Health inspection·October 25, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated, Resident #23 had a BIMS score of 5 (five) indicating severely impaired cognition. The MDS section for PASRR indicated Resident #23 did not have a serious mental illness. The MDS section, Psychiatric/Mood Disorder, indicated Resident #23 to have a diagnosis of schizophrenia. Record review of physician orders dated 09/25/2023-10/25/2023 indicated orders dated 05/01/2023 for resident #23 to receive Seroquel (psychotropic drug) 3 times a day and Zyprexa (psychotropic drug)1 time daily for treatment of schizophrenia. Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated Resident #23 was receiving antipsychotic medications on a routine basis. Resident #45 Record review of Resident 45's PASRR Level 1 Screening completed on 03/27/2023 indicated in section C0100 this resident did not have evidence of having a mental illness. Record review of an undated face sheet indicated Resident #45 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, and PTSD. Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated Resident #45 had a BIMS score of 15(indicating his cognition to be intact) and dependent on staff for ADLs due to a diagnosis of quadriplegia (paralysis of all four limbs). The MDS section for PASRR indicated Resident #12 did not have a serious mental illness. The MDS section I, Active Diagnoses, indicated Resident #12 had diagnoses of depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. The Medications section of the MDS indicated Resident #45 was receiving antipsychotic medications on a routine basis. Record review of the physician's orders dated 09/25/23-10/25/2023 indicated orders for Resident #45 to receive Depakote, Seroquel, and Zyprexa (medications used to treat schizophrenia and bipolar disease) on a routine basis. Record review of Resident #45's care plan dated 03/29/2023 indicated resident required drugs for the treatment of schizoaffective disorder and interventions were aimed at reducing the risk of drug-related complications. During an interview with the MDS Nurse on 10/24/2023 at 9:45 AM, she said she was responsible for tasks related to PASRR and MDS processes. She said she was hired in May of 2023 and was new to the PASRR and MDS process. She said at the time of Residents #'s 12, 23, and 45, she thought the PASRRs completed by the discharging facility were incorrect and said she notified the local authority of her concerns. She said the local authority told her she would follow up on her concerns. She said she did not do anything else because she did not know she was supposed to. The MDS Nurse said she understood the importance of PASRR Level 1 Screenings being accurate because the facility needed to make sure eligible residents were getting the correct resources. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 2 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment was completed prior to admission. For 1 of 12 residents (Residents #60) reviewed for PASRR Level I screenings. Residents Affected - Few The facility failed to have a level 1 PASRR assessment for Resident #60 available/documented. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #60's face sheet, date 09/20/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Resident #60 diagnoses included non-Alzheimer's dementia unspecified severity, with other behavioral disturbance on admission, psychotic disorder with delusions due to known physiological condition, major depressive disorder, recurrent severe without psychotic features, anxiety disorder, and Parkinson's disease. Record review of Resident #60's admission MDS assessment, dated 06/07/23, indicated section A1500 was marked 0 or no. This indicated the resident was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section A1510 was not marked for level II PASRR conditions. The assessment indicated she had a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. Record review of Resident #60's electronic medical record a PASRR level 1 screening assessment was unable to be identified or located. During an interview on 10/25/23 at 1:16 PM, the MDS Coordinator said she was still working on the facility's PASRR forms, and it was possible the PASRR forms had not been uploaded to the electronic record. She said she would try to locate Resident 60's PASRR Level 1 assessment forms. During an interview on 10/25/23 at 3:38, the MDS Coordinator said she was unable to locate documentation on Resident #60's PASRR Level 1 Screening assessment forms. Resident #60 was admitted to facility on 5/25/23 from another long-term care facility. Record review of the resident Assessment and Care Screening (Nursing Home Comprehensive Item Set indicated on 06/07/23 section A1500 assessment was completed as the most recent admission entry. Record review of the facility's policy, specialized rehabilitative services, stated: .Specialized services for MI [mental illness] or MR [mental retardation] For a resident with MI or MR, the community will ensure that the individual receives the services necessary to assist him or her in maintaining or achieving as much independence and self-determination as possible. The preadmission screening and resident review (PASRR) indicates specialized services required by the resident. The state is required to list those services in the report, as well as to provide or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 3 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 arrange for the provision of the services. Level of Harm - Minimal harm or potential for actual harm Even if the state determines that the resident does not require specialized services, the community is still responsible for providing all services necessary to meet the resident's mental health or mental retardation needs. Residents Affected - Few The community provides interventions that complement, reinforce, and are consistent with any specialized services (as defined by the resident's PASRR) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 4 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 observation, interview, and record review, the facility failed to post the daily nurse staffing data at the beginning of each shift in a prominent place, readily accessible to residents and visitors that included the facility name; the total number of hours worked per shift by the registered