Health inspection·November 2, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 44's Facility Care Plan, dated 9-2-2023, indicated that an intervention for Resident # 42's skin breakdown, pain, falls, cognition, and ADL self-care called for Resident # 42's call light to be placed within arm's reach. Record review of Resident # 44's BIM indicated a score of 4. Residents Affected - Some Observation on 10-31-2023 at 11:06 AM reflected Resident # 28's call light out of arm's reach. The call light was four feet away from the resident on the right side of the bed on the floor between the resident's room furnished chair and Resident # 28's oxygen machine. The metal clip on the call light cord was bent and inoperable. Observation and interview on 10-31-2023 at 11:07 AM with Resident # 28 revealed that Resident # 28 was in bed and could not reach the Call Light, when asked, to locate it. Resident # 28 was observed having reached along the left side of the mattress and the wall. Resident # 28 stated the Call Light was usually placed on the left side of the bed between her and the wall. The call light was observed four feet away on the right side of the bed. Resident # 28 stated that she could not reach the Call Light. Interview on 10-31-2023 at 11:10 AM with CNA A revealed that the correct placement of the Call Light was supposed to be within arm's reach of the resident. CNA A looked at the clip and confirmed that the clip was broken. CNA A stated that broken clips were reported to maintenance for repair. CNA A placed the call light on the right side of Resident # 28's bed and reported the broken clip to maintenance. Observations on 10-31-2023 at 1:18 PM reflected Resident # 42's call light out was out of arm's reach of the resident. The call light was three feet away from the resident behind her draped over some folded bedding on the resident's room furnished chair. The clip was operable. Interview and observation on 10-31-2023 at 1:19 PM with Resident # 42 revealed that Resident # 42 was seated in the middle of the living area in a wheelchair watching TV and could not reach the Call Light, when asked, to locate it. Resident # 43 was observed having turned her wheelchair with one wheel and propelled herself close enough to secure it. Resident # 42 stated she did not like it when the Call Light was placed too far from reach by the staff. Observations on 11-2-2023 at 9:33 AM reflected Resident # 44's call light out was out of arm's reach of the resident. The call light was two feet away from the resident behind her draped over some folded bedding on the resident's room furnished bed and tucked in a drawer. The clip was operable. Interview and observation on 11-2-2023 at 9:34 AM with Resident # 44 revealed that Resident # 44 was seated in the middle of the living area in a wheelchair watching TV and could not reach the Call Light, when asked, to locate it. Resident # 44 was observed having turned her wheelchair with one wheel and leaned close enough to secure it. Resident # 44 stated that her bedding was just changed, and the caregiver left the Call Light where it was. Interview on 11-2-2023 at 1:57 PM with CNA B revealed that CNAs were trained to answer Call Lights right away. CNA B stated that CNAs are instructed to make sure the Call Light was placed within arm's reach of the resident, regardless is that resident can move to reach it. Interview on 11-2-2023 at 2:24 PM with CNA C revealed that CNAs were trained to answer the Call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 2 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Lights right away. CNA C stated that CNAs were trained to make sure the Call Lights were always in arms' reach of the resident, regardless if they can move to reach it. CNA C stated that clips have broken before, and those repairs were reported to maintenance. Interview on 11-2-2023 at 4:32 with the DON revealed that Call Lights were placed in the room for the resident to use if they needed assistance with anything. The DON stated that it was everybody's responsibility to make sure the Call Lights were within arm's reach. The DON stated that the Call Light should have been placed next to the resident and that the resident was not supposed to have to move to the Call Light's location. The [NAME] stated that staff was trained to contact maintenance for broken clips on the Call Lights right away, or document it in the book, so maintenance could fix it the next morning. The DON stated that dangers associated with Call Lights out of reach were falls, accidents, and skin breakdown without the ability to call for help. Interview on 11-2-2023 at 4:56 PM with the ADM revealed that the Call Light system was in place for residents to call for help when needed. The ADM stated that it was everybody's responsibility to make sure that the Call Lights were within arm's reach. The ADM stated that the Call Light should be within arm's reach when the resident was in bed; The ADM stated that the Call Light should have been placed within arm's reach of residents in wheelchairs, but a resident's movement away from the Call Light would be out of the staff's control. The ADM stated that staff was instructed to tell maintenance for any damaged parts of the Call Light. The ADM stated that negative outcomes of Call Lights out of reach were skin breakdowns, falls, ad unintended accidents. Record review of the facility Call Light Policy, undated, stated to (8) endure to position the call light conveniently for the resident to use; tell the resident where the call light is and show him/her [NAME] to use the call light; (10) notify the maintenance department and enter defective call light locations in the maintenance log; and (11) be sure all call lights are placed on the bed at all times, never on the floor or bedside table. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 3 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I Screening for residents diagnosed with mental illness were accurate and residents were provided with a PASARR Level II Screening for 1 (Resident #27) of 2 resident's reviewed for PASARR coordination, by failing to ensure: Residents Affected - Some 1. Resident # 27's PASARR Level I was completed accurately for Resident #27 who had active mental health diagnosis. This failure could place residents at risk for inappropriate placement in the nursing facility for long term care and at risk of not receiving appropriate care and services from the local authority, which could result in a possible decline in mental health The findings were: 1. Record review of Resident # 27's face sheet, dated 11/02/23, reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included unspecified psychosis (certain types of schizophrenia, paranoid, and other psychotic disorders), psychotic disorder (a condition of the mind that results in difficulties determining what is real and what is not real), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and major depressive disorder (a mental condition characterized by a persistently depressed mood and long term loss of pleasure or interest in life often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). Record review of Resident # 27's Quarterly MDS dated [DATE] reflected a BIMS score of 00, indicating Resident #27 was cognitively impaired. Further review reflected in section D, 0100 that Resident #27 should have a mood interview conducted, section D 0200 reflected had symptoms of feeling down, depressed, or hopeless for 2-6 days (several days). Section G reflected Resident #27 required extensive one person assist with bed mobility, transfers, locomotion on and off unit, dressing and personal hygiene, supervision with one person assist for eating, and total one person assist for toilet use. Section I, 5900 Bipolar Disorder, I, 5950 reflected Resident #27 had active diagnosis of - Psychotic Disorder (other than Schizophrenia). Record review of Resident # 27's client progress notes titled Psych notes dated 09/06/23 reflected that Resident #27 had been seen for a psychiatric visit for depression, psychosis, and psychotic disorder. Record review of Resident # 27's PASARR Level I screening dated 09/30/19 reflected Resident # 27 did not have a mental illness. Record review of Resident # 27's PASARR Level I screening dated 01/29/22 reflected Resident #27 did not have a mental illness. Record review of Resident # 27's PASARR Level I screening dated 03/03/22 reflected Resident #27 did not have a mental illness. Record review of Resident # 27's PASARR Level I screening dated 04/13/22 reflected Resident #27 did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 4 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 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 0645 not have a mental illness. Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 27's clinical record reflected there was no PASRR Level II Screening found. Residents Affected - Some Record review of Resident # 27's care plan, dated 10/17/19, last revised on 09/28/23, reflected a care plan for Resident #27 residents ability for decision making needs to be anticipated by staff due to psychosis, and psychotic disorders with delusions. Goal: Resident needs will be anticipated and met by staff as evidenced by being clean, appropriately dressed daily through next review date. Interventions: If resident becomes agitated, provide for safety, remove for common area if affecting others, back away, reproach when calm, and seek help as needed. Record review of Resident # 27's care plan, dated 11/16/19, last revised on 09/28/23, reflected Resident #27 had a communication problem related to his CVA, psychosis, and psychotic disorders with delusions. Resident said minimal 2-3 words at a time and only when he wants to speak. Speech is unclear most of the time. Goal: The resident would maintain current level of communication function through the review date. Interventions: Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express. Nurse to evaluate resident dexterity/ability to use communication board, writing, use computer or use of sign language as alternate communication to speech. Use effective strategies touch, facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, interpreter, time to communicate, 1:1, quiet setting for communicating with resident. Record review of Resident # 27's care plan, dated 11/24/19, last revised on 09/28/23, reflected Resident #27 had a diagnosis of depression. Goal: The resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date. Interventions: Monitor/record/report to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. In an observation on 11/01/23 at 09:28 AM Resident # 27 was sitting up in wheelchair. Resident #27 appeared clean, groomed, and dressed appropriately for the weather and temperatures. Resident #27 did not reveal any signs of pain or distress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 5 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 11/02/23 at 09:32 AM with the MDS, she stated the documents she had given surveyor were the only documents that were available regarding any PASARR screenings for Resident #27. She stated there were multiple level 1 PASARR screenings for Resident #27, but no level 2 PASARR evaluations because resident did not have a positive level 1 PASARR screening. She stated she called her local authority, and they told her they did