Health inspection·February 8, 2023

F 0577 Observation on 02/08/23 at 06:53 PM revealed the survey results binder was empty. Level of Harm - Potential for minimal harm During an interview on 02/08/23 at 06:59 PM, the ADM stated the survey results binder was available near the front entrance. The ADM stated she was not aware that the survey results binder was empty. The ADM stated she realized the survey results binder was empty on 02/08/23 at 10:30 AM. The ADM stated she did not update the survey results binder after realizing it was empty because she did not have time. The ADM stated the survey results binder was updated last week. The ADM stated she expected the survey results binder to always be updated and available to all residents. The ADM stated she was responsible for updating and ensuring the survey results binder was updated and available to all residents. The ADM stated residents who could not review the survey results binder would be inconvenienced. Residents Affected - Many Record review of the Resident Rights policy revised in December 2016 revealed federal and state laws guaranteed certain basic rights to all residents at the facility. These rights included the residents' right to examine survey results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 2 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 0583 Keep residents' personal and medical records private and confidential. 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 residents had the right to secure and confidential personal and medical records for three (Resident #41, Resident #52, and Resident #65) of five residents reviewed for privacy. Residents Affected - Some The facility failed to ensure Resident #41, Resident #52, and Resident #65's diagnoses of Covid -19 were kept confidential. This failure placed residents at risk of having their medical information accessed by unauthorized persons. Findings included: A record review of Resident #41's face sheet dated 2/07/2023 reflected an [AGE] year-old female readmitted on [DATE] with diagnoses of unspecified dementia (cognitive disorder), hypertension (high blood pressure), depression, hypothyroidism (hormone disorder), and gastro-esophageal reflux disease (acid reflux). A record review of Resident #41's care plan last revised on 2/06/2023 reflected she tested positive for Covid-19 and was to be isolated per the facility's protocol. A record review of Resident #41's MDS assessment dated [DATE] reflected a BIMS score of 12, which indicated moderate cognitive impairment. A record review of Resident #52's face sheet dated 2/07/2023 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of unspecified dementia (cognitive disorder), cerebral infarction (stroke), acute kidney failure, morbid obesity (extreme obesity), type 2 diabetes (uncontrolled blood sugar), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). A record review of Resident #52's care plan last revised on 2/06/2023 reflected she tested positive for Covid-19 and was to be isolated per the facility's protocol. A record review of Resident #52's MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated little to no cognitive impairment. A record review of Resident #65's face sheet reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of Chron's disease (inflammatory bowel disease), chronic pain syndrome, depression, hypotension (low blood pressure), chronic hepatic failure (liver failure), and asthma (difficulty breathing). A record review of Resident #65's care plan last revised on 2/06/2023 reflected she tested positive for Covid-19 and was to be isolated per the facility's protocol. A record review of Resident #65's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. During an observation and interview on 2/06/2023 at 9:55 a.m., Resident #52 was observed lying in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 3 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 0583 her bed. Resident #52 stated she had no concerns with her care. Level of Harm - Minimal harm or potential for actual harm An observation on 2/06/2023 at 3:01 p.m. revealed Resident #52 had a sign posted on her door which read COVID POSITIVE PLEASE SEE NURSE DROPLET PRECAUTION. Residents Affected - Some An observation on 2/06/2023 at 3:03 p.m. revealed Resident #41 had a sign posted on her door which read COVID POSITIVE PLEASE SEE NURSE DROPLET PRECAUTION. An observation on 2/06/2023 at 3:04 p.m. revealed Resident #65 had a sign posted on her door which read COVID POSITIVE PLEASE SEE NURSE DROPLET PRECAUTION. During an observation and interview on 2/06/2023 at 3:05 p.m., Resident #65 was observed lying in her bed. Resident #65 stated it bothered her that her personal business was on her door, and she did not understand why because staff did not disclose to her names of other residents who were positive for Covid-19. During an interview on 2/06/2023 at 3:11 p.m., LVN F stated that herself as well as other staff worked together that day to put up isolation signs on residents' doors. LVN F stated she had found a stack of the isolation signs on the nurse's station and did not know where they came from, who wrote the message, or who printed them out. During an observation and interview on 2/06/2023 at 3:45 p.m., Resident #41 was observed lying in bed. Resident #41 said it bothered her that her door said she had Covid-19 because she did not believe she had it. During an interview on 2/07/2023 at 10:59 a.m. CNA M stated she did not know why the isolation signs were different that