Inspection·October 29, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete January 2017 reflected the following: Policy Statement Residents, family, and resident representatives have the right to voice or file grievances, either orally or in writing, to the facility staff or the agency designed to hear grievances (e.g. the state Ombudsman) You are requested to follow the procedures outlined below when filing grievance or complaint: 1. Any resident, family member or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility.2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form and without fear of discrimination or reprisal.3. All grievances, complaints or recommendations stemming from residents or family groups concerning issues of residents' care in a facility will be considered. Actions on such issues will be responded to in writing including a rational for the response.4. The administrator has delegated the responsibility of grievance and or complaint investigation to the grievance officer5. Within five (5) working days of the date you filed the grievance; you will be notified of the results of the investigation. (Note: Complaints of abuse, harassment, or mistreatment will be immediately investigated, and you may request a report of the findings, recommendations, and/or corrective action taken within five (5) working days of the filing of the report.)6. It is the policy of this facility to assist you in filing a grievance or complaint. Should you feel that our staff has not assisted you in this matter, or you feel that you are being discriminated against for taking such steps, you are encouraged to report such incidents to the Administrator at once.7. The grievance officer, administrator and staff will take immediate action to prevent further potential violations of residents' rights while the alleged violations are being investigated. Event ID: Facility ID: 745021 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to provide adequate supervision for 1 of 3 residents (Resident #17) to prevent an avoidable accident.The facility failed to provide a timely response to the call light during change of shift for Resident #17 to prevent an avoidable accident. This resulted in Resident #17 having an actual fall on 08/09/2025, suffering a sprained left ankle injury.The failure could place residents at risk for accidents/ injury over which the facility had control, provided supervision, and assistive devices to each resident to prevent avoidable fall accidents. Finding included:Resident #17, named in the allegation, was not observed, or interviewed during the investigation. Discharge summary records revealed she was discharged on 08/19/2025 to an assisted living facility and was not available during the investigation. A review of Resident #17 face sheet dated [DATE] indicated she was a [AGE] year old female initially admitted on [DATE] with diagnoses of streptococcal infection, insomnia, sepsis unspecific, Parkinson's disease without dyskinesia (movement disorder), lichen sclerosus (condition that causes thin patches of the skin), pain in the left knee, trigger finger, age related osteoporosis, dysphagia (difficulty swallowing foods or liquids), ataxia (impaired balance or coordination), and cognitive communication deficit. A review of Resident #17's, quarterly MDS section C dated 08/5/2025, revealed a BIMS score of 10 (Brief Interview for Mental Status), indicated moderate cognitive impairment. A review of Resident # 17's care plan dated 07/28/2025, Transfers', indicated the resident required moderate assistance. Care Planned focus goals, indicated the resident was at risk for falls related to gait/balance problems, weakness, Parkinson's, difficulty ambulating. The resident was care planned for camera consented for surveillance to be on file. A review of Resident # 17 Nurse's Note dated 08/09/2025, revealed Fall Risk assessment indicated 1-2 falls in past 3 months. Recent hospitalization history in last 30 days, (Gait Balance problem while walking or unstable when making turns). Required use of assistive devices and balance problems while standing. A review of Resident #17's Provider Investigation Report dated 08/11/2025 indicated the resident had an unwitnessed fall dated 8/9/2025 at approximated 6:15AM to 6:30AM. The resident was found on floor near doorway in a slight leaning position, during morning shift change by CNA (C) and CNA (D). The provider investigation report indicated both CNA's immediately notified CN LVN (A), a full assessment was done, Resident #17# was able to answer questions, denied hitting her head, no bruises, or lacerations noted. A review of Resident #17's Provider Investigation Report dated 08/09/2025 at 11:00AM, the resident was transferred to hospital after complaining of left ankle soreness on standing. Hospital post x-ray resulted in sprained left ankle. Review of facility incident/accident reports for the past three (3) months revealed un-witnessed fall incidents report dated 08/03/2025 to 8/28/2025 during the 6PM to 6AM night shift, totaling 11 un-witnessed fall incidents throughout the facility, including hallway's 100, 300, and 400. During an interview on 10/27/2025 at 3:00PM, CNA (C) said, on 08/09/2025, she had arrived for 6AM shift and heard a resident in hallway 200 call for help, she immediately went down the hallway to Resident #17's room and sees the resident on the floor, a second aide arrived just seconds later. CNA (C) said, she immediately goes to get CN LVN (A). CNA (C) said, CN LVN (A) arrived and asked Resident #17 if she was hurt anywhere several times, Resident #17 said no. CNA (C) said, CN LVN (A), continued with her assessment, took the resident's vital signs, checked her head, and asked Resident #17 if she wanted to be sent out to the hospital. Resident #17 said no . CNA (C) said, she and the other aid assisted the resident up and got the resident up in her chair. During an interview on 10/27/2025 at 3:30PM, CNA (D) said on 08/09/2025 she was scheduled for a 6:00AM shift, she was asked to work hallway 200 (due to a CNA was a no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 - Actual harm Residents Affected - Few show), CNA (D) stated when she arrived, she saw the disturbance and immediately went to Resident #17's room. Resident #17 was lying on the floor and immediately called for the CN LVN (A), she stated, the nurse checked the resident and recalled LVN (A) had asked Resident #17, three times, did she need to go out to the ER and Resident # 17 said no, and that she was fine. Both CNA (C), and CNA (D), identified that the call light was on when they arrived in the room, but was unsure of the length of time due to both CNA's were coming on for the 6AM to 6PM Shift. During an interview on 10/27/2025 at 4:00PM, CN LVN (A) named in the allegation said on 08/09/2025, she was scheduled for 6AM morning shift. While receiving reports and counting narcotics, an aide notified her that Resident #17 was found on the floor. She immediately went to Resident # 17's room, said approximated times was between 6:15AM and 6:30AM, she could not recall if the call light was ON or Off at the time of arrival to Resident # 17's room. LVN (A) said, the resident was in the entry doorway on the floor in a slight leaning position. LVN (A) said, at the time of the initial assessment, the resident was able to answer questions, denied hitting her head, vital signs were taken, no noted bruise or laceration, and the resident stated, that she was fine. LVN (A) said, she repeatedly asked Resident #17 if she wanted to go to the ER and the resident repeatedly said no. LVN (A) said the two CNAs assisted the resident back to her chair and the fall incident was reported to ADON, DON, physician and Resident #17's RP. LVN said, after the arrival of the resident's care givers later that morning, and the assistance of the resident up to be toileted, Resident # 17 complained of pain in the left ankle. LVN (A) said the resident's left ankle was noted to be slightly swollen, it was decided to send the resident to the ER to be further evaluated. 11:00AM Resident #17 was sent out via ambulance to the ER to be further evaluated. LVN (A) said she was suspended during the facility's internal investigation. Durning a phone interview on 10/28/2025 at 12:30PM with Resident # 17's Responsible Party/Caregiver she said on 08/09/2025 she was notified by the facility that Resident # 17 had fallen. She said she was Resident # 17's Responsible Party, and caregiver, and there was no family available. The RP caregiver said Resident #17 had an electronic monitor in her room and the video was reviewed by Prior Interim ADM and prior ADON. The RP/caregiver said you could see on the phone video that the call light was on, stated the video revealed Resident #17 called out for help, Resident #17 was sitting on the side of the bed, after waiting the resident got up and fell in her room by her bed. The surveyor requested video to be sent and reviewed on state phone. The RP/ caregiver agreed to send video to surveyor's states phone. The surveyor attempted twice to retrieve the capture video, after 24hr the Electronic Video was never received or reviewed by the state surveyor during investigation. During a phone interview on 10/29/2025 at 10:30AM CNA (E), named in the allegation, said on 08/09/2025, she worked the night shift and was scheduled on hallway 200. The CNA (E) said on the morning of 08/09/2025, she and the CN LVN (B) made rounds approximated 5:55AM, and said Resident #17 was in bed, and the resident call light was not on. She said she heard no one say help. CNA (E) said, the on-coming day shift CNA was a no show on the morning of 08/09/2025, and she notified the oncoming CN LVN (A) that she had to leave. The CNA (E) said she left the facility at 6:15AM. CNA (E) said two days later she was notified by Prior ADON that Resident #17 had fallen and to come in and give her statement of the incident. Both Prior Interim Admin., and prior ADON met with her in the meeting, and both said they had reviewed Resident #17's electronic video, but stated she never saw the video. CNA (E) said on 08/15/2025, she was suspended pending investigation and then terminated due to inaccuracies in her accounts of the events. Durning an attempted phone interview on 10/29/2025 at 11:30AM, CN LVN (B), named in the allegation was not interviewed after two