Health inspection·October 4, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an Interview on 10/04/2024 at 3:10 PM the Administrator stated tubing is to be stored in a bag when not in use. In an Interview on 10/04/2024 at 3:30 PM DON stated When is in not in use it needs to be covered, in a bag. With resident that are mobile, they will take it off lay it down and staff doesn't know it laying out, with residents with limited mobility staff will place it in the bag. If not store properly they can collect dust or being damaged. In an observation on 10/03/24 at 3:45PM revealed Resident #11 was laying in bed. She was using a nasal cannula attached to an ocygen concentrator. Her wheelchair contained a portable oxygen tank and was observed with tubing and nasal cannula attached. A storage bag was on the wheelchair; howver, the tubing and cannual were hung on the handle of the wheelchair, and not stored inside the bag. The facility provided a policy titled Oxygen Administration that states Oxygen/nebulizer tubing/masks to be changed by nursing department, weekly, and documented in the electronic health record. Place oxygen tubing in a clear plastic bag when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 2 of 13 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 10/04/2024 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 record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (April 2024, May 2024, and June 2024) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 19 days of 91 days in April, May, and June 2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Record review of the CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 3, 2024 (April 1, 2024 - June 30, 2024), run date 09/24/2024, revealed partial (on 04/27/24) or no evidence of RN coverage for 19 of 91 days: 1. 04/06/2024 with no RN coverage. 2. 04/07/2024 with no RN coverage. 3. 04/13/2024 with no RN coverage. 4. 04/14/2024 with no RN coverage. 5. 04/20/2024 with no RN coverage. 6. 04/21/2024 with no RN coverage. 7. 04/27/2024 with only 6.25 hours of RN coverage. 8. 05/04/2024 with no RN coverage. 9. 05/05/2024 with no RN coverage. 10. 05/11/2024 with no RN coverage. 11. 05/12/2024 with no RN coverage. 12. 05/18/2024 with no RN coverage. 13. 05/19/2024 with no RN coverage. 14. 06/01/2024 with no RN coverage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 3 of 13 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 10/04/2024 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 15. 06/02/2024 with no RN coverage. Level of Harm - Minimal harm or potential for actual harm 16. 06/08/2024 with no RN coverage. 17. 06/09/2024 with no RN coverage. Residents Affected - Some 18. 06/22/2024 with no RN coverage. 19. 06/23/2024 with no RN coverage. In an interview and record review on 10/04/2024 at 10:00 AM, the Administrator provided the timecard reports for the months of April 2024, May 2024, and June 2024, for the dates of 04/06/2024, 04/07/2024, 04/13/2024, 04/14/2024, 04/20/2024, 04/21/2024, 04/27/2024, 05/04/2024, 05/05/2024, 05/11/2024, 05/12/2024, 05/18/2024, 05/19/2024, 06/01/2024, 06/02/2024, 06/08/2024, 06/09/2024, 06/22/2024, 06/23/2024. They revealed there was no RN coverage or a full 8 hours of RN coverage for those dates. The Administrator verbally confirmed there was no RN coverage or a full 8 hours of RN coverage for the dates of 04/06/2024, 04/07/2024, 04/13/2024, 04/14/2024, 04/20/2024, 04/21/2024, 04/27/2024, 05/04/2024, 05/05/2024, 05/11/2024, 05/12/2024, 05/18/2024, 05/19/2024, 06/01/2024, 06/02/2024, 06/08/2024, 06/09/2024, 06/22/2024, 06/23/2024. In an interview on 10/04/2024 at 12:04 PM, the DON said her understanding of the facility policy is an RN is to be on staff 8 hours a day. However, it took them a long time to find RNs. She said they try the best they can and they are not always successful. She continued to say, it's always better to have them. When asked about what the possible negative outcomes would be if a resident needed an assessment that only an RN could do she said I'm only 15 minutes down the road and I always answer my phone and if they call I'm coming. A facility policy was requested from the Administrator on 10/04/2024 at 11:15 AM. A policy statement was provided that states A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. The administrator reported finding RN staffing is difficult in this area; however, they have recently employed three RNs whom they have implemented into the RN staffing schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 4 of 13 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 10/04/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication carts observed for medication storage. The facility did not ensure the Medication Cart (C/D hall cart) was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: Observation on 10/04/2024 at 11:57 AM revealed the medication cart for C/D hall was found unlocked parked on the left side of the nurse's station. There was no nurse in sight, and no nurse near the nurse's station. The medication cart was unattended. Medications in the cart included prescription medications, over the counter medications and narcotics. In