Health inspection·October 9, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and records review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 3 patios and 1 of 6 entrance/exit doors reviewed for environment . 1. The facility failed to ensure 2 of 3 non-designated smoking outdoor patios were free of smoke and cigarette butts. 2. The facility failed to ensure smoke did not enter hallway 300 of the nursing facility. These failures could place residents at risk for a clean and comfortable environment. Findings included: 1. Record review of Resident #210's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with medical diagnoses which included irregular heart rate, type 2 diabetes, high blood pressure, depression, and impaired vision. During an interview on 10/06/2023 at 2:28 PM, Resident #210 stated she swept up cigarette butts in the smoking area often. She said the smell of cigarette smoke still continued to be a problem for her and her neighbors. She said she would most often stay in other parts of the building or keep her door closed to cut down on the bothersome cigarette smoke smell . 2. Record review of Resident #212's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. No medical diagnoses were documented in the electronic records. During an interview on 10/07/23 at 3:09 PM, Resident #212 said she could smell cigarette smoke in her room sometimes when the exit door was opened or was left open while smokers were on the patio. Resident #212 said her neighbor went out and swept up cigarette butts in the smoking area. Resident #212 said she did not like the smell of cigarette smoke and would often keep her door closed so she would not have to smell the smoke. She said she had deodorizers in her room to cut down on the smell, but they did not always work. Resident #212 said she did not like that she had to keep her door closed all the time but felt that was the only way to keep out the smell. 3. Record review of Resident #313 face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses which included Sepsis, Pneumonia, Shortness of breath, Hypoxemia, Acute respiratory failure with hypoxia, COPD . Resident was a nonsmoker. Page 1 of 14 675001 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0584 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 10/08/23 at 4:28 PM, Resident #313 was wearing O2 via NC lying in bed with the head of the bead elevated approximately 45 degrees. He said he could often smell the smoke when residents were outside smoking. He said there were times he had difficulty breathing from the smoke and would have a bout of coughing that sometimes got so bad he would have to go to the nurse's station for his inhaler to make it stop . Residents Affected - Some 4. Record review of Resident #312 face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included functional dyspnea, shortness of breath, Respiratory disorder, Emphysema . Resident was a nonsmoker. During an observation and interview on 10/08/23 at 4:41 PM, Resident #312 was sitting up in the recliner and had an O2 concentrator near her. She said she would wear the O2 at night or when she had difficulty breathing. She said the smell of smoke would be strong in her room as the smoking residents came back in each day after their smoke break. She said it would be strong for a little while then slowly start to disappear. Resident #312 said it bothered her, but she did not think there was anything she could do about it . During an observation on 10/06/23 at 11:15AM, revealed the outside perimeter of the building, the walkway of designated smoking area was covered in dead grass. Ruts from tires were noted on each side of the walkway from the exit door. The designated smoking area had cigarette butts and ashes on the ground and cigarette butts sitting on top of the rock facade. The grass surrounding the smoking area was brown and dry. The one ashtray was full of cigarette butts. During an observation on 10/06/23 at 3:15 PM revealed the end of Hall 200 that lead to the designated smoking area had the odor of cigarette smoke. Numerous residents and staff were standing and/or sitting within 3 feet of the exit door smoking . Staff began to move residents from the smoking area back inside the building. The smell was strong up the 200 hall as well as up the 300 hall. Staff began to discard the cigarette butts from the ashtray into the red foot lever trash bin. Staff did not sweep away the ashes on the ground. As the residents entered Hall 300, there was a significant smell of smoke coming into the hallway. During an observation on 10/06/23 at 3:25 PM the patio area, just off the dining room, had 2 ceramic planters with sand inside and 5 cigarette butts in the planter to the left, 2 cigarette butts in the planter to the right. There were cigarette butts on the concrete of the patio. There was a pack of cigarettes that still contained 2 unused cigarettes sitting on the rock façade of the wall. During an interview on 10/06/2023 at 4:18 PM, the ED said she was aware of resident complaints about smelling cigarette smoke inside the building. She stated she requested the smoking section be moved after the only