day than they were the day prior (2/06/2023). CNA M stated the nurses put up the signs. During an interview on 2/07/2023 at 11:03 a.m. LVN F stated she did not know why the signs on the door had a different message than they did the day prior (2/06/2023). LVN F stated she did not put the signs up and she thought management put them up. An observation on 2/07/2023 at 11:15 a.m. revealed Resident #65 and Resident #52 had been moved and isolated in the same room on the 400 hall which was designated as the hot unit. Resident #65 and Resident #52 no longer had signage on their door indicating their diagnoses of Covid-19. An observation on 2/07/2023 at 11:19 a.m. revealed Resident #41's room had moved to the 400 hall, which was designated as the hot unit. Resident #41 had signage on her door which reflected STOP ISOLATION PRECAUTIONS SEE NURSES DESK BEFORE ENTERING. Resident #41 no longer had signage on her door indicating her diagnosis of Covid-19. During an interview on 2/07/2023 at 11:35 a.m. the DON stated the facility's policy on protecting residents' medical information included not disclosing any information to anyone not listed as a resident's medical POA. The DON stated two identifiers were required prior to disclosing medical information to entities such as hospitals. The DON stated residents' diagnoses were part of their medical information. The DON stated herself and the ADON put up the isolation signs on 2/06/2023. The DON stated the signage was changed on 2/07/2023 because having Covid-19 on residents' doors who were exposed but tested negative was misleading. When asked how residents' medical information posted on their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 4 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some door could negatively impact them, the DON stated, when we say covid positive, there are two people in the room, so we are not saying their names. The DON stated they needed isolation signs on doors because it was a state requirement. During an interview on 2/07/2023 at 11:55 a.m. the DON stated with all of the chaos the day prior, with so many residents testing positive, they were just trying to get a sign up as soon as possible. The DON stated, yesterday was a one-time thing and their diagnosis should not have been on the door. The DON stated started in-servicing staff on not including Covid-19 on the isolation signs. During an interview on 2/07/2023 at 1:52 p.m. the ADON stated herself and the DON put up the isolation signs on 2/06/2023 and we realized we should not have put that they were covid positive on their door. The ADON stated she did not know who created the message, just that the isolation template was already on the computer. The ADON stated a resident's diagnosis should not be on the door and no one needs to know that. The ADON stated, it does affect residents' privacy. During an interview on 2/08/2023 at 11:00 a.m., the ADM stated there should be a sign on the door any time a resident was on isolation for anything and the sign should say see nurse before entering. The ADM stated, no that the sign should not have a resident's diagnosis. The ADM stated usually it was a nurse or nurse manager who created the isolation signs and she had no idea who put them up on 2/06/2023. The ADM stated, it could have been a CNA that put residents were covid positive on the door. The ADM stated all managers, but mostly the nurse mangers, were responsible for monitoring compliance of the facility's policy on isolating residents. When asked what potential negative impact on residents there could be if their diagnosis of Covid-19 was posted on their door, the ADM stated she felt like it could be a dignity issue. The ADM stated, yes that privacy and dignity went hand in hand. A record review of the facility's policy titled Confidentiality of Information and Personal Privacy dated October 2017 reflected the following: Policy Statement Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his or her: a. accommodations; b. medical treatment; c. written and telephone communications 4. Access to resident personal and medical records will be limited to authorized team and business associates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 5 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 0583 Level of Harm - Minimal harm or potential for actual harm 7. Release of resident information, including video, audio, or computer stored information, will be handled in accordance with resident rights and privacy policies. A record review of the facility's policy titled Isolation - Categories of Transmission-Based Precautions dated September 2022 reflected the following: Residents Affected - Some Policy Statement Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. b. Signs and notifications comply with the resident's right to confidentiality or privacy. A record review of the facility's policy titled Resident Rights dated December 2016 reflected the following: Policy Statement Team members shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: t. privacy and confidentiality; 3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA Compliance Officer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 6 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 provide residents respiratory care consistent with professional standards of practice for 3 or 11 residents (Resident #36, #45, and #61) reviewed for oxygen therapy. Residents Affected - Some The facility failed to ensure: - the oxygen tubing on Resident #36 and