nurses, the licensed vocational nurses, and the certified nurse aides directly responsible for resident care for the facility for 2 of 3 days reviewed for staffing postings (10/22/23 - 10/23/23) and did not maintain the posted daily nurse staffing data for a minimum of 18 months. Residents Affected - Many The facility did not post the required staffing with hours worked daily for the public and residents and did not maintain the staffing for a minimum of 18 months. This failure could place the census of 76 residents, families, and visitors at risk of not having the daily nurse staffing data. Findings include: During a daily observation on 10/22/2023 to 10/23/2023 beginning at 9:30 a.m. each day, revealed no staffing posting was posted in the lobby, halls to resident's rooms, or at the nurse station with total hours worked for RNs, LVNs and CNAs. During an interview on 10/22/2023 at 3:20 pm, LVN A said she did not know where the staffing posting was located. During an interview on 10/22/2023 at 3:25pm, ADON said the staffing posting should be posted on board in front of the administrator's office. She said it was her responsibility because they currently were without a staffing coordinator. During an interview on 10/22/2023 at 3:30 PM., the Administrator said let me go and find the posting and surveyor said I will go with you and to find they did not have anything posted for staffing. He said, they did not have a staffing coordinator, let me get the DON to post the staffing , since it's her responsibility to make sure this is posted. During an observation of the posting dated 10/25/2023 the RN posting was incorrect due to the facility did not have an RN for actual direct care staff. During an interview with the DON on 10/25/2023 at 3:45 pm, she said she thought she could count herself as the RN. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 5 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 1 of 4 residents reviewed for pharmacy services. (Resident #127). The facility failed to ensure pantoprazole granules DR for oral suspension were administered correctly to Resident #127. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them correctly as directed by manufacturer's directions. Findings included: Record review of Resident #127's face sheet, dated 10/22/2023, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. She had diagnoses which included gastro-esophageal reflux disease (acid indigestion), congestive heart failure, fractured femur, high blood pressure, dementia, and anxiety. Record review of Resident #127's admission progress notes, dated 10/03/2023, indicated she was alert and oriented to herself only; she had a BIMS (Brief Interview for Mental Status) of 99 indicating she was unable to complete the interview and was severely cognitively impaired; required assistance of 1 staff with ADLs; frequently incontinent of bowel and bladder, but could use the bedside commode. Record review of Resident 127's consolidated physician orders dated October 2023 indicated the resident had an order entered on 10/12/2023 to start pantoprazole granules DR for suspension in packet, 40 mg. orally with special instructions to mix with water or juice for her gastro-esophageal reflux disease. Record review of Resident #127's MAR, dated 10/2023, indicated she received the pantoprazole granules DR every day at 8:00 AM starting on 10/13/23 through 10/24/23. The MAR indicated the medication was to be mixed with water or juice. During an interview and observation on 10/25/23 at 8:45 AM MA C pulled up the MAR for Resident # 127 and the order indicated to give pantoprazole granules in water or juice. She said she would give the resident a full glass of water (7 oz) indicating the plastic cups on her cart. She said she tried to get residents to drink as much water as she can to keep them from getting dehydrated and getting UTIs. She also had healthshakes on her cart where the first ingredient was nonfat milk. She said she only used water with Resident # 127. MA C pulled the medication packet from the medication cart and the pharmacy label indicated to give 1 pkt as directed and give by mouth daily. Another small label on the bottom of the medication bag indicated Do not crush. Give with apple juice or applesauce. The label did not indicate any specific amounts of applesauce or apple juice. MA C said she never used apple juice or applesauce and indicated she had not noticed the additional label indicating to use apple juice. During an interview on 10/25/23 at 9:05 AM the ADON was asked to pull up the physician orders in the electronic record for viewing for Resident # 127. She said she entered the order for pantoprazole (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 6 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm granules given by the NP on 10/12/23 to discontinue the pantoprazole tablet and to begin the pantoprazole granules. She said the NP did not indicate how to prepare the suspension. She said she added give with water or juice and she said any juice the resident preferred could be used and she would expect it to be administered using 6-8 oz. She said she did not know the specific parameters regarding the administration of the pantoprazole granules. Residents Affected - Some During an interview on 10/25/23 at 9:10 AM the DON said she was not aware pantoprazole suspension granules had to be given in a specific way. She said new medication orders are reviewed every morning in stand-up meeting. She said she tried to review resident charts and physician orders for accuracy weekly. She did not indicate whether she had reviewed Resident # 127's physician orders for accuracy. During an interview on 10/25/23 at 9:15 AM the RN Consultant had pulled the directives from the manufacturer concerning the preparing of the pantoprazole suspension using only apple juice or applesauce when administering the pantoprazole granules and said staff would be in-serviced regarding the administration. Review of the manufacturer's instructions on 10/25/2023 at Pfizer's website at pfizermedicalinformation.com indicated the following: Instructions for Use: PROTONIX (pantoprazole sodium) for delayed-release oral suspension .should only be taken with applesauce or apple juice; should not be mixed in water or other liquids, or other foods; packet should not be divided to make a smaller dose. Taking PROTONIX for oral suspension with applesauce: 1. Open the packet of PROTONIX for oral suspension. 