation and interview on 2/13/24 at 11:58 a.m., CR #1 was lying in her bed in the facility. She said she felt fine, but the staff were not very good and rushed her care. CR #1 coughed multiple times but said she felt fine. Residents Affected - Few Record review of CR #1's nursing note dated 2/13/24 at 10:01 a.m. (Late Entry Date: 2/14/24 at 4:23 p.m.) by LVN Z read, .This writer to ask resident's name. Resident response was (correct name). This writer to ask resident's name 10 seconds later, resident responded (incorrect name). ADON to inform MD, New order in place to send resident to hospital for further evaluation. Record review of CR #1's nursing note dated 2/14/24 at 9:35 a.m. by ADON A read in part, Late entry, resident didn't want to go to dialysis on yesterday. (Name) NP aware will be in the building to assess. Record review of CR #1's nursing note dated 2/14/24 at 9:51 a.m. by ADON A read, This nurse assess resident and informed NP of my findings of confusion and lethargy, ordered to send to hospital. Record review of CR #1's nursing note dated 2/14/24 at 11:45 a.m. by LVN Z read, Two EMS in facility to transport resident to hospital . resident in stable condition at time of discharge. Record review of CR #1's SBAR Communication Form dated 2/14/24 by ADON A revealed the change in condition, symptoms, or signs observed and evaluated was: altered mental status. The condition, symptom, or sign had not occurred before. The Mental Status Evaluation was: an altered level of consciousness. The Function Status Evaluation was: needs more assistance with ADLs. The recommendation was to send to hospital. In an interview on 2/14/24 at 4:02 p.m. LVN Z said CR #1 was sent to the hospital for altered mental status. She said this morning (2/14/24) she asked CR #1 for her name and CR#1 responded incorrectly. She said yesterday (2/13/24) she was able to make her needs known when she hit the call light but this morning (2/14/24) she could not remember why she hit the light. She said the resident was on dialysis and she monitored the shunt for bleeding. She said the dialysis orders were put in today. She said CR #1 refused to go to dialysis on Tuesday 2/13/24 but said the resident did not tell the refusal to her. In an observation and interview on 2/14/24 at 4:15 p.m. with ADON A, she said CR #1 was more lethargic and confused today. She said she had altered mental status and could be getting toxic. She said she notified the NP and the NP said to send her out to the hospital to be dialyzed. She said CR #1 did not go to dialysis on Saturday (2/10/24). She said her ejection fraction (the amount of blood pumped out of your heart's lower chambers each time it contracts) was 26 (ejection fraction in a healthy heart is 50% to 70%) and they were discussing CR #1 going on hospice. She said CR #1 told her she was not going to dialysis on Saturday because her family member said they were not going to do dialysis. She said at that time CR #1 was alert but had some confusion. ADON A said yesterday (Tuesday, 2/13/24) she asked CR #1 if she was going to dialysis and CR #1 said no because she did not feel good. She said she entered CR #1's dialysis orders into the system today (2/14/24) because she was scrubbing her medical charts. She said the orders were in CR #1's hospital history and physical and she had not followed up on the resident's chart prior to today. She said CR #1's dialysis orders should have been in the system so everyone would know about the orders. She said she did not know why they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 11 of 22 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 02/17/2024 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few were not put in the system on admission. She said she could not say if nurses were monitoring the dialysis port. She said the port should be monitored for bleeding because a resident could bleed out and die quickly. She said if a resident refused dialysis, staff should notify the MD. Observation of ADON A's cell phone revealed a new admission alert text message. The message included CR #1's name, dialysis days T-Th-Sat, chair time: 6:30 a.m., and dialysis address. In an interview on 2/14/24 at 4:47 p.m. with LVN Z, she said she was supposed to document the assessment of CR #1's dialysis port in her chart. In an interview on 2/15/24 at 9:04 a.m. with CR #1's family member, she said she was not aware CR #1 was sent to the hospital and was not notified about her missing dialysis on Saturday and Tuesday. She said CR #1 had been a dialysis resident for over 21 years and would never refuse dialysis because she knew what happened if she missed even one treatment. She said she was at the facility on Monday and Tuesday (2/12/24 and 2/13/24) of this week and CR #1 was heavily sedated. She said she reported the information to LVN M. She said CR #1's dialysis days were Tuesday, Thursday, and Saturday. She said no one got the resident up on Tuesday for dialysis and she missed it. She said she also missed dialysis on Saturday 2/10/24. She said it would be bad if CR #1 missed dialysis. She said