Health inspection·April 27, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Record review of facility policy and procedure titled, Perineal Care with a revised date of 01/20/23 reflected the following: Policy Statement: Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition. Residents Affected - Few Steps in Procedure: A. For a Female Resident: 1. Using the cleansing wipe, clean perineal area, wiping from front to back FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 2 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 0692 Provide enough food/fluids to maintain a resident's health. 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 offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 6 of 6 residents (Residents #1, 2, 10, 14, 20 and 28), in that: Residents Affected - Some The facility failed to provide Residents #1, 2, 10, 14, 20 and 28 with their physician ordered therapeutic diets that included fortified foods, a renal diet, and/or large portions for the noon meal on 04/26/23. This failure could place residents at risk for hunger, weight loss, and chemical imbalances. The findings include: Resident #14: Record review of the face sheet for female Resident #14 dated 4/26/23 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old, and had diagnoses of, acute respiratory failure with hypoxia (insufficient oxygen), muscle wasting and atrophy, not elsewhere, classified (loss of muscle tissue), hyperkalemia (high potassium), age related cognitive decline, bipolar current episode (mental disorder), hypomanic and hypokalemia (low potassium). Record review of the quarterly MDS for Resident #14 dated 2/2/23 revealed that the resident had a BIMS score of 15 (cognitively intact). Active diagnosis listed were hyperkalemia, stroke, hemiplegia or hemiparesis and manic depression. There was no documentation of weight loss or weight gain. Record review of Resident #14 care plan revealed a problem documented as, Problem start date: 4/6/23. Category: nutritional status. Nutritional status diet. Edited: 4/6/23. Edited by: DON. Approaches listed included, . Approach start date: 4/6/23. Diet as ordered: renal diet, no fish, peaches, or strawberries. Edited: 4/6/23. Edited by: DON. Record review of the physician orders for Resident #14 dated 4/26/23 revealed that the resident had an order documented as, Diet: renal diet with thin liquids. No fish, peaches, or strawberries. Start date 12/16/21. End date - open ended. Record review of the chemistry lab report for Resident #14 dated 1/3/23 revealed that the resident had a potassium level of 3.29 mmol/L on a normal range of 3.5-6.1. This indicated the resident's potassium was low. Additional record review of the lab report revealed that the resident had an albumin level of 3.2 g/dL on a normal range of 3.5 to 5.0 indicating the resident's albumin was low. Record review of the Weight Variance Report dated 10/1/22-4/26/23 revealed Resident #14 had a 4.6% weight loss between 3/6/23 and 4/5/23. The resident went from 154.3 pounds to 147.2 pounds. Record review of the Dietician A Progress Notes for Resident #14 between 10/27/22 and 4/26/23 revealed no documentation of any dietary or dietitian notes. Record review of the Nutrition Recommendation form by Dietitian A dated 2/8/23 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 3 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some following documentation regarding Resident #14, Add diet texture to orders. Daily activities tracking form. Annual assessment. No diet changes, other than texture were mentioned. Record review of the Lunch: Wednesday, 4/26/23 diet card for Resident #14 revealed that her diet was documented as regular with a special note: no fish, peaches, strawberries. There was no documentation that the resident was on a renal diet. On 4/26/23 at 12:40 PM, Resident #14 received 1 slice cheesecake, 1 slice toast, 4 ounce spaghetti, 4 ounce squash, 6 ounce meat sauce, and tea. None were identified as foods for a renal diet. On 4/26/23 at 4:01 PM an interview was conducted with the Director of Nurses regarding resident diets. Regarding Resident #14's therapeutic diet, he stated, he was not sure why the resident was on this diet. Resident #10: Record review of the face sheet for male Resident #10 dated 4/26/23 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of Alzheimer's disease with a late onset, adult failure to thrive and vitamin D deficiency. Record review of the annual MDS for Resident #10 dated 2/8/23 revealed that the resident had no BIMS score. The resident was documented as having long-term and short-term memory problems and was severely impaired cognitively. Active diagnosis listed for the resident was Alzheimer's disease. Further record review revealed that the resident had experienced a weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Record review of the current care plan for Resident #10 revealed a problem as Problem start date: 3/6/23. Category: nutritional status. My diet order is a mechanical soft. Edited: 3/16/23. Edited by: DON. The Goal listed was as follows, Long-term goal target date: 6/1/23. I will be offered an appetizing meal and an alternative meal to help me keep my weight at an acceptable range and help me avoid choking on food that I cannot eat over the next 90 days. Edited: 3/6/23 . Record review of the physician orders for Resident #10 dated 4/26/23 revealed the following order, . Diet: regular texture: mechanical soft. Fluid consistency: thin. Large portions. Special instructions: fortified foods. Order start date 2/8/23. End date - open ended. Record review of the chemistry lab report for a Resident #10 dated 2/20/23 documented that the resident had an albumin level of 3.5 g/dL on a normal scale of 3.5 - 5.0. Record review of the Weight Variance Report dated 10/1/22-4/26/23 revealed Resident #10 had a 2.6% weight loss between 1/6/23 and 4/13/23. The resident went from 175.2 pounds to 170.6 pounds. Record review of the Progress Notes by Dietitian A dated 11/10/22 for Resident #10 revealed the following documentation, . 8.4% weight loss in 60 days. Diet: regular, mechanical soft, thin liquids, (fortified foods). At risk for dehydration, related to dementia and diarrhea . Record review of the Lunch: Wednesday, 4/23/26/23 diet tray card for Resident #10 revealed that the resident was on a regular/mechanical soft diet. Special notes: fortified food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 4 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 4/26/23 at 12:08 PM, Resident #10, tray received 1 slice cheesecake, 1 slice toast, 4 ounce spaghetti, 4 ounce squash, 6 ounce meat sauce, and tea on his prepared tray. The resident received the same serving sizes as all other residents. None were identified as fortified foods. On 4/26/23 at 4:01 PM an interview was conducted with the Director of Nurses regarding resident diets. Regarding Resident #10's therapeutic diet (fortified), he stated the resident had some weight loss a while back and had a decline. Resident #1: Record review of the face sheet for female Resident #1 dated 4/25/22 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of, Alzheimer's disease, with late onset, anxiety disorder, unspecified (mental disorder), pneumonia, unspecified organism (respiratory infection), unspecified protein calorie malnutrition (poor nutrition), and vitamin D deficiency unspecified. Record review of the significant change MDS for Resident #1 dated 3/10/23 revealed that the resident had a BIMS score of three ( severe cognitive impairment). Active diagnoses listed revealed the resident had pneumonia, Alzheimer's disease, and malnutrition or at risk for malnutrition. Further record review of the MDS revealed the resident had not experience a weight loss or weight gain. Record review of the care plan for a Resident #1 revealed the following problem, Problem start date: 3/3/23. Category: nutritional status. My diet order is: mechanical, soft, but I request puree at times. Edited: 4/14/23. Edited by: DON. The Goal documented was as follows, Long-term goal target date: 5/31/23. I will be offered an appetizing meal and an alternative meal to help me keep my weight at an acceptable range and help me avoid choking on food that I cannot eat over the next 90 days. Edited: 3/3/23. Edited by: DON. Record review of the physician orders for Resident #1 dated 4/25/23 revealed an order that stated, . Diet: regular texture: mechanical soft. Fluid consistency: thin. Special instructions: fortified foods. Start date 2/11/22. End date - open ended. Record review of the chemistry Lab report for Resident #1 dated 3/10/23 revealed that the resident had an albumin level of 2.7 g/dL on a normal scale of 3.4 to 5.0. Indicating the resident had a low albumin level. Record review of the Weight Variance Report dated 10/1/22-4/26/23 revealed Resident #1 had a 5.3 % weight loss between 3/6/23 and 4/12/23. the resident went from 103.5 pounds to 98. Record review of the Dietitian A Progress Note dated 4/18/23 for Resident #1 revealed the following documentation, . Weight change: 5.3% weight loss in 30 days. Diet: regular, mechanical soft, thin liquids. Fortified foods. Note: At risk for dehydration related to diuretic use and Alzheimer's disease. Future weight loss is likely expected related to hospice. Record review of the Lunch: Wednesday, 4/26/23 diet card for Resident #1 documented that the resident was on a regular/mechanical, soft diet. It further documented, Supplement - one serving fortified food. Special notes: fortified foods, health shakes lunch. On 4/26/23 at 12:07 PM, the tray for Resident #1 was prepared and the resident received 1 slice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 5 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cheesecake, 1 slice toast, 4 ounce spaghetti, 4 ounce squash, 6 ounce meat sauce, and tea. None were identified as fortified foods. On 4/26/23 at 4:01 PM an interview was conducted with the Director of Nurses regarding resident diets. Regarding Resident #1's therapeutic diet, he stated, the resident was on hospice. He added the facility tried to get extra calories into the resident. Resident #20: Record review of the current face sheet for male Resident #20, dated 4/26/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had documented diagnoses of non-displaced fracture of base of neck of left femur, subsequent encounter for close fracture with delayed healing (leg fracture), cognitive communication deficit, muscle wasting and atrophy, not elsewhere classified, age related cognitive decline, other schizophrenia (mental disorder), and Cachexia (wasting). Record review of the admission MDS for Resident #20, dated 1/17/23 revealed that the resident had a BIMS score of 12 (cognitively intact with some confusion). Active diagnosis listed were schizophrenia and hypertension. Further record review revealed that the resident had not experienced any weight loss or weight gain. Record review of the current care plan for Resident #20 revealed a problem that stated, Problem start date: 4/19/23. Category: nutritional status. Nutritional status diet. Edited: 4/25/23. Edited by:, DON. Approaches included the following . Approach start date: 4/19/23. Diet as ordered: regular diet. No added salt. Thin liquids. Edited: 4/25/23. Edited by: DON. Record review of the current physician orders for Resident #20, dated 4/26/23 revealed the following documentation, . Diet: regular diet: regular fluid consistency: thin liquids. Large portions/fortified foods. Start date 3/27/23. End date - open ended. Record review of the Weight Variance Report dated 10/1/22-4/26/23 revealed Resident #20 had a 13.4% weight loss between 3/6/23 to 4/5/23. The resident went from 143.3 pounds to 124.1 pounds. Record review of the Progress Notes from Dietitian A dated 4/18/23 revealed the following documentation for Resident #20, . Weight change: 13.4% loss in 30 days, 22.7% loss 90 days. Diet: regular, regular texture, thin fluids. Large portions, fortified foods. Noted diagnosis of Cachexia - metabolic syndrome, involuntary, decreased muscle mass/weight loss. Record review of the Lunch: Wednesday, 4/26/23 diet tray card for Resident #20 revealed that he was on a regular NSOT/regular diet, (no salt on tray). There was no documentation that the resident was ordered large portions and fortified foods. On 4/26/23 at 12:11 PM, Resident #20 received 1 slice cheesecake, 1 slice toast, 4 ounce spaghetti, 4 ounce squash, 6 ounce meat sauce, and tea. The resident received the same serving sizes as all other residents. None were identified as fortified foods. On 4/26/23 at 4:01 PM an interview was conducted with the Director of Nurses regarding resident diets. Regarding Resident #20's large portion therapeutic diet, he stated, the resident had lost some weight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 6 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 0692 Resident #28: Level of Harm - Minimal harm or potential for actual harm Record review of the current face sheet for female Resident #28, dated 4/26/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed for the resident were other Alzheimer's disease, Muscle wasting and atrophy, not elsewhere classified, hypokalemia (low potassium level), and acute kidney failure unspecified. Residents Affected - Some Record review of the quarterly MDS for Resident #28 dated 2/8/23 revealed that the resident had a BIMS score of six (severe cognitive impairment) and active diagnoses of renal insufficiency, Alzheimer's disease and depression. Further record review of the MDS revealed no known weight loss of weight gain. Record review of the current care plan for Resident #28 revealed a problem documented as, Problem start date: 2/28/23. Category: nutritional status. Nutritional status diet. Edited: 3/16/23. Edited by: DON. Approaches included, Approach, start date: 2/28/23. Diet as ordered: regular. Edited: 2/28/23 . Record review of the Order Report by Category: 4/25/23-4/25/23 revealed Resident #28 had the following diet, General. Start date - 4/18/23. End date - open ended. Flowsheet - Dietary. Order description - Diet: regular diet. Texture: regular. Fluid consistency: thin liquids. Fortified foods. Record review of the chemistry lab report for Resident #28 dated 12/1/22 revealed that the resident had an albumin level of 4.1 g/dL on a normal scale of 3.5 - 5.0. Record review of the Weight Variance Report dated 10/1/22-4/26/23 revealed Resident #28 had a 7.6% weight loss between 1/6/23 through 4/17/23. The resident went from 140.2 pounds to 129.5 pounds. Record review of the progress note by the Dietitian A, dated 4/18/23 for Resident #28 revealed the following documentation, . 8.3% weight change loss in 90 days. Note: At risk for dehydration related to Alzheimer's disease. Recent decline in dementia. Recommend fortified foods at all meals for weight support. Record review of the tray card for Resident #28 for Lunch: Wednesday, 4/26/23 revealed the resident was on a regular diet, and there was no documentation that the resident was ordered fortified foods. On 4/26/23 at 12:18 PM Resident #28 received 1 slice cheesecake, 1 slice toast, 4 ounce spaghetti, 4 ounce squash, 6 ounce meat sauce, and tea. None were identified as fortified foods. On 4/26/23 at 4:01 PM an interview was conducted with the Director of Nurses regarding resident diets. Regarding Resident #28's therapeutic diet, he stated, the resident had a recent weight loss and decline. Resident #2: Record review of the face sheet for female Resident #2, dated 4/25/23 revealed that the resident was admitted to the facility on [DATE] and was readmitted on [DATE]. The resident was [AGE] years old, and had diagnoses of Alzheimer's disease with late onset, and muscle wasting and atrophy, heart disease, unspecified, chronic kidney disease, unspecified, and personal history of other malignant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 7 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 0692 neoplasm of large intestine (cancer). Level of Harm - Minimal harm or potential for actual harm Record review of the annual MDS for Resident #2 dated 2/3/23 revealed the resident had a BIMS score of five (severe cognitive impairment). Active diagnoses listed were Alzheimer's disease, malnutrition, or at risk for malnutrition and depression. Further record review of the MDS revealed the resident had not experienced a weight loss or a weight gain. Residents Affected - Some Record review of the current care plan for Resident #2 revealed the following documentation, Problem, start date: 