Health inspection·October 11, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. Record review of Resident #12's face sheet dated 10/09/23 indicated Resident #12 was a [AGE] year-old female and admitted on [DATE] with diagnoses including Schizoaffective disorder (is a chronic mental health condition characterized primarily by symptoms of schizophrenia (is a serious mental illness that affects how a person thinks, feels, and behaves), such as hallucinations (involve sensing things such as visions, sounds, or smells that seem real but are not) or delusions (A belief or altered reality that is persistently held despite evidence or agreement to the contrary), and symptoms of a mood disorder, such as mania (is a period of extreme high energy or mood) and depression (the feelings of sadness are constant)) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). The face sheet indicated Resident #12's resident representative and responsible party was Family Member A. The face sheet indicated Resident #12's emergency contact was Family Member B. Record review of Resident #12's quarterly MDS assessment dated [DATE] indicated Resident #12 was sometimes understood and sometimes had the ability to understood others. The MDS indicated Resident #12 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #12 had short-and-long term memory loss with severely impaired cognitive skills for daily decision making. The MDS indicated Resident #12 required supervision for eating, limited assistance for bed mobility and transfer, extensive assistance for dressing, toilet use, and personal hygiene, and total dependence for bathing. The MDS indicated Resident #12 received antipsychotic within the 7-day review period. The MDS indicated Resident #12 received antipsychotic on a routine basis only and a gradual dose reduction (attempts for antipsychotics (unless clinically contraindicated) and tapering of other medications, when clinically) was attempted on 05/14/23. Record review of Resident #12's baseline care plan dated 11/17/22 indicated Resident #12 was a new admission to skilled nursing facility for long term care. Intervention included nursing staff will educate resident and/or responsible agent related to antipsychotic medications ordered. Consent will be obtained as indicated with possible adverse reaction/side effects reviewed. Record review of Resident #12's care plan dated 04/10/23 indicated Resident #12 was at risk for adverse consequence related to receiving antipsychotic medication Zyprexa (Olanzapine) for treatment of Schizophrenia. Intervention included assess/record effectiveness of drug treatment. Record review of Resident #12's care plan dated 04/10/23 indicated Resident #12 had impaired decision making related to Alzheimer's Dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Intervention included respect resident's rights to make decision (s). Record review of Resident #12's Physician Order Report dated 03/01/23-03/31/23 indicated Olanzapine (Zyprexa) 10 mg ½ tablet oral, give ½ tab by mouth twice a day, DX: Schizoaffective disorder, start date 11/17/22 and end date 05/19/23. Record review of Resident #12's Physician Order Report dated 06/01/23-06/30/23 indicated Olanzapine (Zyprexa) 5mg 1 tablet oral, give 1 tablet by mouth daily, DX: Schizoaffective disorder, start date 05/19/23 and no end date. Record review of Resident #12's MAR dated 05/01/23-05/31/23 indicated Olanzapine (Zyprexa) 10 mg ½ tablet oral, give ½ tab by mouth twice a day, DX: Schizoaffective disorder, start date 11/17/22 and end date 05/19/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 2 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #12's MAR dated 05/01/23-05/31/23 indicated Olanzapine (Zyprexa) 5mg 1 tablet oral, give 1 tablet by mouth daily, DX: Schizoaffective disorder, start date 05/19/23 and no end date. Record review of Resident #12's consent for use of Psychotropic medication dated 05/19/23 at 3:13 p.m., created and completed by ADON G, indicated .Include date, medication, dose, diagnosis for use, and drug category .Olanzapine .telephone consent given by Family Member B 05/19/23 . The consent did not include date, dose, diagnosis for use, or drug category. The telephone consent was given by the emergency contact not the responsible party/representative. The consent did not have a follow up handwritten consent by the responsible party/representative. Record review of Resident #12's consent for use of Psychotropic medication dated 05/19/23 at 3:13 p.m., created and completed by ADON G, indicated .Include date, medication, dose, diagnosis for use, and drug category .Olanzapine .telephone consent given by Family Member B 05/19/23 . Progress note . decrease Olanzapine 5mg twice a day to once a day .left message with ER contact Family Member B . The consent did not include date, dose, diagnosis for use, or drug category. The telephone consent was given by the emergency contact not the responsible party/representative. The consent was not signed by two nurse due to telephone consent being obtained. 2. Record review of Resident #37's face sheet dated 10/09/23 indicated Resident #37 was a [AGE] year-old male and admitted on [DATE] with diagnoses including depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and insomnia (is a sleep disorder in which you have trouble falling and/or staying asleep). The face sheet indicated Resident #37 was not responsible for self. The face sheet indicated Family Member C was the ER contact, but no responsible party/representative was indicated. Record review of Resident #37's quarterly MDS assessment dated [DATE] indicated Resident #37 was understood and understood others. The MDS indicated Resident #37 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #37 required supervision for bed mobility, transfer, dressing, eating, and bathing, and limited assistance for toilet use and personal hygiene. The MDS indicated Resident #37 received antianxiety within the 7-days assessment period. Record review of Resident #37's care plan dated 05/30/23 indicated Resident #37 received antianxiety medication Buspar for treatment of anxiety. Intervention included monitor resident's mood and response to medication. Record review of Resident #37's care plan dated 05/30/23 indicated Resident #37 had memory/recall problem related to confusion and forgetfulness. Intervention included ensure resident's area are free of hazards. Record review of Resident #37's care plan dated 09/15/23 indicated Resident #37 had diagnosis of depression and at risk for increased depression and side effects to medications, takes Zoloft. Intervention included provide medications as ordered. Record review of Resident #37's Physician Order Report dated 10/01/23 indicated Buspirone (Buspar) 10 mg, 1 tablet, oral, TID, DX: Generalized anxiety disorder, start date 08/07/23 and no end date. Record review of Resident #37's Physician Order Report dated 10/01/23 indicated Sertraline (Zoloft) 25 mg, 1 tablet, oral, once a day, DX: Depression, start date 09/15/23 and no end date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 3 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #37's MAR dated 08/01/23-08/31/23 indicated Buspirone (Buspar) 10 mg, 1 tablet, oral, TID, DX: Generalized anxiety disorder, start date 08/07/23 and no end date. The MAR indicated Buspirone 5 mg, 2 tablets, oral, BID, DX: Insomnia, start date 06/28/23 and end date 08/03/23. The MAR indicated Buspirone 5 mg, 2 tablets, oral, TID, DX: Insomnia, start date 08/03/23 and end date 08/07/23. Record review of Resident #37's consent for use of Psychotropic medication dated 08/03/23 at 11:27 a.m., created and completed by LVN F, indicated .Buspar 10mg TID, 08/03/23, antidepressant, depression .signed by LVN F and LVN E . The consent did not have a resident/family signature. Record review of Resident #37's consent for use of Psychotropic medication dated 09/14/23 at 4:04 p.m., created and completed by LVN J, indicated .consent for Sertraline (Zoloft) .Sertraline . The consent indicated Resident #37 signed on the Facility Representative Signature and no date to indicate when the consent was signed. 3. Record review of Resident #40's face sheet dated 10/09/23 indicated Resident #40 was [AGE] year-old male and admitted on [DATE] and 09/07/23 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (is a feeling of fear, dread, and uneasiness), and unspecified psychosis (is when people lose some contact with reality). The face sheet indicated Resident #40 was not responsible for self. The face sheet indicated Friend D was the ER contact. Record review of Resident #40's quarterly MDS assessment dated [DATE] indicated Resident #40 was understood and understood others. The MDS indicated Resident #40 had a BIMS score of 00 which indicated severely impaired cognition and required limited assistance for bed mobility, transfer, eating, dressing, and extensive assistance for toilet use, personal hygiene, and total dependence bathing. The MDS indicated Resident #40 received antipsychotic within the 7-days assessment period and received on a routine basis. Record review of Resident #40's baseline care plan dated 07/20/22 indicated Resident #40 was a new admission to skilled nursing facility for long term care. Intervention included nursing staff will educate resident and/or responsible agent related to antipsychotic medications ordered. Consent will be obtained as indicated with possible adverse reaction/side effects reviewed. Record review of Resident #40's care plan dated 06/13/23 indicated Resident #40 was at risk for adverse consequence related to receiving antipsychotic medication Seroquel for treatment of psychosis. Intervention included monitor resident's behavior and response to medication. Record review of Resident #40's care plan dated 07/19/23 indicated Resident #40 had impaired decision making related to dementia. Intervention included support and reassured in new situations. Record review of Resident #40's Physician Order Report dated 02/01/23-02/28/23 indicated Quetiapine (Seroquel) 50 mg, 1 tablet, oral, at bedtime, DX: unspecified psychosis, start date of 01/11/23 and end date of 04/17/23. Record review of Resident #40's Physician Order Report dated 06/01/23-06/30/23 indicated Quetiapine (Seroquel) 50 mg, 1 tablet, oral, at bedtime, DX: unspecified psychosis, start date of 04/17/23 and end date of 07/19/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 4 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #40's Physician Order Report dated 08/01/23-08/31/23 indicated Seroquel (Quetiapine) 100 mg, 1 tablet, oral, at bedtime, DX: unspecified psychosis, start date of 07/19/23 and no end date. Record review of Resident #40's MAR dated 06/01/23-06/30/23 indicated Quetiapine (Seroquel) 50 mg, 1 tablet, oral, at bedtime, DX: unspecified psychosis, start date of 04/17/23 and end date of 07/19/23. Record review of Resident #40's MAR dated 08/01/23-08/31/23 indicated Seroquel (Quetiapine) 100 mg, 1 tablet, oral, at bedtime, DX: unspecified