Health inspection·July 14, 2022

F 0582 disorder; insomnia; essential hypertension; and history of UTI, sepsis, and bacterial infection of urine. Level of Harm - Minimal harm or potential for actual harm Review of Resident #43's Nursing Notes, dated 5/23/22, revealed she received an initial dose of antibiotic medication for a diagnosis of UTI. Residents Affected - Some Review of Resident #43's Resident Census Record revealed she had been receiving State Medicaid benefits, and on 5/24/22 she started receiving Medicare Part A skilled services. The record documented on 6/05/22, Resident #43 was receiving State Medicaid benefits. Review of the NOMNC form revealed Resident #43 was notified current Medicare services would end 6/05/22. The form was signed by the resident on 6/03/22. There was no documented evidence a SNF ABN form was provided to the resident. In an interview on 7/14/22 at 11:38 AM, the MDS Coordinator stated she was responsible for completing NOMNC forms. She stated that was all she used and all she has been trained to use. She stated she tried to get the NOMNC forms signed 48 hours (2 days) before residents discharge off Medicare Part A, if they had days remaining. She stated the forms were signed by the resident coming off Part A services or their responsible party if they were unable to sign. The MDS Coordinator stated she was trained by the facility's Corporate MDS Coordinator and she had received 2 days of training on 5/18/22 and 5/19/22. She stated she had not heard of the SNF ABN form and had not ever used it. She stated she was only trained on the importance of completing the NOMNC form. She stated she had to google the other form just to see what it was. She stated she just did it yesterday and now knew she should use both the NOMNC and SNF ABN forms for residents who remain in the facility after discharge from Part A services with days remaining. The MDS Coordinator stated she did not have a specific policy for when to use the NOMNC form, only has the training materials she was provided. She stated she found and printed CMS instructions for NOMNC and SNF ABN forms. She stated the instructions may be used as the policy but would need to be approved by the corporate office first. In an interview on 7/14/22 at 11:50 AM, the MDS Coordinator stated the therapy department staff were notifying residents and/or responsible parties when skilled care would end. She stated the PTA spoke with Resident #46 and the resident's family member regarding the date the resident would be discharged from Medicare Part A services. She stated the resident was notified in advance by the therapy department that skilled services would end on 5/14/22, and the resident did not leave AMA (against medical advice). She stated the decision was made by Resident #46 and his family after being told by the PTA that skilled services would be ending on 5/14/22. She stated the resident should have received a NOMNC. She stated she did complete the NOMNC for Resident #43 and did not know he should have received the SNF ABN form, too. In an interview on 7/14/22 at 12:17 PM, the PTA, Director of Rehabilitation for the facility, stated he used the NOMNC for residents coming off Medicare Part B services. The PTA stated the Business Office Manager was doing the Medicare Part A NOMNC forms. The PTA stated Resident #46 had been Part A and therapy did not do the NOMNC for him. The PTA stated therapy did a home visit evaluation for Resident #46 and he needed a ramp to access the house due to not being able to lift his leg high enough to climb stairs. In an interview on 7/14/22 at 12:25 PM, the PTA stated Resident #43 was skilled for UTI. The PTA stated the resident had therapy on and off with both Part A and Part B at times. The PTA stated the resident was currently on Part B for occupational therapy 3 times/week, starting 6/05/22, so there was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 2 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete no interruption in services. The PTA stated he did not know why the resident went from Part A to Part B services. The PTA stated that was what the office staff told him and that was what the therapy department did. In an interview on 7/14/22 at 12:40 PM, Resident #43 stated she was told she would be going from receiving therapy 5 times a week to 3 times a week. She stated it was ok with her, but continued therapy 5 days per week might have been of more help. She stated no one explained to her why her therapy was being decreased to 3 times per week. Event ID: Facility ID: 455808 If continuation sheet Page 3 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation, and misappropriation of resident property for 5 of 8 employee files (CNA A, Housekeeper B, CNA C, Dietary Aid D, LVN E, and LVN F) reviewed for abuse protocol. Residents Affected - Some The facility did not complete reference checks on CNA A, Housekeeper B, CNA C, Dietary Aid D, LVN E, and LVN F, prior to employment at the facility. This failure could place residents at risk for abuse, neglect, and exploitation. Findings included: Review of the facility policy Abuse Prevention Program, Med-Pass 2001 (revised in January 2011), revealed the following: Policy Statement: Our residents have a right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntarily seclusion. Policy Interpretation and Implementation: 2. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. A Record Review of the employee files revealed they did not include reference checks for the following employees prior to employment: CNA A - Hired on 04/18/2022. Housekeeper B - Hired on 06/17/2022. CNA C - Hired on 06/06/2022. Dietary Aid D - Hired on 06/30/2022. LVN E - Hired on 05/23/2022. In an interview with the Administrator, on 07/13/2022 at 4:30 p.m., revealed no reference checks were conducted on new employees hired from the period of October 2021 to May 2022 as the employee, Assistant Business Office Manager, did not know they were to be conducted. She said the error was caught in an audit and was now corrected. The employee worked at the facility from October 2021 to May 2022 and is no longer employed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 4 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct an accurate comprehensive, assessment for one resident (Resident #16) of 45 residents reviewed for MDS assessments and care plan. The facility failed to complete an accurate comprehensive assessment for Resident #16 following her admission to the facility which did not indicate the proper number of staff to safely transfer her from the wheelchair to the shower chair. The failure placed all 45 residents at risk for not having their care and treatment needs assessed ensuring necessary care and services provided to meet these needs. Findings included: Resident #16's undated Face Sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #16's Care Plan dated 07/12/2022 and revised 07/12/2022 revealed Resident #16 was a [AGE] year-old female admitted to facility on 07/11/2022 and had diagnoses of Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar), Essential (Primary) Hypertension (high blood pressure), heart failure (inability of the heart to provide adequate function pumping blood), and cerebrovascular accident, a loss of blood flow to part of the brain, which damages brain tissue. The Care Plan did not include the number of staff required to transfer Resident #16 to bed, chair, wheelchair or standing position. The care plan was Updated on 07/12/2022 by the ADON indicating 1 person for transfer to and from the wheelchair to the bed and/or chair. Review of Resident #16's MDS (minimal data sheet) dated 05/30/2022 assessment revealed she had a BIMS (brief interview for mental status) of 12 indicating she had mild cognitive impairment indicating she could make her needs known. Section G ADL (activity for daily living) question B - How resident transfer between surfaces including to or from: bed, chair, wheelchair standing position (excludes to and from bath/toilet). Self-performance (3) was entered indicating Extensive assistance needed resident involved in activity, staff provide weight-bearing support. Support (3) was selected indicating Two + persons physical assistance. She required two-person transfer between surfaces including to or from bed, chair, wheelchair standing position. Functional range of motion Resident #16 lower extremity on both sides hip knee ankle and foot. Review of the facility accident and incident report dated on 06/03/2022 revealed Resident #16 fell during assistance from her wheelchair to a shower chair with one person assisting Resident #16. Incident report stated Resident #16 had a bump on her head and neurological checks were conducted every two hours. Resident #16 refused to be transferred to the hospital for evaluation. Review of Nurses Noted dated on 06/03/2022 at 4:08 PM revealed the following: This nurse (MDS Coordinator) was assisting resident with transferring over to the shower chair at this time. Resident had on no slip socks on during transfer. This nurse had locked the wheel of the shower chair before transferring resident stood well with minimal assistance, we then pivoted back side to shower chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 5 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident began sitting in shower chair and was unsuccessful. The resident fell to the floor and hit her elbow and hit her head. Housekeeping in room currently. This RN called the DON to the room for assistance. Vital signs were taken and are stable. CNA (unidentified) assisted [Resident #16] off the floor and into shower chair. An interview with the ADON on 07/13/2022 at 11:10 AM said Resident #16 had a care plan and said that the care plan did not designate how many staff members were to assist in transferring her. She said she will update the care plan to indicate how many staff members should transfer Resident #16 An interview on 07/13/2022 at 11:20 AM interview with the MDS Coordinator said Resident #16 was weight bearing and able to transfer from her wheelchair to bed or shower chair with the help of one1 person. She said she sometimes help on the floors and she was working on the floors the day of the incident, helping Resident #16 get ready for her shower. She said she transferred the resident by herself from the wheelchair to the shower chair and the shower chair brakes slipped and Resident #16 fell. She said she can usually stand and is weight bearing and usually transfer safely with one person assist. She said the reason the MDS showed reflected a two-person transfer is because CNAs chart using two-person assistance and it codes it that way (two-person transfer). She said there is not a physician's order for a two-person transfer