Health inspection·August 26, 2023

F 0637 Section O- Received oxygen while a resident and while not a resident. IV Medication while not a resident. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #40 face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] for aftercare following right hip replacement surgery on 07/20/2023. Resident #40 had diagnoses which included dementia (loss of memory), pathological fracture of hip (broken hip), pain, aftercare following joint replacement surgery, and urinary tract infection (care after joint replacement surgery and an infection in the urinary tract). Residents Affected - Few Record review of progress note, dated 08/12/2023, revealed Resident #40 complained of discomfort to his right hip. Resident #40's right hip was red with a scant amount of white drainage at the incision site. The Medical Director was notified, and Resident #40 was sent to the emergency room for evaluation on 08/13/2023. Record review of discharge paperwork from the hospital, dated 08/13/2023, revealed Resident #40 had a yeast infection surrounding the incision site, as well as a potential bacterial infection within the incision itself. The staples were noted to have brown cream-colored exudative discharge. Foul smell was noted. The 8 staples were removed. The resident was treated for both fungal and bacterial infections. The resident was placed on the oral antibiotic Bactrim for the infection and oral antifungal fluconazole for the yeast infection. In an interview on 08/25/2023 at approximately 11:10 AM, the Regional MDS Coordinator said she was the one who was responsible for completing the MDS's and identifying if the resident had a significance change. She revealed Resident #14 and Resident #40 had a decline when they went to the hospital, and she should have completed a significant change MDS upon their return. She revealed this failure placed the residents at risk for not having a comprehensive assessment and an updated CAAS. She revealed it was not updated to reflect the change in condition due to her missing it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 2 of 16 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 08/26/2023 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 0641 Ensure each resident receives an accurate assessment. 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 assessments accurately reflected the resident's status for 1 of 15 sampled residents (Residents #'s 12) reviewed for accuracy of assessments. Residents Affected - Few 1. The facility failed to ensure Resident #12's MDS was accurately coded as receiving dialysis. 2. The facility failed to ensure Resident #12's MDS continence status was accurately . This failure could place residents at risk of not receiving the proper care and services due to inaccurate records. Findings include: Record review of Resident #12's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #12 had diagnoses which included retention or urine (not able to urinate properly), acute kidney failure (kidney is unable to filter waste), Type 2 diabetes mellitus (body does not produce enough insulin) and cerebral infarction (disrupted blood flow to the brain to due problems in the blood vessels). Record review of Resident #12's admission MDS, dated [DATE], revealed the following: Section H revealed the resident was coded as having in indwelling catheter in H0100 under appliances but was always continent in H0300 under urinary continence. Section O revealed the resident received dialysis while a resident. Record review of Resident #12's current care plan revealed the following areas: Problem: Indwelling Catheter Potential for complications related to indwelling urinary catheter. Goal: Will remain free s/sx of complications related to catheter through review date. Problem: Resident has history of dependence on renal dialysis related to renal failure. Resident came off of dialysis in 2021. Goal: Resident will not exhibit signs of fluid volume excess. In an interview on 08/23/2023 at 2:05 PM with the ADON revealed Resident #12 had not been receiving dialysis. She was unsure why he was coded as receiving while in the facility . In an interview on 08/25/2023 at approximately 11:10 AM, the Regional MDS Coordinator said she was the one who was responsible for completing the MDS's with accuracy. She said she had inaccurately coded Resident #12 as receiving dialysis, since he was previously receiving dialysis. She revealed she should have checked the record more thoroughly. She revealed Resident #12 had an indwelling catheter and she should not have coded him as being continent under urinary continence. She stated she should have coded him as not rated , resident had a catheter. She revealed this failure could place residents at risk for inaccurate assessments and inadequate care areas . She revealed she went by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 3 of 16 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 08/26/2023 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 0641 Resident Assessment manual for guidance. Level of Harm - Minimal harm or potential for actual harm Record review of CMS'S RAI Version 3.0 Manual version 1.17.1, dated October 2019, revealed: The RAI process has multiple regulatory requirements, require that Residents Affected - Few (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 4 of 16 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 08/26/2023 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents, (Resident #11) reviewed for PASRR Level 1 screenings. Residents Affected - Few The facility did not correctly identify Resident #11 as having a mental illness and did not complete a