Inspection·August 29, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 50% of a meal, and weekly skin assessments. The orders also included prescriptions including amlodipine 10mg tablet one tablet once daily at 9:00 AM, atorvastatin 80mg tablet one tablet once daily at 7:00 PM, and doxycycline hyclate 100mg capsule one capsule twice daily at 9:00 AM and 7:00 PM. Record review of CR #2's discharge plan of care dated 8/10/2023 revealed she was discharged home with home health care assistance on 8/10/2023. Interview on 8/26/2023 at 11:35 AM with CNC revealed the facility did not create a comprehensive plan of care for CR #2. CNC said the facility should have CR #2 was present at the facility more than seven days after the MDS assessment was completed on 7/25/2023. Interview on 8/28/2023 at 10:41 AM with the DON, she said the care plan ensures the IDT was on the same page related to resident care. The DON said the MDS leads to the care plan. The DON said the MDS nurse was the MDS coordinator and responsible for both the MDS and care plan. The DON said if a resident did not have a care plan, the staff would not have the required information to provide appropriate care. Interview on 8/28/2023 at 10:03 AM with MDS LVN revealed she had been employed by the facility for approximately one and a half years. MDS LVN said her primary duties as the MDS coordinator was to ensure the MDS were completed timely, approving admissions to the facility, ensuring comprehensive care plans were completed timely, and scheduling care conferences. MDS LVN said the MDS was due within fourteen days of a resident's admission to the facility. MDS LVN said when the facility was fully staffed and included ADON's, the ADON's would be responsible for completing sections of the MDS. MDS LVN said because the facility was not fully staffed, and there were no ADON's, she was responsible for ensuring the completion of the MDS. MDS LVN said a comprehensive care plan was due within fourteen days of the start of the MDS assessment. MDS LVN said the initial comprehensive care plan was due within nine days of the completion of the MDS assessment's completion. MDS LVN said the facility had policy and procedure for MDS assessments and care planning. MDS LVN said she was trained by the previous MDS coordinator for her current position. MDS LVN said she was trained for approximately two months in the MDS coordinator position. MDS LVN said if a resident did not have a care plan completed, the facility would not know how to meet the residents needs or plan of care. Interview on 8/28/2023 at 1:17 PM with ALVN E revealed she worked at the facility quite frequently. ALVN E said her primary duties at the facility included supervising the CNA's and MA's, ensuring medications were administered appropriately, ensuring residents' ADL's were performed, and resident safety. ALVN E said care plans ensured the residents received the services and treatments required for their care. ALVN E said the MDS coordinator was responsible for ensuring a care plan was created. ALVN E said if she determined a resident did not have a care plan she would inform the DON. ALVN E said if a resident did not have a care plan, that resident could have negative outcomes including death. ALVN E said a resident may receive the wrong diet and choke on un-pureed foods or aspirate on thin liquids Interview on 8/28/2023 at 7:14 PM with LVN K revealed she had been employed by the facility for thirteen months as an LVN for the 6:oo PM to 6:00 AM shift. LVN K said her primary duties included ensuring medication administration was completed accurately, gastronomy tube feedings and medication administration was completed, wound care was completed, residents ADL's were completed, and residents were repositioned to mitigate pressure wounds. LVN K said care plans were important because they documented a resident's goals in care and the interventions to achieve those goals. LVN K said the care plans aid in ensuring the resident's status doesn't decline unnecessarily. LVN K said the IDT was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 2 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 responsible for creation of and updating residents' care plans. LVN K said if she found out a resident did not have a care plan in place, she would investigate to determine why it did not exist. LVN K said if a resident did not have a care plan, that resident's health and/or psychosocial well-being could decline. LVN K said a resident' may receive the wrong diet without a care plan, and if a resident received the wrong diet, he/she could choke on wrong-textured foods or aspirate on wrong-textured liquids, or the resident could lose weight. LVN K said if the care plan was missing, a resident could receive the wrong medications or wrong dosages. Interview on 8/28/2023 at 7:38 PM with LVN D revealed she had been employed by the facility for a little over one year. LVN D said her duties as an LVN included providing all forms of resident care, supervision of the MA's and CNA's, medication administration, assisting with ADL's when needed, and checking on the residents. LVN D said care plans aided staff in caring for residents. LVN D said the care plans provide the plans, including goals and interventions to reach those goals, for the residents in care. LVN D said the RN and IDT are responsible for creating and updating care plans. LVN D said if a resident did not have a care plan, the resident would not receive the care required to ensure his/her goals were met. Interview on 8/29/2023 at 10:16 AM with the DON, she said a resident's care plan was used to ensure he/she received the care required for his/her physical and psychosocial well-being. The DON said the care plan also ensures the IDT and floor staff was aware of a resident's needs. The DON said if she determined a resident did not have a care plan in place, she would first go to the MDS coordinator and determine why there was no care plan, and she would then notify the administrator. The DON said if a resident did not have a care plan in place, the facility staff could not know how to properly care for that resident. Interview on 8/29/2023 at 10:20 with the Admin, he said the care plan informs the facility staff about a resident. The Admin said if a resident did not have a care plan; the resident could suffer negative outcomes. The Admin said the staff responsible for care planning were the MDS coordinator, nursing administration, and the IDT. The Admin said the IDT reviews the care plans and meets with resident and families to discuss the care plans implementation. Record review of the facility's Care Area Assessments policy dated December 2011 revealed a policy statement which read Care Area Assessments (CAAs) will be used to help analyze data obtained from the MDS to develop individualized care plans. CAAs are the link between assessment and care planning. The policy documented that triggered CAAs would be evaluated by the IDT. Per the policy CAA's included the following: identification of areas of concern triggered by the MDS assessment; review of the CAA's for resident specific assessment; determining care planning for the identified CAA's; and documenting the care plan. Record review of the facility's Care Plans-Comprehensive policy dated October 2010 revealed a policy statement which read An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The policy documented the comprehensive care plan would be completed by the IDT, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 3 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 the resident, and/or the resident's RP. Per the policy, the care plan is based on, but not limited to, the MDS assessment. The policy revealed the care plans were to be designed for to do the following: Level of Harm - Minimal harm or potential for actual harm incorporate identified problem areas, and risk areas associated with those problem areas; Residents Affected - Few reflect the resident and/or RP's expressed wishes, treatment goals, timetables, and objectives; identify professional services needed; aid in the prevention of decline; enhance the resident's optimal functional levels; and reflect the current standards of practice. The policy documented the care plan would include identified CAAs. Per the policy, the interventions would be designed with consideration for the resident's problem areas and their causes. The policy revealed the following: The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 4 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0661 Level of Harm - Immediate jeopardy to resident health or safety Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure all residents were provided with a discharge summary for an anticipated discharge for two (CR #1 and CR #3) of six residents reviewed for discharge requirements. Residents Affected - Few -CR #1 was discharged on 8/16/23 to a hotel and facility failed to provide CR#1 with Post-Discharge Plan of Care. -CR #3 was discharged on 8/23/2023 with no documentation of any pre-discharge planning, discharge summary, and an incomplete plan. On 8/25/2023 at 2:17 PM an Immediate Jeopardy (IJ) was identified for discharges. While the IJ was lowered on 8/29/2023 at 10:29 AM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of further unsafe discharge and potential physical, mental, and/or psychosocial harm. Findings include: CR #1 On 08/24/23 at 12:05 p.m. CR# 1 was observed asleep in a local hospital room. He had an IV antibiotic hanging that appeared to be finished. Interview on 8/24/2023 at 12:45 PM CR #1 said he did not remember getting a letter from the nursing home. He said he thought he was going to an appointment. He said the facility staff did not tell him where he was going to stay. He said the facility told him he had to leave because he had not paid. He said he had his friend pick him up. He said the facility staff told him if he and his friend did not leave, they would call the police and have him arrested for trespassing, so they left, and his friend took him to a hotel. Record review of CR #1's face sheet revealed an [AGE] year-old man who was admitted on [DATE] and discharged on 8/16/2023. The face sheet documented his diagnoses included moderate protein-calorie malnutrition (a state of nutrition in which an imbalance of energy, protein, and/or other nutrients cause measurable adverse effects on the body), anemia (lack of healthy red blood cells or hemoglobin), dysphagia (difficulty and/or discomfort in swallowing), mild cognitive impairment (an early stage of memory loss or other cognitive ability loss), muscle wasting (loss of muscle leading to shrinkage) and atrophy (progressive and degenerative shrinkage of muscle), and Methicillin-Resistant Staphylococcus Aureus (MRSA-a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections.) Record review of CR #1's Quarterly MDS dated [DATE] revealed his BIMS score was 10, indicating cognitive impairment. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering and/or elopement behaviors. Per the MDS, CR #1 required one-person supervision with bed mobility, transfers, locomotion, and eating. The MDS revealed he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 5 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0661 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few required one person assistance with walking, but he rarely walked in his room, and did not walk in the corridors. The MDS documented he required extensive one-person assistance with dressing, toileting, and personal hygiene. Per the MDS, CR #1 was frequently incontinent of bladder and bowel, but was not on a toileting program. The MDS revealed he was on a mechanically altered diet. The MDS documented he was at risk for pressure ulcer/injury but did not have any. Per the MDS, he received diuretic medications four of the seven days prior to the assessment. The MDS revealed he had received speech therapy for 157 minutes over five days during of the seven days prior to the assessment. Record review of CR #1's care plan dated 6/28/2023 included a focus on his hearing loss with interventions including ensuring the staff had his attention prior to speaking, repetition of phrases as needed, and clear speaking. The care plan documented a focus on his resistance to care, specifically bathing, with interventions including consistent care, provision of control, avoidance of power struggles, and allowing options. The care plan included a focus on his falls including injury with interventions including provision of toileting, monitoring when out of bed, ensuring the floor was clean, ensuring the bed was in the lowest position, provision of a mobility device, reminding CR #1 to not ambulate without assistance, and analyzing causes of his falls. The care plan revealed a focus on his memory recall problems with interventions including ensuring his area was free of hazard, ensuring his assistive devices were in good condition, redirect the residents when in unsafe areas, and ensuring he wore proper footwear. The care plan included a focus on his ADL decline with interventions including use of a wheelchair and instruction on its use. Record review of CR #1's medication review dated 8/28/2023 revealed he was prescribed acetaminophen extra strength 500mg tablet, one tablet every six hours as needed for pain, aspirin delayed release tablet 81mg tablet once tablet once daily at 9:00 AM, atorvastatin (antihyperlipidemic used to lower cholesterol) 40mg tablet one tablet once daily at 7:00 PM, furosemide (diuretic used to decrease excess water in the body to lower blood pressure) 40mg tablet one tablet once daily, metoprolol tartrate (beta blocker used to treat high blood pressure) 25mg tablet one tablet twice daily at 9:00 AM and again at 5:00 PM, and potassium chloride (used to treat and prevent low blood potassium levels) 10mEq one tablet twice daily at 9:00 AM and again at 5:00 PM. Record review of CR #1's medical records revealed an order dated 5/1/2023 that he may have his medications altered by crushing, opening, or administering in fluid or foods unless contraindicated. The facility was unable to provide a completed post-discharge plan of summary for CR #1. CR#1's signed and dated (5/20/22) admission packet noted the facility would assist CR #1 in making arrangements for discharge. Record review of CR #1's progress note dated 8/16/2023 noted his PCP was at the facility to assess and discharge him. Per the note, CR #1 nodded his understanding of the discharge. The note revealed LVN C assisted CR #1 to a friend's car and CR #1 left. Record review of CR #1's progress note dated 8/17/2023 revealed a late entry for 8/16/2023. The note documented on 8/16/2023 CR #1's discharge order would be at his PCP's office in one week's time. PCP informed LVN C that CR #1 was leaving with a friend. The PCP spoke with the facility's administration to ensure CR #1's safety at discharge. The note revealed the PCP spoke with CR #1's friend who reported he would take CR #1 with him. The note documented the PCP requested CR #1's friend to call the PCP with any concerns for CR #1's health. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 6 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0661 Level of Harm - Immediate jeopardy to resident health or safety Record of CR #1's financial note dated 8/24/2023 revealed a note on 7/15/2023 which documented the facility's former BOM had discussions about past due payments and was taken to the bank for a withdrawal. The notes documented a note on 8/3/2023 that a thirty-day notice follow-up was conducted by the Administrator. Per a note dated 8/4/2023 the former BOM contacted 211 and was informed the Medicaid application would not be processed until 8/31/2023. Residents Affected - Few CR #3 Record review of CR #3's face sheet dated 8/26/2023 revealed an [AGE] year-old man admitted on [DATE] and discharged on 8/23/2023. The face sheet documented his diagnoses included hemiplegia (one-sided paralysis) and hemiparesis (weakness on one side of the body) following cerebral infarction (a loss of blood flow to part of the brain), hypertension (high blood pressure), atherosclerotic hear disease (condition causing arteries to narrow), chronic systolic heart failure (condition in which the left ventricle of the heart is weak), and benign prostatic hyperplasia (condition in which the flow of urine is blocked due to the enlargement of prostate gland). Record review of CR #3's MDS revealed admission MDS dated [DATE] revealed a BIMS score of 10 indicating some cognitive impairment. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering and/or elopement behaviors. Per the MDS, CR #3 required one or more person assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. The MDS revealed he did not walk. The MDS documented CR #3 was always incontinent of bladder and bowel, but he was not on a toileting program. Per the MDS he received OT and PT. Record review of CR #3's care plan dated 8/4/2023 revealed a focus on his ADL deficit with interventions including allowing him extra time to complete ADL's and monitoring for pain when he was completing ADL's. The care plan documented a focus on his potential bleeding because of anticoagulant therapy with interventions including medication administration, monitoring for signs or symptoms of bleeding and/or pulmonary embolism, reviewing and monitoring lab reports, and notification of change. The care plan included a focus on CR #3's potential to fall with interventions including analyzation of falls for possible causes, ensuring his bed was in the lowest position, and provision of proper footwear. Record review of CR #3's physician's order report dated 8/26/2023 revealed orders including PT and OT, a regular diet with thin liquids, monitoring for signs or symptoms of side effects of medications, and weekly skin assessments. The report documented prescriptions including atorvastatin (antihyperlipidemic used to lower cholesterol) 40mg tablet one tablet at 7:00 PM, finasteride (prostatic hypertrophy agent type II 5-alpha reductase inhibitor used to shrink and enlarged prostate) 5mg tablet one tablet at 9:00 AM, venlafaxine (antidepressant used to treat depression) 75mg tablet one tablet every eight hours, Xarelto (direct factor Xa inhibitor used to prevent blood clots from forming) 20mg tablet one tablet at dinner, and carvedilol (alpha-beta blocker used to treat high blood pressure) 6.25mg tablet one tablet twice daily at 9:00 AM and 5:00 PM. Record review of CR #3's discharge plan of care dated 8/26/2023 revealed the discharge assessment occurred on 8/21/2023 at 2:07 PM. The plan of care documented it was completed by the MDS LVN. Per the plan of care, CR #3 was discharged to the facility. The plan of care revealed a note that he was discharged to the assisted living facility by wheelchair, denied any discomfort, and was awake and alert at discharge. The plan of care included sections for the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 7 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0661 Observation details; Level of Harm - Immediate jeopardy to resident health or safety Discharge Equipment Needs; Residents Affected - Few Medication Upon Discharge; Home Health Services/Referrals; Nutritional Needs Upon Discharge; Post-discharge Appointments/Follow-up Visits; Post-discharge Wound Care/Treatments; ADL's; Special Instructions Upon Discharge; and Documents Given Upon Discharge. None of those sections were completed. Interview on 08/23/23 at 3:40 p.m. a family member said they would check on CR #1 at the hotel. The family member said if CR #1 required medical attention they would take him to the hospital. Interview on 8/23/2023 at 4:50 PM the Admin said the resident owed $50k. He said CR#1 did not pay and would not provide information for the insurance application. He said the physician assessed him and said he was okay to discharge. He said there was an order from the Physician to discharge CR #1. Interview on 08/24/23 at 11:35 a.m. with CNA A revealed the resident was sometimes incontinent and needed assist with changing his brief. Interview on 08/24/23 at 11:40 a.m. with MA B revealed the resident told her They put him out. She said his medications were in the medication room after he discharged . The hospital Charge Nurse said CR# 1 was admitted the previous day (8/23/23), via ER. She said CR# 1 knew his name and DOB but did not know time of day. He was admitted with altered level of consciousness and pneumonia. She said a friend brought him from his hotel. Interview on 08/24/23 via telephone with LVN C revealed there was no paperwork sent with CR #1 when he discharged . He was not provided with medications. LVN C said CR #1 did not sign anything at the time of his discharge. Interview on 08/24/23 at 1:57 p.m. with the Administrator revealed he said there was an order from the PCP to discharge CR #1. He said the PCP assessed him. The Admin said the facility did not send medications with residents upon discharge. He said the PC would call the pharmacy with prescriptions. The Admin was not sure if the PCP called in the prescriptions. Interview on 8/24/2023 at 2:56 PM with the CNC, she said the facility attempted to provide CR #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 8 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0661 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few his medications but he refused to take them. Regional Nurse said the facility failed to document his refusal to take the medications. Regional Nurse said CR #1 often refused to take his medications. Interview on 8/24/2023 at 5:11 PM with The PCP, she said she had been called by the facility administrator at 4:45 PM on 8/16/2023 and informed that CR #1 was discharging that day. The PCP said she asked the administrator if the discharge would be safe because of CR #1's previous history. The PCP said she asked where CR #1 was being discharged to. The PCP said she was informed by the administrator that the discharge would be safe and CR #1 would be checking into a motel. The PCP said she then came to the facility and found CR #1 sitting with a friend. The PCP said