psychosis, start date of 07/19/23 and no end date. Record review of Resident #40's Physician Order Report dated 05/01/23-05/31/23 indicated Depakote Sprinkles 125 mg, 2 capsules (250 mg), oral, BID, DX: dementia, start date of 05/23/23 and end date of 06/28/23. Record review of Resident #40's Physician Order Report dated 06/01/23-06/30/23 indicated Depakote Sprinkles 125 mg, 3 tablets (375 mg), oral, BID, DX: dementia, start date of 06/28/23 and no end date. Record review of Resident #40's MAR dated 05/01/23-05/31/23 indicated Depakote Sprinkles 125 mg, 2 capsules (250 mg), oral, BID, DX: dementia, start date of 05/23/23 and end date of 06/28/23. Record review of Resident #40's MAR dated 06/01/23-06/30/23 indicated Depakote Sprinkles 125 mg, 3 tablets (375 mg), oral, BID, DX: dementia, start date of 06/28/23 and no end date. Record review of Resident #40's consent for use of Psychotropic medication dated 01/11/23 at 1:36 p.m., started and completed by the MDS Coordinator indicated .1/11/23 .Quetiapine (Seroquel) 50 mg . The consent did not have a signature by Resident #40 or telephone consent from Friend D. The consent had two nurses' signature but with no date to indicate when it was signed. Record review of the facility's computerized charting system on 10/10/23 reflected it did not address consent for Seroquel (Quetiapine) 100 mg for Resident #40 started on 07/19/23. Record review of Resident #40's consent for use of Psychotropic medication dated 05/24/23 at 5:45 p.m., started and completed by LVN F, indicated .increase in Depakote .5/23/23 .Depakote Sprinkles .250 mg .BID .Dementia .Antipsychotic . The consent did not have a signature by Resident #40 or telephone consent from Friend D. The consent was only signed by LVN F. Record review of Resident #40's consent for use of Psychotropic medication dated 05/24/23 at 5:38 p.m. but completed on 06/28/23 by LVN F, indicated .increase in Depakote .06/28/23 .Depakote Sprinkles .375 mg .BID .Dementia .Antipsychotic . The consent did not have a signature by Resident #40 or telephone consent from Friend D. The consent was signed by LVN E and LVN F. On 10/11/23, the DON was notified of missing consents for Resident #40's Seroquel started on 07/19/23. No consent was provided prior to exit. During an interview on 10/10/23 at 11:25 a.m., RN D said medication consents needed to be completed to make sure family knew all the information. She said the nurses were responsible to get consents for medications. She said new consent had to be done for dosage changes. She said two nurses had to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 5 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0552 Level of Harm - Minimal harm or potential for actual harm sign the consent, when telephone consent was given. She said two nurse signatures verified the family had been updated on side effects and risk factors and consent was given. She said she thought only the responsible party could sign consents. On 10/10/23 at 2:27 p.m., attempted to contact LVN F by phone. Voicemail left with no call back prior to exit. Residents Affected - Some During an interview on 10/10/23 at 2:59 p.m., the ADON G said the ADONs and LVNs were responsible to get consents for psychoactive medications. She said consent should be obtained as soon as possible. She said the previous DON told staff they only had to put the medication on the consents not the dosage, frequency, indicated for use or drug category. She said the Pharmacy consultation told them to fill out the dose in 2021 on the consents. She said all information needed to be filled out on the consent in case any of the information changed and the right information was told to the family or resident. She said two nurses signed for telephone consent. She said when telephone consent was obtained, the resident/family signature section should have who the telephone consent was given by. She said the RP had to give consent for the ER contact to give consent for medications. She said the RP should be contacted first to give consent. She said new consent had to be done with any new medication order. She said a new consent indicated the resident or RP was aware of the change and gave an informed consent. She said Resident #40 did not have family and Friend D, who he worked used to work, became his ER contact. She said she did not know who Resident #40's responsible party was since he was found on streets. She said she thought he going to be a ward of the State, but the process did not get started. She said Resident #12 family did visit and could have signed consents that were telephone consent. She said a medication was not supposed to be given without consent unless it was a medical emergency. During an interview on 10/11/23 at 10:57 a.m., LVN E said LVNs were responsible to notify the family or resident of the new medication order, get a signature from the doctor and resident. He said consents were to educate the resident on side effects and what the medication was for. He said when telephone consent was done, 2 nurses had to sign the consent. He said 2 nurses signatures said the information on the consent form was verified and correct. He said for a telephone consent, who the telephone consent was given by should be documented on the form. He said all areas on the consents needed to be filled out. He said if the resident had a RP, then the ER contact should not give consent for medications. He said all psychotropic medication required a consent. He said a new consent had to be done for medication, frequency, and dosage changes. He said the nurse who accepted the new order was responsible for getting a consent. He said consent forms needed to be filled out correctly to avoid mistakes, resident or RP and staff aware of what medication is being taken. He said documentation was important. He said if there was no RP listed, he would have to ask the DON for clarification on who could sign the consents. On 10/11/23 at 12:00 p.m., attempted to contact Resident #12's responsible party/representative by phone. A return phone call was not received prior to exit. During an interview on 10/11/23 at 12:11 p.m., the DON said she started at the facility April of the year. She said the charge nurses were responsible to get psychotropic medication consents. She said the consents should be obtained when the medication order is received. She said telephone consent had to be signed by two nurse and who they got telephone consent from should be documented. She said consents needed to be signed before medications were given. She said she did not know if telephone consent had to eventually signed by the RP in person. She said in the care plan meetings the DON, ADONs, and MDS coordinator looked at all obtained consents. She said if they found a problem with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 6 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0552 Level of Harm - Minimal harm or potential for actual harm consent, they had a red book with logged corrections a nurse needed to complete. She said the corrections had to be fixed by the next shift the nurse worked and then rescanned into the resident's chart. She said it was important for the resident or RP to make an informed consent by knowing the benefits, risk, and purpose of the medication. She said when informed consent was not given then the resident losses autonomy and choice. Residents Affected - Some During an interview on 10/11/23 at 12:46 p.m., the ADM said he had been at the facility since August 2023. He said the DON should make sure the LVNs obtained consents for medications before they were given. He said he expected the consent to be filled out correctly and the DON should be making sure they were. He said he did not know the facility's process to establish a responsible party. He said it was important for the facility to know who a resident's responsible party was to know the resident's needs were being addressed. He said clinical advisors should be involved if the resident was unable to give consent. On 10/11/23 at 1:15 p.m., surveyor asked the DON and Regional Nurse to view the red book for consent log corrections. The red book was not provided prior to exit. Record review of a facility's Antipsychotic Medication Use policy dated 06/20 indicated .residents will only receive antipsychotic medication to treat specific conditions for which they are indicated and effective . The facility's policy did not address consent forms for antipsychotic medication use. Record review of a facility Resident Rights policy revised date of 06/20 revealed .federal and state laws guarantee certain basic rights to all residents of this facility .these rights include the resident's right to .be informed of, and participate in, his or her care planning and treatment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 7 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 15 resident (Resident #1) and 1 of 3 halls (Hall 100) reviewed for environment. The facility failed to ensure Resident #1 did not have a loose privacy curtain railing from the ceiling, missing plaster from the corner of the wall, and no corner covering. The facility failed to ensure Hall 100 drainage cap was not loose and flush with the floor. These failures placed resident at risk for diminished quality of life, harm, injury, and falls. Findings included: During an observation on 10/08/23 at 10:47 a.m., on Hall 100, near the end of the hall, a metal circle was floor. The metal circle was not flushed with floor and moved when stepped on. During an observation on 10/08/23 at 10:48 a.m., in Resident #1's room, on the corner edges near the door, a moderate size chunk of plaster was missing. The corner edge near the door had glue residue and the other corners in Resident #1's had a cover piece around them. During an observation and interview on 10/10/23 at 9:50 a.m., Resident #1 was sitting in her room waiting on staff to provide incontinence care. On Resident #1's ceiling, was 6 small rods with screws holding a pole that held the privacy curtain. One of the screws was loose from the ceiling. Resident #1 said she did not know how long it had been loose, but she was afraid it was going to fall on her one of these days. She said she did not like how her wall looked with the chunk plaster missing. During an observation and interview on 10/10/23 at 10:26 a.m., CNA B and CNA C provided care to Resident #1. CNA C pulled the privacy curtain which caused the privacy curtain rod to rock and hit the wall. CNA B said she had been employed at the facility since 2021. CNA C said she had worked at the facility for a year. CNA B and CNA C said they had not noticed Resident #1's curtain rod being loose or heard it hitting the wall when pulled. They said the privacy curtains had been suspended from the ceiling since they had been employed. They said maintenance fixed building issue. They said they placed maintenance issue in a book at the nurse's station or told him verbally. CNA B said the corner cover had fell off the wall