Inspection·July 24, 2024

F 0550 Problem: Behavioral Symptoms Level of Harm - Minimal harm or potential for actual harm -I become fixated on my catheter. I continue to remove the dignity bag and place the bag in the seat of my wheelchair, which increases my risk of UTI. Residents Affected - Some Approach: -Place dignity bag over catheter bag when resident removes. Problem: Indwelling Catheter -I have a urinary catheter . Approach: - Provide catheter care and change catheter per policy. During an observation on 07-22-2024 at 09:27 AM Resident #19 was in his room listening to music. Resident #19 was dressed well and in a specialized wheelchair. Resident #19 was alert but answered each questioned with Ya. No other response given other than a thumbs up when this surveyor was leaving the room. Resident #19 appeared in good condition with his catheter hanging from the far side of his wheelchair out of view. During an observation and interview on 07-22-2024 at 09:39 AM Resident #19 was in the hallway in his wheelchair with his catheter bag hanging from the right side of his wheelchair with no privacy bag. A small amount of amber urine could be observed in the catheter bag. When questioned if he wanted the catheter bag in a privacy bag Resident #19 stated Ya. During an observation on 07-22-2024 at 09:50 Resident #19 was at the nurse's station with his catheter bag hanging from his wheelchair with no privacy bag. Noted was a small amount of urine present in the catheter bag. This surveyor noted two residents present and 1 staff member present at the nurse's station. During an observation on 07-22-2024 at 12:00 PM Resident #19 was in the dining room sitting at a table with 3 other residents. This surveyor noted that Resident #19's catheter bag could be observed with no privacy bag hanging from his wheelchair. This surveyor noted a small amount of amber urine in the catheter bag. A total of 17 residents were present in the dining room. During an observation on 07-23-2024 08:09 AM Resident #19 was in the dining room finishing the AM meal with 9 other residents present. Resident #19's catheter bag was hanging from his wheelchair without a privacy bag. A small amount of amber urine was observed in the catheter bag. Resident #89 Record review of Resident #89's face sheet revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include heart failure (a chronic condition in which the heart dose not pump blood as well as it should), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), benign prostatic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455989 If continuation sheet Page 2 of 8 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 455989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Borger 1316 S Florida Borger, TX 79007 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hyperplasia (age-associated prostate gland enlargement that can cause urinary dysfunction), obstructive and reflux uropathy, and diabetes. (a chronic condition that affects the way the body processes blood sugar (glucose). Record review of Resident #89's clinical record revealed he had not been in the facility long enough for a MDS to be completed. Record review of the care plan with admission date of 07-16-2024 for Resident #89 revealed a baseline/general care plan that was not specific for his catheter care. During an observation and interview on 07-22-2024 at 09:54 AM Resident #89 was observed in his room in his bed with a catheter bag hanging from the side of his bed with no privacy bag. Resident #89 reported no concerns or issues with the catheter or catheter bag and that staff were good about emptying the catheter bag. During an observation on 07-22-2024 12:00 PM, 17 residents were present in the dining room when the first tray was delivered. Resident #19 and Resident #89 were at a table in the middle of the dining room with two other residents present at that table. Residents #19 and #89 had catheter bags present that were not in privacy bags. Small amounts of amber urine could be noticed in each resident's catheter bag. During an observation on 07-22-2024 at 12:46 AM Resident #89 was moved from the dining room in his wheelchair by a CNA to the day area of the facility with his catheter bag hanging from his wheelchair that did not have a privacy bag. [NAME] urine could be observed in the catheter bag. During an interview on 07-23-2024 at 03:29 PM, CNA A and CNA B had just completed incontinent care for Resident #89. Both CNA A and CNA B verified that any resident who has a catheter should have their catheter bag in a privacy bag. CNA A stated, especially when out of their room or in the dining room since that it is a dignity issue and can be an embarrassment for the resident. Both CNA A and CNA B reported that other residents who observed the exposed catheter bags could be affected negatively. CNA A and CNA B reported they were not sure what negative outcomes would be from not placing the catheter in a privacy bag, but they knew it would not be good. CNA A stated that she worked on the hallway that Resident #19 was on during the day shift on 7-22-2024 and stated, I tried to put his catheter