Health inspection·June 7, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications for months. He stated that he sometimes had behavioral problems with aggressive outburst that he was trying to control. In an interview on 06/07/2023 at 3:30 PM, the MDS coordinator said she had just recently been put in this position. She said that she is responsible for ensuring that the residents MDS evaluations are completed accurately. She said that for the 04/20/2023 Quarterly MDS assessments, Resident #27 was on antidepressant medications and antianxiety medications for major depressive disorder and for generalized anxiety disorder. She stated that she incorrectly coded the MDS assessment, by not putting the anxiety and depression diagnosis along with the anti-anxiety medication. She said the error was due to her being in a new in the position, and it was one of the first MDS assessments she had completed. She revealed she had received training and taken an online course prior to completing the assessment. She stated that she was opening and completing a modification of the assessment to accurately code section I and section N. She stated that the failure could place the residents at risk for receiving inaccurate assessment of the care areas. Record review of the facility's policy titled, Accuracy of Resident Assessments dated 2001 revealed: Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 2 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to refer to the local authority, 1 of 4 residents whose PASARR evaluations were reviewed (Resident #27) who had newly evident mental disorders in that: The facility failed to refer Resident #27 for PASARR review following new mental illness diagnoses of Major Depressive Disorder. This deficient practice could affect residents who had qualifying diagnoses with a negative PASARR Level 1 evaluation by not receiving the care they are entitled to. The findings included: Record review of Resident #27's Face Sheet, dated 06/07/2023, revealed a [AGE] year-old male, re-admitted to the facility on [DATE] with admitting diagnoses of generalized anxiety disorder (excessive and persistent worry and fear about everyday situations) and major depressive disorder/ recurrent (mental disorder characterized by at least 2 weeks of pervasive low mood and loss of interest or pleasure in life), which was added on 09/22/2022. Record review of a modified Quarterly MDS, dated [DATE], revealed Resident #27 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Resident #27 had active diagnoses which included anxiety disorder and depression. Resident #27 received antianxiety and antidepressant medications. Record review of Resident #27's Physician's Orders Summary Report, dated 06/07/2023, revealed orders for buspirone tablet; 5 mg; amt: 1; oral at 8:00 AM ordered and started on 01/13/2023 for anxiety disorder, paroxetine HCl tablet; 10 mg; amt: 1; oral at 8:00 AM ordered and started on 01/13/2023 and trazodone tablet; 150 mg; amt: 1; oral at 8:00 PM ordered and started on 01/13/2023 for major depressive disorder. Record review of Resident #27's Care Plan, last revised on 03/21/2023, revealed care plans for: A) Resident #27 has socially inappropriate/disruptive behavioral symptoms as evidenced by: aggression. Resident is also non-compliant with physician orders, particularly fluid restriction, and diet orders. Current socially inappropriate/disruptive behavior pattern includes cursing at others and rejection of care. B) Resident #27 ordered an antidepressant and an antianxiety medication daily. C) Resident #27 would express/exhibit satisfaction for psychosocial well-being. Record review of Resident #27's PL1, dated 12/23/2022, revealed Resident #27 was negative for mental illness. Observation and interview revealed on 06/06/2023 at 2:00 PM, Resident #27 was leaving the resident council meeting. He revealed that he has been on antidepressant and antianxiety medications for months. He stated that he sometimes has behavioral problems with aggressive outburst that he is trying to control. In an interview on 06/07/2023 at 3:30 PM, the MDS coordinator said she has just recently been put in this position. She said that she is responsible for ensuring that the residents PASRR evaluations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 3 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were updated. She said an updated PL1 should have been completed for Resident #27 since he had a diagnosis of mental illness upon his re-admission from the hospital, but it was not completed. She said the failure could prevent or delay services the resident was entitled too. In in interview on 06/07/2023 at 4:00 PM, the Administrator revealed that the MDS coordinator was responsible for identifying residents that would need an updated PL1. Record review of the facility's PASRR Policy dated 02/01/2023 revealed: A resident with MI or ID/DD must have a Resident Review conducted when there is a significant change in the resident's condition. The nursing facility is required to notify the Local Intellectual and Development Disability Authority (LIDDA) or the Local Mental Health Authority (LMHA). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 4 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 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 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 2 of 6 residents (Resident #4 and Resident #11) whose records were reviewed for assessments and care plans. The facility failed to ensure that Resident #4, Resident #11 had a comprehensive care plan developed and updated within 7 days following the completion of the admission comprehensive assessment. This failure could place residents at risk of not have having their care plans completed accurately and timely. Findings included: Resident #4Record review of Resident #4's face sheet dated 06/07/2023, revealed the resident was an [AGE] year-old female who was admitted to the facility 01/10/2023. Resident #4 had diagnoses which included Chronic cholecystitis (inflammation of the gallbladder), anxiety disorder (feelings of worry and anxiousness), hypertension (high blood