assisted living resident that smoked passed away but corporate said no. The ED said they used the charcoal filter bags to assist in removal of the smell of tobacco smoke. During an observation on 10/07/23 at 2:15 PM, the exit door at the end of Hall 200 had charcoal filter bags attached around the top right corner of the door. There was a mild odor of cigarette smoke in the hallway of Hall 200. During an observation on 10/07/23 at 3:25 PM, revealed the patio area just off the dining room of the assisted living unit had 2 ceramic planters with sand inside and 5 cigarette butts in the planter to the left, 2 cigarette butts in the planter to the right. There were cigarette butts on the concrete of the patio. There was a pack of cigarettes that still contained 2 unused cigarettes sitting on 675001 Page 2 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the rock façade of the wall. There was a large white trash can with a foot lever that had a plastic bag and numerous pieces of paper, Styrofoam, ashes, and cigarette butts inside. There was no signage on or near the patio that stated the area was a designated smoking area. During an interview on 10/07/23 at 3:30 PM, CG A said she did not know if the patio area off the dining room of the assisted living unit was a non-smoking area. She said she knew the exit door down the 200 Hall was a designated smoking area and maybe visitors of the assisted living unit went out on that patio and smoked. During an observation and interview on 10/07/23 at 3:35 PM, the ED said the patio directly off the dining room of the ALF unit was for visiting. She said she did not see any signage anywhere that stated the area was a designated smoking area. She said she saw the cigarette butts in the planters and the cigarette pack with unused cigarettes. The ED said the ALF used to have a smoker and that resident would smoke in the area and thought maybe some visitors or staff were still using the area as a designated smoking area, but it was not a designated smoking area. The staff and visitors were supposed to go to the designated smoking area down the 200 Hall . During an observation on 10/07/23 at 3:55 PM, revealed the patio just off the dining room of the nursing facility were several cigarette butts on the ground surrounding the walkway to the door, at corner of the concrete and building in the grass, between fabric windmills and other decorations in the ground. There was a long 2-foot-wide by 6-foot-wide wooden planter box that had numerous cigarette butts in the soil and laying on top of the soil as well as a used surgical mask. There was no signage marking that the patio was a designated smoking area. During an interview and observation on 10/07/23 at 4:05 PM, the ADM said the patio directly off of the dining room of the nursing facility was a non-smoking area. He verified the cigarette butts in all the patio area and said they should not have been there . Staff and visitors were only supposed to smoke in the designated smoking area outside the building near laundry. He said facility staff and visitors may have parked close to the patio area and discarded of the cigarettes as they came up to the building. He again said the patio was a non-smoking area and the area did not have signage that stated it was a smoking area. The ADM said there should not have been any cigarette butts on the ground or in the planter box in that area. He said the facility did not use the patio area as some residents would complain about the smell of smoke when a person came back inside from smoking. During an observation on 10/08/23 at 10:30 AM, there was a smell of cigarette smoke odor along 200 Hall starting at rooms 211 & 212. No smokers were at the designated smoking area. There were still charcoal filter bags attached to the door casing on the top right side of the doorframe. During an observation on 10/08/23 at 11:20AM, there continued to be cigarette butts in both planters on the patio directly off the dining room of the ALF unit . During an observation on 10/08/23 at 2:35 PM, there was a smell of cigarette smoke in the hallway leading to the designated outdoor smoking area beginning at room [ROOM NUMBER]. During an interview on 10/08/23 at 5:25 PM, the ED said she followed the smoking policy the nursing facility used regarding smoking and the admission agreement regarding the physical environment. Record review of the facility policy labeled Smoking Policy-Residents, revised December 2011, reflected: The facility shall establish and maintain safe resident smoking practices. Prior to, or upon 675001 Page 3 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or nonsmoking preferences; for example, in making room assignments. Non-Smoking signs shall be prominently displayed throughout the facility where smoking is prohibited. Smoking restrictions shall be strictly enforced in all nonsmoking areas. Only facility-approved ashtrays and other smoking equipment/paraphernalia shall be used in resident living or sleeping areas. Metal containers, with self-closing cover devices, shall be available in smoking areas. Ashtrays shall only be emptied into designated receptacles Record