9/21/22. Category: nutritional status. Nutritional status diet: regular mechanical, soft. Edited: 3/16/23. Edited by: DON. Approaches included, .Approach start date: 9/21/22. Diet as ordered: regular mechanical, soft, FMP (fortified meal plan). Edited: 9/23/22. Edited by: DON. Record review of the physician orders for Resident #2, dated 4/25/23 revealed the following order, . Diet: regular texture: mechanical soft. Fluid consistency: thin. Special instructions: fortified foods. Start date 9/14/20. End date - open ended. Record review of the Weight Variance Report dated 10/1/22-4/26/23 revealed Resident #2 had a 4.1% weight loss between 3/6/23, and 4/13/23. The resident was 118.1 pounds and declined to 113.2 pounds. Record review of the Progress Notes from Dietitian A dated 7/7/22 revealed the following documentation for Resident #2, . weight change: . Period 4.4% loss at 90 days. Diet: regular, mechanical, soft, thin fluids with fortified foods. Record review of the diet tray card for Resident #2 for Lunch: Wednesday, 4/26/23 revealed that the resident was on a regular/mechanical soft diet. It further documented entrée . One serving fortified foods. On 4/26/23 at 12:19 PM, Resident #2 received 1 slice cheesecake, 1 slice toast, 4 ounce spaghetti, 4 ounce squash, 6 ounce meat sauce, and tea. None were identified as fortified foods. On 4/26/23 at 4:01 PM an interview was conducted with the Director of Nurses regarding resident diets. Regarding Resident #2's therapeutic diet, he stated around COVID, she lost weight. - The following observations were made, and interviews conducted during a kitchen tour on 4/26/23 that began at 11:20 AM and concluded at 12:26 PM: On 4/26/23 at 11:25 AM temperatures were taken on the service line by the Dietary Manager. The foods served were as follows: Meat sauce served with a 6 ounce ladle. Spaghetti served with a 4 ounce ladle. Yellow squash served with a 4 ounce ladle. Puréed meat sauce served with the #6 scoop. Puréed squash served with a #12 scoop. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 8 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 0692 Mashed potatoes served with a #8 scoop. Level of Harm - Minimal harm or potential for actual harm Puréed spaghetti served with a #8 scoop. Puréed cheesecake at room temperature Residents Affected - Some Puréed bread no temperature taken. Regular cheesecake at room temperature No foods were identified as foods for a fortified or renal diet. Meal service started at 11:46 AM Record review of the menu spreadsheet for Wednesday SLP FW 2022 5 week - week 2, revealed that there was no menu guidance listed for a renal diet, large portion diet or fortified diet. These menus were signed by a Dietitian B. The spread sheet documented that residents on Regular, Regular/Mechanical Soft, Regular No Salt on tray diet should have received 3/4 cup (6 ounce) meat sauce, 1/2 cup (4 ounce) spaghetti noodles, 1/2 cup slice zucchini/squash, one each garlic toast half, one slice cheesecake. The only difference from the Regular diet for the High Cal/High Pro/regular diet was that the resident would receive 1 cup meat sauce. The Low Concentrated Sweets/Regular diet only difference from the regular diet was the resident received a half a slice of cheesecake. Record review of the menu spreadsheet for Tuesday SLP FW 2022 5 week - week 2, Wednesday SLP FW 2022 5 week - week 2, Thursday SLP FW 2022 5 week - week 2, Friday SLP FW 2022 5 week - week 2 revealed that there was no menu guidance listed for a renal diet, large portion diet or fortified diet. These menus were signed by a Dietitian B. On 4/26/23 at 12:58 PM, an interview was conducted Dietary staff A regarding how the noon meal foods were made and other issues in the kitchen. Regarding what ingredients she used to make the squash, she stated she used chicken broth, squash, and butter. Regarding how she made the meat sauce, she stated, that the meat sauce was canned and nothing additional was added. Regarding how she made the spaghetti; she stated she used chicken broth and spaghetti. Regarding how she made the mashed potatoes, she stated she used butter, chicken broth and instant potatoes. Regarding fortified foods, Dietary staff A stated that the only fortified food the facility used was mashed potatoes. She stated there were six or seven residents on fortified foods. Regarding how the facility defined a large portion, she stated she could not remember. Regarding a Renal diet she stated there were no residents on a renal diet. She stated Resident #14 was served a regular diet. She further stated that she had worked in the facility 4 years, and they trained her for two months. On 4/26/23 at 1:20 PM, an interview was conducted with the Dietary Manager regarding issues found in the dietary department. Regarding fortified diets he stated that the diets contained mashed potatoes and evaporated milk. He added he had the recipe on a paper in the kitchen. He further stated that specific ingredients were added to foods to make them fortified. Regarding what food was fortified food for the noon meal, he stated residents on fortified diets should have received potatoes. Regarding why residents did not receive fortified foods as he described, since the mashed potatoes did not contain evaporated milk, he stated, Dietary staff A was nervous. He stated he asked Dietary staff A if she served fortified foods on the trays. He added that staff usually serve fortified foods, and these foods should have been made with butter, evaporated milk, and regular milk. Regarding how they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 9 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some defined large portions, he stated, they should get bigger portions. Regarding renal diet, he stated the facility had no one on a renal diet, the Dietary Manager was shown the diet order for Resident #14 on the Diet Order List that stated the resident was on a renal diet. He stated he was not aware the resident was on a renal diet. Also, at that time, the Dietary Manager looked through the resident tray cards, and there was no renal diet found. Regarding the menu diet spreadsheet not having a renal diet listed, he stated, this was the only spreadsheet he was given. Regarding what could result from residents not receiving their physician order diet/therapeutic diet, he stated residents could die or get sick. Regarding whom was responsible for residents receiving their prescribed physician diet, he stated that the Dietary Manager was responsible. Regarding what he expected staff to have done, he stated staff should have followed the physician's order. Regarding how long the dietary staff were oriented or trained, he stated three days. On 4/26/23 at 2:40 PM an interview was conducted with the Dietary Manager. He stated, he could not find a tray card for Resident #14. He added that he had been told by nurses that a renal diet would be a diet with low salt. On 4/27/23 at 10:05 AM, an interview was conducted with the Administrator about observations made in the facility. Regarding therapeutic diets not being served as ordered, he stated he expected staff to have followed the diet orders. He added that the errors may have been caused by a software system problem. Regarding what could result from these issues, he stated there could be a resident decline. He was then asked who was responsible to ensure that staff serve the therapeutic diet as ordered by the physician. He stated the Administrator and Dietary Manager were responsible to ensure that staff served therapeutic diets as ordered by the physician. Record review of the facility's, Diet Manual dated 2021 revealed the following documentation, Diet and Textures. Diet Descriptions. Regular. Large portion - Increase portions to 1 1/2 that of the regular diet. Fortified foods - Regular diet with one or more menu items replaced with a super foods recipe. Renal 60 g pro - Low sodium (2 gm), low potassium (2 gm), 60 g proteins. Record review of the facility policy labeled Nutrition & Food Service Policies & Procedures Manual, 2018, Section 3-12, revealed the following documentation, Policy: Tray Service. Policy Number: 03.006 . Policy: The facility believes that accurate tray service and adequate portion sizes are essential to the resident's, well-being and safety. The facility will ensure that diets are served accurately, and in the correct portions and that preferences are met. Procedures. 