not have anything related to PASARR's for Resident #27. She stated the local authority had come out to the facility the following day to evaluate Resident #27 for PASARR services. In an interview on 11/02/23 at 03:40 PM with the MDS, she stated she was responsible for completing and ensuring the accuracy of resident's PASARR screenings and evaluations. She stated she was not aware Resident #27's PASARR screening was not completed accurately or that he had not been referred to the local authority to possibly receive services. She stated that Resident #27's PASARR was done prior to her taking the position as MDS nurse. She stated if a PASARR was completed incorrectly, it could cause a resident to not receive the services they may want or need. She stated she had been trained on PASARR completion and accuracy and making sure resident information was sent over to the local authority. In an interview on 11/02/23 at 03:50 PM with the DON, she stated the MDS nurse was responsible for completing and ensuring accuracy of resident's PASARR screenings and evaluations. She stated she was not aware Resident #27's PASARR screening was not completed accurately or that he had not been referred to the local authority to possibly receive services. She stated if a PASARR was not completed correctly, a resident may not get the services and benefits that they needed. She stated the staff responsible for completing and ensuring accuracy of PASARR screenings and evaluations had been trained on PASARR's. In an interview on 11/02/23 at 04:01 PM with the ADM, he stated the MDS nurse was responsible for completing and ensuring accuracy of resident's PASARR screenings and evaluations. He stated he was not aware that Resident #27's PASARR screening was not completed correctly or that he had not been referred to the local authority to possibly receive services. He stated if a PASARR was completed incorrectly, residents may not get all of the services they are funded or are eligible for. He stated was not sure if the staff responsible for completing and ensuring accuracy of PASARR screenings and evaluations had been trained on PASARR's. Record Review of undated facility policy FourCooks Senior Care, LLC - Section 18 - Minimum Data Set (MDS) - Policy: Preadmission Screening and Resident Review (PASRR ) - It is the policy of this facility to ensure that all residents are screen and appropriately addressed via the PASRR process as outlines by the regulations. The result of this process will be used to develop, review and revise the residents care plan. The facility will not admit any new resident with: 1. A mental disorder unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, a. That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and b. If the individual requires such level of services, rather the individual requires specialized services. Procedure: 1. The facilities designated staff will review all potential admission for possible positive PASSR conditions and ensure that CMS Preadmission guidelines are followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 6 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 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 for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 resident (Resident #54) of 8 residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #54's skin concerns. This failure could place residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care. Findings included: Record Review of Resident #54's face sheet, dated on 11/02/23, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #54 with diagnoses that included anxiety (intense, excessive, and persistent worry and fear about everyday situations), type 2 diabetes (characterized by high blood sugar, insulin resistance, and relative lack of insulin), quadriplegia (paralysis of all four limbs), and chronic pain syndrome (when people have symptoms beyond pain alone, like depression and anxiety, which interfere with their daily lives). Record review of Resident #54's quarterly MDS assessment, dated 09/08/23, section C 0500 reflected Resident #54's cognition was intact with a BIMS score of 15, and section GG 0130 revealed he required supervision or touching assistance with eating, partial/moderate assistance for oral and personal hygiene, and substantial/maximum assistance for toileting, showering/bathing, upper and lower body dressing, and putting on and taking off footwear. MDS section H 0300 reflected Resident #54 was incontinent of bowel and bladder. Section M 0210 revealed Resident #54 had one or more unhealed pressure ulcer/injuries. Section M 0300 revealed Resident #54 had one stage 2 pressure ulcer. Section M 1200 revealed Resident #54 received treatment of applications of ointments/medication. Record review of the physician orders tab in Resident #54's EHR reflected the following order: Place pillow between legs/knees when laying on side every shift. Right medial knee wound cleanse with saline or wound cleaner. Apply collagen to wound bed and cover with dry dressing. PRN. Right medial knee wound cleanse with saline or wound cleanser. Apply collagen to wound bed and cover with dry dressing. Resident may have wound care per facility wound protocol. Record review of Resident #54's Care Plan, initiated 10/17/19 with last revision on 09/28/2023, reflected the care plan did not address the resident's stage 2 pressure area to right medial knee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 7 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 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 Record review of facility wound care sheet dated 10/29/23 reflected Resident #54 had an old wound to right knee, treatment