assistance. She said she did not know why the Care Plan did not show how many staff needed to transfer Resident # 16. (No staff were indicated in transferring Resident #16 in the Care Plan) (MDS Coordinator thought a Physician order was needed for how many staff members were needed to transfer a Resident). An interview on 07/13/2022 at 1:40 PM an interview with LVN I said she had been called to do vital signs on Resident #16. She said she understood the resident slipped and fell. She said she did not know if there was a second person assisting but she said the resident could not safely transfer with only one person because she complains about her knees hurting and her legs sometimes gave out. She said, in her opinion she should not be transferred with only one person. An interview with Resident #16 on 07/13/2022 at 2:00 PM Resident #16 said, she was getting ready for a shower and was moving over to the shower chair and slipped and fell when the shower chair moved. She said the MDS Nurse was helping her by herself, but several people came to help get her up even office people. She said she hit her head and her knee, but she was okay, and they wanted her me to go to the hospital, but she said I was ok. An interview on 07/14/2022 at 2:30 PM CNA F said he frequently works with Resident #16 and he sometimes transfers her by himself, but she has complained about her knees hurting and her legs give out. He said he felt Resident #16 cannot safely transfer with only one person. An interview on 07/14/2022 at 2:40 PM CNA G said she frequently worked with Resident #16 and sometimes transfer her by herself. She said she felt a one-person transfer was not safe because she complained her knees hurt, and her legs sometimes would give out. An interview n 07/14/2022 at 2:50 PM CNA H said she frequently works with Resident #16 and sometimes transfer her by herself and felt she cannot safely transfer with one person. She said she complains about her knees hurting and her legs give out. An interview on 07/14/2022 at 3:30 PM the Administrator said MDS Nurse has not been at the position for long. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 6 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop the resident's comprehensive care plan for one (Resident #16) of 45 reviewed for care plans that describe the services to be provided to attain the resident's highest practicable physical, mental, and psychological well-being in that: Resident #16 did not have a care plan to address transfer assistance. The findings included: Resident #16's undated Face Sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #16's Care Plan dated 07/12/2022 and revised 07/12/2022 revealed Resident #16 was a [AGE] year-old female admitted to facility on 07/11/2022 and had diagnoses of Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar), Essential (Primary) Hypertension (high blood pressure), heart failure (inability of the heart to provide adequate function pumping blood), and cerebrovascular accident, a loss of blood flow to part of the brain, which damages brain tissue. The Care Plan did not include the number of staff required to transfer Resident #16 to bed, chair, wheelchair or standing position. The care plan was Updated on 07/12/2022 by the ADON indicating 1 person for transfer to and from the wheelchair to the bed and/or chair. Review of Resident #16's MDS (minimal data sheet) dated 05/30/2022 assessment revealed she had a BIMS (brief interview for mental status) of 12 indicating she had mild cognitive impairment indicating she could make her needs known. Section G ADL (activity for daily living) question B - How resident transfer between surfaces including to or from: bed, chair, wheelchair standing position (excludes to and from bath/toilet). Self-performance (3) was entered indicating Extensive assistance needed resident involved in activity, staff provide weight-bearing support. Support (3) was selected indicating Two + persons physical assistance. She required two-person transfer between surfaces including to or from bed, chair, wheelchair standing position. Functional range of motion Resident #16 lower extremity on both sides hip knee ankle and foot. Review of the facility accident and incident report dated on 06/03/2022 revealed Resident #16 fell during assistance from her wheelchair to a shower chair with one person assisting Resident #16. Incident report stated Resident #16 had a bump on her head and neurological checks were conducted every two hours. Resident #16 refused to be transferred to the hospital for evaluation. Review of Nurses Noted dated on 06/03/2022 at 4:08 PM revealed the following: This nurse (MDS Coordinator) was assisting resident with transferring over to the shower chair at this time. Resident had on no slip socks on during transfer. This nurse had locked the wheel of the shower chair before transferring resident stood well with minimal assistance, we then pivoted back side to shower chair. Resident began sitting in shower chair and was unsuccessful. The resident fell to the floor and hit her elbow and hit her head. Housekeeping in room currently. This RN called the DON to the room for assistance. Vital signs were taken and are stable. CNA (unidentified) assisted [Resident #16] off the floor and into shower chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 7 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 