Health inspection·March 14, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated the facility had a cleaning schedule that captured the morning and evening shifts. The FSS stated that a new cleaning sheet was given to her on 3/12/24 that was more detailed in the areas to check and the sheet would be implemented on 3/13/24. The FSS stated the old cleaning sheet did not provide enough specifics of areas that needed to be sanitized. During a telephone interview on 3/13/24 at 2:03 PM, the Dietician stated,: I made a visit last month for orienting the new [FSS] .the plastic containers were gotten because they had a problem with vermin .I saw no droppings or food products ripped by vermin .I saw a sticky trap .I did a sanitation checked and there were things that needed some improvement .stove needed cleaning I mentioned the need for a cleaning schedule . During a joint interview on 3/13/24 at 3:10 PM, the present Administrator, DON, and Cooperate Director of Quality revealed the Administrator was aware of sanitation concerns in the kitchen; interventions included changes in personnel; Dietician involvement; and addressed issues immediately concerning sanitation. The Administrator stated the local health department report concerning the kitchen reflected the report stated that the there were opportunities to make it [kitchen] cleaner The Administrator stated that as of 3/12/24, additional interventions included: total power washing and sanitization, more sealant and exclusion; and re-education of kitchen staff on items and areas that needed cleaning. Record review of the Retail Food Establishment Inspection Report (local health department) dated 12/29/23 reflected, Kitchen was cleaner, but still opportunity. Visible dust on pot hangers in kitchen. Some ceiling tiles need cleaning. Some walls, ceilings and floors still need further cleaning. Back wall of hood system needs cleaning. Mouse droppings need cleaned off the floor .Vent fan in bathroom need cleaning. ASAP .Evidence of mice droppings in dry goods storage. Clean and resolve ASAP . Record review of facility's Sanitation policy dated October 2008 reflected, The food service area shall be maintained in a calean and sanitary manner . Record review of facility's Sanitation policy dated October 2008 reflected, The food service area shall be maintained in a calean and sanitary manner . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 2 of 6 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 3 dumpsters, in that: Residents Affected - Some The drain plug was missing from Dumpsters #1 and #2. This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The finding were: Observation on 3/13/24 at 11:30 AM with the Maintenance Director of the dumpster site revealed 2 out of 3 dumpsters were missing plugs. The dumpster lids were closed. The bottom of the dumpsters had no holes or metal rot. Only one dumpster had one garbage bag. All three dumpsters dumpster had been empty that morning. There were no pests, vermin and/or animals around the dumpster site. During an interview on 3/13/24 at 11:31 AM, the Maintenance Director stated he was hired three weeks ago and had not checked on the dumpster plugs. The Maintenance Director stated that the plugs were necessary so that liquids formed inside the dumpsters did not drip into the environment attracting pests, vermin and/or animals. The Maintenance Director stated that checking on dumpster plugs had not been included in his checklist of checking the outside environment. The Maintenance Director stated he was unaware that the plugs were missing, and that it was his responsibility to ensure the plugs were present. ; Record review of facility's Food-Related Garbage and Refuse Disposal policy dated revised October 2017 reflected, Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. [The policy did not address plugs.] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 3 of 6 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 1 kitchen in that: Residents Affected - Some Mice and rats were seen in the facility's kitchen in the past. This deficiency practice could affect residents who receive meals from the kitchen and could place them at risk of contracting food borne illnesses. The noncompliance was identified as PNC(past noncompliance). The noncompliance began on 12/29/23 and ended on 2/12/24. The facility had corrected the noncompliance before the survey began. The findings included: Observation on 3/12/24 from 2:30 PM to 3:00 PM of the kitchen revealed there were 13 dried mouse droppings near the pantry area underneath a metal cabinet. Two sticky mouse traps were present on the floor near the pantry. There was a live mouse trap in the ceiling of the kitchen near the ceiling leading to the pantry. As the Maintenance Director removed the ceiling tile near the pantry, five dried vermin droppings fell on a kitchen counter top. There were no fresh droppings in the food pantry or refrigerators. Observation on 3/13/24 at 8:30 AM of kitchen revealed: staff were present and cleaning the kitchen to include the floors and underneath the cabinets and refrigerators and ice chest. There were no signs of vermin droppings. One rat trap was present outside the pantry area. Ceiling openings that could allow vermin entrance were sealed; the surveyor counted 6 areas in the ceiling that were sealed with epoxy. Epoxy sealant was also present in two areas on the kitchen floor near the pantry area There was not food on the floor and all foods were in containers. Food was not being prepared. The FSS stated that meals would be catered on 3/13/24 to allow tome to clean the kitchen. Observation on 3/13/24 of meals for lunch, noon to 1 :00 PM, and dinner, 5:00 PM-6:00 PM revealed the meals were catered and the kitchen was closed for cleaning and removal of any vermin/rodent droppings. Likewise, observation on 3/14/24 at noon revealed the kitchen was closed and meals were catered for breakfast; and scheduled for catering during the lunch and dinner. Observation on 3/13/24 at 8:30 PM of facility revealed: the facility was well lit. There were no signs of rodents in the hall or resident rooms. The kitchen was cleaned and lights were on. In the kitchen there were no signs of rodents or rodent noises in the ceiling. There were 5 traps on the floor with no rodents trapped. Observation on 3/14/24 from 9:45 AM to 10:00 AM of the facility to include the kitchen revealed no signs of rodents; the kitchen was cleaned and staff were present providing further cleaning of the kitchen. During a joint interview on 3/13/24 at 8:35 AM the FSS and the Maintenance Director stated the facility was thoroughly cleaning the kitchen