pressure, and pneumonia (fluid in the lungs). Record review of Resident #4's admission MDS assessment, dated 01/17/2023, revealed the following: Section C revealed the resident had a BIMS score of 10, which indicated moderate impaired cognition. Section K revealed a weight of 149 pounds. Section G revealed: Bed mobility- extensive, Transfersextensive, walk-in room- limited, walk-in corridor- supervision, locomotion on unit- supervision, locomotion off unit- supervision, dressing- extensive, toilet use- extensive and personal hygiene- supervision. Section Z revealed that the RN signature date was for 01/20/2023. Record review of Resident #4's Care Conference notes, dated 06/07/2023, revealed the resident did not have a comprehensive care plan completed until 05/02/2023. Interview withe the MDS Coordinator on 06/06/2023 at 11:00 AM, revealed that she did nto complete Resident #4's comprehensive care plan until 05/02/2023. She stated she was just starting the position and was learning how to complete the assessments independently. Resident #11Record review of Resident #11's face sheet dated 06/07/2023, revealed the resident was a [AGE] year-old female who was admitted to the facility 09/08/2022. Resident #11 had diagnoses which included Alzheimer's disease (neurodegenerative disease), respiratory infection (infection in the respiratory system, and anxiety (state of anxiousness). Record review of Resident #11's Significant Change MDS assessment, dated 05/16/2023, revealed the following: Section C revealed the resident had a BIMS score of 03, which indicated severe cognitive impairment. Section K revealed a weight of 82 pounds. Section G revealed: Bed mobility- supervision, Transfers- supervision. walk-in room- supervision, walk in corridor- supervision, locomotion on unitsupervision, locomotion off unit- supervision, dressing- limited, toilet use- extensive and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 5 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 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 personal hygiene- extensive. Section Z revealed that the RN signature date was for 05/23/2023. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #11's Care Conference notes, dated 06/07/2023, revealed the resident did not have a care plan meeting until 06/06/2023. Residents Affected - Few Record review of Resident #11's Care plan reflected the resident did not have her Comprehensive Care Plan updated until 06/05/2023. In an interview on 06/05/2023 at 2:55 PM, the MDS coordinator revealed they got behind with care plans and the meetings but corrected the care plans with regional leadership and interventions. She stated she was new in the position and there had not been a DON in the building to help with care plans and care plan meetings. She revealed that she was responsible for updating and completed the care plans and care conferences. Record review of the facility's care planning policy, dated revised October 2022, titled Care Plans, Comprehensive Person- Centered revealed: The facilities policy and procedures titled: A comprehensive person-centered care plans dated 2021 revealed: Resident assessments are begun on the first day of admission and completed no later than the fourteenth (14th) day after admission. A comprehensive care plan is developed within seven (7) days of completing the resident assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 6 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Potential for minimal harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility reviewed for nursing services, in that: The facility had not designated an RN to serve as the DON on a full-time basis since April 14, 2023. This failure could place residents at risk of receiving poor and unsupervised nursing services/care. Findings included, In an interview with the ADM on 06/07/2023 at 03:35 PM, the ADM said the previous DON left the faciity on [DATE]. The ADM said her first day was 04/17/2023 and she started working on getting a replacement for the DON then. The ADM did not designate an interim DON. The ADM said the facility posted the DON job on two websites, Indeed.com and Hireology.com and did not receive any applications until the company authorized a sign-on bonus two weeks after the job was posted. The ADM said she interviewed at least four candidates, none who were qualified for the position. The ADM said on 06/06/2023 she offered the DON position to a former employee who met the requirements for the position of the DON. The ADM said the new DON would start work on 06/19/2023. The ADM said that the facility had full-time RN coverage, so she was not worried about the quality of care the residents received. In an interview with the CRN on 06/07/2023 at 4:01 PM, the CRN said the facility had been without a DON since 04/14/2023. The CRN said that the previous DON had given a 30 days notice in March of this year. The CRN said that she was aware of six applicants who applied for the DON position, some who were not even registered nurses which was a requirement for the DON. The CRN said she had interviewed one applicant on 04/05/203 who was not qualified for the position and another on 04/17/2023 who also was not qualified for the DON role. The CRN said that yet another person was interviewed on 05/16/2023 but did not meet minimum qualifications to become the new DON. The CRN said the owners of the facility had what she referred to as Mobile DONs (RNs who work for the company and are qualified to act as a DON) but none were available to fill in. The CRN said outside temporary agencies did not have the RNs that would provide the level of service expected and therefore they did not look in that area. The CRN said the facility did not have a policy on DON coverage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 7 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 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 - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure expired medications, including prescription and over-the-counter medications were removed from use from one of two medication carts ,and one of one medication