CR #1 was upset, and he told The PCP that he had to leave the facility because he was trespassing. The PCP said she was told by CR #1's friend that if he and CR #1 did not leave the administrator was going to call the police on CR #1 for trespassing. The PCP said she was upset by this. The PCP said she told CR #1 the police would not arrest him because he had done nothing wrong and had lived at the facility for a long time. The PCP said she told CR #1 he had not committed any crimes. The PCP said CR #1's friend said he and CR #1 were just going to leave and go to a motel. The PCP said she asked what they would do after the motel. The PCP said CR #1's friend said they would take him to another nursing facility. The PCP said she informed them that getting CR #1 admitted to another nursing facility would be difficult. The PCP said she informed them that they did not have CR #1's paperwork and records. The PCP said she asked them to leave a bag of CR #1's belongings in case he wanted to return to the facility. The PCP said the following morning, 8/17/2023, she reviewed the facility's EMR and found no numbers to contact CR #1 or his friend. The PCP said she was concerned because she could not contact them to ensure his safety. The PCP said on 8/18/2023 CR #1 and his friend came to her office and told her CR #1 wanted to return to the facility. The PCP said she contacted the administrator and was informed CR #1 could return as long as he had the correct information for Medicaid. The PCP said she informed CR #1 and his friend of this and she thought CR #1's friend understood, but was not sure if CR #1 did. The PCP said CR #1 has dementia. The PCP said on 8/23/2023 CR #1's friend returned to the facility and again said CR #1 wanted to return to the facility. The PCP said she contacted the facility's admissions coordinator to assist in obtaining the needed paperwork for CR #1's return. The PCP said later on 8/23/2023 she went to the hospital and found CR #1 in the emergency room. The PCP said CR #1 did not appear as he did on 8/18/2023. The PCP said CR #1 appeared to look confused and drawn out. The PCP said she called the facility admitting personnel today and again asked if he could return to the facility. The PCP said the admission personnel said as long as the Medicaid information was correct, CR #1 could return. The PCP said she saw CR #1 at the hospital again on 8/24/2023. The PCP said he appeared to have better cognition in the morning, but was sedated in the afternoon. The PCP said an MRI had been ordered and CR #1 refused. The PCP said she ordered Xanax for CR #1 and he still refused the MRI. The PCP said CR #1's current low sodium may be related to his discharge because he may not have received the nutrients he would have at the hospital. The PCP said she did not think the pneumonia was caused by a lack of medication. Interview on 8/25/2023 at 7:45 AM with The CNC, she said the facility does not have a standardized training for discharging residents. Interview on 8/26/2023 at 8:37 AM with the DON, she said she had been employed by the facility since 4/20/2023. The DON said her training consisted of one-to-one training with corporate staff reviewing the DON manual. The DON Said the discharge team typically consisted of the administrator, the business office, and the MDS nurse. The DON said the nurses are responsible for creating the discharge plan of care and the discharge summary. The DON said the discharge plan of care documents who picked the resident up, what mode of transportation the used to resident leave the facility, who accompanied the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 9 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0661 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident, medications, orders for post-discharge medical appointments, dietary orders, and what assistance is needed in ADL's. The DON said if a resident was not provided a discharge plan of care, he/she/they may not have the information he/she/they required, including information related to the resident's post-discharge care, medications, and post-discharge medical appointments. The DON said if a resident did not receive the discharge plan of care the resident's continuation of care could be interrupted. The DON said if a resident was discharged without a plan of care, to a hotel, and that resident required assistance with eating and medications, that would be concerning. The DON said it would be concerning because that resident may not have their medications or have the means to take the medications. Interview on 8/26/2023 at 10:18 AM with the Admin, revealed he had been employed by the facility since 11/2022. The Admin said CR #1's discharge had been an ongoing concern. The Admin said the facility had been working on CR #1's payment status for some time. The Admin said CR #1 kept saying he would pay his outstanding balance. The Admin said the payment situation went on for months. The Admin said the facility ultimately could no longer allow CR #1 to remain without payment and he was given notice. The Admin said CR #1 continued to say he would provide the past-due payments needed. The Admin said CR #1 would change his plan from paying the past-due balance and leaving. The Admin said during the thirty days after CR #1 was given a thirty-day notice he failed to provide the facility with all the information needed to obtain payment, or repayment of the past-due balance. The Admin said after the thirty days CR #1's friend was contacted. The Admin said the friend was aware CR #1 either had to provide the information needed to obtain insurance payment or pay the past-due amount, or CR #1 would have to leave the facility. The Admin said CR #1 said he was going to his house. The Admin said CR #1's friend said he would take CR #1 to his home. The Admin said on the day of the discharge the plan changed, and CR #1 decided he and his friend said would stay go to a motel, and CR #1's friend would stay with him at the motel. The Admin said the plan was for CR #1 to stay at a hotel for one night then go to another nursing facility. The Admin said prior to the discharge The PCP was notified. The Admin said The PCP wanted to complete an in-person discharge assessment. The Admin said the PCP came to the facility, CR #1 informed her that he would be going to a motel for one night, then admitting to another nursing facility. The Admin said the PCP completed a discharge order with instructions to come for a follow-up appointment the following week. The Admin said the PCP wrote CR #1 one prescription when he discharged . The Admin said the following day CR #1 went to another nursing facility and refused to provide them the information to obtain insurance payment and did not admit. The Admin said The PCP saw CR #1 in her office, and he said he would be coming to the scheduled follow-up appointment with the information needed to readmit to the facility. The Admin said the facility's back-up plan during the time after the thirty-day notice was given was for CR #1 to leave and go home. The Admin said CR #1's friend reported CR #1's home was not livable, but CR #1 could live with the friend. The Admin said on the day of the discharge that plan changed to going to a hotel for one night and then admitting to another nursing facility. The Admin said prior to discharging, CR #1 received all of his medications for that day. The Admin said CR #1's friend reported he would be able to assist CR #1 with his crushed medications and altered diet if needed. The Admin said CR #1 and the friend were instructed to call The PCP with any concerns of any kind. The Admin said the facility was never informed of CR #1 having any concerns or issues with his crushed medications or altered diet. The Admin said CR #1's discharge was safe because there was an order for discharge and instructions to reach out to The PCP for any concerns, even though CR #1 had no means to crush his medications or alter his diet's texture. Interview on 8/26/2023 at 11:35 AM with the CNC revealed the facility did not complete the discharge plan, or discharge planning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 10 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0661 documentation for CR #3. Level of Harm - Immediate jeopardy to resident health or safety Record review of the facility's Discharge Summary and Plan policy dated December 2012 revealed a policy statement which read When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The policy included information related to the discharge summary and plan, the post-discharge plan, and the notice of discharge. The policy documented that the discharge summary would include a recapitulation of the resident's stay at the facility and final summary of the resident's status at the time of discharge. The discharge summary for the resident included the following: Residents Affected - Few medical conditions; medical status; mental and physical status; sensory and/or physical impairments; special treatments; mental and psychosocial status; discharge potential; and dental condition. The post discharge plan for the resident required the following: a description of the resident's and the family's preferences for care; description of how the resident and family will access such services; description of how the care should be coordinated; the identity of the specific resident needs after discharge; and a description of how the resident and family need to prepare for the discharge. Per the policy, the resident or representative should provide the facility with a minimum of 72 hours' notice of discharge to ensure an adequate discharge plan is created. This was determined to be an Immediate Jeopardy (IJ) on 8/25/2023 at 2:17 PM. The Administrator , DON, and CNC were notified. The Administrator was provided the Immediate Jeopardy template on 07/29/23 at 2:22 PM. The following Plan of removal submitted by the facility was accepted on 8/27/2023 at 2:37 PM: FACILITY: Colonial Living and Rehabilitation Bay City (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 11 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0661 Facility ID Number: Level of Harm - Immediate jeopardy to resident health or safety SURVEY TYPE: Complaint Survey Residents Affected - Few Plan for REMOVAL SURVEY DATE: 8/25/23 Plan to remove immediate jeopardy. The facility failed to provide one resident with a discharge summary for an anticipated discharge.