in place, resident refuses to place pillow or blanket in between knees to relieve pressure as ordered at times. In an interview on 10/31/23 at 10:19 AM Resident #54 stated he was doing ok, and things were fine. He stated he got his showers and medications as scheduled. He stated he had a sore on his knee and the staff took care of it and treated it for him when they were supposed to. He stated he used the call light to call for help and he felt safe in the facility. He stated he had no concerns about anything. In an interview on 11/02/23 at 03:40 PM with the MDS, she stated she was responsible for completing care plans. She stated all wounds and skin concerns should be care planned as long as they are a stage 2 or greater. She stated she had been trained on how to complete care plans and what should be included in the care plan . She stated if a residents care plan was not completed correctly the resident may not get the proper care. he stated she was not sure if there was a policy that informed her of what to care plan. In an interview on 11/02/23 at 03:50 PM with the DON, she stated the MDS nurse was responsible for completing care plans. She stated she initiated initial care plans and then the MDS nurse did the rest of the care plans. She stated she expected all wounds and skin concerns to be care planned. She stated the staff responsible for completing care plans had been trained on how to complete a care plan and what should be included in care plans. In an interview on 11/02/23 at 04:01 PM with the ADM, he stated the MDS nurse was responsible for completing care plans. He stated he expected all wounds and skin concerns to be care planned. He stated he was not sure about what level of training the MDS nurse had been given but he knew that the Cooperate MDS nurse came to the facility the past week and had done some trainings with the MDS nurse. In an interview on 11/02/23 at 04:08 PM with MDS, she stated there was not a policy on what to care plan and she was told previously that she was only to care plan stage 2 and higher skin concerns. She stated she clarified what should have been care planned with the cooperate nurse and she was to care plan everything including all wounds no matter the stage and all skin concerns. She stated she would care plan every skin concern from now on. Record review of the undated facility's policy titled FourCooks Senior Care, LLC - Section 18 - Minimum Data Set (MDS) - Policy: Comprehensive Care Plans - Procedures 1. The facility will develop and implement a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a residents' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being. 4. The services provided or arranged by the facility must: a. Meet professional quality standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 8 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, the facility failed to post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by Registered Nurses, Licensed Practical Nurses or Licensed Vocational Nurses, Certified Nurse Aides and Resident Census at the beginning of each shift in a prominent place readily accessible to residents and visitors. Residents Affected - Many The facility did not post the required staffing information on 10-31-2023, 11-1-2023, and 11-2-2023. This failure could place residents and visitors at risk of not knowing how many nursing staff were on duty and the actual hours worked per each shift daily. Findings include: Based on observation throughout the facility on 10-31-2023 from 8:00 AM till 3:30 PM, 11-1-2023 from 8:00 AM till 4:00 PM, and 11-2-2023 from 8:00 AM till 3:45 PM, the facility did not post the required nurse staffing information in a visible location and in a readable format. Interview and observation on 11-2-23 at 3:45 PM with the ADM revealed that the postings were placed near the front of the lobby. The ADM walked to the front of the lobby to point out the nurse staffing postings, but they were not there. Interview on 11-2-2023 at 5:00 PM with the DON revealed that they were new at the DON position and was not aware of the posting requirement and that it would be investigated. Interview on 11-2-2023 at 5:05 PM with the ADM revealed that the facility had posted the required nurse staffing in the past and was unsure why the nurse staffing was not posted during the times of recertification survey. Interview and observation 11-2-2023 at 5:10 PM with the DON revealed that the nurse staffing information was in a five-inch-thick black binder located at the nursing station. The DON stated that LVN A was responsible for creating the document and posing it in a visible location in a readable format. Interview on 11-2-2023 at 5:11 PM with LVN A revealed that the nurse staffing information was created each day. LVN A stated that she usually posted the information at the nurse's station, but had not for 10-31-2023, 11-1-2023, and 11-2-2023 because they had been working on the floor providing care. The facility did not present a policy, requested on 11-2-2023 from the ADM at 3:45 PM, governing the requirement to prominently display the nurse staffing information in a visible location and in a readable format. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 9 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals were stored in locked compartments for treatment cart 1 (Treatment Cart #1). 