3. For tray line service, Nutrition and Food Service Staff will check each resident's tray cards prior to service to ensure their preferences and dislikes are honored, the correct diet is served, portion sizes are accurate, and appropriate substitutions provided. 4. For non-tray line service methods, staff will obtain food preferences for the meal from each resident. Serving staff will check each tray against the extensions to ensure that the diet is served accurately and the portion sizes of each item is correct. 5. The Nutrition & Food Service Manager or designee may conduct a tray audit once each week during each meal to ensure that diets are served correctly and to identify any training needs. 6. The Nutrition & Food Service Manager, or consultant or RDN/NDTR will conduct in-services with the nutrition, foodservice and nursing staff once per quarter or twice each year to ensure all serving staff are familiar with portion sizes and therapeutic and mechanically altered diets. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 10 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the National Institutes of Health website, National Library of Medicine .Medline Plus (https://medlineplus.gov/lab-tests/albumin-blood-test/) revealed the following documentation, . Albumin Blood Test. What is an Albumin Blood Test? An albumin blood test measures the amount of albumin in your blood. Low albumin levels can be a sign of liver or kidney disease or another medical condition . Albumin is a protein made by your liver. Albumin enters your bloodstream and helps keep fluid from leaking out of your blood vessels into other tissues. It is also carries hormones, vitamins, and enzymes throughout your body. Without enough albumin, fluid can leak out of your blood and build up in your lungs, abdomen (belly), or other parts of your body . Lower than normal albumin levels may be a sign of: Liver disease, including severe cirrhosis, hepatitis, and fatty liver disease Kidney disease Malnutrition Infection Digestive diseases that involve problems using protein from food, such as Crohn's disease and malabsorption disorders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 11 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 staff (Dietary Manager and Dietary staff A) and 1 of 1 kitchen, in that: 1) The facility failed to store, serve or process foods in a manner to prevent contamination, 2) The facility failed to handle food contact equipment in a manner to prevent contamination, 3) The facility failed to ensure food contact surfaces were clean, 4) The facility failed to perform sanitary handwashing between the handling of soiled and clean food equipment during dishwashing, 5) The facility failed to use good hygienic practices, including incorrect handwashing techniques, 6) The facility failed to ensure wiping cloth quaternary sanitizer solutions were not at required levels, 7) The facility failed to ensure food contact equipment storage areas were not maintained in a clean and sanitary manner 8) The facility failed to ensure food preparation area nonfood contact surfaces were not clean, and These failures could place residents at risk for food contamination and foodborne illness. The findings include: - The following observations were made, and interviews conducted during a kitchen tour on 4/25/23 that began at 10:49 AM and concluded at 12:23 PM: The underside of the upper shelf of the stove had an accumulation of dried spills. The drink gun was stored in the hand sink and the drink gun had a buildup of dirt/syrup. The wiping cloth solution was stored on a lower shelf of the kitchen prep table and it was next to a box that contained coffee. On 4/25/23 at 10:57 AM, an interview and observation was conducted with the Dietary Manager. He stated the wiping cloth solution was a (quaternary) sanitizer and that staff had set the solution up that morning. He added staff changed the solution two times a day and looked for a sanitizer level of 200 ppm as correct. At that time the Dietary Manager checked the wiping cloth solution which was dirty and contained cloths and it was tested with a quaternary sanitizer test strip and the level was 0 to 100. The exterior of the utensil storage bin, that was placed on the rack, was dirty. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 12 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 The pantry area food bins exteriors were dirty with smears and buildup. Level of Harm - Minimal harm or potential for actual harm The stainless steel racks had a personal drink container stored on the shelf with clean pitchers. The wall in the food processing area was soiled with dried spatter and spills. Residents Affected - Some The sides of the fryer and stove had a buildup of gummy grease between the two. The wooden cutting board connected to the steam table had a buildup of dried food, dirt and gummy grease. Between the steam table and the wood cutting board, there was a buildup of dried food. The ceiling return air vent in the kitchen had a buildup of dirt and grease. The Dietary Manager rinsed his hands with water only in the two compartment sink and dried them. He then handled clean dishes and put them away. On 4/25/23 at 11:48 AM, the Dietary Manager stated that they had a sign above the sink that tells them the correct order to wash their hands. Dietary staff A washed the processor in the dishwasher. She removed it from the dishwasher and then placed tomatoes in the wet processor and puréed them. On 4/25/23 at 11:35 AM, an interview was conducted with the Dietary Manager regarding why the drink gun was being stored in the hand sink (soiled area). He stated, he guessed staff were nervous. Dietary staff A washed the processor in the dishwasher. She removed it from the dishwasher, and it was wet on the interior. She placed slices of bread in the wet processor with broth and then puréed the mixture. Record review of the Auto Chlor Sanitizing Solution CL (dishwasher sanitizer) label revealed the following. Directions for use . Sanitizing food contact surfaces. 5. Allow equipment or utensils to air dry. The two freezers in the entry area had unshielded lightbulbs. - The following observations were made during a kitchen tour on 4/25/23 that began at 1:20 PM and concluded at 1:40 PM: Dietary staff A was pre-washing soiled dishes and placing them in the dishwasher and then went directly and handle clean dishes without washing her hands. Dietary staff A was again observed handling, and pre-rinsing soiled dishes and then going to clean dishes/trays and drying them off with a disposable towel, and not allowing them to air dry. She also failed to wash her hands between soiled and clean duties. - The following observations were made, and interviews conducted during a kitchen tour on 4/26/23 that began at 11:20 AM and concluded at 12:26 PM: Dietary staff A placed squash in a wet processor and puréed it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 13 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 The ceiling return air vents in the kitchen and exhaust vent were heavily soiled with dust and dirty grease. Level of Harm - Minimal harm or potential for actual harm There was an accumulation of dust on the ceilings. Residents Affected - Some Dietary staff A took a wet processor from the dish machine and placed pasta and chicken bouillon in it. Dietary staff A was about to place the lid on the processor and the surveyor intervened and told her that the lid was dirty with food. She took the lid and washed it, replace the lid on the processor and puréed the pasta/spaghetti. There was a personal drink in an uncovered cup on the stainless steel rack next to Styrofoam plates, food container lids, and an open box of gloves. On 4/26/23 at 12:58 PM an interview was conducted Dietary staff A regarding other issues in the kitchen. Regarding how long she had worked in the facility she stated, 4 years and she was trained two months. She stated that she had not been told to allow the processor to air dry prior to placing food in it. Regarding cleaning in the kitchen, she stated the walls were cleaned daily, and staff mopped the floors. She added there