the family never had a conversation with the facility about CR #1 not going to dialysis and said the family chose this facility because the facility had a contract with CR #1's dialysis center. She said the facility informed her how she would get to dialysis, were aware of the chair time, would assist her with getting ready and would send her to dialysis. In an interview on 2/15/24 at 9:43 a.m. CNA A said she worked with CR #1 on Saturday and Tuesday. She said she did not know CR #1 was a dialysis resident until she was sent to the hospital yesterday (2/14/24) for dialysis. She said CR #1 did not go to dialysis on Saturday. She said no one told her (CNA A) that she needed to go. She said on Tuesday (2/13/24) CR #1 asked her if she was going to dialysis today (Tuesday) and said she was supposed to go to dialysis. She said CR #1 wanted to get in her chair and said she should be getting ready for dialysis today. CNA said she told CR #1 she was not sure and would ask the nurse. CNA said the nurse told her no. She said CR #1 was a new resident and she (CNA) did not know her dialysis days. She said she did not ask the resident and the nurse did not say anything about her being a dialysis resident. In an interview on 2/15/24 at 10:00 a.m. with NP B, she said she saw CR #1 in the facility on Tuesday 2/13/24 and she was alert and oriented at the time. She said she looked at CR #1's dialysis port and nothing was going on. She said CR #1 told her during the visit that her dialysis days were Tuesday, Thursday, and Saturday. She said CR #1 did not say anything about refusing to go. She said ADON A reported to her on Wednesday 2/14/24 that CR #1 was more confused and missed dialysis on Saturday and Tuesday because she refused. The NP said she was not aware prior to Wednesday of the resident refusals. She said the facility usually notified the MD/NPs of dialysis refusals and would normally contact her. She said for the first dialysis refusal, if the resident was stable, the facility should call the dialysis center and reschedule dialysis for the next day. She said for the second dialysis refusal, or if symptomatic, the resident must go to the hospital. She said symptoms could include edema (swelling caused due to excess fluid accumulation in the body tissues), shortness of breath, and not feeling well. She said she ordered to send CR #1 to the hospital because she missed dialysis and had symptoms. She said dialysis was needed and she did not want the resident to miss it. She said the facility told her the resident was dialyzed on Friday 2/9/24 prior to admitting to the facility. She said CR #1 should have gone to dialysis on Saturday. In an interview on 2/15/24 at 10:46 a.m. with CR #1's family member, she said when CR #1 did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 12 of 22 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 02/17/2024 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 0698 get dialysis it caused a major impact on her functioning. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 2/15/24 at 11:05 a.m. with ADON A (with CR #1's family members present), ADON A said CR #1 went to the hospital and ADON A was informed CR #1 would not let the hospital dialyze her last night (2/14/24). Residents Affected - Few In an interview on 2/15/24 at 11:32 a.m. with CR #1's dialysis center, the representative said CR #1's first day missed at the dialysis center was on 2/3/24 and she had not been back since. She said the nursing facility called the dialysis center on 2/8/24 (one day prior to admission) to obtain a nursing home contract. She said the dialysis center sent an email to the facility to obtain information, but they never received a response back. She said they never had a contract with the facility. In an interview on 2/15/24 at 12:19 p.m. with LVN S she said she helped with CR #1's admission and put her orders into the system. She said she did not recall entering dialysis orders for CR #1. She said she medication orders came from the hospital discharge paperwork. She said if the dialysis orders were not on the paper with the medications, she was not sure where to find it. She said CR #1 did not mention dialysis to her that day and she did not see any dialysis ports on the resident. LVN S said she was not trained on admitting residents but there was a packet available at the nurses station with admission instructions that she did not have to refer to. She said if she saw an order for dialysis, she would have put it in. She said she did not have to arrange anything for CR #1. In an interview on 2/15/24 at 12:39 p.m. with the Admissions Coordinator, she said she was working on obtaining the contract with the dialysis center. She said she sent the information for the contract to the dialysis center on 2/8/24 but did not get a response. She said she called the center the next day to speak with the clinical manager, but she was not there. She said she was informed by the dialysis center that they were working on the contract. She said it was required for them to have dialysis contract but if the contract is in