review of the Facility admission Agreement Form 3647, dated June 2022, Smoking Addendum reflected: Smoking is not permitted outside entry doors areas, hallways, common areas, anywhere inside the building, and patios. Residents and guests may not smoke in apartments or resident rooms. Anyone, resident or guest, smoking in any of the above smoke-free areas will be fined $500.00 per offense and is in violation of their lease and subject to eviction proceedings. All residents and guests must smoke in the designated smoking area only. Residents shall inform guests of the smoking policy and are responsible for their guests. Record review of the facility policy labeled Quality of Life-Homelike Environment, revised April 2014 reflected: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Cleanliness and order. Pleasant, neutral scents . 675001 Page 4 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record reviews the facility failed to ensure food and drink was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meals reviewed for palatable foods. Residents Affected - Some 1. The facility failed to provide residents who had an altered textured meal with food that was at a safe and appetizing temperature. 2. The facility failed to provide residents with meals that had a palatable flavor. These findings could place residents at risk of poor nutrition and weight loss. Findings include: During an observation and interview on 10/06/23 at 11:35 AM, the resident's pureed meal plates were on top of a shelf on the wall in the kitchen that had an AC duct blowing cold air on the individually prepared meal plates. The DC said she prepared the pureed meal then plated each individual plate so it would be easy to serve the residents later. She said she always put the plates up on the shelf after she prepared them. DA-A was observed to place each resident's meal plate in the microwave to warm them back up to serving temperature. DA-A then placed the plates on the top of the enclosed food cart, which also had an AC duct blowing cold air on the individually prepared meal plates. DA-A said the air blowing on top of the prepared meal plates was cold. She said when she got to the skilled nursing facility dining room she would probably need to reheat them in the microwave again to bring them back up to serving temperature. The DC and DA-A said they would not eat food that was prepared and allowed to go cold then reheated twice via a microwave if they had a choice. During an observation on 10/06/23 at 12:00 PM, DA-B was setting up resident trays with silverware and desserts in the skilled nursing facility dining room while DA-A left to get a thermometer to check the temperatures of the foods that were placed on the steam table for the skilled nursing facility dining area. He said they did not typically check the temperatures of the foods after they left the kitchen on the other side of the building and were placed in the steam table of the nursing facility dining area. He said they did not utilize the steam table for all the meals for the skilled nursing facility dining area, and maybe 2 to 3 meals a week were about all they used the steam table. During an observation on 10/06/23 at 12:18 PM, DA-A took the temperature of the individual pureed meal that measured the following: Pureed popcorn Shrimp 102.4 degrees Pureed macaroni and cheese 99.4 degrees Fahrenheit Pureed steamed broccoli 102.0 degrees Fahrenheit. DA-A reheated the pureed meal tray for a second time in the microwave behind the nurse's station and the temperatures were as follows: Pureed popcorn Shrimp 128.0 degrees Fahrenheit 675001 Page 5 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0804 Pureed macaroni and cheese 121.0 degrees Fahrenheit Level of Harm - Minimal harm or potential for actual harm Pureed steamed broccoli 129.0 degrees Fahrenheit . Residents Affected - Some During an interview and observation on 10/06/23 at 12:30 PM, revealed the State Surveyor tasted the popcorn shrimp and it was an overtly salted popcorn shrimp, no seasoning to the macaroni and cheese, little flavor in the steamed broccoli and the dessert baked apples had hard undercooked apples. The ADM said the shrimp tasted fine to him, the macaroni and cheese could have had salt and pepper added and the apples had been hard and undercooked. The ED of the assisted living center that housed the building's kitchen said the shrimp did not taste salty to her, but she did not like or dislike the popcorn shrimp. She said she agreed the macaroni and cheese had no flavor and needed salt and pepper, she was not personally a fan of the steamed broccoli, but that was because she just did not like broccoli in that form. The ED said the apples in the dessert were hard and undercooked. During an interview on 10/06/23 at 12:45 PM with LVN-C, she said the residents always told her the food was cold. She said that made it to where residents did not want to eat, and it could lead to weight loss. She said it was a constant issue. LVN-C said she complained to the ADM, DON and ADON. During an interview on 10/06/23 at 3:30 PM with the Resident Council, they said the food was mostly cold