was no cleaning of the ceilings. Regarding cleaning of the wooden board attached to the steam table, she stated it was cleaned daily. Regarding going from soiled to clean dishes and not washing her hands, she stated staff had been told to wash their hands between handling soiled and clean dishes. Regarding the result of the dietary sanitation issues mentioned, she stated, cross-contamination. On 4/26/23 at 1:20 PM, an interview was conducted with the Dietary Manager regarding issues found in the dietary department. Regarding the processor, he stated, he told staff to air dry. Regarding when his last in-service was conducted with the dietary staff, he stated he conducted in-services at the first of the year. Regarding cleaning in the kitchen, he stated, he did most of it. Regarding cleaning of the walls and ceilings. He stated, they were not cleaned too often. He added that he cleans them when he can. Regarding the last time that the ceiling vents were cleaned, he stated it happened about a month and a half ago. Regarding personal drinks stored in food areas he stated, he told staff they should place personal drinks in the pantry area. Regarding dishwashing and going from soiled to clean items without washing their hands, he stated, staff had been told to wash their hands between soiled and clean duties. Regarding the drink gun being dirty, he stated, staff cleaned it daily. He added staff cleaned between the fryer and the stove approximately once a month. Regarding the wooden cutting board that was attached to the steam table, he stated, it should be cleaned every day. He stated that the board was clean. Regarding what could result from the dietary sanitation issues mentioned, he stated, residents could get sick. Regarding whom was responsible to ensure that the dietary sanitation actions were correct, he stated, the Dietitian, Administrator; it's really the Dietary Manager. Regarding why he thought these dietary issues occurred, he stated, staff were getting in a hurry. Regarding what he expected staff to have done, he stated, he expected them to do the right thing. Regarding how long the dietary staff were oriented or trained, he stated staff were trained three days. On 4/27/23 at 8:55 AM an observation was made in the kitchen, and it was found that the lights in the entry area freezers were not shielded. On 4/27/23 at 10:05 AM, an interview was conducted with the Administrator about observations made in the facility. Regarding dietary sanitation issues that were found, he stated he expected staff to conduct proper handwashing, and dish cleaning. Regarding what could result be from these issues, he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 14 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated, the possibility of illness; a far possibility. Regarding whom was responsible to ensure that dietary staff actions were appropriate, he stated the Dietary Manager and Administrator. Record review of the label on the quaternary sanitizer, Auto Chlor Solution QA, revealed the following documentation, .Directions for Use. Sanitizing Food Contact Surfaces: Use half ounce per 1 gallon water 200 ppm active of this product for sanitizing and cleaning of equipment and utensils in . institutional kitchens Record review of the In-Service Sign In sheets for the dietary department since January 2023 revealed that there were two in-services conducted on 2/8/22 that covered dish washing, recording temps, weekly handwashing, and mask from chin to nose. An additional in-service was conducted on 1/31/22 on dishwashing and recording temperatures. The Dietary Manager and Dietary staff A attended these in services. Record review of the Hand Hygiene Competency Criteria Checklist for the Dietary Manager, dated 3/22/23, revealed no documentation as to if he correctly demonstrated competency or missed a step or was incorrect. The two signatures at the bottom of the page were, ADON, and the Dietary Manager. Record review of the Hand Hygiene Competency Criteria Checklist, dated 4/11/23, revealed it only had the signature of the employee Dietary staff A and there was no documentation if she correctly demonstrated competency or missed steps or was incorrect. Record review of the facility policy, titled Nutrition & Food, Service Policies & Procedures. Manual, 2018, Section 4-1, revealed the following documentation, policy: employee sanitation. Policy number: 04.001 . Policy: The Nutrition & Food Service Employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. Procedure . 3. Employee cleanliness requirements . e. Employees will not eat or drink in food storage and preparation areas, or in areas containing exposed food or unwrapped, utensils, or where utensils are clean or stored. 5. Handwashing. a. Employees must wash their hands and exposed portions of their arms at designated handwashing facilities at the following times. iv. Immediately before engaging in food preparation including working with exposed food, cleaning equipment, and utensils, and unwrapped single service and single use articles. vii. After engaging in other activities that contaminate the hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 15 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 of 3 residents (Resident #88) and in 1 of 2 common baths (#1) reviewed for infection control, in that: Residents Affected - Few 1)The facility failed to use proper infection control precautions when providing care for Resident #88 who was COVID positive, and 2)The facility failed to ensure clean linens were stored in a sanitary manner. These failures could place residents at risk for infections. Findings include: 1)Resident #88 Record review of the face sheet for Resident #88 dated 4/25/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. Resident had diagnoses of metabolic encephalopathy (chemical brain disorder), cellulitis of right lower limb (leg infection), and obesity (overweight). Record review of the current care plan for Resident #88 revealed the following problem, Problems start date: 4/25/23. Category: General. Resident is (COVID-19 positive). Resident is at risk for related complications due to associated comorbidities. Resident is at increased risk of social isolation due to social distancing precautions. Edited: 4/25/23. Edited by: DON. Approaches listed included the following, . Approach start date: 4/25/23. Follow principles of infection control, and universal/standard precautions. Created: 4/25/23. Created by: DON. Approach start date: 4/25/23. Minimize resident to resident and unnecessary staff contacts. Created: 4/25/23. Created by: DON . Record review of the physician orders for Resident #88 dated 4/25/23 revealed the following, . COVID-19 monitoring once a day. 6 AM to 6 PM. Start date 4/17/23. End date - open ended. Record review of the Progress Notes for Resident #88 dated 4/24/23 at 3:19 PM revealed the following . Additional note: COVID-19 positive 4/25/23 at 8:52 AM. Day 2/10 COVID positive. No signs or symptoms at this time, no concerns by resident or staff. On 4/25/23 at 1:00 PM, an interview was conducted with the Director of Nurses. He stated Resident #88 was interviewable, a new admit and had cellulitis, bilateral. He added the resident was a new admit of only 10 days and had tested positive for COVID yesterday (4/24/23). On 4/26/23 at 8:40 AM, an observation was made of Resident #88's room. His call light was on above the door and the door was closed. There was a red bag/unit hanging on the front of the door that contained PPE (gloves, gowns, masks). There was signage at the door stating the resident was on droplet precautions and there was signage for donning and doffing PPE. CNA C entered the room to answer the call and had only a regular face mask on. The CNA had on no other PPE - (N95 mask, gown, shield or gloves). While in the room, the CNA touched the resident's computer, moved the over bed tray table, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 16 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few which had his breakfast meal on it, and touched the knee of the resident. The CNA then left the room and LVN C stated to her, What are you doing? The CNA responded regarding COVID precautions for Resident #88, I didn't notice it; meaning she did not notice the postings that stated the