An interview with the ADON on 07/13/2022 at 11:10 AM said Resident #16 had a care plan and said that the care plan did not designate how many staff members were to assist in transferring her. She said she will update the care plan to indicate how many staff members should transfer Resident #16 An interview on 07/13/2022 at 11:20 AM interview with the MDS Coordinator said Resident #16 was weight bearing and able to transfer from her wheelchair to bed or shower chair with the help of one1 person. She said she sometimes help on the floors and she was working on the floors the day of the incident, helping Resident #16 get ready for her shower. She said she transferred the resident by herself from the wheelchair to the shower chair and the shower chair brakes slipped and Resident #16 fell. She said she can usually stand and is weight bearing and usually transfer safely with one person assist. She said the reason the MDS showed reflected a two-person transfer is because CNAs chart using two-person assistance and it codes it that way (two-person transfer). She said there is not a physician's order for a two-person transfer assistance. She said she did not know why the Care Plan did not show how many staff needed to transfer Resident # 16. (No staff were indicated in transferring Resident #16 in the Care Plan) (MDS Coordinator thought a Physician order was needed for how many staff members were needed to transfer a Resident). An interview on 07/13/2022 at 1:40 PM an interview with LVN I said she had been called to do vital signs on Resident #16. She said she understood the resident slipped and fell. She said she did not know if there was a second person assisting but she said the resident could not safely transfer with only one person because she complains about her knees hurting and her legs sometimes gave out. She said, in her opinion she should not be transferred with only one person. An interview with Resident #16 on 07/13/2022 at 2:00 PM Resident #16 said, she was getting ready for a shower and was moving over to the shower chair and slipped and fell when the shower chair moved. She said the MDS Nurse was helping her by herself, but several people came to help get her up even office people. She said she hit her head and her knee, but she was okay, and they wanted her me to go to the hospital, but she said I was ok. An interview on 07/14/2022 at 2:30 PM CNA F said he frequently works with Resident #16 and he sometimes transfers her by himself, but she has complained about her knees hurting and her legs give out. He said he felt Resident #16 cannot safely transfer with only one person. An interview on 07/14/2022 at 2:40 PM CNA G said she frequently worked with Resident #16 and sometimes transfer her by herself. She said she felt a one-person transfer was not safe because she complained her knees hurt, and her legs sometimes would give out. An interview n 07/14/2022 at 2:50 PM CNA H said she frequently works with Resident #16 and sometimes transfer her by herself and felt she cannot safely transfer with one person. She said she complains about her knees hurting and her legs give out. An interview on 07/14/2022 at 3:30 PM the Administrator said MDS Nurse has not been at the position for long. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 8 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observations and interview and record review the facility failed to ensure they posted the nursing staffing data that indicated the resident census for 3 of 3 days (7/12/22, 7/13/22 and 7/14/22) observed in that: Residents Affected - Many The facility did not post the resident census on the daily staffing posting for 7/12/22, 7/13/22 and 7/14/22. The facility's failure could place residents, their families, and facility visitors at risk of not having access to accurate information regarding the facility census. Observation on 7/12/22 at 10:00 AM of the facility's only staffing posting document titled, Daily Staffing Sheet dated 7/12/22 and posted on the facility's front window adjacent to the front door revealed the following DON - 8 hours, ADON - 8 hours, MDS - 8 hours, RN - 8 hours, LVN 6a-6p - 36 hours, LVN 6p-6a 16 hours, CNA 6a - 6p - 36 hours, CNA 6p - 6a - 16 hours. The resident census was not documented. Observation on 7/13/22 at 10:30 AM of the Facility's only staffing posting document titled, Daily Staffing Sheet dated 7/13/22 and posted on the facility's front window adjacent to the front door revealed the following DON - 8 hours, ADON - 8 hours, MDS - 8 hours, RN - 8 hours, LVN 6a-6p - 36 hours, LVN 6p-6a 16 hours, CNA 6a - 6p - 36 hours, CNA 6p - 6a - 16 hours. The resident census was not documented. Observation on 7/14/22 at 10:00 AM of the facility's only staffing posting document titled, Daily Staffing Sheet dated 7/14/22 and posted on the facility front window adjacent to the front door revealed the following DON - 8 hours, ADON - 8 hours, MDS - 8 hours, RN - 8 hours, LVN 6a-6p - 36 hours, LVN 6p-6a - 16 hours, CNA 6a - 6p - 36 hours, CNA 6p - 6a - 16 hours. The resident census was not documented. In an interview on 7/14/22 at 3:00 PM, the facility Administrator stated, the DON was responsible for posting the daily nursing staffing hours and census each day. The Administrator further stated, That failure to include the resident census could negatively affect the residents, family members, and visitors by not including the actual resident census . In an interview on 7/14/22 at 3:10 PM, the DON stated, she was responsible for the daily staffing postings. She stated she failed to include the resident census on the Daily Staffing Posting and this failure could negatively affect the residents, family members, and visitors by not including the actual resident census . Record review of the facility's policy dated August 2006 titled Posting Direct Care Daily Staffing Numbers reflected in part: 3.Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: a. The name of the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 9 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0732 b. Level of Harm - Potential for minimal harm The date for which the information is posted. c. Residents Affected - Many The resident census at the beginning of the shift for which the information is posted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 10 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to employ sufficient personnel to safely and effectively carry out the functions of the food and nutrition service. Residents Affected - Many 1. Meals were not served on time at the scheduled time. 2. Cleaning in the kitchen was not being completed routinely. The facility's failure placed residents at risk of weight loss, decreased psycho-social well-being, receiving food that was not palatably warm and was not prepared under sanitary conditions. The findings include: Observation on 7/12/22 at 9:25 AM revealed the meal times were posted near the entrance to the dining room, on the wall to the left of the door to the kitchen, and were scheduled for 7:30 AM, 12:00 PM, and 5:00 PM. In an interview on 7/13/22 at 8:45 AM, the Dietary Manager stated the morning cook, [NAME] G, had called in today. The Dietary Manager stated she would be cooking all 3 meals for the day, and she would be at facility until 8 PM tonight. The Dietary Manager stated the dietary department was short-staffed and she only had 2 cooks, [NAME] G and [NAME] H, and 2 dietary aides, Dietary Aide D in the morning and Dietary Aide F in the evening. She stated [NAME] H was only part-time in the kitchen, as she helped with activities and drove the facility van to take residents to and from appointments. The Dietary Manager stated she would begin preparing the pureed food at 11:45 AM for the two residents receiving pureed diets. In an interview on 7/13/22 at 11:45 AM, the Dietary Manager stated she was not ready to prepare the pureed diets. She stated she had just taken the chocolate brownies out of the oven and needed to place the single cut square servings into individual bowls. Observation on 7/13/22 at 11:55 AM revealed the Dietary Manager was preparing to begin the pureed diet food. Observation on 7/13/22 at 12:30 PM revealed the Dietary Manager started checking the steam table food holding temperatures, using a stainless steel digital thermometer and alcohol wipes/pads to clean the thermometer between food items. Observation on 7/13/22 at 12:36 PM revealed the lunch meal service was starting with the dining room residents being served first. The lunch meal service was scheduled to start at 12:00 PM/noon. Observation and interview on 7/13/22 at 1:00 PM revealed the meal tray cart with 12 trays was taken to Hall C memory care unit. The Dietary Manager stated today the meal tray cart for the memory care unit residents would be served before the hall meal tray carts for residents who ate in their rooms. She stated the usual order of meal services was to serve residents who ate in the dining room first, resident who ate in their rooms second, and the memory care unit last. In an interview on 7/14/22 at 10:21 AM, the Dietary Manager stated [NAME] G had health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 11 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many complications and had requested time off. The Dietary Manager stated the facility had been advertising dietary positions on-line with an employment website. She stated the local fast-food restaurants paid better. The Dietary Manager stated since they had been short on dietary staff, cleaning schedules were not used, and cleaning was done when the staff had time. She stated the evening dietary staff did most of the cleaning, since they only had one meal to prepare and serve. She stated food preparation counters and counters beneath them were cleaned daily and the floor was swept and mopped. Review of the Dietary Staff Weekly Schedules, dated July 2022, revealed a total of 5 staff consisting of the dietary manager, 2 cooks, and 2 dietary aides. Dietary Aide D was scheduled for training 5/04/22 - 5/07/22. The morning staff worked 5:30 AM - 2 PM, with 1 cook and 1 dietary aide scheduled. The evening staff worked 2 PM - 8 PM, with 1 cook who worked 2 PM - 8 PM and 1 dietary aide dietary aide who worked 4 PM - 8 PM. Review of the evening shift schedule for 7/13/22-7/15/22 revealed [NAME] G was taken off the evening shift and the dietary manager was scheduled to cook all 3 meals those days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 12 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed. Residents Affected - Many 1. The staff did not use the handwashing sink with the eye wash station and used one of two compartments of the food preparation sink for handwashing. 