2. Sprinkle all of the granules in the packet on 1 teaspoon of applesauce. 3. Swallow the granules and applesauce within 10 minutes of putting the granules on the teaspoon of applesauce. 4. Take sips of water to make sure the granules are washed down into the stomach. Take more sips of water as needed. Taking PROTONIX for oral suspension with apple juice: 1. Open the packet of PROTONIX for oral suspension. 2. Empty all of the granules in the packet into a small cup that contains 1 teaspoon of apple juice. 3. Stir the granules-apple juice mixture for 5 seconds. The granules will not break up. 4. Swallow the mixture right away. 5. To make sure that the entire dose is taken, add more apple juice to the cup, stir and swallow the apple juice right away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 7 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 6. Repeat step 5 if there are granules left in the cup . 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: 455834 If continuation sheet Page 8 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the drug regimen was free from unnecessary medication for 1 of 5 (Resident #74) residents reviewed for unnecessary medications. Residents Affected - Some 1. The facility failed to ensure Resident #74 did not receive a medication she was allergic to (ibuprofen) ordered for a swollen right hand on 5/22/23. 2. The facility failed to ensure Resident #74 was not given medications she was allergic to as ordered (ibuprofen 400 mg by mouth 4 times a day for 14 days). Resident #1 received ibuprofen from 05/22/23 to 07/23/23 (63 days). 3. The facility failed to ensure Resident #74's ibuprofen was discontinued after Resident #1 returned from the hospital from an upper GI bleed. Resident #1 received scheduled ibuprofen on 07/26/23 through 07/27/23 (4 doses). An Immediate Jeopardy (IJ) was identified on 10/20/23. While the IJ was removed on 10/21/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate threat due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm or death related to receiving unnecessary medications. Findings included: Record review of Resident #74's face sheet, dated 10/20/23, indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (damage to or loss of nerve cells in the brain that causes memory loss, confusion, the ability to think or make decisions), gastrointestinal hemorrhage (bleeding in the digestive tract caused by a disease or condition) and gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #74's Care Plan dated 04/27/21 and last revised on 07/31/23 indicated she had an allergy to Lisinopril and Pravastatin and interventions included do not administer allergen, make note on chart of allergies and notify the physician if allergen is ordered. Resident #74's care plan did not address an allergy to ibuprofen. Record review of Resident #74's MDS dated [DATE] indicated she usually made herself understood and sometimes understood others. Resident #74 had severely impaired cognition. Record review of Resident #74's admission History and Physical dated 04/27/21by the Nurse Practitioner indicated she had a past medical history of dementia, anemia (blood disorder in which the blood has a reduced ability to carry oxygen due to a lower-than-normal number of red blood cells), gastro-esophageal reflux disease and peptic ulcer disease (open sores that develop on the inside lining of your stomach and the upper portion of your small intestine causing dark or black stool and vomiting). Resident #74 had an allergy to lisinopril, and pravastatin. Resident #74's admission History and Physical did not list ibuprofen as an allergy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 9 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of hospital records dated 04/30/21 indicated Resident #74 had a fall and was sent to the hospital. Records indicated Resident #74 had an allergy to ibuprofen, lisinopril, and pravastatin. Record review of hospital records dated 08/28/21 indicated Resident #74 had a fall and was sent to the hospital. Records indicated Resident #74 had an allergy to ibuprofen, lisinopril, and pravastatin. Record review of a handwritten telephone order dated 05/22/23 indicated Resident #74 had an order to receive ibuprofen 400 mg by mouth 4 times a day for 14 days. The telephone order was signed by LVN E. Record review of Resident #74's physician's order dated 05/22/23 indicated she had an order for ibuprofen 400 mg by mouth 4 times a day. Resident #74's ibuprofen was discontinued on 07/31/23. Record review of Resident #74's MAR for the month of May, June, and July of 2023 indicated she received ibuprofen on the following dates: *05/22 through 05/31 (10 days) *06/01 through 06/30 (30 days) *07/01 through 07/23 (23 days) Record review of Resident #74's nursing progress notes dated 07/24/23 at 3:00 a.m. by LVN E, indicated at 2:50 a.m. she was called to the shower room. The resident had a black tarry bowel movement with blood. LVN E notified the hospice nurse. Record review of Resident #74's nursing progress notes dated 07/24/23 at 3:59 a.m. by LVN E, indicated she was instructed by the hospice nurse to check the resident's blood pressure and to send her to the hospital for possible gastrointestinal bleed if it was low. Resident's manual blood pressure was 98/54 (normal blood pressure 120/80). Resident was transported to the hospital. Record review of Resident #74's nursing progress notes dated 07/26/23 at 10:22 a.m. by the ADON, indicated she called the hospital, and informed the resident was admitted for a gastrointestinal bleed. Record review of Resident #74 hospital records dated 07/26/23 indicated she had dark bloody stools and was transferred to the hospital on [DATE]. She had an allergy to ibuprofen and a history of peptic ulcer disease (an open sore that develops on the inside lining of your stomach and the upper portion of your small intestine). She had a hemoglobin (a protein in blood that carries oxygen to the body) level of 6.0 (Normal range 12.0-16.0) and was transfused with 2 units (approximately 2 pints) of blood in the emergency department. She was admitted to the intensive care unit (unit with specialized staff, equipment, and standards that handles severe, potentially life-threatening cases) diagnosed with an upper