1. Treatment cart # 1 located in hallway B in the facility, outside of room B20, was observed to be unlocked and left unattended by LVN. This failure could place residents at risk of drug diversion and access to medications. Findings included: An observation on 10/31/23 at 9:49 AM reflected a medication/treatment cart parked on Hall B in the hallway in the facility outside of room B20 was unlocked and unattended. LVN, which was responsible for cart was in room B20 with door closed halfway and privacy curtain pulled. Medication/treatment care was not in visible range of nurse. No residents were present in hallway. In an interview on 10/31/23 at 9:53 AM LVN stated she was aware the medication/treatment cart was unlocked because she was then seeing it. She stated she did not realize she left the cart unlocked or left the keys in the cart. She stated she was receiving training at that time and that was the first day she had worked mornings in the facility. She stated she knew the medication cart was supposed to be locked and she had just made a horrible mistake. She stated there was wound care supplies and creams, medications, insulins, and supplies on the cart and that if a resident were to get into the cart, they could have taken some of the medications and harm could have been caused . She stated she would learn from this experience, and she would never do that again. An observation on 10/31/23 at 9:58 AM revealed inside the medication/treatment cart, there was insulin, medications, supplies, and treatment medications such as creams on unlocked medication/treatment cart. In an interview on 10/31/23 at 11:39 AM the MA stated all medication and treatment carts should be locked when not in use. She stated she was trained on keeping the medication carts locked. She stated if a resident got on an unlocked cart, they could get poisoned. She stated they had a few residents that could possible get into the cart in the facility. In an interview on 11/02/23 at 03:40 PM the MDS, stated if a medication or treatment cart was not in use or was left unattended, it should be locked. She stated she had been in-serviced on keeping medication and treatment carts locked when not in use or unattended. She stated if a medication cart was left unlocked or unattended, a resident could get into the cart and take medications that did not belong to them and that could possibly cause harm to the resident. In an interview on 11/02/23 at 03:50 PM the DON, she stated it was her expectation that any medication or treatment cart that was not in use or was left unattended, should be locked. She stated staff were in-serviced on locking medication and treatment carts when not in use or if unattended. She stated if a medication cart was left unlocked and unattended, a resident could possibly get into the cart and take medications that were not theirs, and it could possibly cause them serious adverse side effects or harm. She stated herself and the ADON would make rounds at anonymous times and anytime (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 10 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some they found a medication or treatment cart unlocked or unattended, they would take the entire cart, and the staff that was responsible for the cart would have to see them and be educated on locking unattended medication or treatment carts prior to getting their carts back. In an interview on 11/02/23 at 04:01 PM with the ADM, he stated it was his expectation that if a medication or treatment cart was not in use or was left unattended, it should be locked. He stated he was not aware if staff were in-serviced on keeping medication and treatment carts locked when not in use or unattended because he has only worked here for about 1 month. He stated a resident could get medications that did not belong to them out of an unlocked, unattended cart which could possibly cause harm to the resident. Record review of undated FourCooks Senior Care, LLC Section 6 - Medication Policy : Storage of Medication reflected: 6. Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes). Record review of undated FourCooks Senior Care, LLC Section 16 - Nursing - Policy: Securing Medication and Treatment Carts - Procedure: It is expected that medication carts and treatment carts are to be remain locked at all times when not in use by the assigned personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 11 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store foods properly and maintain a sanitized food preparation area for the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to safely store food containers in the facility's only pantry, walk-in cooler, and freezer. 2. The facility failed to maintain clean kitchen surfaces/appliances. These failures placed residents at risk of exposure to food borne pathogens. Findings include: Observations on 10-31-2023 beginning at 8:10 PM in the facility's dry storage area reflected six small individual open bags of unsealed biscuit gravy mix placed inside a unsealed plastic bag WLD; one open bag of tricolor pasta stored in a plastic bag maintained past its labeled use by date; one bag of opened corkscrew pasta stored on a plastic bag WLD; one large dented can of blackeye peas; one bag of powdered sugar maintained past is labeled use by date; one opened green gallon sized bottle of real lemon juice WLD; one small box of cream of wheat stored in an unsealed plastic bag WLD; one five gallon plastic bucket of cornmeal maintained past its labeled use by date; one five gallon plastic container of brown sugar WLD; and one unsealed 25 pound bag of flower WLD. Observations on 10-31-2023 beginning at 8:20 AM of the facility's refrigeration system (two refrigerators side by side) reflected: Refrigerator one contained one large bag of cheddar cheese cubes WLD; one large bag of shredded cheddar cheese WLD; one four-inch by four-inch stack of sliced American cheese partially wrapped in aluminum foil WLD; and one 8-inch by four-inch stack of sliced