resident was on droplet precautions. Observation, at this time (on 4/26/23 at 8:40 AM) of the three signs posted on the wall outside of Resident #88's room revealed the following: Check in at nurses station before entering room. Stop droplet precautions stop. Everyone must: clean their hands, including before entering, and when leaving the room. Make sure their eyes, nose, and mouth or fully covered before room entry. Or remove face protection before room exit. US Department of Health and Human Services Centers for Disease, Control and Prevention. Use personal protective equipment (PPE) when caring for patients with confirmed or suspected COVID 19. Before caring for patients with confirmed or suspected COVID-19, healthcare personnel (HCP) must: receive comprehensive training on when and what PPE is necessary, how to don (put on) and doff (take off) PPE, limitations of PPE, and proper care, maintenance, and disposal of PPE. Demonstrate competency in performing appropriate infection control, practices and procedures. Remember: PPE must be donned correctly before entering the patient area (e.g., Isolation room, unit if cohorting). PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted. (e.g., re-tying gown, adjusting respirator/facemask) during patient care. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care. Preferred PPE - Use N 95 or higher respirator. Face shield or goggles. N95 or higher respirator when respirators are not available, use the best available alternative, like a facemask. One pair of clean, non-sterile, gloves. Isolation gown. Acceptable alternative PPE - use face mask. Face shield or goggles. Facemasks, N95 or higher. Respirator are preferred but facemasks are an acceptable alternative. One pair of clean, non-sterile, gloves. Isolation gown . CDC. 6/03/2020. www.cdc.gov/coronavirus. On 4/26/23 at 8:57 AM, LVN C stated CNA C was sent home to shower and change her clothes. On 4/26/23 at 9:38 AM, an interview was conducted with CNA C regarding not wearing proper PPE when entering Resident #88's room. Regarding why she had done that, she stated, she had just happened to see the (call) light and blanked out. She added it was a quick reaction and no one told her Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 17 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #88 was COVID positive. She further stated her first instinct was to answer the call light and noticed the biohazard boxes once she was in the room. She added that day was her first day back to work after being off. Regarding how long she had worked in the facility, she stated she had worked in the facility almost 3 years. She stated she had been trained related to COVID and was told to completely gown up and use proper PPE when entering a COVID room. She added that she knew her PPE and sometimes fell under pressure. Regarding what could result from her entering a COVID positive room without donning the proper PPE. She stated, she could transmit COVID to another resident. 2) On 4/25/23 at 3:19 PM on hall 3 common Bath #1 was observed. There were 2 clean linen carts stored in this bath, which included bed sheets, pillowcases and towels. On 4/26/23 at 8:59 AM an observation was made of common Bath #1. Two of 2 clean linen carts were stored inside the shower room, which included bed sheets, pillowcases and towels. On 4/26/23 at 9:27 AM an interview was conducted with CNA D in Bath #1 regarding issues in the shower. Regarding why the linen carts were stored in the baths, she stated, the carts were either stored in spare rooms or in a bath during meals and staff took them out when they were conducting rounds. After the rounds, the carts were stored in a spare room or the showers. She stated, she did not know that a shower was considered a soiled area and large amounts of linens such as sheets and pillowcases, should not be stored in a soiled area. Regarding what could result from storing clean linens in a soiled area, such as a bath, she stated, cross-contamination. On 4/26/23 at 4:40 PM an interview was conducted with the Director of Nurses regarding linen infection control. He stated, regarding storing linen carts in the baths, staff had been doing that for years. He told staff to place the clean linen carts in the shower but not letting them touch the soiled linen barrels. He added if there was no vacant room, staff stored the carts in the shower. Regarding infection control, and the CNA, who did not wear proper PPE in Resident #88's room he stated, he did not understand why she had done that. He added every three months, the facility conducted handwashing and PPE audits. He stated he did not know what was in the CNA's brain and that she screwed up pretty good. Regarding what CNA C should have done, he stated, she should have knocked; donned PPE per procedure on the wall and doffed per procedure posted. Regarding what could result from staff not wearing the appropriate PPE in a COVID positive room, he stated, she could have exposed herself to COVID. Regarding whom was responsible for ensuring staff wear appropriate PPE. He stated, the Infection Control Preventionist/DON, the ADON; all things in nursing were under his head. On 4/27/23 at 10:05 AM, an interview was conducted with the Administrator about observations made in the facility. Regarding infection control, and linen infection control, he stated that the issue of linens being stored in the shower was new to him. Regarding what he expected staff to have done regarding not wearing appropriate PPE, he stated they should have donned PPE before entering the room. Regarding the result of this issue, he stated that the residents could be exposed to COVID; no one was symptomatic. Regarding whom was responsible for ensuring that staff don proper PPE, he stated, Administrator, Infection Control Preventionist, DON and everyone. Record review of the facility policy title, Personal Protective Equipment, Revised October 2018, revealed the following documentation, Policy Statement. Personal protective equipment appropriate to specific task requirements is available at all times. Policy Interpretation, and Implementation. 1. Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) at no charge. 3. Not all tasks involve the same risk of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 18 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 exposure, or the same kind or extent of protection. The type of PPE required for a task is based on: Level of Harm - Minimal harm or potential for actual harm a. the type of transmission based precaution; b. The fluid or tissue to which there is a potential exposure; Residents Affected - Few c. The likelihood of exposure; d. The potential volume of material; e. The probable route of exposure; and f. The overall working conditions in job requirements. Record review at the facility' policy, titled Infection, Prevention and Control Program, Revised January 2022 revealed the following documentation, Policy Statement. An infection prevention and control program (IPCP) is established and maintain to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Each Center shall refer to and follow CDC guidance and their State guidance for infection prevention and control. Policy Interpretation and Implementation. 11. Prevention of Infection. a. Important Facets of Infection Prevention include. 3. Educating staff and ensuring that they adhere to proper techniques and procedures . 7. Implementing appropriate isolation precautions when necessary; and 8. Following established general and disease specific guidelines, such as those of the Centers for Disease Control (CDC) . 13. Monitoring employee health and safety. c. Those with potential direct exposure to blood and body fluids are trained in and required to use appropriate precautions and personal protective equipment. 