Health inspection·August 10, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the evening because of the heat. She stated they avoided the area of sidewalk covered with water and moss. The resident stated sidewalks were not available for the entire perimeter of the building. She said they walked some on the pavement and some on the sidewalk. During an interview on 08/06/2023 at 1:18 PM, R #108 stated she and another resident (R #101) walked several times a day around the facility. She stated they walked along the side of the driveway where the water was on the sidewalk. R #108 stated the water had been there for a long time but could not say just how long. She stated they were very careful when they walk, especially in that area because it looked slippery. Observation on 08/07/2023 at 7:29 AM, R #101 and R #108 walking along the side of east entrance road. The residents walked to the end of the entrance road, turned, and walked back toward the facility. No sidewalks are available along the entrance roads. During an interview on 08/07/2023 at 9:50 AM, the Administrator stated the water running at the southwest exit of the building and standing water in the corner flower bed outside of the Administrators window was because of the new lawn service company running over the sprinkler heads and breaking them. He stated he was aware of the potential hazard and was working on getting the sprinkler heads fixed. The facility did not provide a policy on maintaining clean and dry walkways prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675001 If continuation sheet Page 2 of 6 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 675001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public at one of one designated smoking areas observed for safety and cleanliness. The facility failed to maintain a clean and safe area for smokers. The facility failed to ensure cigarette butts were properly disposed of. The facility failed to ensure the red metal container (metal container with self-closing cover device which ashtrays can be emptied), was in good working condition. These failures place residents and visitors at risk for being in an unsafe smoking environment. Findings included: Record review of Resident #210's (R #210) face sheet revealed an [AGE] year-old female admitted [DATE] with medical diagnoses of an irregular heart rate, depression, type 2 diabetes, and high blood pressure. A Brief Interview of Mental Status dated 08/25/2022 revealed a score of 15 out of 15 indicated R #210 had intact cognition. During an observation on 08/05/2023 at 9:40 AM of the designated smoking area, ashes and 9 cigarette butts were on the ground. The grass surrounding the smoking area was brown and dry. The foot lever on the red fire-resistant disposal container was broken and the lid on the metal ashtray was broken. The metal ashtray was sitting on a rock ledge against the building and was full of cigarette butts. During an interview on 08/07/2023 at 11:58 AM, RA A, an assisted living staff member, stated R #210 sweeps up cigarette butts in the smoking area often. She did not know who was responsible for keeping the smoking area clean. During an interview on 08/07/2023 at 1:08 PM, R # 210 stated she did go out to the designated smoking area and sweep cigarette butts. She stated she also sweeps in the hallways and sitting areas. During an interview on 08/07/2023 at 2:18 PM, the Executive Director of the assisted living unit described the incident when a fire started at the outside smoking area. She stated it was a grass fire she assumed was started with a cigarette butt. Stated she used the fire extinguisher located near the smoking area to put the fire out. But when she thought it was out, it flared back up again. Stated she had to use 3 different extinguishers to put the fire out which she accomplished before the fire department arrived. The ED stated she requested the smoking section be moved after the one smoker on the assisted living unit passed away and was denied. During an observation on 08/08/2023 at 9:49 AM of the designated smoking area, combustible chairs or chair pads were placed less than 10 feet from the exit door. There were 2 wood chairs with cloth upholstered seats and one metal chair with a cloth covered cushion, and one all wood chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675001 If continuation sheet Page 3 of 6 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 675001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 08/09/2023 at 8:37 AM, no one was present in the designated smoking area. Ashes and cigarette butts noted on ground. Odor of cigarette smoke was noted. The metal ashtray on the rock ledge continued to be full of cigarette butts. During an interview on 08/09/2023 at 2:10 PM, RA B, a staff member in the assisted living unit, stated she was working the day of the fire by the smoking area. She said she thought the fire occurred 3 - 5 months ago. RA B stated she was told someone threw a cigarette butt in the grass. During an interview on 08/10/2023 at 11:04 AM, the Administrator stated housekeeping services for the skilled unit and the assisted living were separate. He stated the designated smoking area attached to the assisted living part of the building was used by the skilled unit residents and staff. He was not able to clarify which facility was responsible for keeping the designated smoking area safe and clean. During an interview on 08/10/2023 at 1:03 PM, the Housekeeping Supervisor stated she was not clear on which staff were responsible for cleaning up the smoking area. She explained the assisted living and skilled unit had separate housekeeping staff. She stated she was not aware of anything in writing and her staff takes care of the 3 halls in the skilled unit plus the memory care unit. During an interview on 08/10/2023 at 1:05 PM, the Maintenance Director stated with both facilities being in one building it can get confusing on who was responsible for areas used by both facilities. He did not have an answer for who was responsible for maintaining safety and cleanliness of the designated smoking area. The facility was not able to provide a policy on maintaining a clean and safe designated smoking area prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675001 If continuation sheet Page 4 of 6 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 675001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448 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 0926 Have policies on smoking. 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 establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 1 of 1 smoking areas observed. Residents Affected - Few The facility failed to take into account nonsmoking resident's exposure to cigarette smoke. This failure placed residents at risk of illness and a decline in health. Findings included: Review of Resident #212 (R #212) face sheet revealed a [AGE] year-old female admitted [DATE]. No medical diagnoses were listed in the electronic medical record. During an interview on 08/06/2023 at 12:09 PM, R #212 stated she could smell cigarette smoke in her room when the exit door was opened or was left open while smokers were the on the patio. She stated her neighbor went out and swept up ash and cigarette butts in the smoking area. Observation on 08/07/2023 at 2:35 PM on the 200 Hall of the assisted living unit, while walking down the hallway towards the exit door to the designated smoking area, an obvious smell of cigarette smoke was noted beginning at room [ROOM NUMBER]. Three smokers were observed outside of the exit door less than 10 feet from the door. Unable to interview at the time due to a situation on another unit. The identity of the smokers was unknown because their backs were turned towards the exit door. Observation on 08/08/2023 at 9:49 AM of the designated smoking area, the red, covered bucket designed for emptying ashtrays into had a broken foot lever. One metal ashtray with a broken top was setting on the rock ledge within 6 feet of the entrance/exit door. Nine cigarette butts and cigarette ash were scattered on the ground. During an interview on 08/09/2023 at 2:10 PM, RA B, a staff member in the assisted living unit, stated in the past she had residents complain to her about the cigarette smoke smell in the building, but she could not recall their names. Observation on 08/10/2023 at 10:20 AM, cigarette smoke odor in 200 Hall of the assisted living unit was noted starting at rooms 211 & 212. No smokers were at the designated smoking area. During an interview on 08/10/2023 at 1:03 PM, the Housekeeping Supervisor stated she was not sure who was responsible for keeping the smoking area clean. She stated the smoking area was located on the assisted living section of the building but the only residents that smoke reside on the skilled nursing section. The HS stated she oversees the housekeeping staff in the skilled nursing section. Review of the Facility smoking policy dated October 2022, revealed 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences and 20. If at any time the facility changes its policy to prohibit smoking (including electronic cigarettes), it will allow current residents who smoke or use smokeless tobacco to continue smoking in an area that maintains the quality of life for these residents and takes into account non-smoking residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675001 If continuation sheet Page 5 of 6 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 675001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448 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 0926 Facility policy did not address responsibility for keeping the smoking area clean. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675001 If continuation sheet Page 6 of 6