new PASRR Level One Screening. This failure could place residents at risk of not being evaluated for PASRR services. The findings were: Record review of Resident #11's face sheet, dated 08/25/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's had diagnoses which included Mood disturbance (decreased blood flow to the brain that causes mood disturbances), bipolar (mental disorder that is characterized by mood swings that last more than 2 weeks), and depression (state of sadness). Record review of Resident #11 Physician Orders, dated 08/25/2023, revealed orders for olanzapine; 5 mg; 1 tablet 2 times a day for bipolar, and an order for Lexapro; 5 mg; 1 tablet 1 time a day for depression. Record review of the admission MDS , dated 08/03/2023, revealed Resident #11 could understand others and was understood by others; had a severe cognitive impairment with a BIMS score of 05, which indicated severe cognitive impairment. No mood or behavior concerns were indicated on the MDS, dated [DATE]. Record review of Resident #11's Care Plan, dated 07/27/2023, revealed the resident received antipsychotic medicine. Record review of Resident #11's PASRR Level One Screening Forms, dated 08/25/2023, revealed he did not have a primary diagnosis of dementia. It revealed he was negative for mental illness, intellectual disability, or developmental disability. The form had not been updated. In an interview on 08/23/2023 at approximately 9:45 AM, the DON revealed she was somewhat familiar with the PASRR process. She stated they were in the process of hiring an in house MDS Coordinator. After looking over the clinical records of Resident #11, she revealed the PL1 should have been positive for mental illness do to the bipolar diagnosis and the resident being on antipsychotics . She had not updated the resident's PASRR due to just starting in her position and not having completed the adequate training to identify the need to update it. In an interview on 08/25/2023 at approximately 11:10 AM the Regional MDS Coordinator said that given the diagnosis of Resident #11 a PL1 reflecting Mental Illness should have been completed. She would be submitting the corrected forms at her earliest convenience. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 5 of 16 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 08/26/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of the resident's admission for 1 of 5 residents (Resident #19) whose records were reviewed in that: for care plans. The facility failed to ensure Resident #19 had a base line care plan developed and implemented upon admission on [DATE]. This failure could place the residents at risk for not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility. The findings included: Record review of Resident #19's face sheet, dated 08/24/2023, revealed resident was a [AGE] year-old male, who was initially admitted to the facility on [DATE]. Resident #19 had diagnoses which Diagnosis included: cerebral palsy (congenital disorder of movement due to abnormal brain development), hypertension (high blood pressure), major depressive disorder (mood disorder that lasts more than 2 weeks), anxiety (state of anxiousness), Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis on the right side after inadequate blood flow to the brain). Record review of Resident #19's clinical record revealed a baseline care plan had not been completed following the resident's initial admission to the facility on [DATE]. In an interview with the DON on 08/03/23, they stated the form titled Baseline care plan in the Resident's electronic medical record were not care plans. They both revealed that staff such as CNA's do did not have access to the care plan assessments that are were completed. They were only assessments that were meant to obtain information to complete the baseline care plan. They stated the failure places placed residents at risk for not getting needed care that would have been identified. Record review of the facility's policy and procedure titled Care Plans- Preliminary dated - Preliminary, dated August 2006, revealed the following [in part]: Policy Statement A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident withing 24 hours of admission. The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 6 of 16 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 08/26/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 12 of 12 residents (Resident #1, Resident #10, Resident #11, Resident #12, Resident #14, Resident #15, Resident #19, Resident #22, Resident #23, Resident #28, Resident #40, and Resident #193) reviewed for care plans. The facility failed to ensure resident care plans were developed and updated within 7 days following the completion of the MDS as well as having an Intradisciplinary Team present and at the care conference and involved in the care planning process. This failure could place residents at risk of not have having their care plans completed accurately and timely. Findings include: 1. Record review of Resident #1's face sheet revealed an [AGE] year-old male who was admitted to the facility 06/07/2023 and readmitted on [DATE]. Resident #1 had diagnoses which included chronic venous hypertension (increased pressure in your veins), dysphagia (difficulty swallowing), Sickle cell disease (sickle cells have become stuck in the blood vessels), and Surgical instruments, materials and anesthesiology devices (including sutures) associated with adverse incidents. Record review of Resident #1's Annual MDS assessment, dated 02/06/2023, revealed the following: Section C revealed the resident had a BIMS score of 08, which indicated moderately Impaired cognition. The care plan had not been updated or revised following the annual assessment. Record review of Resident #1's electronic Care Conference record did not have a care plan meeting since 09/15/2021. 