Resident #45 was dated and the humidifier was not empty for an unknown amount of time. -the oxygen tubing on Resident #61 was changed weekly per facility policy and the sign for oxygen use was on the entrance door to the resident's room. - Resident #45's care plan included oxygen services This failure placed residents at risk of nose and throat discomfort, dryness of nasal passageway, skin breakdown, inadequate respiratory care, and infection control. The findings included: Review of Resident #36's Face Sheet, dated 02/08/23, reflected [AGE] year-old male was admitted to the facility on [DATE] with diagnosis of COPD, (a lung disease that blocks airflow and makes it difficult to breathe), DM (a disease that results in too much sugar in the blood), anxiety (a feeling of excessive and persistent worry), and HTN (high blood pressure). Review of Resident #36's MDS assessment, dated 12-09-22, reflected a BIMS score of 15 which indicated cognition is intact. Review of Resident #36's Care Plan, dated 03/15/22, reflected Resident #36 had oxygen therapy via NC as needed. Review of Resident # 45's Face Sheet, dated 02/07/23, reflected [AGE] year-old male was admitted to the facility on [DATE] with diagnosis of COPD, (a lung disease that blocks airflow and makes it difficult to breathe), DM (a disease that results in too much sugar in the blood), anxiety (a feeling of excessive and persistent worry), and HTN (high blood pressure). Review of Resident #45's MDS assessment, dated 01-12-23, reflected a BIMs score of 0, indicated severe cognitive impairment. MDS did not indicated Resident #45 required oxygen therapy. Review of Resident #45's Care Plan, last revision dated 11/17/22, reflected there was no care plan indicated the use of oxygen. Review of Resident #61's Face Sheet, dated 02/08/23, reflected [AGE] year-old female was admitted to the facility on [DATE] with diagnosis of CHF (A chronic condition in which the heart doesn't pump blood as well as it should), DM (a disease that results in too much sugar in the blood), anemia (a condition that does not have enough healthy red blood cells), and anxiety (a feeling of excessive and persistent worry). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 7 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 0695 Level of Harm - Minimal harm or potential for actual harm Review of Resident #61's MDS assessment, dated 11-17-22, reflected a BIMS score of 15, which indicated cognition is intact. MDS indicated Resident #61 required oxygen therapy. Review of Resident #61's Care Plan, last revision dated 11/17/22, reflected there was no care plan indicated the use of oxygen. Residents Affected - Some Observation and interview on 02/06/23 at 11:01 AM, Resident #61 was in the wheelchair with oxygen on 3L with NC labeled with date of 01/29/23. Resident #61 stated staff usually changes the NC but did not change it the previous day. The door to Resident #61 did not have sign for oxygen being used inside the room. Observation on 02/06/23 at 11:16 AM, Resident #45 was in bed with oxygen on 4L with no date on the NC and humidifier was empty with no water inside the bottle. Resident #45 was not able to recall if NC are being changed by staff. Observation and interview on 02/07/23 at 12:45 PM, Resident #36 in bed with oxygen on 3L with no date on the NC and no humidifier attached to the oxygen concentrator. Resident #36 stated he took off the humidifier bottle as it was empty and was unable to recall when the NC was changed. During an interview on 02/06/23 at 11:26 AM, LVN J stated humidifier should not been empty because it could cause nose to bleed for the purpose of the humidifier was not to dry out the nasal passageway. LVN J stated the NC are changed weekly on Sunday for sanitation purpose. LVN J stated door sign should have been placed for oxygen so no one walks into the room lighting up a cigarette and could result in catching on fire. During an interview on 02/08/23 at 06:46 PM, DON stated the purpose of NC should be dated is for infection control purpose and to inform us when the NC needed to be changed. DON stated the impact of not having the NC dated could lead to resident having some sort of infection. DON stated the charge nurse assigned for the resident is responsible for dating the NC. DON stated per evidence-based practice the facility required NC be changed every seven days and tried to schedule it every Sunday. DON stated the nursing employee are aware of such practice due to orders being populated on the day for NC to be changed. DON stated she had recently employed with the facility therefore have not provided in-service to the staff. DON stated the humidifier should not been emptied because it help for the nasal passageway from drying out. DON stated the charge nurse are also responsible for the proper use of humidifier. DON stated there should be a sing on the door which indicates oxygen had been used for that specific resident. DON stated the impact of not having the sign on the entrance of the door would be people not being informed of oxygen been used and it is a smoking facility so could possibly end in hazardous incidents. During an interview on 02/08/23 at 07:16 PM, ADM stated NC have to be dated but not sure what could result from not having it dated. ADM stated the humidifier should not run out. ADM stated the charge nurses are responsible for dating the NC and nurses are aware of their responsibility from their training during orientation. ADM stated there should be a sign about oxygen on