1. The facility provides personal protective equipment, checks for its proper use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 19 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in 2 of 2 common resident baths (#1 and #2), 3 of 4 halls (1, 2 and 3) in that: 1)The facility failed to ensure resident rooms, resident use equipment and common areas were clean and maintained in good repair 2) The facility failed to ensure chemicals were not accessible to residents. These failures could lead to resident injuries, spread of infections, and cause the facility to have an unsightly appearance. The findings include: On 4/25/23 at 2:39 PM, an observation was made of common Bath #2. The bariatric shower chair had a buildup of residue and dirt on the mesh back. There was a soiled unlabeled cordless shaver on the toilet tank top. On 4/25/23 at 2:43 PM, an observation was made of room [ROOM NUMBER]. There were loose toilet tissue holder brackets pulling from wall. There was approximately a 3 foot section of window trim that was5 missing and it had an exposed nail head and crumbling sheet rock. The entrance door was swollen and hard to open and close. There was chipping paint on the doors in the room. On 4/25/23 at 2:57 PM, an observation of room [ROOM NUMBER]. Both bedside tables had scarred finish. The A bed bedside cabinet had one of three drawer pulls missing. The chest of drawers had two or four drawer pulls that were damaged or missing. One drawer pull was partially attached by one screw, and one had a missing draw pull. The finish was scarred on the chest of drawers. The windowsill at the B bed had a buildup of dirt and trash in the track which included a Band-Aid. The window blinds had a broken loose louver that was protruding out from the blinds and askew. There was peeling paint around the top portion of the hand sink. On 4/25/23 at 3:19 PM, the hall 3 common Bath #1 was observed. Two cordless shavers were stored in a cabinet and were dirty and unlabeled. The shower stall outer grab bar was loose on the wall. The shower stall ceiling vent cover was stick with dust. On 4/26/23 at 8:59 AM, an observation was made of common Bath #1. There was heavy dust accumulation on 2 of 2 ceiling vents in the room. The outer grab bar for the shower was loose on the wall. A wall heater was not operational, one of two. Two electric shavers were unlabeled and dirty. On 4/26/23 at 9:27 AM, an interview and observation was conducted with CNA D in Bath #1 regarding issues in the shower. At that time the surveyor pointed out that the bariatric shower chair from shower #2 was there and had a buildup of residue and dirt on the mesh back. She stated shower chairs were cleaned after each and every shower. Regarding how it happened that this shower chair was still dirty. She stated it was time and wear. Regarding if there was any deep cleaning of shower chairs. She stated, Wheelchairs and shower chairs were cleaned every other night. Regarding what could be the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 20 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 result of residents using dirty shower chairs, she stated cross-contamination. Regarding how long the wall heater had not been working. She stated, this was the first time she had noticed it. Regarding the electric shavers that were soiled and unlabeled, she stated that the green one was used for a specific resident but did not know the resident's name; the larger black shaver she stated belonged to Resident #10. Regarding what staff were told to do after using a shaver, she stated staff were told to clean them and sanitize them. Regarding what could result from not cleaning the shavers after use, she stated cross-contamination. Observation at this time revealed there was a three drawer plastic cabinet in the shower and one of three drawers was cracked and broken. On 4/26/23 at 2:05 PM, an observation was made of common Bath #2. There was a soiled unlabeled cordless shaver present. At that time an interview was conducted with CNA E regarding the cordless shaver. She stated, everybody (staff) used it. Regarding what could result from using the shaver on the residents, and it was soil, she stated, residents could get a rash or something. She added, staff were told to store them in the cabinet. She further stated the facility had a shower aide that took care of that. She stated that when she gave showers, she usually cleaned the shavers and placed them in the cabinet. She added the facility had a new shower aide. An observation at the time in the common Bath #2 revealed that one of two shower chairs had a buildup of dried residue and dirt on the mesh back and along the frame on the underside. At that time CNA E stated the shower chair should have been cleaned every day after each shower. Regarding whom was responsible for ensuring that the shower chairs were clean, she stated usually the shower aide. On 4/26/23 at 3:29 PM, an observation was made of room [ROOM NUMBER]. The windowsill had trash and food and squash from her lunch in it. The drawer pulls, the Maintenance Supervisor stated, It was an ongoing battle. When missing and scarred paint areas were pointed out, he stated, the facility had just received 8 gallons of paint in. He stated he was not sure how long the pieces been missing; meaning drawer pulls. On 4/26/23 at 3:35 PM, an observation was made of hall three near Bath #2 revealed there was a section of wood missing on the wall in the corridor that exposed to nail heads. On 4/26/23 at 3:42 PM, an observation and interview was made of common Bath #1 with the Maintenance Supervisor. Regarding the wall heater that was not operational he stated, it had worked. Regarding the loose Grab bar at the shower, he stated that he had not been told about it. Observation of the door frame revealed the inside entrance door frame of common Bath #1 had an approximately 1 foot section of splintered wood. He stated he was not aware of the situation. Regarding what could result from residents residing in areas where repairs were needed, he stated, a resident could catch a leg on the splintered areas. Regarding whom was responsible for ensuring that the facility was maintained in good repair, he said the Maintenance Supervisor. He added that if he knew about the issues, he would try to get it repaired/resolved. Regarding what he expected of facility staff regarding needed repairs, he stated, he expected staff to report needed repairs. On 4/26/23 at 10:02 AM, an interview was conducted with the Housekeeping Supervisor. Regarding the dirty ceiling vents observed in the facility, she stated, housekeeping was responsible to dust them. She added the painting, and the filters were the responsibility of maintenance. It was observed at that time that the ceiling vent near room [ROOM NUMBER] on hall two was heavily soiled. She stated it needed scrubbing. -Kitchen Observations: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 21 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 - The following observations were made, and interviews conducted during a kitchen tour on 4/25/23 that began at 10:49 AM and concluded at 12:23 PM: On 4/25/23 at 10:51 AM an interview was conducted with Dietary staff A. She stated there were leaks in the kitchen that had not been repaired. Residents Affected - Some The steam table was leaking and pooling water on the floor. On 4/25/23 at 11:54 AM an interview was conducted with the Dietary Manager. Regarding the leaking steam table, he stated, it had been that way a couple of days. The hand sink in the kitchen was leaking and pooling water on the floor. - The following observations were made, and interviews conducted during a kitchen tour on 4/26/23 that began at 11:20 AM and concluded at 12:26 PM: There was an approximately 6 foot section of baseboard, pulling away from the wall behind the two compartment sink area. The wall board was pulling away from the wall behind the stainless steel racks in the kitchen. On 4/26/23 at 1:20 PM an interview was conducted with the Dietary Manager regarding issues found in the dietary department. Regarding maintenance responsibilities in the kitchen, he stated he reported maintenance issues, such as the baseboard and wall board damage, to the maintenance department. He added that he had not noticed the damaged baseboards. 