F661 On 8/25/2023 the Administrator notifies Medical Director of immediate jeopardy. On 8/25/2023 Director of Nursing/Designee contacted Hospital, where he is currently, to ensure that resident is currently safe. On 8/25/2023 Director of Nursing/Designee assessed all residents in the facility who have a plan to discharge in the next 30 days, including residents returning to the Assisted Living Facility to ensure that they have been given reasonable and appropriate notice. No concerns were noted with the residents who have a plan to discharge in the next 30 days. Resident records were reviewed who discharged to the community in the last 30 days to ensure they received a discharge summary, if not follow up was completed to ensure resident is safe, they have medications, and a follow-up has been done with a physician or an appointment was scheduled. This will be completed 8/26/2023. On 8/25/2023 RNC (Regional Nurse Consultant) will complete in-service with Director of Nursing, and Administrator on discharge planning process, including ensuring resident receives a discharge summary to include taking medications and support services are provided if indicated before discharge and that all residents have reasonable and appropriate notice before discharge. Discharge planning will include notifying the physician to receive an order for discharge and all of the needs are anticipated for the resident with interventions put in place before discharge. This was completed 8/25/2023. On 8/25/2023 DON/Designee reviewed all residents in the facility who may wish to discharge from the facility. IDT will review all residents requesting to discharge from the facility to ensure residents have reasonable and appropriate notice, discharge summary, discharge orders, discharge assessment and care plan is updated for the discharge. This was completed 8/25/2023. Starting on 8/25/2023 the Director of Nursing/Designee will initiate in-service with nurses, including new hires, PRN, and agency staff on adequate discharge planning and preparation to include discharge summary, discharge assessment, safe discharge location, discharge medication, reasonable notice and that they have received an order from the MD and will train staff before returning to work. This was completed 8/25/2023. Ad-Hoc QAPI meeting was held on 8/25/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Regional Nurse Consultant, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 12 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0661 The Administrator will be responsible for ensuring this plan is completed on 8/25/2023. Level of Harm - Immediate jeopardy to resident health or safety The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring: Residents Affected - Few Record review on of the POR binder for Discharge IJ revealed audits completed for all planned discharges completed, discharges planned to be completed, and review of discharges to the community in the previous month. The audits were updated on 8/27, 8/28, and 8/29/2023. Interview on 8/28/2023 at 12:41 PM with ALVN J, she said had recently received in-service training at the facility on infection control and discharge planning. ALVN J said she had been instructed during in-service training related to discharge planning that the nurse completing a discharge must ensure the resident's PCP had provided discharge orders and the resident is stable for discharge. ALVN J said the training also enforced that the discharging nurse must ensure the resident, resident's family, and/or RP is provided with the discharge summary, medications, treatments, and/or supplies for any treatments at discharge. ALVN J said the training required the discharging nurse to make notifications to the DON and PCP that the resident was discharging. ALVN J said when the resident discharged , the discharging nurse would review the summary, follow-up appointments, treatments, and medications with the resident and/or resident's RP. ALVN J said following this, she would obtain signatures from the resident and/or RP. ALVN J said if the discharge was unsafe, she would notify the DON and PCP immediately, then she would wait for further orders regarding the discharge. ALVN J said a discharge could be unsafe if the resident did not have a place to discharge to, did not know he/she/they were leaving or who he/she/they were leaving with, did not have supplies, follow-up care was missing, and/or there was a lack of continuity of care. Interview on 8/28/2023 at 1:01 PM with LVN S revealed she had been employed by the facility for a little less than one year. LVN S said she had spent one week shadowing another charge nurse prior to working on the floor independently. LVN S said the facility staff assist her in any way she needs. LVN S said her primary duties as an LVN were to ensure resident safety, providing wound care, medication administration, and ensuring residents were fed when needed. LVN S said she had recently had an in-service training related to discharge planning. LVN S said the training instructed the nurses to complete the discharge summary and plan of care prior to the resident's discharge, including all areas of the discharge summary and plan of care. LVN S said the training instructed the nurses to ensure the residents were leaving in a safe manner, print the discharge summary and plan of care, review those with the resident and/or RP. LVN S said prior to any discharge, the PCP must provide discharge orders for that resident. LVN S said a discharge could be unsafe if the resident was being discharged to a verbally abusive person, a person who was obviously under the influence of alcohol or other substance, and/or the resident was being discharged to an unsafe environment. LVN S said if she felt the discharge was unsafe, she would not discharge the resident, but she would contact the DON and PCP to discuss further options. Interview on 8/28/2023 at 1:17 PM with ALVN E revealed she worked at the facility quite frequently. ALVN E said her primary duties at the facility included supervising the CNA's and MA's, ensuring medications were administered appropriately, ensuring residents' ADL's were performed, and resident safety. ALVN E said she recently received in-service training at the facility related to infection control, cigarettes, and discharge planning. ALVN E said she was informed during the discharge planning in-service that the nurse responsible for discharging a resident must complete the discharge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 13 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0661 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete summary and plan of care, including the resident's vitals and ensuring a safe discharge. ALVN E said prior to any discharge, the resident's PCP must provide a physician's order for the discharge. ALVN E said when a resident is discharged , he/she/they must be provided their medications, belongings, and/or notification of follow-up appointments which had been scheduled. ALVN E said she would ask questions of the resident and/or RP to determine if the discharge was safe. ALVN E said a discharge could be unsafe because the resident had no where to discharge to or was discharging to an unsafe environment, the resident did not have medications, the resident had no assistance for ADL's or medication administration, and/or the resident had no assistance of any kind where they were discharging to. ALVN E said if a resident's discharge was unsafe, she would call the PCP and DON and wait for further instructions. ALVN E said if a resident insisted on discharging to an unsafe placement, the resident would be discharging AMA. ALVN E said care plans ensured the residents received the services and treatments required for their care. ALVN Event ID: Facility ID: 455643 If continuation sheet Page 14 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 4 residents (CR #24, and, Resident #23) reviewed for ADLs. Residents Affected - Few -The facility failed to ensure Resident #24 was provided incontinent care in a timely caused her pants to be wet from front to back. -The facility failed to ensure Resident #23 was provided grooming (shaving) This failure could place residents at risk for discomfort, and dignity issues. Findings include: Resident #24 Record review of Resident #24's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted om 05/19/23. Resident #24 had diagnoses which included diabetes mellitus (body does not produce enough or respond normally to insulin, causing blood sugar(glucose)levels to be abnormally high) hypertension (a condition in which the blood vessels have persistently raised pressure), heart failure (the heart is unable to pump blood around the body properly) and atrial fibrillation(the top chambers of the heart (the atria) quiver or twitch). Record review of Resident #24's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Resident #24's functional status revealed she needed extensive assistance with one staff assistance for bed mobility, transfer, dressing, and personal hygiene. Resident #24 was incontinent of bladder and bowel. Record review of Resident #24's care plan problem start date 06/14/22 and edited 03/14/23, revealed: Resident #24 had bladder/bowel incontinence related to mobility deficit being bed fast, and obesity. Interventions: check for incontinent episode on rounds, provide incontinent care after each incontinent episode. Interview on 08/23/23 at 9:50 a.m., Resident #24 said the night aide changed her a few minutes before 6:00 a.m., and none of the aides from the morning shift had checked on her. She said she was wet, and Resident #24 also thought she had a bowel movement. She said she felt unclean and not cared for by the staff. She said sometimes she would not remember to call for help. Observation and Interview on 08/23/23 at 10:01 a.m., CNA M said she came in and turned off the call light. She said she came to work at 6:00 a.m., had not checked on Resident #24, and had not changed her incontinent brief. She asked the resident if CNA H had changed her today, and Resident #24 said CNA H had not changed her today, and she said she would call her aide so they could change her. Observation on 08/23/23 at 10:22 a.m. revealed the following when CNA H opened Resident # 24's incontinent brief: the brief was saturated with urine and bowel movement from front to back, and bowel movement, which looked semi-dry, showed it had been in the brief for some hours. The wet line indicators were dark blue, and they appeared smashed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 15 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/23/23 at 10:51 a.m., CNA A H said she was Resident #24 aide for today, and she came to work at 6:00 a.m., and she had not checked or changed the resident until now when she pulled her call light. She said the resident incontinent brief was soaked with urine and bowel movement from front to back, and the wet indicator line was fading and dark blue. She said the resident had a bowel movement in her peri area. She stated the aides are supposed to make rounds every two hours for incontinent care. She said if Resident #24 was left in an incontinent brief, wet with urine and bowel movement, the resident might develop redness and skin breakdown or infection. She said she had skills - checkoffs and in-service on ADL, which included incontinent care. She said the charge nurse and staff coordinator monitor the aides by making random rounds. Interview on 08/23/23 at 11:10 a.m., CNAM said Resident #24's incontinent care brief was saturated with urine and bowel movement from front to back, and the resident had a bowel movement in her peri area. She said the bowel movement appeared slightly dry, which