the door if a resident used oxygen. ADM stated the oxygen was combustible which could lead to fire hazards. Record review of facility's policy titled Oxygen Administration dated 10/2010 reflected, The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Place an Oxygen in Use sign on the outside o the room entrance door. Close the door. 8. Check the mask, tank, humidifying jar, etc to be sure they are in good working order and are securely fastened. Be sure there is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 8 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Record review of facility's policy titled Protocol for oxygen administration dated 03/2019 reflected Oxygen tubing, cannuals, nebulizer tubing's, and face masks will be changed weekly and dated/initaled when dispensed. No smoking signs will be visibly displayed upon entrance to rooms where oxygen is located. Event ID: Facility ID: 455785 If continuation sheet Page 9 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to reconcile and dispose of expired medication for three of three medication carts (300-hall nurse's cart, 100-hall med-aid cart, and 100-hall nurse's cart) and two of two medication room (100-200 hall medication room and 300-400 hall medication room) reviewed for compliance. The facility failed to ensure: 1. Medications and medical supplies were stored inside the cabinet in the medication rooms and medication carts past expiration dates. 2. Food and beverages were not stored inside the medication room and medication cart. This failure placed all residents receiving medication from the facility at risk of receving of receiving expired medications resulting in adverse health consequences, not receiving adequate medical supply and/or receive contaminated medications. Findings: Observation on 02/07/23 at 01:24 PM, 300-400 hall medication room revealed a bottle of Calcium 500mg expiration date 06/22, two bottles of Multivitamin expiration date 11/22, a bottle of Coenzyme Q10 100mg expiration date 05/22 with open date 11/03/21, a bottle of Systane eye drops expiration date 04/2020, a bottle of fexofenadine hydrochloride 180mg expiration date 05/22 with open date 11/03/21, a bottle of Magnesium 500mg expiration date 08/22 with open date 03/12/21, a bottle of Fish oil 500mg expiration date 03/22 with open date 05/26/21, and opened cardboard food container box with pizza and wings was on the counter. During an interview on 02/07/23 at 01:30PM, LVN D stated the medication should have been placed into the discard box located inside the medication room which was then picked up by the pharmacy. LVN D stated the expired medication should not been inside the cabinets because the chance of the medication could be administered to residents. LVN D stated in training the nurses are taught to remove the expired medication and to place it into the discard box in the medication room. LVN D stated the food container belonged to LVN J and that food should not be kept with medication inside the medication room. Observation on 02/07/23 at 02:06 PM, 100-200 hall medication room revealed a suction catheter supply with an expiration date 01-21-2022, and an infusion administration set supply with an expiration date 07-03-2022. During an interview on 02/02/23 at 02:21 PM, DON stated the person in charge of the central supply is responsible to check the date of the medical supply and DON has the overall responsibility. DON stated the impact of having expired medical supply would be using the supply on the resident if the staff are not checking the expiration date prior to use and resident could get bad reaction or adverse effect. Observation and interview on 02/08/22 at 12:32 PM, 300-hall nurse's medication cart revealed an insulin pen with open date reported by ADON was 11/22/22. ADON was handed the insulin pen to read out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 10 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 the date but instead of reading out the date the ADON discarded the insulin pen into the sharp container. When inquired why the insulin pen was discarded into the sharp container, ADON stated It was expired. Another insulin pen was opened with no open date. Observation and interview on 02/08/22 at 01:14 PM, 100-hall med aid cart revealed vanilla pudding opened with the date of 02/07/23 10:15 AM placed inside the top drawer and not kept on ice, a bottle of Dr. Pepper was inside the bottom drawer. MA stated the vanilla pudding was opened by her on 02/07/23 and should have been discarded and she was not aware of Dr. Pepper being inside the drawer. MA stated the impact of having the pudding left on the cart could cause flies and beverages stored inside the medication cart could possibly explode and get on the medications and gets contaminated. Observation and interview on 02/08/22 at 01:30 PM, 100-hall nurse's medication cart revealed a medication card of Ondansetron 4mg with 5 pills left had expiration date of 02/28/22, Clonidine 0.1mg medication card with 26 pills left with an expiration date of 07/31/22, and an inhaler with no date or name of the resident. ADON stated expired medications should have been pulled out of the medication cart so it was not administered to the residents. During an interview on 02/08/23 at 06:46 PM, DON stated expired medications should not been stored inside the medication room because it could accidentally be administered to the resident and no food item should not be stored inside the med room because it is only to store medications