an interview on 10/04/2024 at 12:36 PM RN B stated she was not aware that the medication cart was unlocked. She further stated that the medication cart is to be locked at all times when not in use by the nurse. She continued to state that lack of medication cart security could result in tragedy such as residents taking other medications or giving them to other residents. RN B stated that she is responsible for security of her assigned medication cart. In an interview on 10/04/2024 at 1:57 PM Administrator revealed that her expectation is medication carts should always remain locked if the nurse is not directly with the cart or administering medications. She further stated that lack of medication cart security could result in resident or staff access to any medications in the cart. She stated the nurse assigned to the medication cart is responsible for medication cart security. She continued to state nursing management is responsible to ensure security of medication carts through observation and rounds in the facility. In an interview on 10/04/2024 at 2:15 PM DON revealed the medication cart observed unlocked was the medication cart for C/D halls. She stated that her expectation is for medication carts to be locked if the nurse it not with the medication cart. She further stated that lack of cart security would allow any resident and/or staff to open the door, have access to the medications, and could be detrimental. DON stated that the nurse assigned to the medication cart is responsible for security and she was ultimately responsible as well. Record review of policy Medication Labeling and Storage revised February 2023 revealed the following [in-part]: Medication Storage: 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 5 of 13 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 10/04/2024 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 0761 boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 6 of 13 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 10/04/2024 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 1 of 1 kitchen, in that: Residents Affected - Some A. The facility's walk-in refrigerator had dust, food crumbs, and dried, spilled milk on the floor and underneath shelves. B. Kitchen floors were not swept and free from dirt, food particles, and trash. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: Observation on 10/02/24 beginning at 9:40 AM, during the initial tour of kitchen, revealed refrigerator #1 had spilled, dry milk on the bottom in multiple areas, and underneath the shelves. In the corners and against the wall, there was dust and food crumbs. In the kitchen area, the floor was dirty with dirt and food crumbs and trash underneath the shelves and along the walls. In a follow-up interview and observation of the kitchen on 10/02/24 at 11:00 AM, there was no change in the soiled floors. In refrigerator #1, there was dry spilled milk in multiple areas and food crumbs underneath the shelves and along the bottom. In an interview with the Dietary Manager on 10/03/24 at 2:15 PM, The dietary manager stated the refrigerators were usually cleaned every week by the evening cook but, she must not have done it last week. She said there was a cleaning schedule, but it did not work out too well. So, the evening cook cleans the kitchen after the last meal of the day is served. That she follows the next day when she gets to work. She said that system is not the best but it was working out better. On 10/04/24 at 2:30 PM requested a dietary cleaning log and no log was provided. In an interview with the Administrator on 10/04/24 at 2:00 PM, she said it was her expectation for the kitchen to be cleaned daily. If food was spilled, it should be cleaned up at that time. Failure to do so had the potential for infection and pests. A record review of the facility policy Cleaning and Disinfection of Environmental Surfaces, dated as revised August 2019, revealed the following [in part]: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Review of the Food and Drug Administration Food Code, dated 2017, specified [in part]: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 7 of 13 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 10/04/2024 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 surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 8 of 13 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 10/04/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #28) of 5 residents reviewed for infection control, in that: Residents Affected - Some The facility failed to ensure clinical staff donned (put on) proper personal protective equipment when providing care to Resident #28, who was on contact isolation precautions, including gown, gloves, and mask. Facility failed to ensure that staff used proper laundry handling precautions. This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #28's face sheet dated 10/04/2024 revealed a [AGE] year-old male admitted to facility originally on 01/04/2024 with readmission on [DATE]. His diagnoses included: Non-ST elevation myocardial infarction (heart attack), Essential hypertension (high blood pressure), depression, other