American cheese wrapped in plastic wrap WLD. Refrigerator two contained two 6-inch summer sausages WLD; one open package of bacon stored in a plastic bag WLD; and one open package of sliced turkey breast stored in a plastic bag WLD. Observations on 10-31-2023 beginning at 8:30 AM of the facility's freezer system (2 freezers side by side) reflected: Freezer one contained 19 frozen food boxes WLD. The freezer did not contain sufficient racks to allow for foods to be spaced apart to allow proper circulation. Other observations in the freezer revealed a ½ inch of ice on the bottom of the freezer with three boxes of food frozen to the bottom. One package of hot dogs was unsealed and open to the air with an accumulation of ice and freezer burn. Freezer two contained 13 frozen boxed of food WLD. The freezer did not contain sufficient racks to allow for foods to be spaced apart to allow proper circulation. Other observations in the freezer revealed a large spill of a red substance on the bottom of the freezer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 12 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observations on 10-31-2023 beginning at 8:45 AM of the facility's dish, utensil, pots, and pan storage drying area reflected 17 glasses stacked on a rectangular grey tray with debris, stains, and a collection of an oily substance on the bottom of the tray; 11 red small bowls stacked on a grey rectangular tray with food particles on the bottom of the tray; two plastic storage containers at the bottom shelf of the drying racks that stored large spoons, scoopers, and knives that had debris collected at the bottom of each container; a large silver colander with food particles collected in the straining holes; and two fry baskets with food particles stuck in the mesh wiring. Observations on 10-31-2023 beginning at 9:00 AM of the facility's kitchen appliances reflected a coating of grease and food particles collected on the top of the facility's oven; one industrial can opener with collected particles of food and debris in its internal working parts; and collected rust and discoloration inside the venting hood on top of the facility's only dishwasher. Observations on 11-1-2023 at 1:35 PM reflected the facility's manual three-sink washing system not set up with functioning sink stoppers. The facility used two fabricated sink stoppers made of plastic wrap and a kitchen towel. Cleaning solution was observed leaking from the drain and cleaning solutions were not maintained at the at the proper level for sanitization. Interview on 11-2-2023 at 3:38 PM with the DM revealed that food should be stored in sealed containers and labeled with an 'open date' and 'use by date' to ensure food stays fresh, prevents food-borne ill nesses, prevents cross contamination, and prevents bacteria growth. The DM stated that kitchen appliances and equipment should be sanitized regularly to prevent food-borne ill nesses, prevent cross contamination, and prevent bacteria growth. The DM stated that common food-borne illnesses are norovirus, salmonella, e-coli, botulism, and listeria. The DM stated that negative results of food-borne illnesses could result in vomiting, diarrhea, nausea, and untended weight loss. Interview on 11-2-2023 at 4:25 PM with the DON revealed that food safety and proper sanitization of kitchen equipment is important to reduce food- borne pathogens. The DON stated that food-borne illnesses could cause vomiting, diarrhea, food poisoning, and weight loss. Interview on 11-2-2023 at 4:53 PM with the ADM revealed that food safety and proper sanitization of kitchen equipment is important to reduce food-borne pathogens. The ADM stated that cross-contamination and food-borne pathogens can turn out bad for everyone. The ADM stated that negative outcomes from a food-borne pathogen could result in vomiting, diarrhea, dehydration, and UTIs. Record review of the facility's policy for Storage of Food In Refrigerators, undated, indicated all containers must be labeled with the contents and date the food item was placed in storage. Record review of the facility's policy for Dry Storage and Supplies, undated, indicated open packages of food are stored in closed containers with tight covers, and dated as to when opened. Record review of the facility's policy for Storage Refrigerators, undated, indicated food must be covered when stored, with a date label identifying what is in the container. Record review of the facility's policy for Dented Cans, undated, indicated any can presented for delivery that is dented, bulging, or leaking is to be sent back. The policy indicated that any can that has been damaged while in the facility was to be thrown out or placed in the designated area for dented cans. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676343 If continuation sheet Page 13 of 14 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 676343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Waco 9101 Panther Way Waco, TX 76712 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's policy for Cleaning, undated, indicated all (1d) equipment, food contact services, and utensils shall be cleaned whenever contamination has occurred, and (9) refrigerators and freezers must be cleaned quarterly or more often if needed. Record review of the facility's policy for Prevention of Cross-Contamination, undated, indicated cross-contamination can occur when using unclean equipment, such as slicers, can openers, and utensils to prepare food. Directions on how to prevent cross-contamination when storing food indicated that food needed to be covered or wrapped before storing. Event ID: Facility ID: 676343 If continuation sheet Page 14 of 14