gastrointestinal bleed. She was transfused with 1 unit (approximately 1 pint) of blood in the intensive care unit 07/25/23. She was discharged back to the nursing facility on 07/26/23. Record review of Resident #74's MAR for July 2023 indicated she received ibuprofen on the following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 10 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0757 dates: Level of Harm - Immediate jeopardy to resident health or safety *07/26 and 07/27 (2 days) Record review of Resident #74's nursing progress notes dated 07/26/23 at 8:17 p.m. by RN G, indicated she returned to the nursing facility and had dark blood in her brief upon arrival. Residents Affected - Some Record review of Resident #74's nursing progress notes dated 07/27/23 at 6:10 p.m. by RN G, indicated the family notified her the resident had vomited. RN F observed a moderate amount of coffee ground emesis and the family requested for the resident to be sent to the emergency room. Record review of Resident #74's nursing progress notes dated 07/27/23 at 6:22 p.m. by RN G, indicated the resident was transferred to the hospital. Record review of Resident #74 hospital records dated 07/31/23 indicated she had vomited blood at the nursing facility and was transferred to the emergency department on 07/27/23. She had an allergy to ibuprofen and a history of peptic ulcer disease. She had a hemoglobin level of 9.8 (Normal range 12.0-16.0) on arrival and trended to a hemoglobin level of 6.9. She received 2 units (approximately 2 pints) of blood and was admitted . She was discharged to the nursing facility on 07/31/23. Record review of Resident #74's allergy history indicated ibuprofen was added as an allergy on 08/01/23 by the ADON. Record review of Resident #74's census dated 10/21/23 indicated she was discharged from the facility on 08/16/23 to another nursing facility. During an interview on 10/20/23 at 2:14 p.m., LVN E said she worked the 6:00 a.m.-2:00 p.m. shift and was the charge nurse for Resident #74 when the ibuprofen was ordered on 05/22/23. LVN E said Resident #74 had a swollen wrist, and she notified the hospice nurse. LVN E said the hospice nurse came to the facility to assess Resident #74 then notified the physician. LVN E said the hospice nurse hand wrote an order for Resident #74 to take ibuprofen 4 times a day for 14 days. LVN E said she signed the hospice nurse's handwritten order then entered it into Resident #74's electronic chart. LVN E said she did not enter the date to discontinue the ibuprofen after 14 days. LVN E said Resident #74 received ibuprofen for almost 2 months because she entered the incorrectly. LVN E said a resident taking ibuprofen with peptic ulcer disease is at risk of bleeding. LVN E said Resident #74 had peptic ulcer disease and was taking ibuprofen when she was sent to hospital for a gastrointestinal bleed. LVN E said she did not know Resident #74 had an allergy to ibuprofen prior to going to the hospital. During an interview on 10/20/23 at 2:23 p.m., the DON said the charge nurse was responsible for entering physician's orders in a resident's chart and she was responsible they were entered in correctly. The DON said Resident #74 had a swollen wrist and was ordered ibuprofen for 14 days. The DON said LVN E entered the order in Resident #74's chart and she did not enter the date to discontinue the ibuprofen after 14 days. The DON said she did not check Resident #74's chart to see if LVN E entered the order correctly. The DON said Resident #74 received ibuprofen for almost 2 months. The DON said Resident #74 was sent to hospital twice for a gastrointestinal bleed. The DON said the ibuprofen was discontinued and added as an allergy to her electronic chart when Resident #74 returned from the hospital the second time . The DON said she did not know Resident #74's past hospital records listed ibuprofen as an allergy. The DON said she did not review Resident #74's hospital records because she assumed they were reviewed by the previous DON before she was hired. The DON said a resident taking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 11 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0757 Level of Harm - Immediate jeopardy to resident health or safety ibuprofen with peptic ulcer disease is at risk of bleeding. The DON said Resident #74 had peptic ulcer disease and was taking ibuprofen when she went to the hospital. The DON said she did not know Resident #74 had an allergy to ibuprofen prior to going to the hospital and have since changed how they monitored medications. The DON said a list of new medications ordered from the previous day is printed out and reviewed during their daily clinical meeting for resident allergies and to ensure orders are entered accurately. Residents Affected - Some Record review of the facility's Medication-Administration policy dated 08/2020 indicated, It is the policy of this home that medication will be administered and documented as ordered by the physician and in accordance with state regulations . Record review of the facility's Physician Services policy dated 08/2020 indicated, .Procedure .8. Physician's orders for treatment and medication shall be recorded in the medical record and shall be signed by the attending physician. Such orders shall be in effect for the number of days specified by the physician .11. The DON/Administrator will be responsible to monitor physician visits to assure that the resident is receiving appropriate care and services . The Administrator was notified on 10/20/23 at 6:38 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 10/20/23 at 6:44 p.m. The facility's Plan of Removal was accepted on 10/21/23 at 3:00 p.m. and included: Resident Specific o An allergy for ibuprofen was added into Resident #1's electronic medical record on 8/1/23 due to having the GI bleed. o Resident #1 no longer resides at the facility as Resident #1 was discharged on 8/16/2023. o Medical Director notified of IJ on 10/20/2023 at 7:58 PM by Administrator. o Notified Pharmacy Consultant of IJ on 10/20/2023 at 7:58 PM by Director of Nursing. System Changes o Audit of all medication orders for NSAID use and stop dates completed on 10/20/2023 for all residents by Director of Nursing and Assistant Director of Nursing at 10:30 PM. o Head to toe assessment completed for all residents on 10/20/2023 by Treatment Nurse/LVN