and sealing any holes that could allow vermin/rodents to re-enter. During an interview on 3/13/24 at 11:13 AM, the Maintenance Director stated that the outgoing Maintenance Director informed him of the vermin/rodent issue in the kitchen. The Maintenance Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 4 of 6 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated, I addressed the issue by sticky pad traps .sealed holes .we contacted pest control .surveyed the outside for holes and filled in cracks .we have been at it since I arrived .I trapped about 7 mice .last trapping was the time I was employed, 2/26/24 .the live traps caught no mice a saw them [rodents] in the morning time in the kitchen a couple of weeks ago .never saw them in the residents rooms or hallways .not sure whether the local health department was informed .after [surveyor entrance on 3/13/24] deep cleaning of the kitchen .power washing .cleaning walls .sealing and corking .drywall the area that was opened in the ceiling and dry wall one of the entrance doors .AC units were corked .corked all the base boards in the pantry and still working on the kitchen to prevent any mice/rat re-entry .transferred all box foods in an non-working freezer .all walls checked and shelves powered washed .opened boxes have been sealed .and stored in the non-working freezer .only cans remain in the open pantry. During an interview on 3/12/24 at 3:01 PM, the FSS stated that she was hired three weeks ago and had been addressing kitchen sanitation and pest control. The FSS stated that about three weeks ago 20 mice had been trapped; and the pest control company trapped 6 more mice. The FSS stated that there had been no other mice trapped in the past three weeks; and the facility had made a concerted effort to control pests in the kitchen. The FSS stated that food in the pantry had been taken off the floor; and pantry food put in sealed plastic containers. During a joint interview on 3/13/24 at 8:35 AM the FSS and the Maintenance Director stated the facility was thoroughly cleaning the kitchen and sealing any holes that could allow vermin to re-enter. During a telephone interview on 3/13/24 at 11:15 AM, Dietary Aide A, stated: she had been employed for the past year. She saw a live rat about a month ago in the kitchen and informed the previous FSS. The previous FSS informed her that the facility would buy traps. She had not seen any vermin in the past three weeks alive or dead in the kitchen. She stated that the vermin never got into the food or got into the pantry to chew on boxes in the past [last three weeks] or in the present. During a telephone interview on 3/13/24 at 2:03 PM, the Dietician stated, I made a visit last month to orient the new [FSS] .I saw no droppings or food products ripped by vermin .I saw a sticky trap .they [the facility] had [hired] a pest control company .they were doing cleaning .there were traps . During a telephone interview on 3/13/24 at 2:30 PM, the Medical Director stated that he participated in an Ad hoc QAPI meeting to discuss the vermin issue in the kitchen. The Medical Director stated he interviewed nursing staff on 02/06/24 and no nurse reported that residents were affected by the food coming from the kitchen due to the sighting or rodents. During a telephone interview on 3/13/24 at 2:43 PM, Dietary Aide B, stated she notified the Maintenance Director on 1/12/24 that she saw a rat in the kitchen; her shift was from 1PM-8 PM. She also saw some droppings on the floor and the bread revealed signs that vermin had eaten some of the bread that was not in closed containers. Dietary Aide B stated the facility responded by putting out sticky traps, replacing the bread, and buying plastic bins. Dietary Aide B stated that after the incident on 1/12/24 she saw no other vermin or signs of vermin in the kitchen. During a joint interview on 3/13/24 at 3:10 PM with the present Administrator, DON, and Cooperate Director of Quality revealed: the Administrator was aware on 1/12/24 of the vermin issue in the kitchen and started to address the issue and interventions included: sealing and exclusion of the building, traps, and notify staff to report any sightings, in-service on pest control, and contract with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 5 of 6 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pest control. The Administrator stated that the health department report reflected that there were vermin droppings in the kitchen and needed to be resolved ASAP. The Administrator stated that no recommendation was made by the health department to close the kitchen. The Administrator stated as of 3/12/24 additional interventions included: total power washing and sanitization, more sealant and exclusion; and further re-education on cleaning items and the kitchen The DON and Administrator stated that no resident, visitor, or staff had alleged to seeing vermin in the halls or resident rooms. During interviews on 03/13/24 from 8:56 AM to 9:57 AM with Residents #1, #2, #3, #4, #5 and #6 revealed no information that residents had seen signs of mice/rats or rodents in the halls or resident rooms. During a telephone interview on 3/13/24 at 5:30 PM with the contracted pest control company the surveyor requested an assessment from the customer service representative as to whether the rodent/vermin issue in the facility's kitchen had been resolved. The customer service representative stated that she would check on the assessment and be in contact with the surveyor in the future. Record review of Resident Council minutes for the months of January, February and March 2024 revealed no complaints about pest control or vermin/rodents seen in the kitchen on halls or resident rooms. Record review of Facility's Ad-hoc QAPI: Pest Control meeting was held on 2/6/24 to discuss the Pest Control issue in the kitchen. Attendees were the Administrator, maintenance director and Medical Director. Record review of facility's in-service sheets on Pest Control training from 3/5/24 to 3/13/24 revealed 63 signatures (100%); total paid staff was 63. Record review of facility's Pest Control contact revealed one was present and was signed on 11/16/2018. Record review of facility's pest control company invoices revealed: company made visits on 9/18/23, 10/16/23, 11/17/23, 12/18/23, 1/23/24, and 2/12/24 to address pest control issues in the facility and put in effect preventative measures. Record review of facility's pest control report dated 2/12/24 revealed the pest control company assessed all possible entry points for vermin and rodent/vermin activity was not noticed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 6 of 6