could mean it had been in the brief for some time. She said if Resident #24 was left in a wet incontinent brief for an extended period, CNA M stated Resident #24 could have a skin breakdown and infection. Interview on 08/23/23 at 12:20 p.m., the DON said CNA M and CNA H should make frequent rounds, and she does not like to say every two hours because they may not be able to get to the resident every two hours. She said if Resident #24 was left in a wet incontinent brief for an extended time, the resident could develop MASD (moist associated skin damage), redness, and an infection. She said the staffing coordinator monitors the aides to make sure the aides are providing care for residents by doing random rounds. Resident #23 Record review of Resident #23's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted om 05/03/23. Resident #23 had diagnoses which included diabetes mellitus (body does not produce enough or respond normally to insulin, causing blood sugar(glucose)levels to be abnormally high) hypertension (a condition in which the blood vessels have persistently raised pressure), peripheral autonomic neuropathy(damage to the nerves that control automatic body functions ) and bipolar disorder(a mental illness that cause unusual shifts in a person's mood energy, activity levels, and concentration). Record review of Resident #23's annual MDS, dated [DATE], revealed a BIMS score of 01 out of 15, which indicated the resident's cognition was severely impaired. Resident #23's functional status revealed she needed extensive assistance with one staff assistance for bed mobility, transfer, dressing, and personal hygiene. Resident #23 was incontinent of bladder and had colostomy. Record review of Resident #23 's care plan target date 07/12/23, revealed: Resident #23 needs extensive assist of staff for personal hygiene. Goal: resident will be assisted to keep clean, dry, odor free. Observation and Interview on 08/25/23 at 10:55 a.m., revealed that Resident #23 had white and black facial hair on her chin, and Resident #23 said she wanted to be shaved. Interview on 08/25/23 at 11:25 a.m., NA R said Resident #23 was a night shower, and they usually do not shower her, and she does her best to shower the resident. She said she saw Resident #23 had black and white facial hair on her chin, and she did not shave or plug it. NA R said Resident #23 should be shaved by the aide on shower days and as needed. She said if Resident #23 wanted to be shaved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 16 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and she was not shaved, she would feel unkempt, which was also a dignity issue. She said she had in service on ADL, and it included shaving. She said the charge monitored aides by making random checks on the residents. Interview on 08/25/23 at 11:49 a.m., LVN I said Resident #23 had white and black facial hair on her chin, and she did not notice the facial hair when she made rounds this morning until it was pointed out to her by the surveyor. She said the aides should shave or pluck Resident #23, depending on the resident's choice, during the shower and as needed. She said the floor nurses monitored the aides by making rounds, and the nurse managers monitored the nurses by making random rounds on the residents. She said it would be a dignity issue if Resident #23 wanted to be shaved and she was not shaved. She said Resident #23 said she wanted to be shaved. Interview on 08/25/23 at 12:13 p.m., the DON said NA R should have shaved Resident #23 when she showered today. She said residents are shaved on shower days and as needed. She said if a female resident wanted to be shaved and she was not shaved, it was a dignity issue, and it could affect how the resident felt. She said she could only find one shower sheet for resident #23 for August 2023. She stated the resident should be showered at least three times a week. Record review of Resident #23 's skin site identification form dated 08/07/23 revealed Resident #27 was not shaved. Record review of the facility policy on Perineal care 2001 MED - PASS, Inc (Revised October 2010) read in part . the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infection and skin irritation . Record review of the facility policy on shaving 2001 MED - PASS, Inc (Revised October 2010 read in part . the purpose of this procedure is to promote cleanliness and to provide skin care . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 17 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #24) reviewed for incontinent care. - The facility failed to ensure CNA H and CNA M followed proper infection control procedures and did not completely clean Resident #24 during incontinent care. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings include: Record review of Resident #24's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted om 05/19/23. Resident #213 had diagnoses which included diabetes mellitus (body does not produce enough or respond normally to insulin, causing blood sugar(glucose)levels to be abnormally high) hypertension (a condition in which the blood vessels have persistently raised pressure), heart failure (the heart is unable to pump blood around the body properly) and atrial fibrillation (the top chambers of the heart (the atria) quiver or twitch). Record review of Resident #24's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Resident #24's functional status revealed she needed extensive assistance with one staff assistance for bed mobility, transfer, dressing, and personal hygiene. Resident #24 was incontinent of bladder and bowel. Record review of Resident #24's care plan problem start date 06/14/22 and edited 03/14/23, revealed: Resident #24 had bladder/bowel incontinence related to mobility deficit being bed fast, and obesity. Interventions: check for incontinent episode on rounds, provide incontinent care after each incontinent episode. During an Observation on 08/23/23 at 10:22 a.m., CNA M placed incontinent care items on Resident #24's bedside table. They did not remove the resident personal items, such as her drink cup with exposed straw, snacks, chips, and cookies, before CNA M the incontinent supplies were placed on the table and used during incontinent care. During an observation and interview on 08/23/23 at 10:22 a.m. revealed, CNA H and CNA M provided incontinent care for resident #24. CNA H cleaned Resident #24's peri during incontinent care without separating the labia. She cleaned out bowel movements from the peri area three times, and there was a substantial amount of bowel movement each time. CNA H turned the resident to her right side, and CNA M cleaned her buttocks without separating her buttocks, and she did not clean the resident's butt checks. Both aides did not wash or sanitize their hands when they changed gloves four times each because the gloves hand bowel movement each time. The surveyor intervened when CNA M was about to apply a clean incontinent brief on the resident. CNA M wiped Resident #24 butt checks twice, and there was a bowel movement. When CAN H separated the resident labia and cleaned the area twice, there was a substantial amount of bowel movement on the wipes, and on the fourth wipe, it was clean. During an interview on 08/23/23 at 10:56 a.m., CNA H said she forgot to separate Resident #24's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 18 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few labia during peri care, and if she did not clean the resident's peri area and vagina well, the resident could develop infection and rashes. She said she had in-service on perineal care and skill check-off on incontinent care. She said the charge nurse checked the aide when she made random rounds on the resident to ensure the aide was providing care for the residents. CNA H said she forgot to wash or sanitize her hands when she changed gloves, but she should because the gloves may have tiny holes, and there were bowel movements on the gloves. She said it was an infection control issue when she did not separate the labia and did not sanitize her hands when she changed the gloves, which were soiled with bowel movements. During an interview on 08/23/23 at 11:07 a.m., CNA M said she did not separate Resident #24 buttocks when she cleaned the resident. CNA M stated she did not clean the resident properly because there was still bowel movement on the resident's buttocks when she had to clean it again. She said if she did not clean the resident thoroughly, the resident could develop skin rashes, skin breakdown, or even infection. She said it was cross-contamination when she placed the bag with the peri-care items on the resident's bedside table with Resident #24 Items. She said she could have contaminated the drinking cup with a straw, chips, and cookies which could make the resident sick. She said it was an infection control issue when she did not wash or sanitize her hands when she changed her gloves, even when they were soiled with bowel movements. She said she had skills checks off on incontinent care, and the floor nurse made random rounds on residents to make sure the aides were providing care for the residents. During an interview on 08/23/23 at 12:30 p.m., the DON said CNA H was supposed to separate Resident #24's labia and made sure she cleaned both sides and the middle properly to prevent rash and UTI (urinary tract infection). During an interview on 08/23/23 at 12:32 p.m., the DON said CNA H and CNA M should wash or sanitize their hands when they change their gloves during incontinent care for Resident #24. She said the gloves may have tiny openings because they were going from dirty to clean (to prevent the spread of germs). During an interview on 8/23/23 at 12:39 p.m., the DON said CNA M should have disinfected the bedside table and placed a barrier on the bedside table. She then stated the aide should move Resident #24's items away from the bedside to prevent cross-contamination, and the CNA M should disinfect the bedside table after she returned before Resident #24 personal items to the table. She said Resident #24 personal items could be contaminated when CMA M left Resident #24 water cup and snacks on the table. Record review of the facility policy on Perineal care 2001 MED - PASS, Inc. (Revised October 2010) read in part . the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infection and skin irritation . steps and procedure #9b1 . separate labia and wash area .#94c . wash the rectal area thoroughly . Record review of CNA H's skills checklist - peri care revealed CNA H signed it on 06/23/23. Record review of CNA M's skills checklist - peri care revealed CNA M signed it on 06/23/23. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 19 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals and a system of medication records that enables periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 3 of 10 residents (Residents #27, Resident #22 and Resident #26) reviewed for pharmacy services, in that: -The facility failed to ensure MA W did not sign off on control medication before the administration time for Resident #27, Resident #22, and Resident #26. This failure could place residents at risk of not receiving their medication and drug diversion. Findings include: Resident #27 Record review of Resident #27's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted om 01/23/21. Resident #27 had diagnoses which included mononeuropathy (damage that happens to a single nerve) heart failure (when heart muscle does not pump blood as well as it should), and dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities). Record review of Resident #27's physician order report dated for August 2023 revealed zolpidem 10 mg (schedule 4 controlled substance): 1 tablet by mouth at bedtime. During an observation on 08/23/23 at 5:30 p.m., of the medication cart for 200 and 500 hall with MA W and RN R revealed, Resident #27's Zolpidem tartrate 10mg had 20 tables in the blister packet, but the count sheet had 19 tables. Resident #22 Record review of Resident #22's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted om 01/23/21. Resident #22 had diagnoses which included hypertension (a condition in which the blood vessels have persistently raised pressure), heart failure (when heart muscle does not pump blood as well as it should), and atrial fibrillation (irregular heartbeat rhythm that begins in the upper part of heart). Record review of Resident #22's physician order report dated for August 2023 revealed clonazepam 0.25 mg (schedule 4 controlled substance): 1 tablet by mouth at bedtime. During an observation on 08/23/23 at 5:30 p.m., of the medication cart for 200 and 500 hall, with MA W and RN R, revealed Resident #22's Clonazepam 0.5 mg: give half tablet had 28 tablets in the blister packet, but the count sheet had 27 tablets. Resident #26 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 20 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 Record review of Resident #26's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #26 had diagnoses which included hypertension (a condition in which the blood vessels have persistently raised pressure), dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), and polyneuropathy (malfunction of many peripheral nerves throughout the body). Residents Affected - Some Record review of Resident #26's physician order report dated for August 2023 revealed pregabalin 75 mg (schedule 5 controlled substance): 1 tablet by mouth three times a day: 7:00, 15:00, and 19:00. During an observation on 08/23/23 at 5:30 p.m., the medication cart for 200 and 500 hall cart with MA W and RN R revealed Resident #26's Pregabalin 75mg capsule had 7 capsules in the blister packet, but the count sheet read 6 capsules. During an interview on 08/23/23 at 6:02 p.m., MA W said she signed off on the medication sheets for the following residents: Resident # 22, Resident #27, and Resident #26 without popping the medication because she knew she would administer the drug later. She said the medicines were due by 7:00 p.m. and signed off on them around 5:15 p.m. She said she was not following the facility protocol on control medication administration because you pop the medication before you sign off on the count sheet. She said she signed off medication sheets but did not pop the pill, and it could appeared as drug diversion. She said she had a skills check on medication administration, including drug diversion. She stated that the nurse managers make random rounds during medication administration. During an interview on 08/23/23 at 6:06 p.m., RN R said MA W should not have signed off on the medication sheets before she popped the medication for Resident #22, Resident#27, and Resident #26. She said medication should not be signed off hours before the medication is due. She should follow the six medication rights to prevent missed pills and drug deviation. During an interview on 08/24/23 at 3:15 p.m., the DON said MA W should not have signed off on the control medication sheets before the medication was punched for Resident #22, Resident #27, and Resident # 26 to prevent drug diversion. She said medication should be punched at the scheduled time when MA W was about to administer the medication and signed after she popped it. Record review of the facility policy on controlled medication storage 2007 PharMerica Corp read in part . medication included in the drug enforcement administration classification as controlled substances are subject to subject to special handing, storage, disposal and record keeping in the nursing care center . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 21 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 out of 2 medication carts (medication aide cart for 200 and 500 hall cart), reviewed for medication storage. - The facility failed to ensure MA W did not leave discontinued control medication in the 200/500 hall medication cart, and one of the tablets was punched out and taped back to the blister packet. This failure could place residents at risk of getting discontinued medication and drug diversion. Findings Include: Record review of Resident #25's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted om 08/12/23. Resident #25 had diagnoses which included diabetes mellitus (body does not produce enough or respond normally to insulin, causing blood sugar(glucose)levels to be abnormally high) hypertension (a condition in which the blood vessels have persistently raised pressure), and diabetic neuropathy (a type of nerve damage that occur with diabetes). Record review of Resident # 25' s physician order report dated for August 2023 revealed Pregabalin 75 mg (schedule 5 controlled substance: 1 capsule by mouth two times a day was discontinued on 08/15/23. Observation on 08/23/23 at 5:30 p.m., the control box in the 200 and 500 medication cart revealed Resident #25 had Pregabalin 75 mg, which was discontinued on 08/15/23 and was still in the cart and had three capsules. One of the capsules was punched and placed back in the blister packet, taped with clear tape. It also revealed it was signed off twice and scratched off twice after being discontinued. Interview on 08/23/23 at 6:04 p.m., MA W said when the doctor stopped Resident #25's medication, she should have taken the drug out of the cart right away to prevent administering the wrong medication and diversion. She said once a staff popped a pill, and the staff should not place the medicine back with a tap but destroy it with a nurse and make the count corrections. Interview on 08/23/23 at 6:07 p.m., RN R said when the doctor discontinued Resident # 25's control medication, MA W should have removed it from the medication cart. RN R stated that that would prevent medication errors and drug diversion. She said MA W should not have placed the popped medication in the blister packet with tape but destroyed it with a nurse. Interview on 08/24/23 at 3:13 p.m., the DON said if any staff pushed out a medication, it should not be placed back with a tape but destroyed by two staff, a nurse, and a medication aide. She said when any medication, even control medication, was discontinued, the medication aide should remove the medicine from the cart and place it in the destruction box in the medication room, and MA W should give the control medication to the DON who would lock it up until medication destruction with the pharmacist. She said this included Resident #25's discontinued medication. She said this would prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 22 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 medication errors and drug diversion. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy on storage of medications 2001 MED - PASS, Inc. (Revised April 2007) read in part . policy interpretation and implementation #4 . the facility shall not use discontinued . Residents Affected - Few Record review of the facility policy on controlled medication storage dated 2007 PharMerica Corp read in part . procedures #7a . control medications remain in the nursing care center after the order has been discontinued . in a securely double locked area restricted access until destroyed as outlined by state regulation . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 23 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to honor residents' preferences in choosing hospice care in 2 (Resident #30 and Resident #32) of 5 residents reviewed for hospice care. The facility failed to allow Residents #30 and Resident #32 choose their own hospice provider. The facility took Resident #30 off hospice services against family wishes and Resident #30 expired within 6 months. These failures could place other residents at risk for not receiving hospice services of their choice and not receiving appropriate end of life care. Findings include: Record review of Resident #30's Face Sheet revealed a [AGE] year-old female who was admitted [DATE] with diagnoses of Heart Failure (Inadequate pumping of the heart), Anxiety Disorder (Excessive Worry), Urinary Tract Infection (Infection in urine drainage tract), Pressure Ulcer of Sacral Region Stage 3 (Skin breakdown below spine), Dementia (Memory loss). Status: Expired. discharged [DATE]. Record review of Resident #30's quarterly MDS dated [DATE] revealed a BIMS of 3 out if 15 indicating the resident was severely cognitively impaired. Resident #30 required extensive assistance with bed mobility and dressing. Resident was a two person assist with bed mobility, transfers, dressing and toilet use. Walking in room or corridor did not occur. Section O noted Hospice Care. Record review of Resident #30's Care Plan dated [DATE] read in part . (problem start date [DATE] .Resident was on hospice R/T Terminal condition .hospice service had been discontinued but now reinstated [DATE] .as of [DATE] rt terminal condition .Approach start date [DATE] .coordinate with hospice services on POC .Approach start date [DATE] Involve resident in care and decision making to maximal potential. Record review of Resident #30's Physician Orders dated [DATE] read in part . Revoke Hospice, Signed by Nurse Practitioner and Physician #1. Section O noted Hospice Care. Record review of Resident #32's Face Sheet revealed a [AGE] year-old female who was admitted [DATE] with a diagnosis of Cerebral Infarction (Disrupted Blood Flow to the Brain), Urinary Tract Infection (Infection in Urine Drainage Tract), Post Viral Fatigue Syndrome (Extreme Tiredness After a Viral Illness). Status: Expired. discharge date : [DATE]. Record review of Resident #'32s quarterly MDS dated [DATE] revealed a Cognitive Skills for Daily Decision Making of 3 indicating the resident was severely impaired. Resident #32 required total assistance with bed mobility, dressing, eating, toilet use and personal hygiene. Walking in room and locomotion in corridor did not occur. Record review of Resident #32's Care Plan dated [DATE] read in part . Problem start date: [DATE] .Resident requires hospice R/T CHF and malnutrition .on Hospice #1 XXX[DATE] changed to Hospice #3 . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 24 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on [DATE] at 9:08 a.m., the Patient Care Manager with Hospice #1 she said their Medical Director, Physician #2 was a physician at the nursing facility along with some other physicians. She said due to some issue between him and the facility, the facility decided he was being paid too much and he resigned. She said he stayed on as the medical director of their hospice company, Hospice #1. She said the two other physicians in the building were associated with another company, Hospice #2. She said Hospice #2 went into Resident #30's room who had been on their service (Hospice #1) for several weeks and tried to write discharge orders and then tried to put Resident #30 on their hospice service (Hospice #2). She said Physician #1 never called and told them they wrote orders on their patient. She said the family called the administrator and tried to discuss this with him and were told those physicians could write orders on them if they wanted to. She said their hospice agreed to write discharge orders if the resident decided to go with the new hospice. She said the family did not want to change hospice services over to a new company. She said they were providing Resident #30 with wound care, baths and had provided an air mattress and the residents family did not want to change services. She said from the meeting with Resident #30 the administrator banned Hospice #1 from the facility and their patients were discharged . She said the administrator told them if their nurse came to the facility, he would call the police. She said prior to this there was no wrongdoing with the hospice care, and this had transpired strictly due to Physician #2 leaving the facility. In an interview on [DATE] at 9:20 a.m., with Resident Representative #31 she said Resident #30 passed away on [DATE]. She said she would have loved for Resident#30 to stay on hospice services. She said Resident #30 showed a significant decline in [DATE]. She said she had heard of Hospice #1 and inquired about them. She said Resident #30 was placed under their services. She said hospice services lasted [DATE] and [DATE]. She said she was told by the facility administrator Hospice #1 was no longer allowed on the property. She said she was never told anything was going on and was then told her mother was not allowed to have their services. She said she never gave permission to terminate hospice services. She said she was told Resident #30 was no longer on hospice services by LVN A. She said she was never called or involved in the decision-making process. She said she was told by the Nurse Practitioner who worked for the new Medical Director, Physician #1 her mother no longer qualified for hospice services. She said she pushed the new hospice the new Medical Director was affiliated with and saw her on social functions with them on their website. She said on [DATE], the administrator called her and said Resident #30 would no longer be under hospice care. She said on [DATE], Resident #30 had an incident at the facility, and they found her unresponsive. She said she was told they gently massaged her chest. She said Resident #30 continued to decline in February 2023, [DATE] and [DATE] and started hallucinating and could not get out of bed. She said she had a bedsore. She said by the time Resident #30 got to the hospital the week of [DATE], the wound on her sacrum was a stage 4 and she had a UTI. She said the physician at the hospital recommended hospice and she went with Hospice #3. She said Resident #30 returned to the facility and a week later she was found on the floor with a broken tibia. She said Resident #30 died with only two weeks of hospice services. In an interview on [DATE] at 11:45 a.m., LVN A said she had worked at the facility since October of 2021. She said there was a discrepancy between the facility and Hospice #1, and they decided to no longer use Hospice #1. She said the facility had a problem with financial issues with Physician #2 and they decided to cut ties and got rid of Hospice #1. She said when the new physician, Physician #1 took over Resident #1's care they cancelled her hospice. She said Hospice #2 and Hospice #3 are the only two hospice companies allowed in the building. She said since ties were cut between the physician and the facility, they fired the hospice company also. She said the residents no longer had the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 25 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 option of staying with Hospice #1. Level of Harm - Minimal harm or potential for actual harm In an interview on [DATE] at 11:50 a.m., the Administrator said Physician #2 decided he no longer wanted to be their Medical Director. He said Physician #2 gave notice to his residents in November and signed them over to another physician. He said Physician #2 did not want to be Medical Director or be an attending physician at the facility. He said he was not administrator at the facility when this initially happened. He said the new company took over the facility and decided not to renew services with Hospice #1. He said residents can choose hospice services with any company they choose. He said one hospice company is the same as the other hospice company and one hospice nurse is the same as another hospice nurse. He said it does not matter what hospice company you have. He said residents were told if they wanted to keep Hospice #1, they could move to another nursing facility that took them. He said when Physician #2 decided to leave, they decided not to renew his hospice company as his contract was expired even though they knew he had residents at the facility under their care. He said one nurse is the same as another and they are alike. He said there is no difference between hospice companies. Residents Affected - Some In an interview on [DATE] at 12:11 p.m., with Resident Representative #33 she said the nursing home forced them to change hospice services and they booted Hospice #1 out. She said they did that with everyone in the nursing home and there were a lot of people on Hospice #1. She said she had no options and had to go with it because her mother, Resident #32 had to have care and she passed away a month later. In an interview on [DATE] at 1:02 p.m., the Executive Director of Hospice #1, she said they had started business with the previous company three years before but there was a buyout with a new company and had and they had contract. She said they reinstated the contract with the new company. She said the nursing facility and Hospice #1 had the same medical director Physician #2. She said the facility had two medical directors Physician #2 and Physician #3. She said the facility was trying to cut costs and only wanted one Medical Director in the building and had Physician #2 step down from that role. She said they had never had any issues in the past three years. She said when they had a new administrator and new company then the hospice got backlash when Physician #2 decided to only see hospice patients. She said the facility administrator refused to let Hospice #1 in the building and had the facility physician order to discharge their hospice services. She said the families were not aware of the changes and the hospice had three active patients at the facility at that time. She said the owner of the nursing facility told them they had a forged contract and that was the reason for not allowing them to have a contract in the building anymore. She said the facility went behind the backs of the residents and the hospice. She said they had to do live discharges on all their patients. Record review of facilities Nursing Facility Services Agreement dated [DATE] read in part .is responsible for the palliation and management of a Hospice Patients terminal illness and related conditions .Hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided .this agreement shall commence on the effective date and shall continue, unless sooner terminated for cause for a period of one year. Record review of facilities policy titled, Resident Rights Guidelines for all Nursing Procedures, dated 2013 read in part . Resident notification of rights, services and health/medical condition . Resident freedom of choice. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 26 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 5 Staff (CNA H, CNA M, NA R, and Laundry aide J) reviewed for infection control. Residents Affected - Some - The facility failed to ensure CNA H and CNA M followed proper infection control procedures and did not completely clean Resident #24 during incontinent care. - The facility failed to ensure outside contractors(podiatrist) followed proper infection control while providing care (toenail care) to residents. - The facility failed to ensure NA R followed proper infection control and PPE procedures while walking on the hallway and making a resident's bed. - The facility failed to ensure laundry aide J followed proper infection control procedures while picking up dirty laundry from different halls. These deficient practices could affect residents and place them at risk for infection, and reinfection. Findings include: Record review of Resident #24's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted om 05/19/23. Resident #24 had diagnoses which included diabetes mellitus (body does not produce enough or respond normally to insulin, causing blood sugar(glucose)levels to be abnormally high) hypertension (a condition in which the blood vessels have persistently raised pressure), heart failure (the heart is unable to pump blood around the body properly) and atrial fibrillation (the top chambers of the heart (the atria) quiver or twitch). Record review of Resident #24's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Resident #24's functional status revealed she needed extensive assistance with one staff assistance for bed mobility, transfer, dressing, and personal hygiene. Resident #24 was incontinent of bladder and bowel. Record review of Resident #24's care plan problem start date 06/14/22 and edited 03/14/23, revealed: Resident #24 had bladder/bowel incontinence related to mobility deficit being bed fast, and obesity. Interventions: check for incontinent episode on rounds, provide incontinent care after each incontinent episode. Observation on 08/23/23 at 10:22 a.m., CNA M placed incontinent care items on Resident #24's bedside table. They did not remove the resident personal items, such as her drink cup with exposed straw, snacks, chips, and cookies, before CNA M the incontinent supplies were placed on the table and used during incontinent care. Observation and Interview on 08/23/23 at 10:22 a.m. revealed, CNA H and CNA M provided incontinent care for Resident #24. CNA H cleaned Resident #24's peri during incontinent care without separating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 27 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the labia. She cleaned out bowel movements from the peri area three times, and there was a substantial amount of bowel movement each time. CNA H turned the resident to her right side, and CNA M cleaned her buttocks