at 11:50 PM. o During stand up/clinical meeting DON and/or ADON to review new orders with stop dates if applicable to ensure correct transcription into EMR. Education o Director of Nursing provided education to all staff on signs/symptoms of GI Bleeding. If signs and/or symptoms of GI Bleeding are identified the staff member should report to charge nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 12 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0757 Level of Harm - Immediate jeopardy to resident health or safety immediately. Once notified the charge nurse should contact physician. All staff present in the facility were educated on 10/20/2023. Staff not present for the education will receive education prior to their next shift. o Director of Nursing provided education to nursing staff regarding Medication Administration of Long Term NSAID's and Risks. All nursing staff present in the facility were educated on 10/20/2023. Staff not present for the education will receive education prior to their next shift. Residents Affected - Some o Director of Nursing provided education to nursing staff regarding The 5 Rights of Medication Administration. All nursing staff present in the facility were educated on 10/20/2023. Staff not present for the education will receive education prior to their next shift. o Administrator, Director of Nursing, and Assistant Director of Nursing in-serviced on 10/20/2023 at 9:43 PM by Regional Clinical Consultant in regard to Monitoring New Orders for Accurate Transcription into EMR. Monitoring o Order obtained from Medical Director by Director of Nursing for every resident on 10/20/2023 to monitor for abnormal bleeding i.e. excessive bruising, bleeding gums, nose bleeds, tarry stools, etc. This is documented Q Shift on the medication administration record in the EMR. On 10/21/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director had been informed of the Immediate Jeopardy from documentation signed by the Administrator. Verifying the Pharmacy Consulted had been informed of the Immediate Jeopardy from documentation signed by the DON. Record review of in services revealed staff were educated on signs and symptoms of gastrointestinal bleeding, report signs and symptoms of bleeding to charge nurse, long term NSAID's and Risks, and The 5 Rights of Medication Administration. Record review of in services revealed the Administrator, DON and ADON were educated on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. Record reviews on four resident charts taking ibuprofen were completed to ensure medication orders for NSAID use and stop dates were completed, head to toe assessment were completed and orders to monitor for abnormal bleeding, excessive bruising, bleeding gums, nose bleeds, tarry stools, etc. each shift. There were no issues identified. Interviews with 5 Licensed Nurses, 3 MA and 9 CNAs (on all shifts 6 a.m.- 2 p.m., 2 p.m.-10 p.m., 10 p.m.6 a.m., 6 a.m.-6 p.m., and Weekend Doubles) were performed on 10/21/23. All licensed nursing staff were able to correctly identify signs and symptoms of gastrointestinal bleeding, who to report it to, monitoring for bleeding each shift and documenting it on the MAR. Licensed nurses and MA were able to correctly identify medication administration of long-term use and risks of NSAIDs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 13 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0757 (nonsteroidal anti-inflammatory drugs) and 5 Rights of Medication Administration. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 10/21/23 at 4:31 p.m., the DON said she in-serviced the nursing staff on signs and symptoms of gastrointestinal bleeding, report signs and symptoms of bleeding to charge nurse, long term NSAID's and Risks, and The 5 Rights of Medication Administration. The DON said staff who were not in serviced would be prior to their next shift. The DON said she was in serviced on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. The DON said clinical meetings are held daily. Residents Affected - Some During an interview on 10/21/23 at 4:44 p.m., the ADON said she was in serviced on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. The ADON said clinical meetings are held daily. During an interview on 10/21/23 at 4:53 p.m., the Administrator said he was in serviced on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. The Administrator said clinical meetings are held daily. On 10/21/23 at 5:30 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 14 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0759 Ensure medication error rates are not 5 percent or greater. 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 a medication error rate less that 5 percent. There were 3 errors out of 34 opportunities, resulting in an 8 percent medication error rate involving 1 of 3 residents (Resident #13). Residents Affected - Few MA B failed to administer 2 scheduled medications, spironolactone (to treat excess fluid in the tissues) and vitamin D3 (to treat vitamin deficiency), to Resident #13 as ordered by the physician. MA B failed to follow physician's orders regarding specific instructions for the administration of polyethylene glycol 3350 (for treatment of constipation). These failures could place the resident at risk of not receiving the therapeutic effect of the mediations and could result in a decline health status. Findings included: Record review of an undated face sheet indicated Resident #13 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including hypertension (elevated/high blood pressure), chronic peripheral venous insufficiency (improper functioning of the valves in the leg causing swelling), acute pulmonary edema (excess fluid in the lungs), vitamin deficiency, and constipation. During observation and interview on 10/23/2023 at 09:10 AM, MA B administered the following scheduled medications to Resident #13: aspirin, citalopram, loratadine, cranberry tablet, vitamin B12, duloxetine, lactulose, Lasix, rivastigmine, and polyethylene glycol mixed in a liquid supplement, multivitamin, ferrous sulfate, and prednisolone eye drops. MA B was not able to locate two medications, a multivitamin and ferrous sulfate, in the cart and obtained them from the nurse. Record review on 10/23/2023 at 11:20 AM of the physician orders dated for 09/23/2023-10/23/2023 indicated Resident #13 was also to