room. One (1) prescription medication inside the refrigerator located in the medication room was expired and three (3) over-the-counter overstock medications on shelves inside the medication room were expired. There were two (2) over-the-counter medications that were expired in one (1) of two (2) medication carts reviewed. This failure places residents at risk of receiving expired medications which may have reduced efficacy. The findings included: Observation on 06/06/2023 at 02:38 PM of the medication cart for hall F and ½ of Hall E revealed a bottle of docusate sodium 100mg (a product to soften stool in the digestive tract) with an expiration date of 04/2023. There were approximately 30 softgels in the bottle. A bottle of simethicone 80mg (product used to reduce gas in the stomach) containing between 35 to 40 tablets was found to have an expiration date of 05/2023. In an interview on 06/06/2023 at 02:47 PM, LVN-C said medication carts were checked monthly for expired products. Observation on 06/06/2023 at 02:55 PM of the facility's only medication room revealed the following expired over-the-counter products: Thiamin (Vitamin B1) 100 x 2 bottles (100 tablets each) with an expiration date 05/2023, niacin 100mg x 1 (100 tablets) with an expiration date of 04/2023 and naproxen 220mg (pain medication) x 2 bottles (100 tablets each) with expirations dates of 05/2023. A pharmacy prepared Anaphylaxis Kit (used to treat allergic reactions) prepared exclusively for Resident #96 had an expiration date of 06/03/2023. In an interview with ADON-D on 06/06/2023 at 03:20 PM, ADON-D said medications carts were checked weekly for expired products and the medication room was checked monthly by the night shift. ADON-D indicated that resident outcomes for taking outdated products ranged from the product not working as effectively or other types of harm. Record review of a facility policy titled Storage of Medications, 2001 MED-PASS, Inc. (Revised November 2020) revealed in part the following: Policy heading 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 8 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 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 resident's medications were properly stored in locked compartments for one of two medication carts (cart for Hall D). One (1) medication cart (for Hall D) was left unlocked and unattended. The failure could cause harm to residents who may access medications not intended for them, or result in drug diversion (illegal transfer of a legally prescribed medication from a resident to someone else). Findings included, Observation on 06/05/2023 at 10:54 AM revealed the medication cart for Hall D was unlocked (the keyed bolt was sticking out ¾ of an inch from flush with the cabinet) and unattended, with an employee sitting behind the counter out of direct site of medication cart, due to a high countertop. In an interview with RN-A on 06/05/2023 at 10:54 AM, RN-A said his expectations should have been for the medication carts to be locked when not attended. In an interview with MA-B on 06/05/2023 at 10:54 AM, MA-B said she was covering for another nurse and forgot to lock the cart after she removed a medication for a resident. Record review of a facility policy titled Storage of Medications, 2001 MED-PASS, Inc. (Revised November 2020) revealed in part the following: Policy heading 6. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 9 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 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 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, in that: Residents Affected - Many 1. The manual can opener food contact surface was soiled with a dark-colored substance. 2. The electric mixer stand was soiled with a dried, splattered white colored substance. 3. The wooden shelf units in the kitchen and dry food storage area had gouged and scraped paint surfaces, which were not sealed surfaces. 4. The wooden shelf units in the kitchen were covered with vinyl shelf liner in various patterns, sizes, and layers, which were soiled with grease and dust. 5. Food items in the non-perishable food storage area were not stored in sealed containers or resealable storage bags after the manufacturer's package seal was opened, including a 50-pound bag containing dry pinto beans. 6. The storage containers in use in the dry food storage area had soiled lids and one container was damaged and the lid did not fit securely on the container. 7. The commercial refrigerator unit contained 2 opened bags of shredded cheese which had been rolled closed with a binder clip used to keep the bags closed. 8. The residential style refrigerator-freezer unit had an opened bag of sweet red cherries which was open to the freezer compartment air and had not been placed in an airtight bag or container. The facility's failure placed residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated. The findings included: Observations during the initial tour of the facility kitchen on 6/05/23, starting at 10:25 AM, revealed the following: - the electric mixer stand was soiled with a dried, splattered white colored substance; - the manual can opener was soiled with a build-up of a dark colored substance around the sharp metal piece used to puncture and cut the canned food lids; - two wooden shelf units with 5 wooden shelves each (10 shelves total), used to store stainless steel pots and pans that were inverted, were covered with vinyl shelf lining that was frayed on the edges; some of the vinyl was loose from the painted wood shelf surfaces; some pieces of vinyl had not been accurately cut and placed to cover the wooden shelves; and the vinyl was greasy and soiled; - the wooden shelf above the food preparation counter had spilled spices, spilled ground black (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 10 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 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 pepper, and a scraped painted surface (no shelf liner on it); Level of Harm - Minimal harm or potential for actual harm - the commercial stainless steel refrigerator unit contained 2 large bags with