2. Record review of Resident #10's face sheet revealed a [AGE] year-old female who was admitted to the facility 01/21/2022. Resident #10 had diagnoses which included Depression (feelings of severe despondency and dejection), Anemia (low blood count), Atrial fibrillation (irregular often rapid heart rate), dementia (decline in cognitive abilities), repeated falls and psychotic disorder (mind cannot determine what is real or not real). Record review of Resident #10's admission MDS assessment, dated 12/20/2022, revealed the following: Section C revealed the resident had a BIMS score of 02, which indicated severe cognitive Impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #10's electronic Care Conference record did not have a care plan documented until 08/03/2023. 3. Record review of Resident #11's face sheet revealed an [AGE] year-old male who was admitted to the facility 07/27/2023. Resident #11 had diagnoses which included Vascular dementia (dentinal due to decreased blood flow), unspecified severity, with mood disturbance (inadequate blood flow to the brain which causes mood irregularities), Anemia (low blood count), bipolar (periods of mood disturbances and swings that last more than 2 weeks), and hypertension (high blood pressure). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 7 of 16 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 08/26/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of Resident #11's admission MDS assessment, dated 08/03/2023, revealed the following: Section C revealed the resident had a BIMS score of 05, which indicated severe cognitive Impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #11's electronic Care Conference record did not have a care plan meeting since admission in the facility. 4. Record review of Resident #12's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #12 had diagnoses which included retention or urine (not able to urinate properly), acute kidney failure (kidney is unable to filter waste), Type 2 diabetes mellitus (body does not produce enough insulin) and cerebral infarction (disrupted blood flow to the brain to due problems in the blood vessels). Record review of Resident #12's admission MDS assessment, dated 06/21/2023, revealed the following: Section C revealed the resident had a BIMS score of 15, which indicated no cognitive impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #12's electronic Care Conference record did not have a care plan meeting until 07/26/2023. 5. Record review of Resident #14's face sheet revealed a [AGE] year-old female who was admitted to the facility 03/02/2021 and readmitted on [DATE]. Resident #14 had diagnoses which included Chronic obstructive pulmonary disease (decreased airflow to the lungs), congestive heart failure (heart is unable to pump adequately), dysphagia (difficulty swallowing) and dementia (decline in cognitive abilities). Record review of Resident #14's Annual MDS assessment, dated 03/10/2023, revealed the following: Section C revealed the resident had a BIMS score of 14, which indicated no cognitive Impairment. The care plan had not been updated or revised following the annual assessment. Record review of Resident #14's electronic Care Conference record did not have a care plan meeting since 11/16/2022. 6. Record review of Resident #15's face sheet revealed an [AGE] year-old male who was admitted to the facility 03/02/2021. Resident #15 had diagnoses which included hypertension (high blood pressure), vascular dementia (inadequate blood flow to the brain which causes memory loss), cognitive communication deficit (unable to communicate adequately) and malnutrition (lack of proper nutrition to sustain the body). Record review of Resident #15's Quarterly MDS assessment, dated 07/26/2023, revealed the following: Section C revealed the resident had a BIMS score of 08 (Severe cognitive Impairment). The care plan had not been updated or revised following the quarterly assessment. Record review of Resident #15's electronic Care Conference record did not have a care plan meeting since 02/15/2023. 7. Record review of Resident #19's face sheet revealed a [AGE] year-old male who was admitted to the facility 01/27/203. Resident #19 had diagnoses which included cerebral palsy (congenital disorder of movement due to abnormal brain development), hypertension (high blood pressure), major depressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 8 of 16 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 08/26/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many disorder (mood disorder that lasts more than 2 weeks), anxiety (state of anxiousness), Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis on the right side after inadequate blood flow to the brain). Record review of Resident #19's admission MDS assessment, dated 02/01/2023, revealed the following: Section C revealed the resident had a BIMS score of 09, which indicated moderate cognitive Impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #19's electronic Care Conference record did not have a care plan meeting since admission. 8. Record review of Resident #22's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included heart failure, chronic respiratory failure, chronic obstructive pulmonary disease (a group of lung diseases that block air flow and make it difficult to breath), bipolar disorder (a mental disorder characterized by mood swings resulting depressive lows and manic highs), Anxiety (state of anxiousness), repeated Falls and Hypertension (high blood pressure). Record review of Resident #22's admission MDS assessment, dated 08/08/2023, revealed the following: Section C revealed the resident had a BIMS score of 2, which indicated severe cognitive impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #22's Care Conference notes did not have a care conference meeting since admission. 