progress, they would still accept the resident. She said the facility did not receive a signed contract and she did not follow up with the dialysis center this week, but it was on her follow up list. She said she did not set up transportation for CR #1 because she was a wheelchair transport and the facility transferred residents in wheelchairs. She said she sent out a new admission alert text to the department heads on 2/9/24 with CR #1's dialysis information. She said she did not receive a text back. She said Van Driver A was not on the group text. In an interview on 2/15/24 at 1:34 p.m. with the DON, she said she was not aware of CR #1's admission until she returned to work on Tuesday 2/13/24. She said she did not learn of the dialysis refusal until Wednesday (2/14/24) and said she was unsure about CR #1's dialysis on Saturday. She said if a resident refuses dialysis nurses should talk to the doctor to see what they want to do, educate the resident, and document in the chart for communication purposes. She said CR #1's dialysis orders were not put in on admission and they should have been because it was a part of her admission. She said there was no legitimate way to know if the dialysis orders were carried out or not and said there was a phrase that said if it was not documented it did not happen. She said ADON A should have reviewed the orders by Monday but did not know why they were not verified. In an interview on 2/15/24 at 2:08 p.m. ADON A said CR #1 refused dialysis. She said CR #1 was confused on Saturday and it was progressive. She said if a resident refused dialysis the nurse should call the MD and get instructions. She said she did not call the MD. She said the facility should have notified the MD. She said CR #1 refused with the night nurse and she did not find out about it until Tuesday. She said she called NP B and told her she did not go to dialysis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 13 of 22 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 02/17/2024 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on 2/15/24 at 2:20 p.m. with the Administrator, she said ADON A informed her on Wednesday (2/14/24) that CR #1 refused dialysis on Tuesday (2/13/24). She said ADON A did not say anything about Saturday. She said she did not know if CR #1's dialysis orders were put into the system on admission. She said the orders should be put in because they had to follow MD orders and communicate what the plan is. She said she could not say if the van drivers were made aware of CR #1's need for dialysis transportation. She said she expected for residents to be transported to and from dialysis. She said resident families and the NP should be contacted on refusals and the protocol for dialysis refusals was to encourage the resident. She said the NP should be contacted at the initial refusal because dialysis is serious, and the facility had to ensure the resident received care and services. She said she and the Admissions Coordinator were responsible for dialysis contracts and said they did not typically admit residents if there was no contract to ensure they are on the same page. In an interview on 2/15/24 at 2:48 p.m. with the Hospital Charge Nurse, she said per CR #1's admission note, CR #1 was admitted from the nursing home due to missing dialysis for 1 week. She said there were no notes of CR #1 refusing dialysis and she had it today in the hospital. In an interview on 2/15/24 at 3:06 p.m. with CR #1 in the local hospital. She said she kept telling the nurses and aides at the nursing facility that she needed to go to dialysis and her dialysis days were T, Th, and Sat. She said staff kept telling her she would go tomorrow but she never did. She said she sat her clothes out on Monday afternoon in anticipation of going to dialysis on Tuesday morning and staff asked her Why are you setting clothes out when dialysis is not until tomorrow? You do not need to set clothes out today. She said she never refused dialysis because she knew what it would do to her body. She said she first started to feel bad on Monday 2/12/24. She said she felt confused/disoriented and started calling a lot. She said she started having jerky movements with her hands and she knew it was from missing dialysis. She said she was tired and slept all day. She said they kept ignoring her and then all of a sudden, they rushed her to the hospital for dialysis (on 2/14/24). She said she still had some jerky movements and could not hear out of her left ear when she could before. In an interview on 2/15/24 at 3:41 p.m. with the Hospital RN, she said the nursing facility called her this morning to get an update on CR #1. She said since CR #1 was admitted to the hospital for missing dialysis, she asked the facility why CR #1 missed dialysis. The facility told her that CR #1 refused. The Hospital RN said she never told the facility that CR #1 refused dialysis at the hospital. She said CR #1 never refused dialysis at the hospital and she had it early this morning. In an interview on 2/15/24 at 5:36 p.m. with LVN K she said when she came to work on Saturday 