2. The dietary aide washing dishes had not been trained to measure the sanitizer content in the low temperature dish machine. 3. The stainless-steel shelf units were soiled with spilled spices, food crumbs, and dried liquids. 4. The appliance surfaces were soiled with dust and grease build-up. 5. Bowls and pans used for food preparation were not stored inverted to protect their sanitized food surfaces from potential contaminants in the air. 6. The walk-in refrigerator was not working and perishable food was stored in ice chest/coolers on the floor. 7. Cleaning tasks in the kitchen were not being completed routinely. These failures could place residents at risk for foodborne illness and a decline in health status. The findings include: Observations and interviews on 7/12/22 at 9:25 AM, during the initial tour of facility kitchen revealed the following: - A sink with soap and paper towel dispensers on the wall above it was also used as an eye wash station; the Dietary Manage stated it was not the hand washing sink and stated to use the right hand side compartment of the two compartment food preparation sink near the dish washing area She stated to throw the paper towel in the trash barrel by the dirty dish side of the dish machine; the trash barrel was not covered. - Dietary Aide D was washing dishes and stated he had never checked the low temperature dish machine sanitizer content and did not know how to do it. He looked down at the 5 gallon container of sanitizer on the floor to see how much was in it. He stated he had been working in the facility for 1 week. - The Dietary Manager stated Dietary Aide F, at night, checked the dish machine sanitizer. She stated it was not documented because they did not have a form to document the chlorine sanitizer PPM; they only had a form to document the dish machine wash and rinse water temperatures. Review of the Dishwasher Temperature Log, dated July 2022, revealed the wash and rinse water temperatures were documented one time daily. The form only had columns for wash and rinse water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 13 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 temperatures to be documented one time daily. Level of Harm - Minimal harm or potential for actual harm Observation of the low temperature dish machine operation on 7/12/22 at 9:35 AM revealed the Dietary Manager measured the chlorine sanitizer content at 50 ppm, which met the manufacturer's minimum recommendation. Residents Affected - Many Observations of the kitchen on 7/12/22 at 9:40 AM revealed the following: - The fryer unit had 2 metal fry baskets covered with dark brown grease build-up; cooking oil dark colored with pieces of fried food crumbs floating in it; side surfaces of the fryer were soiled with grease drips/streaks and top surface was soiled with grease and fried food crumbs; and a stainless steel 1/2 cup measure on the top surface of fryer. - Large stainless steel bowls and sauce pans were stacked upright with their interior food surfaces exposed to the air on the shelf below the stainless steel food preparation counter in the center of the room. - The manual can opener, mounted to the end of the stainless steel food preparation counter, was soiled with a dark colored build-up. - The electric mixer stand was soiled with dried batter splatters and the stainless steel bowl positioned on the stand base was not covered, with the interior food surface exposed to the air. - A vinyl mesh shelf liner was used on a wall shelf with inverted beverage glasses on it; there were food crumbs and dust on the shelf beneath the mesh liner. - The residential style upright door freezer on the far right in the back room did not have a thermometer; frozen bottles of water were in the door holders; gallon sized re-closable plastic bags were filled with water had been placed flat on the shelves. During an observation and interview on 7/12/22 at 9:45 AM revealed the walk-in refrigerator was not working and did not contain food. The Dietary Manager stated the walk-in refrigerator started going out and a repairman was called on 6/27/22. She stated the unit worked for 3 days and went completely out on 7/01/22 or 7/03/22. She stated a part was ordered to repair it. Observation of 7/12/22 at 9:46 AM revealed two ice chests/coolers, one large and one medium size, were on the floor in front of the sliding glass doors to the walk-in refrigerator. The large ice chest/cooler had an open flat egg carton with 2-1/2 dozen regular shell eggs (not pasteurized) on the bottom; the eggs were submerged in water and were covered with approximately 1 inch of water. The ice chest contained an opened package of grated cheese, dated 6/28/22, that had been rolled closed and secured with a bag clip; a one-gallon container of frozen milk; gallon containers with mayonnaise, coleslaw dressing, and dill chip pickles that had been opened and not dated. A thermometer was not observed in the ice chest/cooler. The small ice chest/cooler contained a jar of chopped garlic that had been opened and was dated 6/03/22, a container of beef base that was not dated, frozen turkey luncheon meat, a re-closeable bag with raw bacon, a package with bologna luncheon meat, an unopened bag of frozen liquid eggs, and a carton of vanilla flavored health shake. The carton felt warm. There was water in the bottom of the ice chest/cooler and an empty gallon sized re-closeable plastic