9. Record review of Resident #23's face sheet revealed a [AGE] year-old male who was admitted to the facility 12/03/2020 and readmitted on [DATE]. Resident #23 had diagnoses which included schizophrenia (mental disorder that is characterized by continuous relapses in psychosis), dementia (decline in cognitive abilities) and delusional disorder (mind cannot determine what is real or not real). Record review of Resident #23's Annual MDS assessment, dated 07/28/2023, revealed the following: Section C revealed the resident had a BIMS score by staff assistance that revealed modified independence on cognitive skills. The care plan had not been updated or revised following the annual assessment. Record review of Resident #23's electronic Care Conference record did not have a care plan meeting since 02/15/2023. 10. Record review of Resident #28's face sheet revealed a [AGE] year-old male who was admitted to the facility 12/10/2021 and readmitted on [DATE]. Resident #28 had diagnoses which included Diverticulitis of intestine (inflammation of the large intestines), major depressive disorder (depression lasting more than 2 weeks), struck by turtle (hit with an object that was a turtle), and cognitive communication deficit (difficulty communicating). Record review of Resident #28's admission MDS assessment, dated 12/20/2022, revealed the following: Section C revealed the resident had a BIMS score of 02, which indicated severe cognitive Impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #28's electronic Care Conference record did not have a care plan meeting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 9 of 16 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 08/26/2023 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 0657 since 12/28/2022. Level of Harm - Minimal harm or potential for actual harm 11. Record review of Resident #40's face sheet revealed a [AGE] year-old male who was admitted to the facility 07/22/2023. Resident #10 had diagnoses which included hypertension (high blood pressure), difficulty in walking, cognitive communication deficit (difficulty in communicating), aftercare following joint replacement surgery (surgery aftercare). Residents Affected - Many Record review of Resident #40's admission MDS assessment, dated 07/28/2023, revealed the following: Section C revealed the resident had a BIMS score of 14, which indicated no cognitive Impairment. The care plan had not been updated or revised following the admission assessment. Record review of Resident #40's electronic Care Conference record did not have a care plan documented until 08/16/2023. 12. Record review of Resident #193's face sheet revealed a [AGE] year-old female who was admitted to the facility 03/30/2023 and readmitted on [DATE]. Resident #193 had diagnoses which included chronic pain, hypertension (high blood pressure) and altered mental status. Record review of Resident #193's Quarterly MDS assessment, dated 07/07/2023, revealed the following: Section C revealed the resident had a BIMS staff assessment of 01 for modified independence for cognitive skills. The care plan had not been updated or revised following the quarterly assessment. Record review of Resident #193's electronic Care Conference record did not have a care plan since readmission into the facility. Interview with the DON on 08/23/23023 at 9:55 AM revealed normally the MDS Coordinator was responsible for completing the care plans after the MDS assessments and letting the other departments know to have a care plan meeting. She revealed she updated the care plans when a resident had an acute change of condition, but it was not a comprehensive care plan. She said she was going to start with the help of her ADON to complete the comprehensive care plans. She said they knew it was an issue and was trying to catch up, but she had only been in her position for a couple of months. She revealed this failure could place residents at risk for not having their care plan areas identified accurately . In an interview on 08/25/2023 at approximately 11:10 AM, the Regional MDS Coordinator said she was the one who was responsible for completing the Comprehensive Care plans and notifying the facility to schedule a meeting. She revealed there was a miscommunication, and she did not know she was supposed to complete the comprehensive care plans or even update the care plan. She said they had not been completed by her or anyone else in the building. She stated this failure could place the residents at risk for not having a care plan. Record review of the facility's policy titled: Care Planning- Interdisciplinary team, dated 09/2015 revealed the following: Policy StatementOur facilities care planning interdisciplinary team is responsible for the development of an individual comprehensive care plan for each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 10 of 16 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 08/26/2023 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 0657 Policy Interpretation and Implementation- Level of Harm - Minimal harm or potential for actual harm 1. Residents Affected - Many A conference of care plan for each resident is develop within seven days of completion of the resident assessment MDS. 2. The care plan is based on the residence comprehensive assessment and is developed