and for the most part was terrible. The group said they had a steam table for the food and a few times a week the kitchen staff would use the steam table, the food would be warm or hot and would taste a little bit better, but the kitchen staff usually did not utilize the steam table . During an interview on 10/06/23 at 5:30 PM with the DM, she said the dietary staff were supposed to utilize the steam table in the skilled nursing facility dining area for breakfast and lunch each day. She said they typically made the meal trays and put them on the enclosed food cart for supper each night because she did not have as large of a crew for the evening meal. The DM said she was unaware the cold air ran across the areas where they placed the resident prepared pureed meal plates or the tray would need to be reheated 2 times in the microwave to maintain a palatable temperature. She said the dietary staff should have prepared the pureed food items and stored them in pans on the steam table and only plate the food at the time of food service to maintain the temperature and palatability of the food. The DM said the facility had a set menu and an alternative menu. She said if the residents did not like a meal, they had the alternate meal choice and that was all. The DM said even if the entire facility did not like a meal, corporate told her she could not take it off the menu because they had an alternate meal choice they could ask for instead. Record review of the facility policy labeled Resident Nutrition Services, revised 11/2009, reflected: Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance .To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41 degrees F to 135 degrees F) will be kept to a minimum . 675001 Page 6 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food storage. The facility failed to properly store food in the dry food storage, refrigerators and freezer in the kitchen . This failure could place residents at risk for foodborne illnesses. Findings include: During an observation on 10/06/23 at 4:15 PM of the kitchen revealed the following: Dry Food Storage 1 small can of powdered milk with an opened date of 10/26/21 with an expiration of 01/2022. 1 small can of baking powder with an open date of 01/03/22 with an expiration date of 10/18/23. 1 bag of egg noodles was half empty and unsealed. 1 bag of cereal was ¾ empty was unsealed. 1 bottle of pancake syrup that was 2/3 empty had an unreadable opened date. 1 bottle of soy sauce was ¾ empty and was not closed completely. 1 5-gallon tub appeared to be a brown rice with no label on the container. 1 5-gallon tub appeared to have oats on it had 1 label that stated rice with a date of 3/27 and another date on the tub that read 9/27. 1 5-gallon tub that appeared to be brown sugar had a label written on side that stated cereal. Freezer 1 clear plastic bag with what appeared to be 10 breaded chicken tenders had no label to identify the food item and it was unsealed. 2 clear plastic bags with what appeared to be popcorn shrimp had no label to identify the food item. 1 large blue bag wedged between other boxes and bags had no label to identify the food item. 1 clear plastic bag with round breaded patties had no label to identify the food item. 675001 Page 7 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0812 Level of Harm - Minimal harm or potential for actual harm 5 pieces of a flat rectangular bakery crust with layers of wax paper between them was uncovered and exposed to the air had no label to identify the food item. 7 meat patties with wax paper to separate the patties was wrapped in a clear plastic wrap that did not cover all the meat exposing some of the meat to the air had no label to identify the food items. Residents Affected - Many The contents of the freezer were extremely packed and while inspecting items on lower shelves, 1 box slid onto the State Surveyor. Refrigerator #2 1 clear plastic tub had 4 eggs with 1 label that stated it was cranberry sauce and another label stated boiled eggs expiration date of 10/06/23. 1 commercial package of sandwich sliced turkey had an expiration date of 10/03/23. 1 large glass bowl with what appeared to be cottage cheese did not have a label to identify the food item. 1 metal pan with white roll of meat was on last shelf defrosting over the top of a box of bacon on the floor of the refrigerator. 1 metal pan Refrigerator #1 1 1-gallon jug of lime juice was ¾ empty had a best by date of 08/10/23. 1 dispenser with a white liquid with green flecks inside had no label to identify the food item. 1 dispenser with a tan liquid inside had no label to identify the food item. 1 dispenser with a thick white substance inside had no label to identify the food item. 1 commercial tub of cottage cheese had mechanically alter meat inside had a label that stated mech (mechanical) soft ham . 1 bag of what appeared to be shredded cabbage had a stamp of best by 10/03/23. 