and medical supplies. During an interview on 02/08/23 at 07:16 PM, ADM stated there should not been any expired medication in the medication cart and not stored inside the cabinets in the medication room. ADM stated the nurses are responsible for checking the expiration on the medication and discard the medication that have been expired so it is not accidently given to the resident. ADM stated beverage and food should not been stored in the medication cart or medication room due to cross contamination. ADM stated nurses are responsible for checking the expiration dates on the medical supplies. ADM stated the person in charge of the central supply should check for the expiration date but ultimately the nurses are to check the expiration date prior to use of supply. Record review of facility's policy titled Storage and Expiration of Medications, Biologicals, Syringes and needles dated 2017 reflected, 3.6 Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored. 4. Facility should ensure that medication and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 6. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 15. Facility should ensure that medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider. 16. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law, and in accordance with Policy 8.2 (Disposal/destruction of Expired or Discontinued medication). Record review of facility's policy titled Disposal/Destruction of Expired or Discontinued Medication: dated 2017 reflected, 2. Once an order to discontinue a medication is received. Facility staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 11 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 should remove this medication from the resident's medication supply. 4. Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinue and subject to destruction. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 12 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The DM failed to ensure all food items were properly labeled, dated, covered, and discarded prior to their use-by or expiration date. Cook C failed to properly sanitize dishes. Cook C failed to wash her hands when changing tasks. These failures placed residents at risk of foodborne illness. Findings included: Observations of the kitchen's reach-in refrigerator on 2/06/2023 from 9:14 a.m. through 9:16 a.m. revealed the following: At 9:14 a.m., the reach-in refrigerator contained a storage container of diced ham labeled 1/27/2023. At 9:15 a.m., the reach-in refrigerator contained thickened water with an opened date of 1/20/2023 and a printed manufacturer's best-if-used-by date of 1/16/2023. At 9:16 a.m. the reach-in refrigerator contained a container of opened barbecue sauce with no opened date. During an interview on 2/06/2023 at 9:20 a.m., DA E stated all items in the reach-in refrigerator should be tossed after five days. DA E stated leftovers such as ham were good for five days and the diced ham should have been discarded. DA E stated all opened items should be labeled with an opened date. DA E stated kitchen staff adhered to best-if-used-by dates and stated the thickened water should have been discarded. An observation of the kitchen's production area on 2/07/2023 at 10:46 a.m. revealed an uncovered bulk container of a white unidentifiable substance. Observations of [NAME] C on 2/06/2023 beginning at 10:36 a.m. revealed she pureed vegetables, washed and rinsed the food processor, then proceeded to puree egg rolls. [NAME] C did not sanitize the food processor and she did not wash her hands before beginning a new task. Observations of [NAME] C on 2/06/2023 beginning at 10:47 a.m. revealed she pureed egg rolls, washed and rinsed the food processor in the three-compartment sink, and proceeded to puree pork. [NAME] C did not sanitize the food processor and she did not wash her hands before beginning a new task. During an interview on 2/06/2023 at 10:53 a.m., [NAME] C stated the three-compartment sink process included washing, rinsing and sanitizing dishes. [NAME] C stated no that she did not sanitize the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 13 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many food process because she was nervous. [NAME] C stated yes that hands should be washed between handling dirty dishes and starting a new task. [NAME] C stated she did not wash her hands because she forgot. During an observation and interview on 2/06/2023 at 11:43 a.m., the bulk container of white unidentifiable substance was uncovered. [NAME] C stated the substance was dry milk powder and it was uncovered because she had used it to make mashed potatoes. Observed [NAME] C then cover up the container and an observation of the lid revealed it was labeled and dated 1/26/2023. During an interview on 2/06/2023 at 3:57 p.m., the DM stated she started working at the facility in August of 2022. The DM stated there were no in-services in place when she started so she stated she started training staff on food storage and sanitation via in-services. When asked how kitchen staff were trained upon hire, the DM stated she did not know because they all started before she became DM. During an interview on 2/07/2023 at 12:02 p.m., the RDN stated leftovers should be discarded after seven days. The RDN stated all items should be labeled with the date they were produced. The RDN stated all food should be covered, including bulk containers of dry good. The RDN stated hands should be washed when changing gloves and when changing tasks. The