without separating her buttocks, and she did not clean the resident's butt checks. Both aides did not wash or sanitize their hands when they changed gloves four times each because the gloves hand bowel movement each time. The surveyor intervened when CNA M was about to apply a clean incontinent brief on the resident. CNA M wiped Resident #24 butt checks twice, and there was a bowel movement. When CAN H separated the resident labia and cleaned the area twice, there was a substantial amount of bowel movement on the wipes, and on the fourth wipe, it was clean. Interview on 08/23/23 at 10:56 a.m., CNA H said she forgot to separate Resident #24's labia during peri care, and if she did not clean the resident's peri area and vagina well, the resident could develop infection and rashes. She said she had in-service on perineal care and skill check-off on incontinent care. She said the charge nurse checked the aide when she made random rounds on the resident to ensure the aide was providing care for the residents. CNA H said she forgot to wash or sanitize her hands when she changed gloves, but she should because the gloves may have tiny holes, and there were bowel movements on the gloves. She said it was an infection control issue when she did not separate the labia and did not sanitize her hands when she changed the gloves, which were soiled with bowel movements. Interview on 08/23/23 at 11:07 a.m., CNA M said she did not separate Resident #24 buttocks when she cleaned the resident. CNA M stated she did not clean the resident properly because there was still bowel movement on the resident's buttocks when she had to clean it again. She said if she did not clean the resident thoroughly, the resident could develop skin rashes, skin breakdown, or even infection. She said it was cross-contamination when she placed the bag with the peri-care items on the resident's bedside table with Resident #24 Items. She said she could have contaminated the drinking cup with a straw, chips, and cookies which could make the resident sick. She said it was an infection control issue when she did not wash or sanitize her hands when she changed her gloves, even when they were soiled with bowel movements. She said she had skills checks off on incontinent care, and the floor nurse made random rounds on residents to make sure the aides were providing care for the residents. Interview on 08/23/23 at 12:30 p.m., the DON said CNA H was supposed to separate Resident #24's labia and made sure she cleaned both sides and the middle properly to prevent rash and UTI (urinary tract infection). Interview on 08/23/23 at 12:32 p.m., the DON said CNA H and CNA M should wash or sanitize their hands when they change their gloves during incontinent care for Resident #24. She said the gloves may have tiny openings because they were going from dirty to clean (to prevent the spread of germs). Interview on 8/23/23 at 12:39 p.m., the DON said CNA M should have disinfected the bedside table and placed a barrier on the bedside table. She then stated the aide should move Resident #24's items away from the bedside to prevent cross-contamination, and CNA M should disinfect the bedside table after she returned before Resident #24's personal items to the table. She said Resident #24's personal items could be contaminated when CMA M left Resident #24 water cup and snacks on the table. Observation on 08/23/23 at 10:54 a.m., revealed CNA M used the same paper towel she dried her hands and turned off the water faucet. Interview on 08/23/23 at 11:02 a.m., CNA M said she turned off the water faucet with the wet paper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 28 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0880 Level of Harm - Minimal harm or potential for actual harm she dried her hands, but she should have used a dry paper to prevent cross contamination which could lead to the spread of germ and resident could become sick if the resident was exposed to the germs. Interview on 08/23/23 at 12:35 p.m., the DON said CNA M should have discarded the wet paper towel used dry paper towel to prevent of cross contamination. Residents Affected - Some Observation on 08/25/23 at 10:51 a.m., revealed the podiatrists cut the residents' toenails on the bare floor in the private dining room and walked away with the same gloves they wore during toenails care from the dining room to the memory care hall. Observation on 08/25/23 at 11:00 a.m., revealed one of the podiatrists came out of room [ROOM NUMBER], where they were cutting a resident's toenails. She went out of the resident's room with the same gloves she was attending to the resident and went into room [ROOM NUMBER]. She removed the resident's socks, ran her hand through her toes, and checked her toenails. Then she came out of the room still wearing the same gloves and returned to the first room (309). She came back and continued assisting the other podiatrist. Interview on 08/25/23 at 12:05 p.m., the corporate nurse, the DON, and the administrator said they needed clarification on whether they signed the facility policy on infection control. The corporate nurse said they should observe the facility's infection control protocol. She stated the podiatrist should have had a barrier on the floor in the private dining room where they cut toenails, or any treatment residue would fall into instead on the floor to prevent the spread of germs. She said the podiatrist knew better than to wear used gloves on the hall from the dining room to the memory care hall and from one resident to another because they are doctors. Interview on 08/25/23 at 12:11 p.m., the DON said the podiatrists should not have worn gloves in the hallway or go from one resident room to another because they could spread germs from one resident to another and could cause fungi infection on resident toes. Observation on 08/25/23 at 10:41 a.m., revealed NA R took gloves from her uniform pocket and donned them in the hallway. She entered room [ROOM NUMBER] and assisted a resident with her clothes. Then she left the room still wearing the same pair of gloves. Then she pulled the clean linen in one hand and the dirty cart linen in the other to room [ROOM NUMBER]. She entered the room with the same dirty gloves, striped the A bed linen, came out of the room, and placed the dirty linen inside the dirty linen cart. She opened the clean linen cart, went through three shelves, took clean linen and pillowcases from the cart, went back into the room, and started to make up the resident's bed, still wearing the same dirty gloves. Interview on 08/25/23 at 10:45 a.m., NA R said she should not have worn the gloves from her uniform pocket because the gloves had her germs, and gloves are not worn in hallways. She said she should have changed her gloves and washed her hands before she left the resident's room. NA R said she should not pull the clean and dirty linen cart at the same time and touch the clean linen with dirty gloves. NA R also said she should not have gone into another resident or gone into the clean linen care with dirty gloves because she had contaminated the clean carts and linen and could have transferred germs from her to the resident, and it could have made the residents sick. She said she had in service on infection control, hand washing, and PPE. Interview on 08/25/23 at 12:13 p.m., the DON said the NA R should not have donned gloves from her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 29 of 30 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 455643 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Bay City 700 12th St Bay City, TX 77414 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 0880 Level of Harm - Minimal harm or potential for actual harm uniform pocket and attended to any resident, and she should not have worn used gloves out of a resident's room to prevent the spread of germs. She said NA R should not have touched the clean linen cart or touched the linens in the cart because she had contaminated the clean linens when she opened it and took clean from the cart with the dirty gloves. She said the gloves from her uniform pocket had her germs, which NA R could have transferred to the resident, which could have caused the resident to be sick. Residents Affected - Some Observation and Interview on 08/23/2 at 11:45 a.m., it revealed Laundry aide J was entering the memory care unit with gloves on, and she was pushing the dirty linen cart. She said she had been picking dirty linen from one hall to another. She said she wore the same gloves. Laundry aide J said she forgot to take the dirty gloves off after she picked the dirty laundry from each hall, and it was an infection control issue because she could be spreading germs from one hall to another and on the keypad. She said if the residents came in contact with the germs, they could become sick. She said she had in-service on hand washing, infection control, and PPE. Interview on 08/25/23 at 12:15 p.m., the Administrator said once Laundry aide J picked the dirty linen from one hall, and she should remove the dirty gloves and wash or sanitize their hands to prevent the transfer of germs from one area to another because it was infection control. Interview on 08/25/23 at 1:05 p.m., the laundry supervisor said laundry aide J should not have worn dirty gloves in the hallway or gone from one dirty linen closet to another soiled linen closet from one hall to prevent the spread of germs, which could have caused the resident to become sick. She said laundry aide J should have removed the dirty glove and washed or sanitized her hand after picking dirty linen from one closet before going to another in a different hall. Record review of the facility policy on handwashing/hand hygiene 2001 MED - PASS, I NC (Revised April 2012) read in part .the facility considers hand hygiene the primary means to prevent the spread of infection . when to wash hands #5b . when hands are visibly solid with . #5l . upon and after coming in contact with a resident intact skin . hand washing procedure #4 . dry hands thoroughly with paper towels and then turn off faucets with clean, dry paper towel . Record review of CNA M handwashing competency revealed CNA M signed it on 08/23/23. Record review of CNA H handwashing competency revealed CNA H signed it on 12/14/22. Record review of the facility in service on picking up laundry dated 03/04/23 read in part . when picking up dirty laundry remove your gloves before heading back on the hall. Always sanitize your hands between halls . Record review of the facility policy on Perineal care 2001 MED - PASS, I NC (Revised October 2010) read in part . the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infection and skin irritation . steps and procedure #9b1 . separate labia and wash area .#94c . wash the rectal area thoroughly . Record review of CNA H's skills checklist - peri care revealed CNA H signed it on 06/23/23. Record review of CNA M's skills checklist - peri care revealed CNA M signed it on 06/23/23. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455643 If continuation sheet Page 30 of 30