6 bags of what appeared to be shredded lettuce had no label to identify the food item or when it was placed in the refrigerator or when to use by. 5 bags of shredded cabbage had no label to identify the food item or when it was placed in the refrigerator or when to use by. 7 bags of what appeared to be liquid eggs laid on the bottom shelf had no label to identify the food item or when it was placed in the refrigerator or when to use by. 675001 Page 8 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 10/06/23 at 5:30 PM with the DM, as she went back through all the food storage areas, she said the items in the freezer were all her fault because the other freezer had gone out almost five (5) weeks prior and she had to put all frozen foods into the 1 freezer. She said originally the former maintenance director had ordered a part to fix the freezer, but it was the wrong size and the part was discontinued so the facility was awaiting a new freezer. The DM said all items no matter what they were or where they were stored needed a label to identify the food item and when it was opened. She also said all items should have been sealed. She verified items in the dry food storage room and said the egg noodles, soy sauce and cereal were not sealed. She said she did not know the last time the powdered milk or the baking powder was used other than possibly before the skilled nursing facility moved into the building. As she verified the items in the freezer, she identified the clear bag with breaded strips was breaded chicken tenders. She identified the 2 clear bags with what appeared to be popcorn shrimp were breaded popcorn shrimp. The DM said the large blue bag inside the freezer was breaded chicken fried steak patties. She said the bakery crusts were cobbler tops that the cook utilized any time they made a fruit cobbler. She said the facility had large clear plastic zipper sealed bags the cobbler tops should have been placed in. The DM said the meat patties were beef patties for hamburgers and they should not have been covered with plastic wrap but should have been placed in a clear plastic zipper sealed bag. She said she did not usually put any type of label on an item if they had not opened the item and just removed the bag from the box. Further interview revealed, the DM verification of the refrigerators identified the glass bowl did have cottage cheese that was used on the salad bar of the assisted living facility dining room earlier in the day . She said the clear plastic tub had boiled eggs that needed to be discarded that day. She said the labels stuck to containers really well and their dish washer machine did not effectively remove the old labels from containers. The DM said she thought that since the meat was in a pan and it only had another box of meat below, it was fine to defrost the meat on the shelf. She also said the meat was turkey. The DM verified the white liquid with the green flecks was ranch salad dressing, the tan liquid was thousand island salad dressing and the thick white liquid was mayonnaise . She said the bottles should have labels on them as they would be hard to identify the items. The DM said the clear bags with the green shredded items were coleslaw and lettuce and the yellow liquid was liquid eggs. She said she was not aware she needed to place labels on the items to identify them when they had not yet been opened, even after removing the bags from their shipping boxes. The DM said without a label on those items, it would be difficult to identify the food items. She said the turkey sandwich meat was brought in by a resident only a few days prior. She also said the shredded cabbage was used for coleslaw with the expiration date of 10/03/23 was shipped to the facility last week. Record review of the facility policy labeled Food Receiving and Storage, last revised 07/2014, revealed: Food shall be received and stored in a manner that complies with safe food handling practices . Dry foods that are stored in bins will be removed from original packaging, labeled and dated (used by date) . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing . Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready to eat foods . Review of the FDA Food Code 2022 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 675001 Page 9 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0812 (B) Label information shall include: Level of Harm - Minimal harm or potential for actual harm (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; Residents Affected - Many (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. 675001 Page 10 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 took into account nonsmoking residents for 1 of 1 smoking area and 2 of 3 patio areas reviewed for smoking. Residents Affected - Some 1. The facility failed to consider nonsmoking resident's exposure to cigarette smoke. 