RND stated the steps of the three-compartment sink included wash, rinse, and sanitize. The RDN stated yes that dishes needed to be sanitized. The RND stated the DM was responsible for training staff on food storage and sanitation policies. The RDN stated she did not know how kitchen staff were trained upon hire but stated all of them should have received basic training through obtaining their food handlers. The RDN stated she knew the DM completed regular in-services with kitchen staff. The RDN stated she had seen some in-service trainings that the previous RDN completed with kitchen staff. The RDN stated it was her first day working in the facility and she had not yet completed a sanitation audit of the kitchen. The RDN stated she monitored the kitchen via monthly quality assurance checks and through completing walk throughs of the kitchen when she visited the facility twice a month. The RDN stated the DM was primarily responsible for monitoring the kitchen since the Dietary Manger was the one working there every day. The RDN stated if policies on food storage and sanitation were not followed, foodborne illness would be a major concern. During an interview on 2/08/2023 at 11:00 a.m., the ADM stated all leftovers should be discarded and there should not have been any leftovers in the kitchen. The ADM stated all opened food items should be labeled with an opened date and items past their use-by date should be thrown away. The ADM stated bulk bins of food should have lids and be covered when not in use. The ADM stated yes that hands should be washed when going from handling dirty dishes to preparing a pureed food item. The ADM stated the process of the three-compartment sink was to wash with soap, rinse, and sanitize. The ADM stated the sanitize step needed to happen every time. The ADM stated kitchen staff were trained on these policies upon hire and the DM was responsible for ensuring they were appropriately trained. The ADM stated yes that all kitchen staff had been trained by the DM. The ADM stated all kitchen staff had their food handlers which she believed covered food storage, hand washing, and ware washing. When asked if all trainings were included in the in-services provided to the survey team, the ADM stated she believed so, but she would have to look. The ADM stated the kitchen was monitored for compliance by the DM and the RDN. The ADM stated the DM completed daily rounds and the RDN came in twice a month. When asked what a potential negative resident outcome would be if kitchen policies were not followed, the ADM stated, foodborne illness would be my first indication. A record review of the facility's policy titled Food Labeling and Dating dated 2010 reflected the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 14 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 following: Level of Harm - Minimal harm or potential for actual harm Discussion Residents Affected - Many B. Proper food labeling - All leftover foods or foods removed from their original containers require proper labeling when stored. Proper food labeling require the following: NAME, IDENTIFICATION, DATE OF PREPARATION AND DATE FOODS ARE TO BE USED OR DISCARDED. 2. Dates recorded e. Once refrigerated items are properly stored with name and dates, they need to be used or disposed of within seven days. (Check state regulations.) A record review of the facility's policy titled Proper Storage of Leftovers - Perishable and Non-Perishable dated 2010 reflected the following: A. Storage of perishable leftovers. 1. Cover, label with name, date stored and the date it must be used or discard by. 2. Leftovers can be stored under refrigeration up to seven days. Check state and local regulations. B. Storage of non-perishable food items removed from original containers. 1. Be sure to reseal, label and date all products. Items should be sealed in an airtight manner: in containers with tight fitting lids or in Ziploc bags. 2. Use products within 'use by date' stated on original package. A record review of the facility's policy titled Food Storage dated 6/01/202 reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. A record review of the facility's policy titled Manual Cleaning and Sanitizing of Utensils and Portable Equipment dated 10/01/2018 reflected the following: Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 15 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procedure: Level of Harm - Minimal harm or potential for actual harm 1. Use a three-compartment sink with running hot and cold water for cleaning, rinsing and sanitizing. Residents Affected - Many 6. In the first sink, immerse the equipment or utensils in a hot, clean detergent solution at a temperature of no less than 120°F. 7. Rinse in the second sink using clear, clean water between 120°F and 140°F to remove all traces of food, debris and detergent. 