2/10/24 she received report from the night nurse LVN B that CR #1 was stable. She said LVN B did not say anything to her about dialysis or refusals for CR #1. She said there may have been something on the paper shift report about dialysis, but she could not remember. She said she was not aware CR #1 was a dialysis resident and did not find out until yesterday (2/14/24). She said CR #1 did not say anything to her about dialysis. She said she was not aware of a dialysis port and there were no skin assessments done. She said she normally found out about dialysis through the resident's admission packet and through report. In an interview on 2/15/24 at 6:07 p.m. with LVN B she said she knew CR #1 went to dialysis on T, Th, Sat but said she was unaware of her chair time and did not think she would be sent out on her shift, the night shift. She said she saw CR #1 dialysis days on her hospital paperwork and wrote the days down on the 24-hour report. She said CR #1 did not refuse anything with her and she did not have to notify the physician. She said CR #1's admitting nurse put her orders in and passed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 14 of 22 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 02/17/2024 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few information onto LVN B's partner nurse, LVN C. She said CR #1's dialysis orders should have been in the system. She said if her chair time was at 6:45 a.m. she would have been sent out on her shift, the night shift. She said no one told her CR #1 would be going out on her shift and there was no report given to her about dialysis. She said the nurse to relieve her was LVN K. She said when she came back to work the next night during shift report there was nothing to report and no changes. She said she asked the nurse if everyone went to dialysis and the nurse said yes. She said she did not specifically ask if CR #1 went to dialysis. She said she was not trained on new admissions but said there was a paper that told them what to do. In an interview on 2/15/24 at 6:44 p.m. with LVN C she said she assisted LVN S by completing the last portion of CR #1's admission assessment - the ADL and transfer portion. She said she did not remember if CR #1 said anything to her about dialysis. She said she did not recall seeing information on CR #1's dialysis. In an interview on 2/15/24 at 7:00 p.m. with CR #1's family member, she said CR #1 received dialysis at the hospital today. She said the hospital had no recollection of CR #1 refusing dialysis at the hospital as said by ADON A earlier. She said CR #1 made an outcry that she wanted to go to dialysis while at the nursing facility but could not. In an interview on 2/16/24 at 1:51 p.m. with Van Driver A, she said she provided transportation for residents in wheelchairs to dialysis and doctors appointments. She said she did not know who CR #1 was and only had one new resident since October 2023 that the Administrator notified her of, Resident #3. She said on Tuesdays she arrived at the facility between 6:30 a.m. and 6:50 a.m. and transported Resident #3, Resident #49, and Resident #23 to dialysis. She said since she started as the van driver she was only notified of one dialysis refusal one time and that was with Resident #23 around the time of the Christmas party. In an interview on 2/16/24 at 7:46 p.m. with LVN M she said she knew CR #1 was on dialysis but did not know her chair time and thought she would be leaving on the morning shift. She said she did not have to get CR #1's dialysis paperwork ready. This Surveyor told LVN M that CR #1's chair time was no later than 6:45 a.m. LVN M said if it was at that time CR #1 would have left on her shift between 5 and 6 a.m. She said she reported to the day shift verbally and maybe on the 24 hour summary report that everyone on 100, 300, and 400 were on the T ,Th, Sat dialysis schedule. She said CR #1 was a new admission and the information was not passed on. She said on Tuesday night (2/13/24) CR #1's family member came to the facility. She said she (LVN M) looked for CR #1's dialysis communication paper and it was not there. In an interview on 2/17/24 at 5:21 p.m. LVN M said on Tuesday night 2/13/24 CR #1's family member was in the facility and was concerned about CR #1 being so tired. She said CR #1's family member told her she was supposed to go to dialysis. She said she checked to see if she went but saw she did not. She said CR #1 did not refuse dialysis with her but maybe did that morning. She said she never sent the resident out to dialysis. Record review of email correspondence between this Surveyor and the Administrator revealed the dialysis contract for CR #1's dialysis center and the nursing facility was requested on 2/16/24 at 6:30 p.m., 2/17/24 at 7:57 a.m., and 2/17/24 at 12:57 p.m. The contract was not provided. Record review of email correspondence between this Surveyor and the Administrator dated 2/17/24 at 1:12 p.m. revealed the Administrator said she would reach out to the dialysis center on Monday (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 15 of 