shredded cheese that had been opened; the open end of the bags were rolled closed and had binder clips to hold the rolled ends of the bags in place; the date written on the bags was not easily observed. Residents Affected - Many Observation on 6/05/23 at 10:38 AM, of the dry food storage area revealed the following: - 5 wooden shelf units had scraped, gouged paint surfaces (not a sealed wooden surface -and no shelf liner used); - a 50-pound paper bag of pinto beans was opened and rolled closed; the bag was not in a sealed, airtight container and was not dated when opened; the bag had been placed on top of a storage container on a bottom shelf; - plastic storage containers, used for storing bulk flour, bulk granulated sugar, bags with elbow macaroni, bags of pasta, condiment packets, bags with dry cereal, and individual packages of crackers, had lids soiled with food particles; - the lid for the container used to store bags of pasta noodles did not fit the container and there was a gap of space between the lid and the sides of the container (not sealed); one bag of pasta had been opened and was not resealed in an airtight bag or container; - the top shelf held an opened bag of tortilla chips; the open end of the bag had been rolled to close and a binder clip was used to hold the rolled end in place; the chips were not in an airtight bag or sealed container. Observation on 6/05/23 at 10:55 AM revealed a residential style refrigerator-freezer unit was positioned near the door to the kitchen. The top freezer compartment contained bags of frozen sweet cherries, 2 loaves of specialty bread, and a container of deli sliced luncheon meat stored in plastic shopping bags. One of the bags of sweet red cherries had been opened and was not in a sealed container or airtight bag. The cherries were open to the freezer unit air and were in an open plastic shopping bag with the date 4/13/23 written with a marker pen on the outside of the shopping bag. In an interview on 6/05/23 at 10:58 AM, the Dietary Manager stated the foods in the top freezer compartment of the refrigerator-freezer were bought for a specific resident and the staff provided the food when requested by the resident. She stated the open frozen cherries were not stored the way an opened frozen food package was supposed to be stored. During an interview and observation on 6/06/23 at 3:10 PM, the Dietary Manager requested the wooden shelf units in the kitchen be observed. She stated she had washed all the shelf liner and it would be removed and the wooden shelves painted. She stated the painting would need to be done at night. The Dietary Manager stated the shelf liner would be left on the shelves until the painting was going to be done. Observed one of the shelves had 2 layers of shelf liner of different patterns. The Dietary Manager stated, You don't want to look under the shelf liner. It's nasty. She stated the dry food storage room shelves and container lids had been cleaned and organized. She stated the Administrator was going to get new storage containers for storing dry foods. In an interview on 6/07/23 at 2:15 PM, the Dietary Manager stated the staff used daily cleaning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 11 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 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 schedules. She provided copies of the facility's dietary policies and procedures and the daily/weekly cleaning schedule forms used for May 2023 and the first week of June 2023. Review of the daily/weekly cleaning schedules dated for May 2023 and June 1-7, 2023 (6/01/23-6/06/23 to date) revealed all items were initialed daily as being completed. The items initialed as cleaned included: the mixer - thoroughly clean; food storage bins - clean/label/date; can opener - after each use, thoroughly clean; undershelves - clean. The task for food items in airtight containers was not initialed or dated. Review of the facility's dietary department policy and procedure for General Kitchen Sanitation, dated 10/01/2018, revealed [in part]: Policy: The facility recognizes that foodborne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. Procedure: 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. 4. Clean and sanitize all multi-use utensils and food-contact surfaces of equipment used in the preparation or storage or potentially hazardous food prior to each use . 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition Review of the facility's dietary department policy and procedure for Food Storage, dated 6/01/2019, revealed [in part]: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms: d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated Review of the facility's dietary department policy and procedure for Cleaning Schedules, dated 10/01/2018, revealed [in part]: Policy: The facility will maintain a cleaning schedule prepared by the Nutrition & Foodservice Manager and followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 12 of 13 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 455555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Graham 1224 Corvadura St Graham, TX 76450 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 1. The Nutrition & Foodservice Manager will develop a cleaning schedule for daily, weekly and monthly cleaning . 3. The cleaning list will be posted weekly and initialed off and dated by each employee upon completion of the task. The Nutrition & Foodservice Manager or designee will verify that the tasks were completed as assigned. Review of The Food and Drug Administration Food Code 2022 specified [in part]: Chapter 3 Food 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Chapter 4 Equipment, Utensils, and Linens 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Cleanability 4-202.11 Food-Contact Surfaces. (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) SMOOTH; Pf (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; Pf (3) Free of sharp internal angles, corners, and crevices; Pf (4) Finished to have SMOOTH welds and joints FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455555 If continuation sheet Page 13 of 13