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: a. Immerse for at least 30 seconds in clean, hot water at a temperature of 170°F or above. When hot water is used for sanitizing, the facility must have and use: i. An integral heating device or fixture installed in, on, or under the sanitizing compartment of the sink capable of maintaining the water at a temperature of at least 170 degrees Fahrenheit and ii. A digital or numerically scaled indicating thermometer, accurate to plus or minus three degrees Fahrenheit convenient to the sink for frequent checks of water temperature. b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75°F or ii. A minimum of 12.5 parts per million of available iodine in a solution with a pH not higher than five and a temperature not less than 75°F or iii. Any other chemical sanitizing agent which has been demonstrated to be effective and non-toxic under use conditions and for which a suitable field test is available. Such other sanitizing agents, in-use solutions, shall provide the equivalent sanitizing effect of a solution containing at least 50 parts per million of available chlorine at a temperature not less than 75°F. The concentration and contact time for quaternary ammonium compounds shall be in accordance with the manufacturer's label directions. c. Be sure to cover all surfaces of the utensils and/or equipment with hot water or the sanitizing solution and keep them in contact with it for the appropriate amount of time. A record review of the facility's policy titled Personal Hygiene dated 2010 reflected the following: Overview Every food service employee can, by developing daily habits of careful hygiene, aid in providing quality products to facility clients. High standards of personal cleanliness are essential to protect clients against potential food contamination. An impeccable, professional appearance contributes to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 16 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 efforts to assure clients of superior sanitation practices in the facility. The following are defined to guide employees toward excellent personal hygiene habits. Level of Harm - Minimal harm or potential for actual harm Hand Washing and Bathing Residents Affected - Many Hands are the major source of food contaminants. Frequent hand washing with special attention under fingernails, can greatly reduce instances of foodborne illness. Clean hands: -Before handling or serving food -After handling soiled equipment, dishes, or utensils A record review of the facility's in-service titled Sanitation and Infection Control dated 9/13/2022 reflected kitchen staff were trained on ware washing. A record review of the facility's in-service titled Handwashing dated 9/13/2022 reflected kitchen staff were trained on handwashing. A record review of the facility's in-service titled Label & Date dated 11/14/2022 reflected kitchens staff were trained on labeling and dating. A record review of the kitchen's sanitation audit titled Quality Assurance Monitor I Kitchen/Food Service Observation dated 12/08/2022 reflected all foods were not covered, labeled, dated and discarded per policy. A review of the Food and Drug Administration's 2017 Food Code reflected the following: The PERSON IN CHARGE shall ensure that: (K) EMPLOYEES are properly SANITIZING cleaned multiuse EQUIPMENT and UTENSILS before they are reused, through routine monitoring of solution temperature and exposure time for hot water SANITIZING, and chemical concentration, pH, temperature, and exposure time for chemical SANITIZING Hands and Arms 2-301.11 Clean Condition. The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 17 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Residents Affected - Many 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 18 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 observations, interviews, and record reviews, the facility failed to establish and maintain an IPCP designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 2 of 20 residents (Residents #38 and #61) reviewed for infection control. Residents Affected - Few The staff failed to implement appropriate standard for the use of Personal Protective Equipment (PPE) consisting of protective clothing, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection. The hazards addressed by PPE biohazards, and airborne particulate matter, and transmission-based precautions. These deficient practices could place residents at risk for exposure to COVID-19, which could result in serious illness, hospitalization, and/or death. Findings include: Observation on 02/8/2023 at 12:14 PM revealed CNA A as she entered the open door of room [ROOM NUMBER] of R#38 and R#61, residents who tested positive for COVID-19. wearing an N95 mask and gloves with no gown, face shield or goggles. The door to room [ROOM NUMBER] was not closed after CNA A entered. Observed a notice posted on the outside of room [ROOM NUMBER] that read, isolation, please see nurse before entering. Wearing an N95 mask and plastic gloves (no gown, face shield or goggles) CNA A exited room [ROOM NUMBER] wearing gloves and did not remove gloves and sanitize her hands, she removed a lunch tray from the meal cart in the 300 hallway and re-entered room [ROOM NUMBER]. She served a lunch tray to R#61 and exited the room. The door was left open. It was not observed if CNA A removed and disposed of her gloves when she exited room [ROOM NUMBER]. R#38 was seated on the side of her bed and faced the open door and asked CNA A, who stood outside of room [ROOM NUMBER], to clean R#38's bedside commode. CNA A entered room [ROOM NUMBER], wearing an N95 mask and gloves (no gown, face shield or goggles) and removed the plastic bag that was placed inside R#38's bedside commode to collect any urine and feces, made a knot close to the top of the plastic bag to seal waste and placed bag in the bathroom. CNA A told R#38 she could not take the plastic bag containing the waste into the hallway to be disposed because lunch was being served. CNA A exited room [ROOM NUMBER], removed her gloves, it was not observed if she sanitized her hands, and passed lunch trays to resident rooms that did not have a sign stating, isolation, please see nurse before entering. In an interview on 02/08/2023 at 12:20 PM CNA A stated she was aware that R#38 and R#61 in room [ROOM NUMBER] were COVID positive because of the sign on the door stating. Isolation, please see nurse before entering. Observation on 02/08/2023 at 2:20 PM revealed CNA A in room [ROOM NUMBER] with COVID-19 positive R#38 and R#61. CNA A moved behind the privacy curtain for R#61. CNA A wore an N95 mask and gloves (no gown, face shield or goggles). 