22 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 02/17/2024 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 0698 (2/19/24). Level of Harm - Immediate jeopardy to resident health or safety Record review of the facility's policy End-Stage Renal Disease, Care of a Resident with dated September 2010 read in part, .Residents with end-stage renal disease will be cared for according to currently recognized standards of care. Policy Interpretation and Implementation: .4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed . Residents Affected - Few Record review of the facility's policy Hemodialysis Catheters - Access and Care of dated February 2023 read in part, .Care of Central Dialysis Catheters 1. The central catheter site must be kept clean and dry at all times . Documentation: the nurse should document in the resident's medical record every shift as follows: 1. Location of catheter, 2. Condition of dressing . 3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis . Record review of the facility's policy Requesting, Refusing and/or Discontinuing Care or Treatment dated February 2021 read in part, .1. Residents/representatives are informed (in advance) of: a. the care that will be furnished or made available to the resident based on his or her assessment and plan of care; b. the risks and benefits of the proposed care, treatment, treatment alternatives or treatment options . 5. If a resident/representative requests, discontinues or refuses care or treatment, an appropriate member of the IDT will meet with the resident/representative to: a. determine why he or she is requesting, refusing or discontinuing care or treatment; b. try to address his or her concerns and discuss alternative options; and c. discuss the potential outcomes or consequences (positive and negative) of the decision . On 2/16/24 at 12:26 p.m. the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template was provided to the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on 2/17/24 at 9:12 a.m.: IMMEDIATE JEOPARDY PLAN OF REMOVAL February 16, 2024 IMMEDIATE ACTION: Please accept this as a Plan of Removal to remove the IJ Identified in area of Quality of Care Systematic Approach: 1. CR #1 was transferred to on 2/14/24 at 11:45 am for further evaluation and treatment. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 16 of 22 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 02/17/2024 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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The Medical Director was immediately notified by the Administrator on 2/16/24 at 1:41pm and the Chief Operating Officer at 12:32 pm of Immediate Jeopardy. 3. Administrator reviewed facility's policy on Care of a Resident with End-Stage Renal Disease, Care of Residents on Hemodialysis, Charting Guidelines, Change in Condition and Refusal of Treatment and CMS Dialysis Critical Element Pathway on 2/16/24. Charting Guidelines were modified on 2/16/24 to specifically include hemodialysis care. 4. All current Dialysis Appointments will be entered on the Resident Event calendar in PCC, facility's EHR system on 2/16/24 which is viewable by all clinical users. License Nurses, Dept. Managers and Van Drivers will be in-service on this process 2/16/24-2/17/24 by the Administrator. All future dialysis appointments will be added upon admission. New nurses, department managers and van drivers will be trained on this process during orientation. 5. All current Dialysis Residents (including name of Dialysis Center and day/time of chair appointment) will be entered on the PCC Dashboard on 2/16/24 to ensure all users are aware. New admissions requiring hemodialysis services will be added upon admission. 6. Order template for dialysis orders was reviewed by the regional nurse consultant on 2/16/24; these order templates will be queued in PCC by the DON, nurse manager. 7. and/or weekend RN supervisor for all residents requiring hemodialysis prior to admission to facility. 8. 100% of Charge nurses (RN/LVN), Nurse Managers and Weekend Supervisor will be educated per the DON by 2/17/2024 on the following topics. Any nurse who has (sic) completed the training will be removed from the schedule until their training is completed. A. Admission/readmission Process, which will emphasis (sic) the importance of reviewing transferring clinicals to determine the Plan of care, required Medical Equipment or Specialty Supplies is warranted. Emphasis placed on required care and documentation of residents requiring hemodialysis B. Notification of Change in Condition of physician and responsible party (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 17 of 22 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 02/17/2024 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 0698 C. Level of Harm - Immediate jeopardy to resident health or safety Entering and following Physician Orders in a timely manner Residents Affected - Few Resident Assessment related to residents' receiving hemodialysis D. E. Care of Residents with End Stage Renal Disease F. Hemodialysis Access Care and documentation G. Dialysis Communication Form H. Charting Guidelines I. Refusal of Care and Treatment J. Resident Rights and how to address residents' concerns The topics above will be included in the New Hire Training for nurses hired after 2/16/2024. 