2. The facility failed to maintain nonsmoking areas free of cigarette butts. These failures placed residents at risk of illness and a decline in health. Findings include: Record review of Resident #210's face sheet revealed an [AGE] year-old female admitted [DATE] with medical diagnoses of an irregular heart rate, type 2 diabetes, high blood pressure, depression, and impaired vision. During an interview on 10/06/2023 at 2:28 PM, Resident #210 stated she swept up cigarette butts in the smoking area often. She said the smell of cigarette smoke still continued to be a problem for her and her neighbors. She said she would most often stay in other parts of the building or keep her door closed to cut down on the bothersome cigarette smoke smell. Record review of Resident #212's face sheet revealed she was a [AGE] year-old female admitted [DATE]. No medical diagnoses were in the electronic records. During an interview on 10/07/23 at 3:09 PM, Resident #212 said she could smell cigarette smoke in her room sometimes when the exit door was opened or was left open while smokers were on the patio. Resident #212 said her neighbor went out and swept up cigarette butts in the smoking area. Resident #212 said she did not like the smell of cigarette smoke and would often keep her door closed so she would not have to smell the smoke. She said she had deodorizers in her room to cut down on the smell, but they did not always work. Resident #212 said she did not like that she had to keep her door closed all the time but felt that was the only way to keep out the smell. Record review of Resident #313 face sheet revealed an [AGE] year-old male admitted [DATE]. He had a diagnosis list that included Sepsis, Pneumonia, Shortness of breath, Hypoxemia, Acute respiratory failure with hypoxia, COPD. Resident was a nonsmoker. During an observation and interview on 10/08/23 at 4:28PM, Resident #313 was wearing O2 via NC lying in bed with the head of the bead elevated approximately 45 degrees. He said he could often smell the smoke when residents were outside smoking. He said there had been times that he had difficulty breathing from the smoke and would have a bout of coughing that sometimes got so bad he would have to go to the nurse's station for his inhaler to make it stop. Record review of Resident #312 face sheet revealed an [AGE] year-old female that admitted on [DATE]. She had a diagnosis list that included functional dyspnea, shortness of breath, Respiratory disorder, Emphysema. Resident was a nonsmoker. 675001 Page 11 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0926 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 10/08/23 at 4:41PM, Resident #312 was sitting up in recliner and had an O2 concentrator near her. She said she would wear the O2 at night or when she had difficulty breathing. She said the smell of smoke would be strong in her room as the smoking residents came back in each day after their smoke break. She said it would be strong for a little while then slowly start to disappear. Resident #312 said it bothered her, but she did not think there was anything she could do about it. Residents Affected - Some During an observation on 10/06/23 at 11:15AM, the outside perimeter of building, the walkway of designated smoking area was covered in dead grass. Ruts from tires were noted on each side of walkway from the exit door. The designated smoking area had cigarette butts and ashes on the ground and cigarette butts sitting on top of the rock facade. The grass surrounding the smoking area was brown and dry. The one ashtray was full of cigarette butts. During an observation on 10/06/23 at 3:15PM the end of Hall 200 that lead to the designated smoking area had the odor of cigarette smoke. Numerous residents and staff were standing and/or sitting within 3 feet of the exit door smoking. Staff began to move residents from the smoking area back inside the building. The smell was strong up the 200 halls of the Assisted Living unit as well as up the 300 hall of the Nursing unit. Staff began to discard the cigarette butts from the ashtray into the red foot lever trash bin. Staff did not sweep away the ashes on the ground. During an observation on 10/06/23 at 3:25 PM the patio area just off the dining room had 2 ceramic planters with sand inside and 5 cigarette butts in the planter to the left, 2 cigarette butts in the planter to the right. There were cigarette butts on the concrete of the patio. There was a pack of cigarettes that still contained 2 unused cigarettes sitting on the rock façade of the wall. During an interview on 10/06/2023 at 4:18 PM, ED said she was aware of resident complaints about smelling cigarette smoke inside the building. She stated she had requested the smoking section be moved after the only assisted living resident that smoked passed away but corporate said no. ED said they used the charcoal filter bags to assist in removal of the smell of tobacco smoke. During an observation on 10/07/23 at 2:15PM, the exit door at the end of Hall 200 had charcoal filter bags attached around the top right corner of the door. There was a mild odor of cigarette smoke in the hallway of Hall 200. During an observation on 10/07/23 at 3:25PM, the patio area just off the dining room of the assisted living unit had 2 ceramic planters with sand inside and 5 cigarette butts in the planter to the left, 2 cigarette butts in the planter to the right. There were cigarette butts on the concrete of the patio. There was a pack of cigarettes that still contained 2 unused cigarettes sitting on the rock façade of the wall. There was a large white trash can with a foot lever that had a plastic bag and numerous pieces