bag. A thermometer was not observed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 14 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 the ice chest/cooler. Level of Harm - Minimal harm or potential for actual harm In an interview on 7/12/22 at 9:50 AM, the Dietary Manager stated the ice chests/coolers melted ice water in the bottom of them. She stated the frozen ice packs had melted and frozen gallons of milk and the bag of frozen liquid eggs were added to the coolers to help keep the other food cold. The Surveyor inquired if there were thermometers in the ice chests/coolers to monitor the food storage temperatures. The Dietary Manager stated she had not been monitoring the ice chest/cooler temperatures. She looked and did not see thermometers in the 2 ice chests/coolers. Residents Affected - Many In an interview on 7/12/22 at 9:53 AM, the Administrator stated she was aware the walk-in refrigerator was not working. She stated the local refrigeration service/repair business had been called and came to the facility and a part had been ordered on 6/28/22. She stated the facility kept waiting for the part to arrive every day. She stated very little perishable food was being ordered, and the Dietary Manager was supposed to be monitoring the ice chest/cooler temperatures. In an interview on 7/12/22 at 10:05 AM, the Administrator stated she had called the corporate office regarding the food being stored in the ice chests/coolers in the kitchen. She stated she was instructed to throw out the food and was told a refrigerator would be sent to the facility. Observation on 7/12/22 at 10:28 AM revealed the 2 ice chests/coolers had both been emptied of food and contained water from melted ice. One metal thermometer was observed floating in the water in each ice chest/cooler. The Dietary Manager stated the food has been discarded; she stated she found the thermometers floating in the water after the food was removed. Containers of mayonnaise, coleslaw dressing, beef base, chopped garlic, shredded cheese, and broken shell eggs were observed in the uncovered garbage barrel by the dish machine. During observation and interview on 7/12/22 at 10:30 AM, the Dietary Manager's office, located on Hall B, had canned foods on a metal rack shelf unit. 5 large plastic bulk storage containers were on the bottom shelf for storing rice, cracker crumbs, dry milk, corn meal and pasta. The lids to the storage containers were soiled with dust/spilled food and felt gritty to touch. The Dietary Manager stated she sometimes wiped-off the container lids. In an interview on 7/13/22 at 9:10 AM, the Dietary Manager stated she had found a low temperature dish machine temperature and sanitizer log form and would start using it to document the dish machine wash and rinse temperatures and sanitizer ppm 3 times/meals daily. Observations and interview on 7/13/22 at 11:50 AM of the kitchen revealed the following: - The fryer unit was soiled with oil streaks on side surfaces and top surface soiled with cooking oil and fried food crumbs The Dietary Manager stated the fryer was not used today. - A vinyl mesh shelf liner was used on a wooden shelf with small dessert bowls on top of the mesh liner; crumbs and dust were on the shelf beneath the liner; - A vinyl mesh shelf liner was on the stainless steel counter to the right of the hand washing sink and to the left side of the dish machine (corner); 3 silverware holders had been placed on top of the mesh liner. [The counter was not easily cleaned beneath the mesh liner.] Observation on 7/13/22 at 11:55 AM revealed the Dietary Manager was assembling the food processor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 15 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 to prepare pureed diets for 2 residents. The food processor was on the stainless steel counter to the left of the food preparation sink. The counter was soiled with chocolate brownie crumbs and spilled milk. There was a pale with sanitizer water and a rag on the counter, but the Dietary Manager did not wipe off the counter. She used a stainless steel spoon to stir the food (carrots) and check the consistency of the food in the food processor, and placed the spoon with pureed carrots on the counter. She picked up the spoon again to stir and check the consistency of the food in the food processor and again placed the spoon on the counter. In an interview on 7/13/22 at 4:35 PM, Dietary Aide F stated she had checked the low temperature dish machine wash and rinse temperatures and the sanitizer ppm, but only wrote down the water temperatures on the form, as there was not a column to write down the sanitizer. She stated now there was a new form that was for water temperatures and sanitizer ppm. Review of the U.S. Food and Drug Administration, 2017 Food Code, reflected: Preventing Contamination from the Premises 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . Storing 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 16 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the quality assessment and assurance committee (QAA) met at least quarterly and consisted of the required members for one of one quarterly QAA meetings. Residents Affected - Many The facility failed 6 of 6 QAA's reviewed to have the appropriate members (Medical Director or his/her designee) for their QAA committee meetings held on 01/25/22, 02/23/22, 03/31/22, 04/26/22, 