9. The facility DON conducted an audit on 2/15/24 on all 7 residents receiving dialysis services to ensure orders are entered and are carried out according to MD Order. The audit findings revealed that all orders were accurate and complete. A clinical assessment will be performed on current Dialysis Residents on 2/16/24 by the nurse managers. 10. Monitoring a. The DON will conduct weekly randomized audits for a period of 4 weeks ensuring Nursing Staff Members demonstrate knowledge of Policies and Procedures for residents receiving Dialysis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 18 of 22 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 02/17/2024 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 0698 b. Level of Harm - Immediate jeopardy to resident health or safety New/Readmissions' charts will be reviewed daily by the DON, ADON and/or[TRUNCATED] Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 19 of 22 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 02/17/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of two medication carts (the 100/300/400 nurse cart) reviewed for pharmacy services. -The facility failed to account for 53 of CR #1's Oxycodone-Acetaminophen tablets. - Staff failed to document the administration of narcotic medications in a correct manner for CR #1. This failure could place residents at risk for drug diversion and delay in medication administration. Findings include: Record review of CR#1's face sheet revealed a [AGE] year-old female admitted on [DATE] and discharged to an acute care hospital on 2/14/24. Her diagnoses included spondylosis without myelopathy or radiculopathy, lumbar region (a small crack between two vertebrae without spinal cord compression or nerve root compression), polyneuropathy (damage to multiple peripheral nerves), end stage renal disease, unspecified kidney failure, heart failure, and mild cognitive impairment. Record review of CR #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. Record review of CR #1's baseline care plan dated 2/14/24 revealed she was alert, cognitively intact, and did not have pain. Record review of CR #1's Pain assessment dated [DATE] by LVN C revealed she did not have pain or was hurting at any time in the last 5 days. Record review of CR #1's History and Physical dated 2/10/24 by NP A revealed she complained of chronic back pain. Diagnosis, Assessment, and Plan: Back pain, continue with Percocet (oxycodone/APAP), lidocaine patch, Flexeril, gabapentin; continue to monitor pain level; discussed with staff to administer pain medication and to reassess. Record review of Resident CR #1's Physician's order dated 02/09/24 revealed an order for oxycodone-Acetaminophen oral tablet 10-325 mg (oxycodone w/Acetaminophen) give 325 mg (1 tablet) by mouth every 4 hours as needed for pain. Record review of CR #1's Medication Administration Record for the month of February 2024 revealed Oxycodone-Acetaminophen oral tablet 10-325 mg was not documented as administered on 02/09/24, 02/10/24, 02/11/24, 02/12/24, 02/13/24 and 02/14/24. Record review of CR #1's Narcotic Record for Oxycodone-Acetaminophen 10 mg - 325 mg dated 2/9/24 revealed 60 tablets were received on 2/9/24. The next entry revealed a corrected count with 59 tablets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 20 of 22 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 02/17/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm remaining. The following entries indicated there were 52 tablets documented as administered/removed from the blister pack between 2/10/24 and 2/14/24. One portion of the record did not account for 1 tablet when the documentation skipped from 41 tablets remaining to 39 tablets remaining. The handwriting was the same for those 52 entries and the dates, times, and signatures were illegible. There were 20 entries that did not have a nurse signature. There were 6 tablets remaining on the Narcotic Record. Residents Affected - Few In an observation on 2/15/24 at 10:50 a.m. of CR #1's Oxycodone/APAP 10 mg - 325 mg tablet blister pack which was removed from the 100/300/400 nurse cart revealed there were 6 tablets remaining out of 60. In an interview on 2/15/24 at 9:04 a.m. with CR #1's family member, she said she visited the facility on 2/13/24 and CR #1 was heavily sedated. She said she told LVN M to take her off the pain medicine. In an interview on 2/15/24 at 12:19 p.m. with LVN S. She said she put CR #1's orders in during admission. She said CR #1 was not in pain at that time. In an interview on 2/15/24 at 3:06 p.m. with CR #1 in the local hospital, she said she never asked for any pain medication or Oxycodone while at the Nursing Home. She said she was taking it at the hospital before the nursing home, but never needed it at the facility. She said nursing staff asked her about pain only a couple times and she