in a privacy bag once yesterday, but he just removed it. CNA A verified a second time that she only attempted one time to put Resident #19's catheter bag in a privacy bag. During an interview on 07-24-2024 at 09:29 AM the CRN reported that catheter bags are supposed to be in privacy bags especially when residents are out of their rooms so other residents or visitors do not have to observe the resident's urine. The CRN reported that it could negatively affect the resident with the catheter or residents who observe the catheter by causing embarrassment for the resident with the catheter and affecting residents observing by causing affects like losing their appetites and not being able to eat. Record review of facility provided policy titled, Dignity revised February 2021 revealed the following: Policy Statement: Each resident shall be care for in a manner that promotes and enhances his or her sense of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455989 If continuation sheet Page 3 of 8 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 455989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Borger 1316 S Florida Borger, TX 79007 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 0550 well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Level of Harm - Minimal harm or potential for actual harm 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist resident; examples are: Residents Affected - Some a. helping the resident to keep urinary catheter bags covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455989 If continuation sheet Page 4 of 8 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 455989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Borger 1316 S Florida Borger, TX 79007 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of for 4 of 9 anonymous residents observed for 3 of 3 days and reviewed for quality of life. Residents Affected - Some The facility failed to ensure activities provided met residents' needs or desires. These failures could place residents at risk of boredom and a decline in their quality of life. Findings included: During an observation and interview on 07/22/24 at 10:15 AM, an anonymous resident stated she did not get an activity calendar each month and stated she wished there were more games in the facility. Observation of her room revealed there was no activity calendar. During an anonymous interview on 07/23/24 at 10:00 AM, 4 of 9 residents stated there were few activities provided by the facility, and the activities that were provided were boring. The residents stated they were bored a lot and they only get bingo 2 times a week, on the big screen tv. The residents stated the activities were provided on the tv. Observation on 07/23/24 at 10:45 AM revealed bulletin board in dining room of July calendar of activities. On 07/23/24 at 11:00 AM the activity listed was Tuesday Tea on the lawn. Observation on 07/23/24 at 11:04 AM revealed there were 3 residents on the front patio drinking iced tea with 2 staff members. Observation on 07/23/24 at 2:01 PM revealed residents were in the dining room waiting for bingo to start. Bingo was on an application on the big screen television. Observation of Med Rec/Transport staff struggling to work the bingo application on the big screen tv. During an interview on 07/23/24 at 3:31 PM, the Med Records/Transport staff member stated she was running bingo today because the AA did not come into work, so she was told to fill in by the AD. She stated she did not know what she was doing since it was not her job. She stated she just came from trying to round up residents for the Glam Grandmas, which was an activity that was on the calendar for 3:00 PM, which allowed residents to put on makeup, but no one wanted to participate. She stated she had worked here for 3 months, and the AD was supposed to do activities when the Activity Assistant was not here, but the AD stated she did not have time. During a telephone interview on 07/23/24 at 04:22 PM with family member of an anonymous resident. She stated that it was pitiful that the facility does not engage her family member who has dementia and was completely dependent on staff. During an interview and observation on 07/24/24 at 08:15 AM, anonymous resident stated she had lived in the facility about a month and has been confined to her bed because of an illness. She stated she had never been able to go to activities, and no one had offered her any activities in her room, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455989 If continuation sheet Page 5 of 8 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 455989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Borger 1316 S Florida Borger, TX 79007 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some but she would love to do word puzzles if she could. At 8:20 AM there was no activity calendar observed in anonymous resident's room. During an interview on 07/24/24 at 8:20 AM, anonymous resident stated he does not participate in any activities in the facility because they do not offer anything he was interested in and that he was bored all the time. In an interview on 