attempts, surveyor was unable to make contact during investigation. Reviewed Prior ADON written statement: Prior ADON contacted LVN (B) requested employee to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete return to facility to complete a statement of the incident events. LVN (B) stated Yall have it all backward. Several attempts were made by Prior ADON to encourage employees to come to the facility to resolve the issue. Employee LVN (B), self-terminated 08/15/2025, due to failure to return to give statement of incident. Durning a phone interview on 10/29/2025 at 3:30PM the Prior Interim ADM and prior ADON said, they both had reviewed the RP/care giver provided video footage. Both prior staff members indicated that the video revealed Resident #17 was sitting on the side of the bed calling for help, and the call light button was on, the video clip time stamped approximated 5:17AM or 5:22 AM . They also witness Resident #17 fall on the floor but unable to recall the exact time of fall because the video clip was not time stamped. Both prior Adm., and ADON. said, the provider responded with safe surveys conducted. Scheduled observations of Resident #17 were performed for 72hr. Suspension of staff pending investigation, and termination of one employee. Both stated staff training on abuse and neglect, fall prevention, notifying administration of staffing shortage, and call light response times all were completed. During an interview on 10/29/2025 at 4:30PM the Current ADM said he was not on staff at the time of the incident, but stated, he had reviewed the incident report and stated he had initiated a plan of care, during morning reports to identify any resident's concerns, increased the staffing levels on the heavy hallways (from 2 CNA to 3 CNA's each shift), and hired a new staffing coordinator. In serviced staff on Abuse/ Neglect, falls prevention, call lights response time, and staff expectation stating, All staff are responsible for answering call lights, and reporting incidents. Review of facility policy for Falls prevention, Abuse & Neglect, Call light response time and customer service, revealed all seven (7) elements were addressed: Screening, Training, Prevention, Identification, Investigation, Protection and Reporting. There were no concerns with facility policy. In-services were reviewed and were compliant. Event ID: Facility ID: 745021 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, and interviews, and record review the facility failed to serve food that was palatable for 1 of 1 meal reviewed for food palatability. (noon meal 10/28/2025). The facility did not provide palatable and appetizing food for the residents for the 10/28/2025 noon meal. Residents #1, 3, 4, 6, 11, 14, 15 and 19 complained of cold food and food that was not flavorful. These failures could place residents who received food from the kitchen at risk for diminished meal satisfaction and potential weight loss due to poor meal intake.Findings included: 1.During interviews during the initial tour on 10/27/2025 the following was noted: *At 9:46 AM Resident #11 said the food was very cold and very salty at times. *At 9:50 AM Resident #3 said the food was bad. *At 10:09 AM Resident #4 said the food was not that good. *At 10:31 AM Resident #6 said the food was not good. *At 10:33 AM Resident #15's family member said the food here was not very good. *At 10:35 AM Resident #19 said the food was not the greatest lately. **At 11:17 AM Resident #14 said the food is just ok. 2. During observations on 10/28/2025 at 12:00 PM the test tray left the kitchen after the dining room was served, and was hand delivered by the RD. The test tray for the surveyors. On 10/28/2025 at 12:10 PM the test tray arrived in the work room. The plate of food was on a tray and covered with a hard plastic cover. The RD was present with the tasting of the food. The following were found: *Regular tray- spaghetti with thick noodles, tossed green salad, and a garlic bread stick. Spaghetti was cool, seasoned ok. [NAME] tossed salad cool Garlic bread was hard No dessert on trayNo drinks on tray The second test tray which came after the last hall trays were served on 10/28/2025 at 12:30 pm Spaghetti was cold, seasoned ok. [NAME] tossed salad cool Garlic bread was hard difficult to chew Cup of diced peaches with whip cream on top - coolNo drinks on tray During an interview on 10/28/2025 at 12:30pm The RD agreed with the findings. The spaghetti on the regular tray was not hot, and seasoned ok, the bread stick was hard difficult to bite into, no dessert and no drink. The second test tray's Spaghetti was cold, seasoned ok. [NAME] tossed salad cool. Garlic bread was hard difficult to chew. Cup of diced peaches with whip cream on top - coolNo drinks on tray 4. During interviews on 10/28/2025 the following statements were made regarding the noon meal of spaghetti, salad, bread stick and peaches with whip cream: *At 11:35 AM Resident #11 said it's food, but it's not good. She said, I may eat a little of it. *At 11:36 AM Resident #3 said it may look good, but it never tastes good, she said it is always too spicy. *At 11:49 AM Resident #14 said he was going to eat some of the