said she did not have any pain. She said she told staff when she first came to the facility that she did not want any pain medication. She said staff never told her that they were giving her pain medication or Oxycodone. In an interview on 2/15/24 at 5:36 p.m. with LVN F, she said CR #1 did not have any complaints of pain. She said she did not give her any Oxycodone. In an interview on 2/15/24 at 6:07 p.m. with LVN B, she said CR #1 did not complain of pain. She said she never had to administer Oxycodone to the resident. She said when she did narcotic count during shift change, she and the next nurse would compare the number of pills on the narcotic record with the number of pills in the blister pack. She said the focus was on if the numbers matched. She said when a prn narcotic was given, the nurse would document the time, amount given, amount remaining, and their signature. She said if a signature was missing, she would notify the ADON. In an interview on 2/16/24 at 9:20 a.m., LVN D said she was the nurse for hall 100, 300 and 400. She said she followed the facility's protocol to sign off any resident's medication given/refused on their MAR. She said if a resident received, refused, or did not receive scheduled or PRN medication she would always sign it off on their MAR. LVN D was not able to say what negative outcomes on Residents if their narcotics were not signed off on the MAR. In an interview on 2/16/24 at 9:43 a.m., LVN F said she knew she was to sign-out on the narcotic count sheet after administration and on the medication administration record. She said the failure to do that would cause the narcotic count to show less on the next count and it could lead to a narcotics diversion. She said she had done in-service on medication administration. In an interview on 2/16/24 at 12:23 p.m., with the Administrator, she said oxycodone-Acetaminophen was signed out during the shift of LVN Z from 2/9/24 to 2/14/24. DON reviewed the medications during a family complaint. It was revealed that medications had been signed out for during the time CR #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 21 of 22 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 02/17/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was hospitalized . LVN Z was suspended pending investigation. She was asked to submit to a drug screen. LVN Z submitted to a drug screen at the facility that showed a positive result. LVN Z stated that it was an incorrect reading, so she was outsourced for a drug screening and the ADON followed the LVN Z to the location. In an interview on 2/16/24 at 3:30 p.m. with LVN Z, she said CR #1 was not in pain and she was not familiar with and did not administer Oxycodone-APAP to the resident. She said she arrived at the facility (on 2/16/24) and took a drug screen. She said her test had faint lines and was told she tested positive for benzodiazepines and two other things. She said she was offered to go to an outside vendor but when she got there, she was unable to produce enough urine. She said the outside vendor offered her water, but she decided she did not trust the facility. In an interview on 02/16/24 at 4:20p.m., with the DON and the Administrator. The DON said her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the MAR and to sign on the narcotic log to prevent discrepancies and to have proof the medications were administered. DON said the risk of not logging after administering the medication resident could be administered overdose or miss the dose. She said it was a standard practice for nurses to log off narcotics as they administer. She said she did random audits by comparing the narcotic sheets and by counting the medication. She said she did not check the MARs during those audits. The DON identified the staff member who failed to sign off the oxycodone-Acetaminophen for CR #1's MAR as LVN Z. In an interview on 2/16/24 at 7:46 p.m. with LVN M, she said CR #1 never asked her for pain medicine. She said on Tuesday night (2/13/24) CR #1's family member came in and asked if the Oxycodone and other medications could be discontinued. She said there were 59 Oxycodone tablets remaining at that time. She said she passed the cart on to LVN Z during shift change Wednesday morning (2/14/24) and there was only 1 of CR #1's Oxycodone/APAP pill (out of 60) missing that time. Record review of facility's Administering Medications policy (Revised April 2019) revealed read in part: .Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug . Record review of facility's Controlled Substances (Revised April 2019) revealed read in part: .Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation: 10. Upon Administration: a. The nurse administering the medication is responsible for recording: (1) Name of the resident receiving the medication; (2) Name, strength and dose of the medication; (3) Time of administration; (4) Method of administration; (5) Quantity of the medication remaining; and (6) Signature of nurse administering medication . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676314 If continuation sheet Page 22 of 22