02/08/2023 interview at 2:35 pm CNA A revealed she was in-serviced about infection control over a month ago and the facility discussed PPE at the in-service. If there was a sign on the door reading see a nurse, the sign indicated that the person who entered needed to wear a gown, mask, gloves, and face shield. CNA A stated she would know to wear PPE, by going off the sign on the door. CNA A knew she worked with a few COVID-19 positive residents the past weekend. CNA A acknowledged there was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 19 of 20 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 455785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Western Hills 512 Draper Dr Temple, TX 76504 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 - Few sign on the door of room [ROOM NUMBER] that read, see the nurse but she didn't ask the nurse because, I knew what was going on and the residents in the room had tested positive for COVID-19. CNA revealed she made the mistake of not putting on PPE because the PPE was just brought in and it was time for lunch tray pass. CNA A revealed R#38 wanted CNA A to remove the plastic bag containing urine and feces from R#38's bedside commode and CNA A had a mask and gloves but didn't wear a gown or face shield. CNA A revealed that two times she didn't wear a gown and face shield when she entered room [ROOM NUMBER] for R#38 and R#61. CNA A revealed she was just standing there inside the room waiting for someone else to come in room [ROOM NUMBER] and it slipped her mind that she was not wearing the gown and face shield because she had 30 residents to herself. The facility just placed the PPE in the hallway, and it was not organized. CNA A revealed she began working on hall 300 at 6:00 am and the PPE was not there at breakfast. LVN J told CNA A that the new residents on hall 300 were COVID-19 positive in the morning before breakfast. CNA A said that after breakfast the facility moved the residents. CNA A revealed there were no signs on the resident room doors before breakfast and she passed the breakfast trays to the residents. She revealed she didn't ask the nurse because, I just let the facility do what they do. CNA A revealed she could have asked which residents were COVID-19 positive, but she was not used to the facility not having them place PPE in the room. The impact of not wearing the gown and face shield or goggles when she is in a COVID-19 positive room is that it can spread the virus to anyone. The facility has never run out of supplies for PPE. CNA A revealed she worked with a mix of covid-19 positive residents and non-covid positive residents on 02/08/2023. In an interview on 02/08/23 at 3:47 PM with ADON and infection control specialist revealed that the facility began testing residents for COVID-19 about 5:45 am. One staff member and nine residents tested positive for COVID-19. ADON Revealed the facility made the decision to move some of the residents to the back of the three hundred hallway and as the residents were moved a sign was placed on the resident's door indicating that the residents in the room were COVID-19 positive and to see the nurse. ADON stated that both a facility employee and an agency staff member should know not enter a COVID-19 positive room without the proper PPE. The ADON revealed the nurses on hallway 300 and all staff should have helped to put PPE in front of the rooms of resident who tested positive for COVID-19. The ADON revealed she does not know what the break down was or why setting up the PPE was not followed. The ADON revealed that cross contamination to non-COVID-19 positive residents could occur if staff enters a COVID-19 positive resident room without wearing the proper PPE and then enter the room of a non-COVID-19 positive resident room. ADON revealed that staff did not follow directions to wear the proper PPE and staff know immediately when a resident is COVID-19 positive, and staff were told at the start their shift when they are working with a COVID-19 positive resident. ADON stated that as the facility moved COVID-19 positive residents to new rooms a sign was placed on the COVID-19 positive resident's door informing staff that the resident(s) in the room were positive for COVID-19. Review of the facility COVID-19 Immediate Response Guidelines undated policy reflected that before staff enter a resident COVID-19 positive isolation room and prior to donning PPE the staff are to identify and gather the proper PPE to don, perform hand hygiene using hand sanitizer, put on proper PPE consisting of gown, approved N95 filtering facepiece respirator or higher (use a facemask if respirator is not available), put on face shield or goggles, put on gloves then may enter patient room. The response guideline required training of staff on proper use and maintenance of PPE per CDC guidance and use dedicated staff to provide meal service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455785 If continuation sheet Page 20 of 20