by care planning/interdisciplinary team which includes but it's not necessarily limited to the following personnel . Every effort will be made to schedule care plan meeting so the best time of the day for the resident and family FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 11 of 16 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 08/26/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of one resident (Resident #40) reviewed for quality of care . Residents Affected - Some The facility failed to ensure Resident #40 had physician orders regarding care of the surgery site, post hip replacement surgery, on 07/30/2023. The 8 surgical staples were not removed until 08/13/2023, 14 days after surgery which resulted in a superficial infection. This failure could place residents at risk of unmet care needs and infection. The findings include: Record review of Resident #40's Face Sheet, not dated, revealed a [AGE] year-old male who was admitted to the facility on [DATE] for aftercare following right hip replacement surgery on 07/20/2023. Resident #40 had diagnoses which included dementia (a decline in cognitive abilities that impacts a person's ability to do everyday activities), pathological fracture of hip, pain, aftercare following joint replacement surgery, and urinary tract infection. Record review of Resident #40's electronic record revealed from the time of admission on [DATE] to 08/12/2023 there were no documented surgical wound assessments or treatments until Resident #40 complained of discomfort on 08/12/2023. Record review of progress note, dated 08/12/2023, revealed Resident #40 complained of discomfort to his right hip to the LVN . The LVN assessment revealed Resident #40's right hip was red with a scant amount of white drainage at the incision site. The Medical Director was notified, and Resident #40 was sent to the ER for evaluation on 08/13/2023. Record review of discharge paperwork from the hospital, dated 08/13/2023, revealed Resident #40 had a yeast infection surrounding the incision site. The staples were noted to have brown cream-colored exudative discharge. Foul smell was noted. The 8 staples were removed. The resident was treated for fungal and bacterial infections. The resident was placed on the oral antibiotic Bactrim for the infection and oral antifungal fluconazole for the yeast infection . In an interview on 08/23/2023 at 9:32 AM, Resident #40 said he did not receive any type of care for his surgical wound until after he came back from the hospital on [DATE] with an infection at site of the staples. In an interview on 08/23/2023 at 9:55 AM, the DON said she handled the admission of Resident #40. There was not an order to remove Resident #40's surgical staples when he was admitted to the facility in the resident's admission paperwork. She said there was no documentation which indicated Resident #40's wound was assessed or any type of wound treatment between the time of admission on [DATE] till the time the nurse checked his wound per resident request on 08/12/2023. The DON said Resident #40's staples should have been taken out in 7-10 days. She revealed that the resident's staples were always covered by a clean bandage. She said failure to do so had the potential to result in irritation and infection of the wound site. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 12 of 16 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 08/26/2023 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 0684 Level of Harm - Actual harm Residents Affected - Some In an interview on 08/23/2023 at 10:01 AM, Resident #40 said he did not receive any type of care for his surgical staples until after he came back from the hospital on [DATE]. He said on 08/12/2023 he complained to the nurse that his bandage was bothering him and asked the nurse to check it. He revealed he did not have any type of pain or discomfort from the area around the staples prior to 08/12/2023. That was when signs of infection were discovered, and he was sent to the ER. He said no one had looked at the staples from the time he arrived at the facility until the time he asked the nurse to check it on 08/12/2023. He said he came back from the hospital on antibiotics for a possible infection from his surgical staples. He said the wound was now healed. In an interview on 08/23/2023 at 4:33 PM, the ADON said she did not evaluate or perform any care to Resident #40's surgical wound from the time of admission on [DATE] to 08/12/2023. She said it was the charge nurse that was on duty responsibilitity to assess and treat the wound if needed. In an interview on 08/23/2023 at 5:15 PM, the Medical Director, who is also the primary care physican, said Resident #40's staples should have been removed by day 10 post surgery. He said he was very frustrated with the facility when he was notified on 08/12/2023 that Resident #40's staples had not been removed. He said it was his opinion the staples not being removed by day 10 post surgery caused the infection. He said Resident #40 was sent to the ER, his infection was superficial, he was placed on antibiotics, and returned to the facility. He said the wound was now healed. In a follow up interview on 08/24/2023 at 9:20 AM, the DON said the failure to have the staples removed was her responsibility. She revealed there was documentation for the staples to be removed in 7 to 10 days. When asked to provide the documentation, the DON stated she was too busy training a new agency nurse. In an interview on 08/24/2023 at 9:25 AM, The Administrator said she thought the DON saw something in Resident #40's paperwork about the staples being removed within 7-10 days. She looked in Resident #40's