2) On 4/26/23 at 9:10 AM Housekeeper A was observed in the dining room cleaning with her back turned. Her housekeeping cart was unlocked and unattended in hall three. The unlocked cabinet contained chemicals that included: Room Sense Disinfectant Cleaner labeled, . Causes moderate eye irritation. Harmful if absorbed through skin., AutoChlor Bathroom Cleaner labeled . Do not drink., AutoChlor Common Sense Odor Neutralizer labeled . Do not drink. and Diversey Shine Up Lemon Furniture Polish labeled . Danger. Flammable liquid and vapors. Caution gas under pressure. May explode if heated. May cause an allergic skin reaction. It was also observed that there was a key ring on top of the housekeeping cart with keys, and a small sprayer/aerosol tube attached to it. On 4/26/23 at 9:14 AM an interview was conducted with Housekeeper A regarding the container on the key ring. She stated that it was [NAME], and she usually hid it. She then covered it with a cloth on top of that cart. Regarding why the chemical cabinet was unlocked on her cart, she stated, she placed the cart next to the wall so residents would not bother it. She added she was trained to make sure to lock cart. Regarding her training as a housekeeper, she stated, she worked in the kitchen two years and two years as a housekeeper. She added the Housekeeping Supervisor trained her and the training was about three days. Regarding what could result from leaving her chemical cabinet unlocked and unattended on her housekeeping cart, she stated, residents could be blinded; chemicals could make them sick or have seizures. On 4/26/23 at 9:45 AM there was a housekeeping cart observed in the hall one corridor at a slant from the wall and unattended. The cabinet was unlocked and the cart itself was in the corridor near (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 22 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 room four. Housekeeper B was inside room six mopping the floor and talking to the resident. The cabinet contains chemicals that included: Medline Digester. Warning causes serious irritation. There was also Room Sense Disinfectant Cleaner, Bathroom Cleaner, and Shine Up Furniture Polish. The housekeeper came out of room six and was ringing out the mop head with his bare hands. He had taken the mop head/mat from an uncovered container on the housekeeping cart. Residents Affected - Some On 4/26/23 at 9:48 AM an interview was conducted with Housekeeper B. Regarding how long he had worked in the facility, he stated that he had worked in the facility approximately a year and six months. Regarding why he had left the cabinet unlocked on his housekeeping cart, he stated, he just left it (short period). He added it was unlocked but the key was not working at first, but it was at that time. Regarding what type of training he had received regarding housekeeping and chemicals storage, he stated, staff were told to keep it locked, but not constantly. He stated the Housekeeping Supervisor trained him and the training was two days. Regarding what could result from not securing his chemicals in his housekeeping cart cabinet, he stated, residents could drink something; it was for resident safety to keep it closed. He added it would be his fault. Regarding what chemical was in the mop head/mat bin. He stated it was just what staff used, disinfectant. On 4/26/23 at 10:02 AM an interview was conducted with the Housekeeping Supervisor. Regarding whom was responsible for cleaning the shower chairs. She stated the night CNAs were responsible and housekeepers help at times. Regarding what housekeeping staff were supposed to do regarding the chemical cabinets on their housekeeping carts, she stated, usually staff were supposed to keep it locked. She added, if staff were using it, they should have placed it against the wall. She further stated she had told staff to try to keep the cabinets locked at all times and make sure their cart is in their sight. Regarding why the staff left their housekeeping cart chemical cabinets unlocked, she stated, staff had been in a hurry; they were two new employees. Regarding what could result from leaving the chemical cabinets unlocked on the housekeeping carts, she stated, residents could get a hold of the chemicals and could spray it on themselves. She added, the chemicals could be hazardous. Regarding what she had expected the staff to have done, she stated, staff should have an in-service. Regarding when was the last in-services she had given staff about chemical storage, she stated the in-service was several months back. Regarding whom was responsible to ensure that chemicals were secured and not accessible residents on the housekeeping carts, she stated, it was usually the Housekeeping Supervisor. She stated, she had been employed at the facility for 10 years. On 4/26/23 at 10:17 AM Resident #22 was observed confused and wandering hall three and walking. On 4/26/23 at 11:19 AM Resident #32 and Resident #22 were observed wandering hall three. Both residents had confusion. On 4/27/23 at 10:39 AM Resident #22 was observed confused and wandering the corridors. On 4/26/23 at 3:18 PM, an interview was conducted, and tour observations were made with the Maintenance Supervisor. Regarding whom was responsible for kitchen repairs he stated, he was if he knew about it. He stated he did not know about the damaged baseboard and added, problems in the kitchen did not make it to him. Regarding his system of knowing when repairs are needed, he stated, He had a weekly and monthly TELS list (online maintenance monitoring system). He stated some staff placed work orders in TELS and some placed them on the whiteboard in the Administrators office. Regarding if he was aware of the issue with room [ROOM NUMBER]'s door, he stated he had not been aware or told. Regarding if he was aware of the nails exposed in the windowsill and missing trim, he stated that he had not been aware. He added, the old windowsills were concreted in the windows and were new windows. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 23 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 also stated he had not been aware that the toilet tissue holder brackets were loose on the wall in the restroom. He added, he did try to make random rounds, but probably not as much as he should have. On 4/26/23 at 4:01 PM an interview was conducted with the Director of Nurses regarding the unlabeled, soiled cordless shavers found in the showers. He stated, staff broke the head on one shaver and the facility bought another one. Both were used by the same person. The black one was, Resident #18's. He added, shower aides needed to have rinsed them off afterwards. He added, shower aides were responsible for cleaning the shower chairs between residents. He added, they were to spray down the walls and chairs at the end of the day. Regarding what could result from residents using soiled shower chairs, he stated, it was an infection control issue. On 4/27/23 at 10:05 AM, an interview was conducted with the Administrator about maintenance issues, cleaning issues and chemical storage issues found in the facility. Regarding what he expected staff to have done, he stated, the facility had the TELS system and the board in the Administrator's office for reporting maintenance issues; staff need to report. He added, staff were not reporting enough; they need to report to someone. Regarding what could result from repairs not made, chemicals not stored appropriately, he stated, injury and illness. Regarding whom was responsible to ensure that repairs were completed, and chemicals were stored appropriately, he stated, everyone, Housekeeping Supervisor, Maintenance and Administrator. Record review of a facility list of independently ambulatory and confuse residents, provided to the surveyor on 4/26/20 by the DON, revealed 10 residents fit this description. Residents #22 and #32 were on the list. Record review of the facility policy, titled Maintenance Service, Revised November 2021, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation, and Implementation. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of the maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. h. Maintaining the grounds, sidewalks, parking lots, etc., in good order. i. Providing routinely scheduled maintenance service to all areas. j. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for development and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 24 of 25 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 10. Maintenance personnel shall follow establish safety regulations to ensure the safety and well-being of all concerned. 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: 675014 If continuation sheet Page 25 of 25