acute osteomyelitis, left ankle and foot (bone infection), and pain. Record review of Resident #28's active physician order dated 08/19/2024 revealed contact isolation (contagious requiring barriers between people and germs.) for MRSA (Methicillin-resistant Staphylococcus aureus bacteria) of wound culture. Observation on 10/02/24 at 12:45 PM revealed NA C entered Resident # 28's room to deliver a lunch tray wearing no personal protective equipment. NA C did not use hand sanitizer upon entering resident room or upon exiting resident room. Personal protective equipment station was noted outside of resident room. Contact Isolation sign posted on wall outside door. In an interview on 10/02/2024 at 12:51 PM NA C stated that she is unsure of what contact isolation precautions mean. She further stated that when she entered into Resident #28's room she did not wear personal protective equipment nor did she use hand hygiene upon entry or exit of room. NA C was unsure of what lack of proper infection control precautions could cause to residents or others. In an interview on 10/02/2024 at 1:07 PM Administrator stated her expectation is for staff to follow instructions posted on the wall outside the resident room regarding entering a resident room on contact isolation. She further stated that her expectation is for staff to follow infection control policy regarding PPE when entering Resident #28's room. She stated that lack of following posted infection control precautions regarding contact isolation could put others at risk of infection. ADM further stated that Resident #28 has been on contact isolation precautions since 08/19/2024. In an interview on 10/03/2024 at 3:13PM LA D stated if a resident is on isolation their personal items and linens should be placed in a red or marked bag which would make her aware of contamination and the use of additional personal protective equipment. She further stated that she has not received any linens in red bags or otherwise marked bags, all linens and personal items have been mixed with other resident's laundry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 9 of 13 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 10/04/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 10/03/2024 at 3:28 PM NA D stated that she has changed the linens in Resident #28's room while the resident has been on contact isolation TBP. She further stated that the linens and laundry for Resident #28 were not bagged in a bag that would label them as contaminated. She continued to state that the clinical staff gather all laundry of residents (both linens and personal), take the laundry to the laundry room, and sort the laundry by hand into appropriate bins in the laundry room. She continued to state that she has not worn PPE while doing so nor has she treated Resident #28's laundry as contaminated. In an interview on 10/3/2024 at 4:36 PM the DON stated her expectation regarding the laundry of residents on contact isolation TBP is that laundry should be bagged in a bag and tied outside of the resident's room. She further stated staff should put the tied bag in a bin that also has a clear bag. She stated that bag does not have to be marked or labeled as contaminated. She continued to state that when staff get to laundry, the staff take the big bag out of the bin, and sort into the appropriate bins in the laundry. DON stated that laundry staff should wear full PPE while doing all laundry, and that all laundry should be treated as contaminated. She further stated that she was not aware that clinical floor staff was sorting through resident laundry and linens until this day. In an interview on 10/3/24 at 4:42 PM the Administrator revealed her expectation regarding laundry handling of residents on transmission-based precautions. She stated the laundry of residents on transmission-based precautions (contact isolation precautions) must be bagged in the resident's room in an appropriately labeled yellow bag. She continued to state that appropriate labeling allows laundry staff to handle laundry appropriately regarding PPE for TBP. She stated lack of doing so could cause spread of infection and all staff are responsible. Record review of policy Isolation-Initiating Transmission Based Precautions revised August 2019 revealed the following [in-part]: Policy Statement: Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; . and is at risk of transmitting the infection to other residents. Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. Policy Interpretation and Implementation: 3. When transmission-based precautions are implemented, the infection preventionist (or designee): a. clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used. e. ensures that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment; g. ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 10 of 13 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 10/04/2024 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 0880 are placed in or near the resident's room. Level of Harm - Minimal harm or potential for actual harm Record review of CDC Infection Control https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html dated April 3, 2024 reflected: Residents Affected - Some Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Record review of CDC Infection Control https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html CDC Infection Control dated January 8, 2024 stated [in-part]: G. Laundry and Bedding 3. Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics The laundry process starts with the removal of used or contaminated textiles, fabrics, and/or clothing from the areas where such contamination occurred, including but not limited to patients' rooms, surgical/operating areas, and laboratories. Bags containing contaminated laundry must be clearly identified with labels, color-coding, or other methods so that health-care workers handle these items safely, regardless of whether the laundry is transported within the facility or destined for transport to an off-site laundry service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 11 of 13 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 10/04/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 1 facility reviewed for environmental concerns. Residents Affected - Some The facility failed to replace a ceiling panel, repair water discoloration marks, repair the leak in the ceiling in Resident #29's room and repair water discoloration marks and the sagging ceiling in the dining area. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Observation on 10/02/2024 at 05:35 PM revealed the following: 1. The ceiling inside Resident #29's room near the door was the area of concern. An approximately 2 feet by 2-foot square area of watermarked discolored sheet rock was noted in the ceiling. The area appeared to be a previous replacement or repair. Edges of the area appeared to be worn away due to moisture. A black substance was noted on the middle of the sheet rock patch, and in three other areas on patches. Water damage appeared to be outside of the previously replaced sheet rock area and noted on the textured ceiling. 2. The ceiling in the middle of the dining room was sagging downward with watermark discoloration around the air vent. Texture was flaking off the ceiling. In an interview on 10/04/24 at 09:58 AM Resident #29 stated that the ceiling in her room has been in poor condition since her arrival to that room. Resident #29 further stated that the ceiling leaks at times, with only some due to weather conditions, and the facility staff will put a bucket under leakage. She also stated that due to the location of the spot and leakage in the ceiling being in front of the door to her room, it makes it difficult for her to come in and out of her room with her walker. Resident #29 stated that the ceiling was fixed after surveyor observation. Resident #29 denied any breathing concerns. In an interview on 10/4/24 at 1:45 PM Maintenance Director stated that the dining room has been leaking since 9/24/24 and she has received bids for repair from two companies but needs three bids per corporate advisement. She further stated she is waiting on her corporate office at this time for repair directives. She stated her expectation is for the ceiling to be repaired and not fixing the ceiling could cause the ceiling to fall, causing injury. She continued to state that the maintenance department and administration were responsible for repairs. In an interview on 10/4/24 at 1:57 PM the Administrator stated the ceiling concern was identified on 9/24/24 and bids were received for repair on 9/26/24. She further stated upon identification of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 12 of 13 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 10/04/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some concern, the area was immediately closed off and resident tables were moved away from area of concern. ADM stated ceiling repair for Resident #29's room was done previously in 12/2023 but it has recently started leaking again upon rain. She stated the leaking has been apparent for approximately one month. She further stated that the facility has an open bid that was received on 9/17/24 to repair a larger area of the roof in that portion of the facility. The ADM stated her expectation was for the ceilings in the dining room and in resident rooms to be fully intact, functional, and appealing. She further stated it is also her expectation for residents to remain in an environment free of leaks, cracks, hazards, or potential harm. She further stated that the current ceiling conditions could lead to possible falling materials from the ceiling or trip hazards from debris or moisture on the floor. She stated that it is the responsibility of maintenance director and ADM to ensure a safe and comfortable physical environment for residents. Record review of policy Work Order, Maintenance revised April 2010 revealed the following [in-part]: 5. Emergency requests will be given priority in making necessary repairs. Record review of facility's Maintenance Logbook for the month of September 2024 revealed no work orders for repair of the dining room ceiling or Resident #29's room ceiling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455808 If continuation sheet Page 13 of 13