paperwork but said she didn't see it. She took the paperwork and said she would go and ask the DON. The documentation was never provided by the facility. In an interview on 08/24/2023 at 10:30 AM, LVN A said she did not evaluate or perform any care to Resident #40's surgical wound from the time of admission on [DATE] to 08/12/2023. She said there was not any doctor's orders regarding Resident #40's surgical wound or removal of staples. In an interview on 08/24/2023 at 10:46 AM, LVN B said she did not evaluate or preform any care to Resident #40's surgical wound from the time of admission on [DATE] to 08/12/2023. She said there were not any doctor's orders regarding Resident #40's surgical wound and removal of staples. Record review of the facility's policy admission Notes, dated as revised September 2012, revealed the following [in part]: Policy Statement: Preliminary resident information shall be documented upon a resident's admission to the facility. Policy Interpretation and Implementation: 1. When a resident is admitted to the nursing unit, the admitting Nurse must document the following information (as each may apply) in the nurses' notes, admission form, and other appropriate place as designated by facility protocol: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 13 of 16 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 08/26/2023 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 0684 h. the time the physician's orders were received and verified; Level of Harm - Actual harm j. the presence of a catheter, dressings, etc . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 14 of 16 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 08/26/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 3 of 3 months (January, FebruaryFebruary, and March 2023) reviewed for nursing services. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours on ten weekends January, February, and March 2023 This failure placed could place the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Record review of the facility's nursing schedule for RN coverage for January 2023, February 2023, and March 2023 revealed, the Director of Nurses worked Monday through Friday. The schedule did not reflect another RN working during that time period. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours on Sunday 01/01/2023, Saturday 01/07/2023, Sunday 01/08/2023, Saturday 01/14/2023, Sunday 01/15/2023, Saturday 01/21/2023, Sunday 01/22/2023, Saturday 01/28/2023, Sunday 01/29/2023, Saturday 02/04/2023, Sunday 02/05/2023, Saturday 02/11/2023, Sunday 02/12/2023, Saturday 02/25/2023, Sunday 02/26/2023, Saturday 03/11/2023, Sunday 03/12/2023, Friday 03/24/2023, Saturday 03/25/2023 and Sunday 03/26/2023. In an interview with the Director of Nurses on 08/26/2023 at 10:34 AM, she said she was not employed by the facility at that time, however her expectation was that the facility had seven day a week RN coverage . There were no other RNs working at the facility. The DON further stated, not having RN coverage 7 days a week could put the residents at risk of not having their healthcare needs managed properly. In an interview with the Administrator on 08/26/2023 at 10:45 AM, she stated she was not yet employed by this the facility but it is was her expectation that they provided RN coverage seven days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 15 of 16 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 08/26/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 1 (Resident #40) residents reviewed for clinical records in that: The facility staff were unable to locate documentation in Resident #40s clinical record regarding when to remove surgical staples. This failure could place residents at risk of not having care needs met The findings include: In an interview on 08/23/2023 at 9:32 AM, Resident #40 said he did not receive any type of care for his surgical wound until after he came back from the hospital on [DATE] with an infection of his wound. In an interview on 08/24/2023 at 9:20 AM, the DON said there was documentation for the staples to be removed in 7 to 10 days. When asked to provide the documentation, the DON stated she was too busy training a new agency nurse . She revealed she was ultimately responsible in ensuring the documentation was correct and updated. In an interview on 08/24/2023 at 9:25 AM with the Administrator, she said she thought she saw something in Resident #40's paperwork about the resident's staples to be removed within 7-10 days. She looked in Resident #40's paperwork but said she didn't see it. She took the paperwork and said she would go and ask the DON. The documentation was never provided by the facility. In an interview on 08/24/2023 at 10:30 AM, LVN A said there were not any doctor's orders regarding Resident #40's surgical wound or removal of staples . In an interview on 08/24/2023 at 10:46 AM, LVN B said she said there were not any doctor's orders regarding Resident #40's surgical removal of staples . Record review of the facility policy admission Notes, dated as revised September 2012, revealed the following [in part]: Policy Statement: Preliminary resident information shall be documented upon a resident's admission to the facility. Policy Interpretation and Implementation: 1. When a resident is admitted to the nursing unit, the admitting Nurse must document the following information (as each may apply) in the nurses' notes, admission form, and other appropriate place as designated by facility protocol: h. the time the physician's orders were received and verified; j. the presence of a catheter, dressings, etc . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 16 of 16