receive the following medications at 09:00 AM daily: o Spironolactone 25mg daily to help treat edema (excess fluid in the tissues) and o Vitamin D3 50mcg (2000 units) for vitamin deficiency. These 2 (two) medications were not administered during the observed medication pass at 09:10 on 10/23/2023. Record review on 10/23/2023 at 11:20 A of the physician orders dated 09/23/2023-10/23/2023 indicated an order for polyethylene glycol 3350 powder was to be administered as follows: o Polyethylene glycol 3350 powder 17gm/dose 1 scoop Special Instructions: Stir in 4-8 ounces water, juice, soda, coffee, or tea until dissolved and administer immediately. On 10/23/2023 at 09:10 AM, MA B was observed to place 17gm/dose of polyethylene glycol 3350 powder in a plastic cup. She then poured an unmeasured amount of a liquid supplement (Hi-Cal 2 calories/per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 15 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 ml) into the same cup and used a wooden spoon to mix the two together. After placing the other medications in Resident #13's mouth, MA B attempted to give Resident #13 the polyethylene glycol 3350 mixed with the liquid supplement but the mixture would not pour from the cup. MA B then waked over to the medication cart and added an unmeasured amount of water to the cup, stirred the mixture again, and returned to the resident. MA B held the cup to Resident #13's mouth and poured the thickened mixture, a little at a time, into the resident's mouth. MA B said she had poured 30 mls of liquid supplement and a splash of water into the cup with the polyethylene glycol 3350 powder. MA B did not give Resident #13 any water after administering the medications and polyethylene glycol 3350. On 10/23/2023 at 09:28, MA B said she was finished giving Resident #13 her medications. During the observation of this medication pass, MA B did not go to the medication room to see if the needed medications (spironolactone and vitamin D3) were there, nor did she tell the charge nurse about the missing medications. During an interview on 10/23/2023 at 01:10 PM with the DON and MA B, MA B said she did not give Resident #13 her spironolactone and vitamin D3 because they were not in the cart and said she had documented the medications were not available. She said if she did not have a scheduled medication in the cart, she would look for it in the medication room and if she did not find it, she would document the medication was not available on the medication administration record (MAR). The DON said the medication aide should notify the nurse if a scheduled medication was not available and the charge nurse could access the facility's emergency drug container and obtain needed medication from it. The DON said if a needed medication was not in the emergency container, then the charge nurse would notify the pharmacy and the pharmacy would either deliver it or obtain it from a local pharmacy for delivery. The DON said she would obtain the needed medications from the medication room and have MA B administer them. Record review of the MAR on 10/23/2023 at 01:55 PM indicated MA B had documented the spironolactone as Not Administered: Drug/Item unavailable. The vitamin D3 medication was documented as being administered at 09:00 AM. During an interview on 10/23/2023 at 02:30 PM, MA B said she made a mistake and should have documented the vitamin D3 as not being administered. MA B also said she used the Hi-Cal liquid supplement to mix with the polyethylene glycol powder because she felt Resident #13 needed it. She said she estimated how much water and liquid supplement she used and did not know why she did not measure the amounts given. She said she should have used the ordered amount of water to mix the drug with. Review of the facility's policy titled Medication - Administration dated 08-2020 indicated the following: Policy It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. Procedure .4. Current medications and dosage schedules, except topical used for treatments, are listed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 16 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0759 the resident's medication record (MAR) Level of Harm - Minimal harm or potential for actual harm .7. Supplies and equipment, which are needed during a medication pass, are to be placed on the medication cart. The following equipment and materials are needed for the medication pass: Routine medications needed, including house stock medications. Residents Affected - Few 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the Physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 17 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents (Resident #13) reviewed for medication administration accuracy. Residents Affected - Few MA B failed to administer a scheduled medication, spironolactone (used to treat high blood pressure and excess fluid in the tissues, to Resident #13 as ordered by the physician. This failure could place the resident at risk of not receiving the therapeutic effects of the mediation and could result in a decline health status. Findings included: Record review of an undated face sheet indicated Resident #13 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including hypertension (elevated/high blood pressure), chronic peripheral venous insufficiency (improper functioning of the valves in the leg causing swelling), and acute pulmonary edema (excess fluid in the lungs). Record review of Resident #13's Quarterly MDS assessment dated [DATE] indicated her cognition to be severely impaired as indicated by a BIMS score of 2 out of 15 and dependent on staff for most ADLs. During observation and interview on 10/23/2023 at 09:10 AM, MA B administered medications to Resident #13 including aspirin, citalopram, loratadine, cranberry tablet, vitamin B12, multivitamin, duloxetine, lactulose, Lasix, iron, rivastigmine, polyethylene glycol, and prednisolone eye drops. Record review on 10/23/2023 at 11:20 AM of the physician orders dated for 09/23/2023-10/23/2023 indicated Resident #13 was also to receive the following medication at 09:00 AM daily: o Spironolactone 25mg daily (to help treat edema and hypertension). This medication was not administered during the observed medication pass at 09:10 on 10/23/2023. In an interview on 10/23/2023 at 09:28, MA B said she was finished giving