meat. He said he didn't want the rest of it, and he wished they would improve on the food. *At 1:05 PM Resident #1 said her lunch food was cold and very salty. *At 1:20 PM Resident #19 said it probably would have been good if it were not cold and they don't give me enough. *At 1:25 PM Resident #6 said the food was just ok. She said it was not like home cooked food, she said she always has to wait on her tea, and it is never hot. During an interview with the Administrator on 10/27/2025 at 9:30 AM he said that the dietary manager had called in this morning 10/27/2025 and gave her notice to quit and he currently did not have a dietary manager and his thoughts were that, each resident should be provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident, that food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. The Administrator said this deficiency cold put the resident at risk for weight loss, and multiple dietary issues. Record Review of the facility's policy for Food Preparation and Service dated revised November 2022 documented the following: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. Staff were not wearing bearded hair nets 3 large baking sheets containing carbon build-up were stacked against each other Large and medium steam table pans stacked on rack contained moisture and water on the inside and food particles on the inside The three compartment Sink was stacked and dirty with dirty pots and pans in all three compartments Steam Table dirty with food splatter on glass Dried blood on floor by handwashing sink with no soap and paper towels to wash hands Trash in multiple areas of kitchen debris Open packaged meat, in a 2-door refrigerator, was not labeled, was not in a sealed container. A 2-door refrigerator door left open with freezer residue on outside of the door Refrigerator/Freezer temperature logs had not been taken since 10/20/2025 Dishwasher test log, no test or evidence of test strips for sanitizing dishes, Dishwasher test log had been filled in and completed until end of monthCleaning log dated 09/2025 none for the month of October 2025The ice machine seal dirty with no mention of when had been last cleaned. This item was not listed to be cleaned on the cleaning facility log.These failures could place residents who ate food from the kitchen at risk of foodborne illness.Findings included: During observations on 10/27/2025, the following was noted in the kitchen: *At 9:00 AM both handwashing sinks for hand washing in the kitchen did not have soap nor paper towels to wash hands, the hand sanitizer before you enter the kitchen was empty/broken. *At 9:04 AM Dishwasher-E was not wearing a beard net. He said his beard net was in his pocket, was never seen wearing the beard net. He was observed running the dishwasher without testing the dip pan for proper sanitizer, he said he did not have the test stripes to do the sanitizer. *At 9:08 AM Cook-H said the dietary manager was not here. Upon identifying the cook: carbon build up on 3 large baking sheets stacked together on a rack, 3 large and 2 medium steam table pans stacked together on a rack with moisture and water on the inside of the pans, food particles on the inside of 2 of the large steam table pans. Cook-H said, I see what you are saying. I haven't worked here that long, and it has been built up over the years. I don't know what to say, I will let the dietary manager know. *At 9:13 AM An open package of meat in the 2-door refrigerator in the kitchen was unlabeled and was not enclosed in a sealed container. The door on the 2-door freezer was open with frost built up on the outside. A box of sweet roll dough with expiration date of 8/8/2025 was sitting on the counter to be used. DA G said she will let the dietary manager know. On a follow-up visit and interview on 10/27/2025 at 10:30 AM Cook-H and DA G said that they were not in-serviced on serving sizes and temperatures and now they found out that the DM had quit.During an interview with the Administrator and ADON, on 10/27/2025 at 10:35 AM, they both said Dietary manager did not have any documentation that staff have been in-serviced on kitchen sanitation. They said they could do it today and were not sure if all the kitchen staff had their food handler's certification but would find out. Both said they were not aware of the condition of the kitchen. *At 10:45 AM on 10/27/2025 Dish washer-F said he did not get trained on dish washing and will not use the dishes until he can prove that they are sanitized and ready for use. During an interview with the Administrator at this same time he said, they will use paper products until they get test strips to show proper sanitization. On a follow up visit and interview with FM/CNA J at 10/27/2025 at 11:00 AM, she said she was trained and able to handle the current situation of the kitchen, she now has serving sizes correct, temps recorded, and steam table cleaned. She has her food managers certification. *At 2:21PM on 10/28/2025, the HR director provided food handlers certification for all the dietary staff Review of facility policy for Food Preparation and Service dated revised November 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 8 of 8