of paper, Styrofoam, ashes, and cigarette butts inside. There was no signage on or near the patio that stated the area was a designated smoking area. During an interview on 10/07/23 at 3:30PM CG-A said she did not know if the patio area off the dining room of the assisted living unit was a nonsmoking area. She said she knew the exit door down the 200 Hall was a designated smoking area and maybe visitors of the assisted living unit went out on that patio and smoked. During an observation and interview on 10/07/23 at 3:35PM, ED said the patio directly off the dining room of the ALF unit was for visiting. She said she did not see any signage anywhere that stated 675001 Page 12 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0926 Level of Harm - Minimal harm or potential for actual harm the area was a designated smoking area. She said she seen the cigarette butts in the planters and the cigarette pack with unused cigarettes. ED said the ALF used to have a smoker and that resident would smoke in that area and thought maybe some visitors or staff were still using the area as a designated smoking area, but it was not a designated smoking area. The staff and visitors were supposed to go to the designated smoking area down the 200 Hall. Residents Affected - Some During an observation on 10/07/23 at 3:55PM, the patio just off the dining room of the nursing facility were several cigarette butts on ground surrounding walkway to door, at corner of concrete and building in the grass, between fabric windmills and other decorations in the ground. There was a long 2-foot-wide by 6-foot-wide wooden planter box that had numerous cigarette butts in the soil and laying on top of the soil as well as a used surgical mask. There was no signage marking that the patio was a designated smoking area. During an interview and observation on 10/07/23 at 4:05PM, ADM said the patio directly off of the dining room of the nursing facility was a nonsmoking area. He verified the cigarette butts in all the patio area and said they should not have been there. Staff and visitors were only supposed to smoke in the designated smoking area outside the building near laundry. He said facility staff and visitors may have parked close to the patio area and discarded of the cigarettes as they came up to the building. He again said the patio was a nonsmoking area and that the area did not have signage that stated it was a smoking area. ADM said there should not have been any cigarette butts on the ground or in the planter box in that area. He said the facility did not use that patio area as some residents would complain about the smell of smoke when a person came back inside from smoking. During an observation on 10/08/23 at 10:30 AM, there was a smell of cigarette smoke odor along 200 Hall starting at rooms 211 & 212. No smokers were at the designated smoking area. There were still charcoal filter bags attached to the door casing on the top right side of the doorframe. During an observation on 10/08/23 at 11:20AM, there continued to be cigarette butts in both planters on the patio directly off the dining room of the ALF unit. During an observation on 10/08/23 at 2:35 PM, there was a smell of cigarette smoke in the hallway leading to the designated outdoor smoking area beginning at room [ROOM NUMBER]. During an interview on 10/08/23 at 5:25PM, ED said she followed the smoking policy that the nursing facility used regarding smoking and the admission agreement regarding the physical environment. Record review of facility policy labeled Smoking Policy-Residents revised December 2011: The facility shall establish and maintain safe resident smoking practices. Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or nonsmoking preferences; for example, in making room assignments. Non-Smoking signs shall be prominently displayed throughout the facility where smoking is prohibited. Smoking restrictions shall be strictly enforced in all nonsmoking areas. Only facility-approved ashtrays and other smoking equipment/paraphernalia shall be used in resident living or sleeping areas. Metal containers, with self-closing cover devices, shall be available in smoking areas. Ashtrays shall only be emptied into designated receptacles . Review of Facility admission Agreement Form 3647 dated June 2022, Smoking Addendum: Smoking is defined as inhaling, exhaling, burning, vaping, or carrying any lighted cigar, cigarette, pipe, or any other device containing any tobacco product, or any other leaf, weed, plant, or other product. 675001 Page 13 of 14 675001 10/09/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Smoking is not permitted outside entry doors areas, hallways, common areas, anywhere inside the building, and patios. Residents and guests may not smoke in apartments or resident rooms. Anyone, resident or guest, smoking in any of the above smoke-free areas will be fined $500.00 per offense and is in violation of their lease and subject to eviction proceedings. All residents and guests must smoke in the designated smoking area only. Residents shall inform guests of the smoking policy and are responsible for their guests. 675001 Page 14 of 14