Resident #13 her medications. MA B did not go to the medication room to see if the needed medication (spironolactone) was there, nor did she tell the charge nurse about the missing medication during this observation of the medication pass. During an interview on 10/23/2023 at 01:10 PM with the DON and MA B, MA B said she did not give Resident #13 her spironolactone because it was not in the cart. She said if she did not have a scheduled medication in the cart, she would look for it in the medication room and if she did not find it, she would document the medication was not available on the MAR. The DON said the medication aide should notify the nurse if a scheduled medication was not available and the charge nurse could access the facility's emergency drug container and obtain needed medication from it. The DON said if a needed medication was not in the emergency container, then the charge nurse would notify the pharmacy and the pharmacy would either deliver it or obtain it from a local pharmacy for delivery. Record review of the MAR on 10/23/2023 at 01:55 PM indicated MA B had documented the spironolactone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 18 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 0760 as Not Administered: Drug/Item unavailable. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Medication - Administration dated 08-2020 indicated the following: Residents Affected - Few It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. Procedure .4. Current medications and dosage schedules, except topical used for treatments, are listed on the resident's medication record (MAR) .7. Supplies and equipment, which are needed during a medication pass, are to be placed on the medication cart. The following equipment and materials are needed for the medication pass: Routine medications needed, including house stock medications. 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the Physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 19 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 - Some 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, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to 1 of 2 rooms (DON's office) and 1 of 3 medication carts used for storage of medications and other biological chemicals. The facility failed to ensure MA B kept OTC medications secured in the medication cart and unable to be accessed by unauthorized personnel. The facility failed to ensure the DON's office was secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for misuse of medication and overdose, drug diversions, and adverse reactions to medications. Findings included: During observation of medication administration on 10/23/2023 beginning at 09:10 AM, MA B opened a new bottle containing 100 generic multivitamins, removed 1 (one) tablet from the bottle, put the vitamin tablet in a medicine cup, put the lid on the bottle, and set the bottle on top of the medication cart. MA B obtained other medications from the cart, put those medications in the cup with the vitamin in it, and put those containers back inside the cart. MA B locked the cart, leaving the bottle of multivitamins on top of the cart. MA B left the cart parked against the wall at the entrance to 200 hall, turned her back to the cart and walked across the area (approximately 7 feet) to the resident she was to administer the medications to. MA B administered the medications to the resident and returned to the cart. MA B said she had done all she needed to do. This surveyor pointed to the Multivitamin bottle. MA B said she forgot to put the bottle into the cart. She said someone could have taken it. During observation and interview on 10/25/2023 at 11:20 AM, the DON's office door was noted to be unlocked and fully open. Upon following the DON into her office, a box, measuring approximately 8x16x10 inches and containing multiple cards of medications including medications for high blood pressure, depression, mental illness, nausea, high cholesterol, etc., was noted setting on the floor in front of a locked closet where discontinued narcotics were kept. The DON was observed to count 57 cards containing 1 to 30 medications on each card, 2 bottles of unknown number of vitamin C tablets, 1 partial bottle of lactulose, and 1 hand-held nebulizer for respiratory treatment. The drugs were not secured and were available to anyone who walked into the DON's office. The DON said the medications were to be processed for destruction and she had just put the box in there. The DON did not offer a rationale for not securing the drugs. Record review of the facility's policy dated 08-2020 and titled Medication-Discontinued Medication/Destruction of Drugs indicated the following: 1. When a medication has passed its expiration date or is otherwise deteriorated, or has been discontinued, or for a resident no longer residing at the home, it should be removed from the medication cart as soon as possible and accounted for and kept under lock and key in the medication room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 20 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for infection control and based on observations, interviews, and record reviews, the facility failed to implement infection control practices designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 6 of 7 residents (Resident #'s 6, 27, 32, 46, 68 and 70) reviewed for infection control practices, in that:. Residents Affected - Some *Resident #'s 6, 42, and 68's O2 tubing was not covered and Resident #46's oxygen tubing was not labeled correctly. *Resident #70's Nebulizer tubing was not covered. *Resident #32's CPAP tubing was dirty and not covered; and *Facility staff did not disinfect the glucometer properly before and after it was used on Resident #27. This failure placed residents' risk for exposure to possible transmission of communicable diseases and infections. Findings included: Observations on 10/22/2023 to 10/25/2023 between 9:00 am and 3:30 PM during facility tour revealed the following: *During an observation resident#6 oxygen tubing was not covered in a plastic bag and was hanging on the concentrator. Portable oxygen tubing was hanging from wheelchair being used. *During an observation resident #46 lying in the bed oxygen tubing was not covered in a plastic bag and was hanging on the concentrator. Oxygen tubing had label date of 