a while ago and she thought they were waiting on pieces to fix it. CNA B said the corner cover covered up the missing plaster on the wall before it fell off. They said the loose screw on the privacy curtain could fall and injury the resident. During an interview and observation on 10/10/23 at 2:30 p.m., the maintenance man was in Resident #1's empty room with a ladder. The maintenance man said he had only been employed at the facility for 90 days. He said Resident #1 did have a loose screw on her privacy curtain, but he did not think it would have fallen. The maintenance man asked for the ADM to be included in the interview and went to get him. The maintenance man said he had established a schedule to fix privacy curtain rails. The ADM said the maintenance man had started the schedule about 4 weeks ago. The maintenance man said he wanted to fix the privacy curtain rails but he had to make sure the rooms were empty, or the resident was out of the room. The ADM today was the first-time hearing about Resident #1's loose railing. The ADM said he did not know when Resident #1's corner covering fell off because he just started in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 8 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few August 2023. The ADM said the nurses and CNAs should let maintenance know about issues then the issues were prioritized. The ADM said he assumed staff knew about putting maintenance issues in the book, but he had not done an in-service since he started. The ADM said he had mentioned putting work orders in the maintenance book at meetings though. The ADM said the maintenance man was working on more important issues in the building. The ADM and maintenance man walked down the 100 Hall to the drainage cover on the floor. The metal drainage cover was more lifted and looser than on 10/08/23. The maintenance man lifted the cover and a 5-7 drainage pipe hole was seen. The maintenance man said he knew the covers needed to be replaced with newer ones. The ADM said the loose drainage cover was a safety issue. The curtain repair schedule was requested from the maintenance man and ADM. The Maintenance man returned with a facility map labeled Curtain Repair. The maintenance man showed the map with X and COMP or COMPLETE written. The Maintenance man said he had just completed some rooms and marked off 101, 109, and 406. During an interview on 10/11/23 at 11:16 a.m., LVN H said if she noticed a loose screw in a privacy curtain, she would notify the maintenance man immediately. She said she had not noticed Resident #1's loose privacy curtain or loose drain cover on the 100-hall. She said those issues risked residents falling or curtain falling on the resident which could hurt a resident. She said maintenance issue were placed in the book or verbally told to the maintenance man. During an interview on 10/11/23 at 12:11 p.m., the DON said if an issue was identified then the maintenance man needed to be notified. She said the facility had a maintenance logbook to put work orders in. She said she started in April 2023, and hoped staff had been in-serviced on placing issues in the maintenance book. She said staff should be instructed upon hire the maintenance reporting process. She said if staff did not know how to report any issue, they should tell administration about the it to get it fixed. She said the loose drain cover on the floor was a trip hazard. She said the loose railing could fall on a resident leading to an injury. She said the maintenance was responsible for the maintenance of the building, but everyone was responsible for the safety of the building. Record review of the maintenance book with dates from 08/29/23-10/10/23 did not indicate a work order for Resident #1's privacy curtain or missing corner cover nor loose drainage cover on Hall 100 floor. Record review of the undated curtain repair schedule indicated Rooms 101, 109, 202, 204, 206, 406, 407, 409, Bath on 500 hall had been completed. Record review of an undated facility's General Safety Policy indicated .all employees will maintain a safe environment and report any issue immediately .employees will report all unsafe or potentially hazardous acts or conditions to the supervisor immediately . Record review of an undated facility's Preventive Maintenance policy indicated .provide a safe environment for residents, families, visitors, and staff .it is the job of all staff to identify areas of concern regarding the maintenance of the building . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 9 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 15 reviewed for abuse. (Resident #15) The facility failed to ensure Resident #15 was free from abuse when CNA K grabbed her by the wrist on 09/12/23. This failure could place residents at risk for abuse. Findings included: Record review of a face sheet dated 10/08/23 revealed Resident #15 was [AGE] years old, and was admitted on [DATE] with diagnoses including dementia, difficulty in walking and a history of breast cancer. Record review of consolidated physician's orders for Resident #15 dated 10/11/23 indicated an open order with a start date of 02/11/22 for Aspirin, delayed release, 81 milligrams to be administered daily. Record review of the MDS dated [DATE] revealed Resident #15 was understood and usually understood others. The MDS revealed a BIMS score of 10, indicating moderate cognitive impairment. The MDS indicated Resident #15 required limited assistance with ADLs. The MDS did not indicated Resident #15 had any behaviors. Record review of a care plan dated 10/05/23 revealed Resident #15 had behavior symptoms including when upset scratches self. The care plan indicated the resident had a history of resisting/refusing care at times. The care plan indicated the resident could become verbally/physically aggressive towards staff during care. I refuse to go to bed and be changed at times. I hit, kick, scream, and bite at times. The care plan indicated Resident #15 was prescribed Aspirin and the resident was at risk for increased bleeding and bruising. Record review of a progress note dated 09/12/23 at 10:58 a.m. indicated, Resident brought to ADMIN (administrator) office per therapist and stated she was grabbed by a CNA by bilateral wrist during care this morning. Bilateral bruising noted to wrist along with old skin tear to right wrist and old bruise to right forearm from lab draw. CNA removed immediately. Skin assessment completed per RN, (ADON). RP .notified as well as (physician). Resident does not appear to be in any distress. Currently in therapy exercising with therapist. Will continue to monitor. This note was entered by a corporate nurse. Record review of Intake #452058, with a priority date of 09/20/23 indicated a self-report was made by the facility on 09/12/23 concerning the incident where CNA K grabbed the wrist of Resident #15. Record review of a Skin assessment dated [DATE] at 7:52 p.m. indicated Resident #15 did not have any skin issues. Record review of a Skin assessment dated [DATE] at 10:40 a.m. indicated Resident #15 bruising and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 10 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few skin tear measuring 1.5 centimeters in length and 0.1 centimeters in width to right lower arm. The skin assessment indicated the skin tear had a scant amount of bloody drainage. The skin assessment indicated bruising to left lower arm. Notes in the skin assessment indicated, old skin tear to right wrist and old bruise to right forearm from lab draw. The Skin assessment dated was signed by ADON F. Record review of an agency staffing Provider Management electronic record dated 10/09/23 indicated CNA K was a Do Not Return to the facility. Record review of a Pain Assessment in Advanced Dementia Scale dated 09/12/23 at 10:42 a.m. indicated Resident #15 was experiencing no pain. This assessment was signed by ADON F. Record review of an incident report dated 09/12/23 at 11:19 a.m. indicated, Resident #15 noted with bruising to bilateral wrist. Resident stated CNA grabbed her wrist this morning during care. Interventions were CNA removed immediately, skin assessment, pain assessment, notified family and MD, safe surveys complete, in-service on abuse and neglect, combative residents, monitor for further issues . Record review of a statement made by Resident #15 dated 09/12/23 and was signed by the Administrator indicated, .that the nurse put her finger in her face. She went to push the CNA's hand away from her face when the CNA grabbed her wrist in an overhand fashion and squeezed her wrists . The statement indicated Resident #15 .did not want to tell us but told the PTA (physical therapist assistant) who then informed administration. Record review of a statement dated 09/12/23 and was signed by CNA K indicated, I went in to get (Resident #15) up. She was wet with pee. She had a shirt and a pull up on that was wet. I raised her arms to take her shirt off. She started screaming that she already took a shower last night and she wanted to keep the wet shirt on that had pee on it. She clawed me on right arm, and I said please put your hand down there was a bruise already on her arm. This happened about 6:30 - 6:40 this morning .(Resident #15) said I scratched her or something . Record review of statement dated 09/12/23 at 10:40 a.m. and was signed by ADON F indicated, I .was asked to do a skin assessment & pain assessment on resident due to abuse allegations by an agency CNA. Bruises noted to bilateral lower arms (wrists) along with old bruising and an old skin tear. Resident denies pain at this time. Record review of an undated statement and was signed by PTA L indicated, .Resident brought herself down to therapy .Resident had obvious bruising, swelling on both wrists and a skin tear on the right wrist. Resident stated, nurse beat me up this morning. She explained that she forcefully grabbed her by both wrists because she said something the nurse didn't like. The incident was immediately reported to administrator/abuse coordinator. Record review of an Investigative Summary dated 09/15/23 and was provided by the DON indicated, On September 12th, 2023, at approximately 10:30 AM, (Resident #15 was in therapy with (PTA L) when (PTA L) observed bruising to (Resident #15) wrists. When asked what happened (Resident #15) stated that an aide had grabbed her and was rough with her this morning .I interviewed (CNA K) .she stated that (Resident #15) became combative with her during early morning care - leaving scratches on her arm .This author does not observe scratches on (CNA K's) arm. CNA K further explains that she never grabbed the resident but did move/swipe (Resident #15's) hands away from herself in an attempt to stop (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 11 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Resident #15) from digging her nails into her skin. CNA K reports she did observe bruising to (Resident #15's) right arm prior to the incident with the scratching. I was