05/23/22 and 06/21/22. This failure could place residents at risk for quality deficiencies being unidentified and with no appropriate guidance developed or implemented. Findings included: Review of the QAA meeting sign in sheets dated 01/25/22, 02/23/22, 03/31/22, 04/26/22, 05/23/22 and 06/21/22 revealed the Medical Director or his/her designee did not attended. Review of facility's QAA Policy revealed that the QAA Committee consisted at a minimum, Administrator, Director of Nursing, MDS Coordinator, Medical Director, Business Office Director and Regional Director of Quality Assurance. Interview with the Administrator on 0714/22 at 11:14 AM. revealed they had QAA meetings monthly, but the Medical Director has not attended QAA meetings. Attempt to contact Medical Director for interview, left voice mail by phone but unable to contact FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 17 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. Residents Affected - Many 1. The walk-in refrigerator unit was not maintained in proper working order to ensure perishable food was stored at the proper temperature and the facility had not obtained a replacement refrigerator for the cold storage of perishable food for more than two weeks after the kitchen walk-in refrigerator stopped working. These failures placed the residents at risk for not receiving a variety in meals as planned and placed residents at risk for foodborne illness. The findings include: During an observation and interview on 7/12/22 at 9:45 AM, it was revealed the walk-in refrigerator was not working and it did not have food in it. The Dietary Manager stated the walk-in refrigerator started going out and a repairman was called on 6/27/22. She stated it worked for 3 days and went completely out on 7/01/22 or 7/03/22. She stated a part was ordered to repair it. Review of the refrigeration company's proposal, dated 6/28/22, revealed a documented proposal for the change-out of the condenser fan motor in the freezer; pull out old motor, install new motor, start up new unit and check all operations. Review of the refrigeration company's service invoice, dated 7/01/22, documented: 6/28/2022 Call: Walk-in Cooler Warm - Upon inspection, the technician found the head pressure control tripping on the roof. He reset and everything came back on except for the condenser fan motor. It was over-amping and turning off. He rigged a fan to help the system limp by until a new motor arrived. Motor has been ordered and is in shipping process. Technician will return and install new motor as soon as it arrives. Observation on 7/12/22 at 9:46 AM revealed two ice chests/coolers, one large and one medium sized, were directly on the floor in front of the sliding glass doors to the walk-in refrigerator. The ice chest/coolers contained perishable food items. In an interview on 7/12/22 at 9:53 AM, the Administrator stated she was aware the walk-in refrigerator was not working. She stated the local refrigeration service/repair business had been called, they came to the facility, and a part had been ordered on 6/28/22. She stated the facility kept waiting for the part to arrive every day. She stated very little perishable food was being ordered, and the Dietary Manager was supposed to be monitoring the ice chest/cooler temperatures. In an interview on 7/12/22 at 10:42 AM, the Administrator stated the corporate office had approved a side-by-side refrigerator/freezer to be rented from a local appliance store. She stated the unit would be rented until the part came to fix the walk-in refrigerator in the kitchen. She stated the refrigerator/freezer unit should be delivered by this afternoon. In an interview on 7/12/22 at 11:20 AM, the Administrator stated she had just got off the phone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 18 of 19 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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 0908 with the refrigerator rental store and the refrigerator/freezer was on its way. Level of Harm - Minimal harm or potential for actual harm On 7/12/22 at 11:23 AM the Administrator provided a printed copy of the rental agreement with the appliance rental store. Review of the lease agreement revealed it was dated 7/12/22 and documented a new side-by-side refrigerator with ice and water would be leased for 1 month, with delivery on 7/12/22. Residents Affected - Many Observation on 7/12/22 at 12:38 PM revealed the side-by-side refrigerator/freezer was being delivered by the appliance rental store. Observation on 7/12/22 at 2:16 PM revealed the side-by-side refrigerator/freezer was currently positioned in the dining room to the right of the door to the dish machine area. The unit was plugged into the electrical outlet in the wall behind the appliance. The appliance was empty and cooling; there were no thermometers inside the unit. Observation on 7/13/22 at 9:20 AM revealed the leased side-by-side refrigerator/freezer unit had been moved into the kitchen in front of the walk-in refrigerator and was plugged into an electrical outlet. The refrigerator had a thermometer inside and read 41 degrees F; the appliance thermometer read 37 degrees F. The refrigerator contained cartons of 2.0 supplement, fresh tomatoes, and raw bacon. The freezer side was empty, and the temperature was -08 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 19 of 19