07/24/24 at 9:27 AM, CNA C revealed the AA was responsible for doing activities. CNA C stated residents will ask her what activities are going on in the facility for the day. During an interview on 07/24/24 at 9:35 AM, the AD stated she and the AA are responsible for making stimulating activities for residents. She stated they are having one on ones at 1:00 PM today in residents' rooms with those who are unable to participate in activities. The AD stated activities should be care planned and that it was the SW's responsibility to put activities into care plans from quarterly assessments. She stated the AA would not be in today until 1:00 PM and the SW was not in today. The AD stated a possible negative outcome for not having stimulating activities would be the resident could become depressed or upset. During an interview on 07/24/24 at 9:51 AM, the ADM stated it was the AD and AA's responsibility for providing stimulating activities to residents and she stated she felt there were enough activities for residents. She stated activities should be care planned and the SW and AD were responsible for that. She stated a negative outcome for not having stimulating activities could be depression. Interview and observation on 07/24/24 at 10:21 AM, the AD handed surveyor a folder containing Activities Assessments. The AD stated these were the activity assessments for each resident. Observation of folder did not contain quarterly activity assessments for all residents. During an interview on 07/24/24 at 10:26 AM, the ADM stated she did not know why the activity assessments were not in the care plans and to ask the AD about it. During an interview on 07/24/24 01:08 PM, the AA stated it was her and the AD's responsibility to make the activity calendar each month. She stated she was doing the one on one's activity right now where she goes around to different rooms to see if anyone needs anything. She stated every resident gets a calendar for their room every month. She stated activities should be care planned so that everyone knows what stimuli the resident needs. Observation on 07/24/24 at 01:15 PM of AA coming out of employee break room and going outside to smoking area during facility planned activity of one on ones' from 1:00-2:00 PM. Record review on 07/24/24 of clinical records for 4 anonymous resident's care plans. No documentation of activities in care plans were noted. Record review of facility policy titled Comprehensive Care Plans and dated 01/26/24 revealed the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455989 If continuation sheet Page 6 of 8 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 455989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Borger 1316 S Florida Borger, TX 79007 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete . f. Other appropriate staff or professional in disciplines are determined by the resident's needs or as requested by the resident Examples include, but are not limited to: .ii. Activities director/Staff - responsible for Activity Care Plan . Record review of facility policy titled Resident Rights and dated February 2021 revealed nothing about activities. Event ID: Facility ID: 455989 If continuation sheet Page 7 of 8 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 455989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Borger 1316 S Florida Borger, TX 79007 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm The facility failed to ensure stored food was properly labeled and dated. Residents Affected - Some This failure could put place Residents at risk for foodborne illness. Findings Included: Observation of pantry #1 on 7/22/24 at 9:17 am revealed 1 bag of ground cinnamon with no date. Observation of pantry #1 on 7/22/24 at 9:18 am revealed 1 large container of food thickener with a date of 10/25/22. Observation of pantry #1 on 7/22/24 at 11:08 am revealed 1 box of chili mix with no date. Observation of pantry #1 on 7/22/24 at 11:08 am revealed 2 bags of turkey gravy with no date. Observation of kitchen counter on 7/22/24 at 9:30 am revealed 3 containers of cereal with no label or date. Observation of refrigerator #2 on 7/22/24 at 9:23 am revealed 1 bag of sliced watermelon with no label or date. During an interview on 7/23/24 at 9:40 am, the DM stated all kitchen staff are responsible for safe food storage per their policy. The DM stated all items must be labeled and dated. The DM stated the negative outcome for not practicing food storage would be contamination. During an interview on 7/23/24 at 9:54 pm the [NAME] stated kitchen staff are to follow facility policy for proper food storage. The [NAME] stated a negative outcome for residents would be contamination and food poisoning. Record review of the facility's food service policy, dated 2018, addressed proper dating and labeling of food items and how to store dry goods appropriately. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Date, label and tightly seal all refrigerated foods using clean nonabsorbent covered containers that are approved for food storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455989 If continuation sheet Page 8 of 8