the staff member that notified (Resident #15's emergency contact) . (Emergency Contact) was very understanding and appreciated the call .She verbalizes in plain language that she knows how (Resident #15) could be. (Emergency Contact) asked me, Do you think (Resident #15) could have done this to herself to get a staff member fire?. I responded there is no way to know unless (Resident #15) admitted to it .The fact remains that (Resident #15) does have bruising/redness to her bilateral wrist. She is consistent in her report that the nurse aide (sometimes she states nurse) grabbed her early in the morning. (CNA K) will no longer be utilized in this building. Agency was notified of the incident and ongoing investigation. Record review of Provider Investigation Report dated 09/18/23 revealed on 09/12/23 there was an allegation of abuse to Resident #15 by CNA K where CNA K grabbed Resident #15's wrists and left bruises. The report indicated an assessment was completed on 09/12/23 at 10:40 a.m. by ADON F bruises were noted to bilateral lower arms and an old skin tear. The report indicated the resident had no pain. The report indicated psychosocial services were offered to the resident but Resident #15 had refused. The report revealed the finding of the allegations of abuse on 09/12/23 were confirmed. During an interview on 10/09/23 at 7:42 a.m., the DON said she assessed Resident #15 after the allegation of abuse was made by the resident. She said there was bruising to her wrist but that the bruising was older. She said the older bruise was caused by the resident receiving intravenous therapy. She said besides the older bruising, there was redness to the inside of the resident's wrists. She said the aide denied grabbing the resident wrists. She said the aide was removed that day and was made a do not return. She said the family had voiced big concerns that the aide had not grabbed the resident's wrists. She said the family said the resident had made similar allegations in the past that were not true. During an observation and interview on 10/09/23 at 8:56 a.m., Resident #15 said she did remember the incident back in September. She said she did not even remember what was said between herself and the aide. She said the aide kept sticking her finger in her face. She said she reached up to push the aides hand out of her face. She said the aide grabbed her by her wrists. She said the left wrist was worse than the right. She said her right wrist was bruised from a shot of some sort. She said she told the girl down in therapy and the girl report it to a man. There was no bruising present to the resident's wrists or arms. During an interview on 10/09/23 at 11:00 a.m., PTA L said she did not see the incident or what happened. She said Resident #15 had wheeled herself down to therapy. She said she noticed the bruises to Resident #15's wrists first thing. She said the bruises appeared to be new bruises and were purple. She said she asked Resident #15 what happened, and she said, I got beat up this morning. She said she had provided therapy to Resident #15 the day before and the bruises were not there. She said she would have noticed the bruises. She said she had a good rapport with the resident. She said she did believe the resident was telling the truth about the incident. During an interview on 10/09/23 at 1:36 p.m., a family member (emergency contact) said the facility called them and notified them of the incident on 9/12/2023. The family member said Resident #15 told them the aide was wanting to give her a shower. The family member said Resident #15 said the aide kept putting her finger in her face. The family member said Resident #15 said she reached up to push the aides finger out of her face and the aide grabbed her by the wrist, twisting and pinching. The family member said they came to the facility that afternoon. The family member said both wrists were swollen and were very bruised. The family member said, something for sure happened. She said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 12 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's wrists were very purplish blue the family member said they had last seen the resident on 9/8/2023 and other family had seen her on 9/9/2023 and the bruising was not present. Oh, you could tell those were fresh bruises. The family member said Resident #15 had made one prior allegation of abuse, but it was a long time ago. During an interview on 10/09/23 at 2:55 p.m., CNA K said the morning of the incident, staff had started getting residents up out of bed. She said Resident #15's pants were wet, and she had some kind of spit up on her shirt. She said she was able to change the resident's wet pants. She said she tried to pull off the resident's shirt and when she did the resident started screaming and hollering. She said the resident scratched her arms. She said, I had scratches all over. She said the resident already had a visible bruise on her. She said she never grabbed the resident by the wrist. She said she did push her hands down and told her to stop. During an interview on 10/11/23 at 8:53 a.m., Medication Aide M said she administered medications to Resident #15 on the morning of 9/12/23. She said Resident #15 told her the aide came in the room and tried to get her up and she did not want to get up. She said Resident #15 told her that the aide grabbed her by the wrist and crossed her arms. She said she there was dark purple bruising to both wrists. She said the bruises appeared to be new and were not older bruises. She said she could not remember which one, but one of the wrists was worse than the other. During an interview on 10/11/23 at 9:20 a.m., ADON F said she was told Resident #15 went to therapy and told the physical therapist assistant that the aide twisted her wrist. ADON F said she was working on the floor part of that day because the charge nurse had left. The ADON said she did complete a skin assessment on Resident #15. She said some of the bruises to Resident 15's wrists did look old, but some of them did look fresh. She said the resident was calm but did keep saying I can't believe she did that. She said Resident #15 could get mad and fuss at you. When Resident #15 did not want to do something, she could be very adamant about not doing it. She said it was reported the aide did have scratches on her arm, but she did not witness them. She said the aide was removed from the building pretty quick. She said the aide was agency aide. During an interview on 10/11/23 at 9:31 a.m., the DON said Resident #15 went to therapy the morning of 9/12/2023. The DON said Resident #15 had been in therapy with PTA L. The resident report to PTA L that there was an interaction between herself and an aide. She said PTA L took Resident #15 immediately to the Administrator's office. The DON said she had a conversation with Resident #15. She said the resident could not give her the name of the aide. She said the staff discreetly wheeled her through the back unit so she could identify who the aide was. The DON said Resident #15 indicated it was CNA K. The DON said she called CNA K to her office. CNA K told her that Resident #15 had been hitting at her and had scratched her arms. She said the aide was immediately removed from the facility. She said safe surveys were completed on Resident #15's hall. During an interview on 10/11/23 on 9:53 a.m., the Administrator said he was informed on 9/12/2023 that Resident #15 had bruises on her wrist. He said he had the PTA L write a statement. He said he talked to Resident #15 with another staff member present. He said she did have an older bruise from where she had had an intravenous therapy. He said she did have bruising to the other wrist. He said the bruises did not look like handprints but was suspicious. He said the Resident said she did not know what she had said to the aide, but the aide grabbed her by the arms while she was pushing the aide away. He said the Resident could not tell him exactly when the incident happened. He said she was wheeled down the hallway and was able to identify the aide. He said the CNA K said she went in to change the resident because she was wet. She said the resident dug her nails into her hand and she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 13 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pushed Resident #15 away. He said the aide was immediately removed from the schedule. He said he got a statement from other nurses and a head-to-toe assessment was completed. He said the resident was offered counseling services and she denied all services. He said he did not refer the aide because he wanted to wait until the incident was investigated by the state. He said he wanted to see if the state would substantiate the allegations. He said he had assured the resident that the aide would not be back in the facility. Review of a facility Abuse Prevention Program policy dated April 8, 2021 indicated, .The objective of the Abuse policy is to comply with the seven-step approach to abuse, neglect, and exploitation detection and prevention .It is the policy of this facility to prevent abuse by providing residents, families, and staff information and education on how, when, and to whom to report concerns, incidents, and grievances without fear of reprisal . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 14 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including a missing resident are reported immediately or not later than 24 hours for 1 of 15 residents reviewed for abuse and neglect. (Resident #27) The facility failed to report that Resident #27 had been missing within 24 hours of the resident being missing the morning of 10/07/23. This failure could place residents at risk for abuse and neglect. Findings included: Record review of a face sheet dated 10/08/23 revealed Resident #27 was [AGE] years old and was admitted on [DATE] with diagnoses including Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), muscle wasting, and diabetes. Record review of an MDS dated [DATE] indicated Resident #27 was understood and usually understood others. The MDS indicated a BIMS of 00 which indicated severe cognitive impairment. The MDS indicated Resident #27 required limited assistance with ADLs. The resident was not coded for behaviors on the MDS. Record review of a care plan last revised on 10/07/23 indicated Resident #27 had a potential for elopement. There were interventions to assess resident for use of the Wanderguard system, keep reasonable recent photograph of resident at nurses' station, make resident a nametag with resident name and facility address and ensure resident has it on when restless, and redirect if resident attempts to elope. Record review of a progress notes dated 10/06/23 - 10/08/23 did not indicate Resident #27 had been missing. There was a progress note dated 10/07/23 at 8:23 a.m. that indicated, Head to toe assessment complete. No new changes noted. Record review of a social media post made by the local police department on 10/07/23 indicated, We want to thank .along with our patrol officers for all coming out this morning to help locate a elderly female that was missing. She was found just before 8:00 am safe and sound. Record review of an incident report dated 10/10/23 was provided after surveyor intervention on10/10/23. The incident report indicated the event happened 10/07/23. The incident report indicated the description of the incident was missing person. The incident report indicated, received .notification at 6:05 AM t he staff in building had not been able to (Resident #27). On call LVN advised building staff to call police by this time. On call nurse was notified at 0530 am regarding situation. The rest of team leadership was notified at 6:07 AM. Building staff were notified to make a round around the perimeter of the building and another round within. Upon arrival, administrator directed search plan. At approximately 7:45 AM resident was found by CNA in another resident's room asleep. Head to toe assessment completed without findings. Mood and emotional distress assessed without findings. Elopement risk immediately assessed and documented as well. Wanderguard placed to ankle and profile placed in Wanderguard book. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 15 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of an Elopement Risk assessment dated [DATE] indicated an elopement risk score of 10 which indicated the Resident #27 was not at risk for elopement. Record review of an Elopement Risk assessment dated [DATE] at 8:07 a.m. indicated Resident #27 had displayed behavior that might indicate an attempt to leave .indicating an elopement might be forthcoming. The elopement risk score was 60 which indicated Resident #27 was at risk of elopement. Record review of a statement dated 10/07/23 at 8:45 a.m. by the Administrator indicated, I .was notified at 0606 on the morning of Saturday, Oct. 7, 2023, by the DON .that (Resident #27) was unable to be located. I was informed that the on-call nurse had went ahead and called 911. I had DON .ensure that all staff present, begin an indoor search of the facility. I arrived at the building at 0645 and was informed that staff had done one sweep of the building and not located (Resident #27). Police, Fire, EMS services had begun a cordon of the outer perimeter and begun a search for (Resident #27) on the exterior. Once inside and after further review of the initial search, we put together two-person teams to begin going back through rooms and doing a more in-depth search with pulling back covers, and more in-depth searching behind and under beds and furniture. Around 0745, (Resident #27), was found after pulling back the sheets curled up against the wall in the bed of (Resident #2). Both residents were fully dressed, facing opposite directions and both were fine and well. Police and other agencies, (Resident #27's) family, Medical Director, and all interested parties were notified that (Resident #27) was found safe in the building. Record review of a Complaint/Incident card from the local Sheriff's Office indicated the call was received on 10/07/23 at 5:39 a.m. from LVN. The card indicated, Complainant advises she is a nurse at (the facility) and one of their residents has gone missing. The resident is (Resident #27) 08/23/1945 78 YO WF white hair black glasses last seen wearing a yellow shirt and khaki pants. The card indicated the fire department was on the scene at 6:32 a.m. and clear of the scene at 8:13 a.m. The card indicated the resident was located. During an interview on 10/08/23 at 2:30 p.m., the Administrator said Resident #27 was not missing overnight and did not actually elope. He said he received the call on 10/7/23 at 6:06 a.m. that she was missing. He said the resident was found by 8:00 a.m. He said they found her sleeping in the bed of Resident #2. He said the police were about to issue a Silver Alert when the resident was found. During an interview on 10/08/23 at 2:25 p.m., the DON said staff had looked in the facility but did not see her when they did the search. She said Resident #2 woke up and found Resident #27 in his bed and hit the call light. The DON said both residents were fully dressed. He said the police were about to issue a Silver Alert when the resident was found. During an interview on 10/08/23 at 2:48 p.m., Resident #2 said he did wake up Saturday morning and Resident #27 was in his bed. He said he did not know how long she had been there or how she had gotten in his bed. He said when he woke up, staff had already found her in the bed and knew she was there. During an interview on 10/08/23 at 2:56 p.m., CNA O said the aide in the back went to make her rounds and found Resident #27 missing from her room. She said the CNA in the back was CNA P and she had stated to her that she had seen Resident #27 walk into her room earlier. She said she thought the police were called at approximately 5:30 a.m. She said Resident #2 had been on his call light off and on and had asked for a breathing treatment. She said when she walked into the room and turned the call light off she saw Resident #27 sleeping in his bed. She said she asked him why he did not tell (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 16 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few them that she was in his bed, and he told her, Because you didn't ask. He said both residents had on clothes. She said LVN N was the nurse on duty. During an interview on 10/09/23 at 12:30 p.m., LVN N said she was the nurse on duty on the 10:00 p.m. to 6:00 a.m. shift on 10/6/23 - 10/07/23. She said when she came on duty Resident #27 was walking around in the dining room. She said she saw Resident #27 going into her room around 1:00 a.m. - 2:00 a.m. the morning of 10/7/23. She said on their next rounds at approximately 2:50 a.m. - 3:15 a.m. they realized she was missing from her bed. She said staff looked for her but was unable to find her. She said she called the on-call phone. She said the person she spoke to was a staff nurse. She was unable to give her name. She said this nurse advised them to do a full sweep of the facility. She said they did this but were unable to locate the resident. She said she even looked outside the building. She said then the rooms were checked again. She said the on-call nurse advised her to call the police. She said this was around 4:00 a.m. The on-call nurse told her she was calling the DON. She said the resident did not have a wanderguard on because she was not considered an elopement risk. She said the DON was at the facility around 6:00 a.m. and they continued to look for the resident. She said the police came and began a search for the resident. She said she was with the aide when the resident was found in Resident #2's bed. She said staff had been in and out of his room all night. She said he had used the call light several times. She said she had been in his room and did not notice Resident #27 in Resident #2's bed. She said she was with the aide when the resident was found. She said she was fully dressed and was sleeping in the bed. During an interview and observation on 10/10/23 at 10:14 a.m., LVN Q said she was the nurse on call the weekend of 10/6/23. She said she was the first staff member called by the LVN N at 5:23 a.m. LVN Q checked the time on her phone. She said she personally notified the DON at 5:27 a.m. She said LVN N did not give her a time that the resident was first noticed missing. She said at 5:29 a.m. she spoke with LVN N and advised her to do a complete sweep of the building and to call the police. She said at 5:30 a.m. she was on her way to the facility and called the DON and ADON. She said when she got to the facility the DON and ADON were at the facility. She said she was not sure what time the resident was found because the day shift did not come to work, and she was having to take report and work the floor. During an interview on 10/10/23 at 10:38 a.m., CNA P said she was Resident #27's CNA the during the night of 10/06/23 -10/07/23. CNA P said she had last seen the resident roaming on her hall and going into her room at approximately 1:00 a.m. She was not sure of the exact time. She said she was making last rounds at approximately 3:30 a.m. to 4:00 a.m. and found the resident was not in her room. She said herself and the LVN N began checking in other rooms and checked all of the doors. She said she did not know what time the DON or the police were called. She said she was not present at the facility at the time Resident #27 was found. She said she had been told she could go home. During an interview on 10/11/23 at 9:20 a.m., ADON F said learned of Resident #27 missing on Saturday, 10/7/2023, from the DON. She said she was off that weekend. She said she got to the facility at approximately 7:00 a.m. She said she searched the parameter and helped search rooms. She said that Resident #27 was found in Resident #2's bed. She said they were about to start another search when the resident was found. She said the resident was not harmed. She said the resident was sleeping and did not want to get out of the bed. She said she was convinced by staff to go back to her room. During an interview on 10/11/23 at 9:31 a.m., the DON said on Saturday, October 7, 2023, she woke up around 6:00 a.m. She said she checked her phone. She said the On-Call nurse, LVN Q, had been trying to get in touch with her. She said it was reported to her that Resident #27 was missing, and she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 17 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0609 Level of Harm - Minimal harm or potential for actual harm had advised the LVN N to call the police. She said LVN Q was already on her way to the facility. The DON said she came to the facility. She said the police were already set up and searching for the resident. She said she and another staff member began searching for the resident. She said she did consider the resident to have been missing. She said the building had been searched twice. She said she understood that the incident did not have to be reported if the resident had been missing for less than 2 hours. Residents Affected - Few During an interview 10/11/23 9:53 a.m., the Administrator said he was called on 10/7/2023 at 6:06 a.m. He said he was told by the DON that staff could not locate Resident #27 in her room. He said an initial sweep of the interior area and external area of the building had been done. He said LVN Q was the on-call nurse and had already told the charge nurse to call 911. He was not informed the resident was last seen at approximately 1:00 a.m. He said he was going to continue the investigation concerning the resident missing and time frames. He said he did not report the incident to the state because their policy indicated the resident had to be missing over 2 hours, to be reportable. He said not reporting incidents could be a safety concern for Resident #27 and Resident #2. He said she may have needed medical treatment, or she could have been anywhere. Review of an Abuse Prevention Program policy date April 8, 2021, indicated, .It is the policy of the facility to respond to all abuse, neglect, misappropriation of property of residents, and mistreatment of residents immediately. Care and attention will be given utmost priority to the resident involved in the incident. It is also the policy of the facility to report all reportable incidents as identified by State and Federal guidelines . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 18 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 15 residents reviewed for assessments. (Resident #37) Residents Affected - Few The facility failed to ensure to code Resident #37's diagnosis of Depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety (persistent and excessive worry that interferes with daily activities), and colostomy (is an operation that creates an opening for the colon, or large intestine, through the abdomen) on his MDS. This failure could place residents at risk of not having individual needs met. Findings included: Record review of Resident #37's face sheet dated 10/09/23 indicated Resident #37 was a [AGE] year-old male and admitted on [DATE] with diagnoses including depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and insomnia (is a sleep disorder in which you have trouble falling and/or staying asleep). Record review of Resident #37's quarterly MDS assessment dated [DATE] indicated Resident #37 was understood and understood others. The MDS indicated Resident #37 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #37 required supervision for bed mobility, transfer, dressing, eating, and bathing, and limited assistance for toilet use and personal hygiene. The MDS indicated Resident #37 received antianxiety within the 7-days assessment period. The MDS did not indicate a diagnosis of anxiety disorder, depression, or ostomy (colostomy) appliances. Record review of Resident #37's care plan dated 05/30/23 indicated Resident #37 received antianxiety medication Buspar (is an antianxiety agent prescribed for the treatment of anxiety) for treatment of anxiety. Intervention included monitor resident's mood and response to medication. Record review of Resident #37's care plan dated 05/30/23 indicated Resident #37 had a colostomy and is at risk for infection, impaired skin integrity, decreased self-image, altered mood states, weight loss, reaction to product, and decreased socialization. Intervention included monitor skin around stoma (is a surgical connection between an internal organ and the skin on the outside of your body) for bleeding, irritation, etc. Notify MD of any changes of condition. Record review of Resident #37's care plan dated 09/15/23 indicated Resident #37 had diagnosis of depression and at risk for increased depression and side effects to medications, takes Zoloft (is an antidepressant medication that works in the brain). Intervention included provide medications as ordered. Record review of Resident #37's diagnostic assessment dated [DATE] indicated .primary diagnosis of generalized anxiety disorder and other recurrent depressive disorder (also known as depression) .treatment plan will address .adjustment, anger, anxiety, depression . Record review of Resident #37's physician order dated 06/29/23 indicated .colostomy care, once a day every 4 days . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 19 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/11/23 at 11:30 a.m., the MDS coordinator said she had become the coordinator April 2023. The corporate MDS coordinator was present for the interview. The MDS coordinator said she got her information for the MDS assessment from observations and incontinence evaluation for bowel/bladder status. She said she got resident's diagnoses from the face sheet, history and physical, and progress notes. The corporate MDS coordinator said information was also gathered from physician notes 60 days old. She said information and diagnoses was also gathered from hospital records and when doctor visited. The corporate MDS coordinator said Resident #37's bowel continence was coded a 9 which indicated resident had an ostomy or did not have a bowel movement for the entire 7 days. The corporate MDS coordinator said the bowel continence and the ostomy appliance should both be coded. The corporate MDS coordinator said Resident #37's anxiety diagnosis was only mentioned in the diagnostic assessment but not by the facility physician. The MDS coordinator said she did not get the psychiatric evaluation paperwork so did not see the diagnosis. The corporate MDS coordinator said it was not just the MDS coordinator job to add diagnoses. The corporate MDS said any clinical staff can add a new diagnosis. The MDS coordinator said the MDS should be correct to give accurate picture of the resident. She said the MDS was for billing and reimbursement. She said the information on the MDS also went on the care plan. The corporate MDS coordinator said they looked at new admission assessments and progress notes. The corporate MDS coordinator said they did daily audits and the corporate RN reviewed MDSs before submission and signed the form. During an interview on 10/11/23 at 12:11 p.m., the DON said the MDS coordinator was responsible for the accuracy of MDSs. She said Resident #37's depression and anxiety diagnosis and colostomy should be coded on his MDS. She said the MDS showed the care the facility provided. She said the MDS accuracy was important for payer source and provided the state information on the residents. She said the regional consultant oversaw and audited the MDSs to ensure accuracy. During an interview on 10/11/23 at 12:46 p.m., the ADM said the MDS coordinator was responsible for MDSs. He expected the MDSs to be done on schedule. He said he expected MDSs to capture everything, and information entered correctly. He said the MDS was important because it showed different ailments being taken care of properly. He said whatever team member of the IDT inputted the information on the MDS, was responsible for the accuracy and the corporate MDS coordinator. He said inaccurate MDSs could show different areas not being assessed, not receiving correct therapy or evaluation. Record review of an undated facility's MDS assessment Compliance Policy policy indicated .must ensure that its' resident receive care and services based upon an accurate MDS assessment .an accurate assessment also ensures that .Medicare and Medicaid claims are for medically necessary services the comply with Medicare and Medicaid billing requirements .the RN (s) responsible for MDS completion will review and monitor supporting documentation for accuracy prior to each MDS completion . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 20 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 4 residents reviewed for baseline care plans. (Resident #37) The facility failed to address Resident #37's stage IV pressure ulcers, colostomy, and indwelling catheter on his baseline care plan. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #37's face sheet dated 10/09/23 indicated Resident #37 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Pressure ulcer of right buttock, stage 4 (Primary; There is full-thickness skin loss extending through the fascia (is a sheath of stringy connective tissue that surrounds every part of your body) with considerable tissue loss) and pressure ulcer of sacral region (is a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis), stage 4. Record review of Resident #37's quarterly MDS assessment dated [DATE] indicated Resident #37 was understood and understood others. The MDS indicated Resident #37 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #37 required supervision for bed mobility, transfer, dressing, eating, and bathing, and limited assistance for toilet use and personal hygiene. The MDS indicated Resident #37 had an indwelling catheter. The MDS did not indicate an ostomy (colostomy) appliance. The MDS indicated Resident #37 had unhealed pressure ulcers/injuries. Record review of Resident #37's hospital records dated 05/13/23-05/18/23 indicated . [Resident #37] had Stage 4 pressure ulcer of right buttocks .pressure injury of sacral region, stage 4 .chronic indwelling catheter related to non-healing peri wound .patients reports that he got colostomy (to divert feces) .patient has a colostomy but unable to keep colostomy bag in place . Record review of Resident #37's physician order report dated 09/01/23-09/30/23 indicated check patency of Foley catheter every shift with a start date of 05/17/23. Record review of Resident #37's baseline care plan dated 05/22/23 did not address stage 4 sacral and right buttock pressure ulcer, colostomy, or indwelling catheter. During an interview on 10/11/23 at 11:30 a.m., the MDS coordinator said she had become the coordinator April 2023. The corporate MDS coordinator was present for the interview. The MDS coordinator said she was responsible for baseline care plans. The MDS coordinator said the facility had a baseline care template and she created problems also based answers from the residents. The corporate MDS coordinator said other care plan problems had to be added to address other area not on the template. The corporate MDS coordinator said Resident #37's Foley catheter, pressure ulcers, and colostomy should be on the baseline care plan. The MDS coordinator said the template addressed code status, PASRR, GDR, and diet. She said the baseline care plan was for initial and short-term goals. She said care plans were so everyone knew how to care for the resident. She said not having an individualized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 21 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0655 baseline care plan affected the resident quality of care. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/11/23 at 12:11 p.m., the DON said the MDS coordinator was responsible for baseline care plans. She said the baseline care plan should address diagnoses, resident's needs, and conditions. She said she expected Resident #37's pressure ulcer, Foley, and colostomy to be on his baseline care plan. She said the baseline care plan was a resident's direct plan of care, individualized needs, and what needed to be addressed from the physician orders. She said not having an individualized baseline care plan may cause staff not to know how to care for the resident or know if their needs were being addressed. She said corporate does audits of baseline care plan and Resident #37's issues should have been caught. Residents Affected - Few During an interview on 10/11/23 at 12:46 p.m., the ADM said the baseline care should be completed by the IDT team and done in a timely fashion. Record review of a facility's Baseline Plan of Care dated 04/19/21 indicated .a baseline plan of care to meet the resident's immediate needs shall be developed for each resident .to assure that the resident's immediate care needs are met and maintained .the interdisciplinary team will review the .orders (dietary needs, medications, routine treatment) .and implement a baseline care plan .the baseline care plan must include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and the minimum healthcare information necessary to properly care for each resident immediately upon admission, which would address resident-specific health and safety concerns to prevent decline or injury . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 22 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. Residents Affected - Some The facility failed to provide RN coverage for 8 consecutive hours daily on 04/01/2023,04/02/2023,04/09/2023, and 04/10/2023. The deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings include: Record review of a nursing staff information sheets dated 04/01/2023, 04/02/2023, 04/09/2023, and 04/10/2023 indicated that the facility did not have an RN in the facility that worked 8 consecutive hours. During an interview on 10/11/2023 at 10:50 a.m., the DON said the facility had a hard time getting RN coverage prior to her arrival at the end of April of 2023. The DON said not having RN coverage left the facility with no supervisory nurse on those days. During an interview on 10/11/2023 at 11:00 a.m., the Administrator said he was unaware the facility had no RN coverage in April. The Administrator said he was not employed by the facility until August 2023 and no issues with RN coverage had occurred since he began. The Administrator said he was aware having an RN was a requirement. Review of an undated policy titled Nurse Requirements in Nursing Facilities revealed The requirements for long-term care facilities require that nursing facilities provide 24-hour licensed nursing, provide a Registered Nurse (RN) for eight (8) consecutive hours a day, seven (7) days a week, and that there be a RN designated as Director of Nursing on a full-time basis. Record review of Appropriate Nurse Staffing Levels for U.S. Nursing Homes (10/10/2023), www.ncbi.nlm.nih.gov/pmc/srticles/PMC7328494 was assessed on 10/11/2023 indicated US nursing homes are required to have sufficient nursing staff with the appropriate competencies to assure resident safety and attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident .nursing homes must take into account the resident acuity to assure they have adequate staff levels to meet the needs of residents .the impact of registered nurses (RN) is particularly positive .higher RN staff levels are associated with better resident quality in terms of fewer pressure ulcers; lower restraint use; decreased infection; lower pain; improved activities of daily living independence; less weight loss; dehydration .higher nurse staffing levels in nursing homes and reduced emergency room use and rehospitalization . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 23 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to employ or contract a qualified social worker for a facility of 120 beds or less for 1 of 1 facility in that: Residents Affected - Some The facility failed to ensure an employed or contracted social worker visited the facility as needed. This failure could place all residents at risk for not receiving necessary social services. The findings included: Record review of the employee roster dated 10/08/2023 revealed there was no social worker on staff at the facility. Record review of the facility grievance log for the past 6 months revealed no grievances for April 2023, May 2023, June 2023, and July of 2023. During an interview on 10/09/2023 at 11:00 a.m., the Administrator said the responsibilities of the social worker had fallen all the department head staff. He said he was responsible for the grievance process since he started in August because it was not being done properly prior to him taking over. The Administrator said the MDS nurse was responsible for discharge planning, and all department heads made referrals to psychological services, podiatrist, eye doctors, and dentists. During an interview on 10/09/2023 at 12:05 p.m., the DON stated, we don't have a social worker and have not had once since I started at the end of April. During a resident council meeting attended by 8 anonymous residents on 10/09/2023 at 1:00 p.m., two anonymous residents (AR1 and AR2) voiced concerns about not having a social worker and wanting to discharge from the facility. AR1 said they asked about discharging to the community and were told by the charge nurses they had to find a place that would accept them with the amount of social security they received each month but were offered no other help to discharge. AR 2 said they wanted to discharge to an assisted living facility, and she mentioned it each time the facility had a quarterly care plan meeting, and no staff member assisted them with discharge planning. During an interview on 10/11/2023 at 1:46 p.m., the Administrator stated, the facility was running an ad to hire a social worker and had been running it for the last several months. The Administrator said the residents who wanted to file grievances knew to come to him with their grievances now, but discharge planning needed to be assigned to someone that had time to follow up with the residents. He said the resident had a right to discharge from the facility and live in the community if they were able. Record review of a facility policy dated 12/2022 titled Discharge Planning and Notification revealed, Social Services staff, as members of the Interdisciplinary Team, will participate in the development of a discharge plan for patients/residents with a potential for discharge to a private residence, another nursing facility or to another type of residential facility. This policy applies to both voluntary and involuntary transfers/discharges. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 24 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 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, interview, and record review, the facility failed to provide food prepared that conserved nutritive value, flavor, and appearance for 5 of 5 pureed diets, reviewed for nutritive value, in that: Residents Affected - Few Cook A did not follow the recipe for the pureed (is cooked food, usually vegetables, fruits, or legumes, that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid) chicken served on 10/09/23. This failure could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: Record review of the facility's Pureed Roasted Chicken with Broth recipe dated 2023 indicated .Day 9 lunch .4 servings .base, chicken ¾ tsp .water ¾ cup .roasted chicken, deboned 3/4lb . Record review of the facility's nutritive value of Day 9 Lunch indicated .calories 949 .Protein 46 .Carb 95 .Fat 43 . During an observation and interview on 10/09/23 at 11:29 a.m., [NAME] A prepared puree entrée for the lunch meal. [NAME] A removed the meat and skin from the bone of approximately 8 pieces of baked chicken. [NAME] A placed the deboned chicken in the food processor then looked at the recipe book. [NAME] A said she needed ¾ lbs. for 4 servings. [NAME] A took the meat out of the food processor then placed it in two bowels. [NAME] A went across the kitchen and got a scale from on top of a refrigerator. The digital scale was wrapped in clear wrapping. [NAME] A unwrapped the scale, plugged it in, then zero it out with an empty bowel. [NAME] A placed some meat on the scale then started pressing button to get the correct metric system. [NAME] A said she did not know what 3/4lbs was or how to use the scale. [NAME] A called over the DM to help with the scale. The DM said she did not know how to work the digital scale. [NAME] A placed meat on the scale and continued to push button. [NAME] A said I am going to be honest. I do not weigh the meat for purees. [NAME] A then placed an unmeasured amount of meat in the food processor. [NAME] A then put some water in measuring pitcher then chicken soup base. [NAME] A poured the solution into the food processor. [NAME] A looked at the recipe then said, I do not think I put enough water. [NAME] A then poured some more water in the measuring pitcher with some more chicken soup base. [NAME] A turned the food processor on then looked inside and said it was too thin from probably adding too much water. [NAME] A then placed some thicken it powder (agent designed to rapidly thicken liquids and food, for patients with dysphagia or swallowing difficulties) in the mixture. During an interview on 10/11/23 at 10:29 a.m., the DM said it was important to follow recipes for pureeing for correct portion control and nutritional status. She said she ensured the cooks followed recipes by monitoring them and having the recipes readily available to follow. She said the cooks should be measuring and weighing food according to the recipes. She said the cooks needed different scales because it was hard to use the digital scales. She said when recipes were not followed then food lost calories and not the right consistency. She said she printed off a report to let the cooks know how many servings was needed for each meal. She said she monitored the cooks to ensure their competency doing purees. She said she needed to monitor [NAME] A more to ensure she was competent in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 25 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0804 following recipes and purees. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/11/23 at 12:11 p.m., the DON said she expected the dietary staff to follow policy and procedure related to following recipes. She said not following puree recipes cause swallowing safety issues and compromised food nutrition value. She said this placed resident at risk of aspiration and weight loss or gain. She said it was important to follow puree recipes to make sure resident got accurate calories. She said resident could choke, have nutrition deficiency, and weight loss. She said the DM was responsible to make sure the cooks followed puree recipes. She said she had not been checked off or had competency skill checks of preparing purees by the DM or Dietician. She said she learned how to puree from a training course prior to hire. Residents Affected - Few During an interview on 10/11/23 at 12:46 p.m., the ADM said she expected the kitchen staff to follow food handler guidelines. He said not following puree recipes could cause resident to choke with swallowing issues, affected palatability and nutritive value of the food. He said resident could have weight loss, mineral and vitamin deficiency, not get enough fat, protein, and calories which could affect wound healing. He said the DM should ensure cooks followed recipes, every meal was nutritive and palatable for the residents. Record review of an undated facility's Food Preparation and Service policy indicated .food will be prepared and served using methods that are safe and sanitary and that will conserve nutrient value and enhance flavor . Record review of an undated facility's Pureed Food Preparation policy indicated .follow these