7/31/2023 and was not in a plastic bag. *During an observation and interview 10/22/23 at 12:07pm with Resident#70 stated he gets Nebulizer treatment and uses oxygen at night. Was noted Nebulizer tubing had the date of 9/27/2023 and was on top of the machine on the side of the table uncovered. *During an observation and interview on 10/22/23 at 12:11pm with resident#32 said he uses the CPAP machine at night., the CPAP mask was on top of the machine, there was dirty tubing on side table uncovered no date indicating when changed and the O2 tubing on floor uncovered. *During an observation on 10/25/23 at 1:15pm In room [ROOM NUMBER]A (Resident #68 was not in the room) oxygen tubing was not covered in a plastic bag and was hanging on the concentrator dangling to the floor and not dated. In an interview on 10/24/2023 at 10:50 AM, the DON stated the oxygen tubing is changed weekly and the oxygen tubing is placed in a zip lock bag for infection control to prevent contamination. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 21 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 stated the CPAP mask are to be cleaned after each use and placed inside zip lock bag. Level of Harm - Minimal harm or potential for actual harm In an interview and Record review on 10/24/2023 at 2pm with the DON she was asked who is responsible to make sure O2 tubing is changed and dated, she said it is the night shift on Sunday's nurse responsibility to change tubing and it's my responsibility to perform infection control audits to review that policies are being followed. Record review revealed the Night shift was signing tasks being done but observation revealed task was not done. Residents Affected - Some In an interview on 10/25/2023 at 1:40 PM, the ADON/IP stated the oxygen tubing and CPAP mask should be placed in a zip lock bag after each use. She stated, the facility did not have an Infection Control policy for cross contamination it is best practice to bag the items as a best practice for infection control. She said it was a system failure that the facility was not monitoring this to ensure it was being done and residents are at risk for respiratory infections. Resident #27 Review of Resident #27's undated face sheet indicated Resident #27 to be a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes. Record review of Resident #27's Annual MDS assessment dated [DATE] indicated her cognition to be severely impaired as indicated by a BIMS score of 7 out of 15 and requiring moderate to maximum assistance with most ADLs. Review of Resident #27's physician orders dated 09/23/2023-10/23/2023 indicated an order dated 05/06/2023 for Resident #27's blood glucose level to be checked 4 (four) times a day with additional instructions to administer doses of Humalog insulin according to a prescribed sliding scale (A sliding scale varies the dose of insulin based on blood glucose level). During observation and interview on 10/23/2023 at 11:40 AM, LVN A cleansed her hands with an alcohol-based hand sanitizer, put on a pair of disposable gloves, and removed a glucometer (a handheld meter used to measure how much glucose is in the blood) and a lancet (a small, sterile needle used to obtain a blood sample to check blood glucose levels) from the drawer of her medication cart and set them on top of the cart. Using her gloved fingers, she obtained a test strip from its container and inserted the test strip into the glucometer. She then picked up the glucometer and lancet and entered Resident #27's room. After cleaning Resident #27's finger with an alcohol pad, LVN B obtained a blood sample from her finger and applied it to the glucometer test strip. LVN A said Resident #27's blood sugar level was 117 and would not be receiving any insulin. LVN A returned to the medication cart, disposed of the lancet, alcohol pad, and test strip, and set the glucometer on top of the medication cart. LVN A then obtained an alcohol pad and used the pad to clean the glucometer. She disposed of the alcohol pad, removed her gloves, and placed the glucometer in the medication cart drawer. She said she had several residents requiring point-of-care blood glucose testing daily but had no more to be done at that time. LVN A said she used an alcohol pad to clean the glucometer before this surveyor arrived at the medication cart. LVN A said she always used alcohol pads to clean the glucometers. During an interview with the DON on 10/23/2023 at 12:05 PM, she said she expected the nurses to follow infection prevention and control practices during point-of-care testing using glucometers. She said the nurses should use an EPA Registered germicidal disposable wipe referred to as Purple Top (PDI Super Sani-Cloth Germicidal Disposable wipes packaged in a purple and white plastic container with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 22 of 23 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 455834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Athens 150 Gibson Rd Athens, TX 75751 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 a purple top) wipes. Level of Harm - Minimal harm or potential for actual harm Record review of the User's Guide for the Evencare G2 glucometer used by LVN A indicated EPA Registered wipes were to be used to disinfect the glucometer. Residents Affected - Some Record review of the facility policy titled Finger Stick Blood Sampling dated 12/1/2018 indicated the following: Equipment and Supplies 2. Germicidal Wipes Procedure 8. Clean the glucometer with germicidal wipes unless otherwise indicated or bleach/water solution diluted with a 1 to 10 ratio before initial use, after final use and between each resident following manufacturer directions. The facility's policy, Respiratory Therapy Equipment dated 12/2018, reflected, [NAME] bottle with date and initials upon opening and discard after seven days or as needed, change oxygen cannula and tubing every seven (7) days and as necessary, keep oxygen cannula and tubing used PRN in a plastic bag when not in use. Nebulizer equipment, store circuit in plastic bag, marked with date and residents name between uses. The Director of Nursing will perform infection control audits to review staff procedure in observation of standard precautions, Infection control and isolation procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455834 If continuation sheet Page 23 of 23