guidelines regarding pureed food preparation .use pureed recipes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 26 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 - Many 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 in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure plaster on the ceiling in the kitchen was not peeling and loose piece hanging down over prep tables. The facility failed to ensure [NAME] A did not prepare pureed items near a trash can barrel with the lid partially open. These failures could place residents at risk of foodborne illness, food contamination, and ingestion of harmful material. Findings included: During an observation on 10/09/23 at 11:29 a.m., the ceiling in the kitchen had peeling popcorn plaster. The peeling popcorn plaster was cracked, and pieces were hanging over 2 prep tables. [NAME] A prepared pureed entrees for the lunch menu. [NAME] A brought some cooked noodles from the steam table to counter where the food processor was located. Next to the food processor, a trash can barrel with a partially opened lid was near it. [NAME] A stood by the trash barrel and prepared the pureed noodles, green beans, and chicken in the food processor. During an interview on 10/11/23 at 10:29 a.m., the DM said the ceiling in the kitchen did have peeling plaster. She said peeling plaster caused a problem with food and dishes. She said the plaster could fall in food and dishes. She said the plaster falling in food or on dishes could cause foodborne illnesses and ingestion germs which could make resident sick. She said the peeling plaster on the ceiling was cited every year during surveys. She said the facility was being renovated but the kitchen had not been worked on in a while. She said the trash can barrel being near the food processor during purees was not good practice. She said it created a potential danger zone. She said it had the potential to transfer germs and cause sickness. During an interview on 10/11/23 at 12:11 p.m., the DON said she had started at the facility April 2023. She said she did not know about the peeling plaster in the kitchen. She said the peeling plaster was a concern for the safety of the resident's food. During an interview on 10/11/23 at 12:46 p.m. the ADM said he had started at the facility August 2023. He said the peeling plaster on the ceiling was not safe, but it had been addressed. He said the kitchen needed to be updated but there was not enough time to block it off to fix it correctly. He said the peeling ceiling in the kitchen had been happening for a while, but he did not know for how long because he just started. During an interview on 10/11/23 at 1:05 p.m., [NAME] A said it was a good practice to do purees near a trash can barrel. She said because it was nasty. She said it was a potential sanitation hazard. She said she knew about safe sanitation practices from training. Record review of an undated facility's Food Preparation and Service policy indicated .food will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 27 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 prepared and served using methods that are safe and sanitary . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 28 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an antibiotic stewardship program that included a system to monitor antibiotic use, for 3 (Resident #37, Resident #1, and Resident #25) of 7 residents reviewed for antibiotic use. Residents Affected - Some 1.Resident #37 was treated with antibiotics per resident requests with no diagnostic testing. 2.Resident #1 was treated with antibiotics from a contaminated urine sample returned by the lab. 3.Resident #25 was treated with antibiotics for a urinary tract infection. Resident #25 had a urinalysis with no UTI indicated. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: 1.Record review of Resident #37's electronic face sheet dated 10/11/2023 revealed he was a [AGE] year-old-male, admitted to the facility on [DATE] with diagnoses of anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), and COPD (a group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #37's most recent quarterly MDS assessment dated [DATE] indicated a BIMS score of 15, which indicated no cognitive impairment. Resident #37 was understood and understood others. Resident #37 required limited assistance of one staff member for toileting and had a foley catheter. Record review of Resident #37's care plan dated 08/19/2023 revealed Resident #37 was taking an antibiotic for an UTI. The intervention revealed to monitor labs and culture of urinalysis for Resident #37. Record review of a progress note from 08/19/2023 at 8:04 p.m. revealed; RN R wrote, Resident reported left flank pain that has gotten worse over the last 3 days. Resident has foley catheter with heavy sediment that requires irrigation. Resident with history of recurrent UTIs. Afebrile. Alert and oriented x 3. Stated he had done well in the past with Bactrim DS. Notified FNP of findings and new order obtained for Bactrim BS 1 tab by mouth twice daily for 5 days. Resident responsible party notified of new order. Initial dose administered by the nurse. Tolerating without adverse effects. Record review of Resident #37's MAR dated August 2023 revealed Resident #37 received Bactrim DS one tablet twice daily beginning on 08/19/2023 and ending on 08/23/2023. Record review of EHR noted no urinalysis was ordered in August 2023 for Resident #37. 2. Record review of Resident #1's electronic face sheet dated 10/11/2023 revealed that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral aneurysm (an abnormal focal dilation of an artery in the brain that results from a weakening of the inner muscular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 29 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some layer (the intima) of a blood vessel wall), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and heart failure (condition that develops when your heart doesn't pump enough blood for your body's need). Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] indicated a BIMS of 08, which indicated moderate cognitive impairment. Resident #1 was understood and understood others. Resident #1 required dependent assistance of 2 staff members for toileting. Resident #1 was frequently incontinent of bowel and bladder. Record review of Resident #1's care plan dated 08/02/2023 revealed Resident #1 was taking an antibiotic for an UTI. The intervention revealed to monitor labs and culture of urinalysis for Resident #1. Record review of a urinalysis dated 09/27/2023 for Resident #1 indicated the sample was contaminated and suggested it be redrawn. Record review of the MAR for Resident #1 dated October 2023 revealed Keflex 500mg three times a day for 5 days was started on 10/2/2023 and ended 10/07/2023. During a telephone interview with FNP S on 10/10/2023 at 12:20 p.m., FNP S said she recalled the urine sample for Resident #1 being contaminated and she expected the facility nurses to redraw the urine if the sample was contaminated. FNP S stated she always expected a urinalysis with a culture, or she would not order antibiotics. FNP S stated the facility must have gotten the order for Keflex from another provider because she would not have ordered antibiotics for a UTI without a culture and not for a contaminated specimen at all. FNP S stated it was important to prescribe antibiotics appropriate to the bacteria to cut down antibiotic resistant strains of bacteria. 3.Record review of Resident #25's electronic face sheet dated 10/11/2023 revealed that he was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses of UTI (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract), BPH ( type of prostate enlargement ), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of Resident #25's most recent quarterly MDS assessment dated [DATE] indicated a BIMS score of 99, which indicated severe cognitive impairment. Resident #25 was usually understood and sometimes understood others. Resident #25 required extensive assistance of one staff member for toileting. Resident #25 was frequently incontinent of bowel and bladder. Record review of Resident #25's care plan dated 08/02/2023 titled Urinary Incontinence, revealed incontinent care would be provided after each incontinent episode. No care plans were noted related to urinary tract infections. Record review of Resident #25's MAR for July 2023 indicated an order for Amoxicillin 875mg twice daily for 5 days. Resident #25 received Amoxicillin 875mg twice daily beginning 07/06/2023 and ending 07/11/2023. Record review of Resident #25's 72 hours antibiotic timeout form dated 07/06/2023 indicated a urinalysis was completed with no culture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 30 of 31 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 675037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pittsburg 123 Pecan Grove Pittsburg, TX 75686 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 0881 Record review of Resident #25's urinalysis dated 07/06/2023 indicated no culture necessary. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/10/2023 at 2:20 p.m., ADON T said she was the facility Infection Control Preventionist (ICP). The ADON said the facility encourages the physicians and nurse practitioners to use antibiotic stewardship. ADON T said she sends 72-hour antibiotic timeouts to the physicians to ask if they would like to stop the antibiotics they prescribe before cultures are back and some are receptive, but others are not. ADON T said it was important to attempt antibiotic stewardship to avoid super bugs and clear the actual infections the residents had. ADON T said not using appropriate antibiotics could lead to antibiotic resistance, sepsis and even death from infections. Residents Affected - Some During an interview on 10/10/2023 at 3:40pm, the DON said that it was important to ensure the antibiotics on a urine culture and sensitivity report have been tested and if the antibiotic prescribed was not listed on the sensitivity report, clarification needed to be made to the physician not only to notify him of the results but also to ensure that the physician does not want to alter treatment. The DON said that the outcome of not obtaining a culture could delay the infection from improving, have the resident on inappropriate antibiotics and potentially the infection could worsen. In an interview on10/10/2023 at 4:12pm, the Administrator said that each department in the facility has a manager and that the operation and oversight was done through a morning stand up meeting every day with all the department heads and issues that developed from the previous day were discussed as well as any ongoing issues. The Administrator said the ADON T was responsible for the Antibiotic Stewardship Program, which included monitoring residents that were receiving antibiotic therapy and ensuring the cultures were ordered and the physicians were notified of the results. Record review of the facility's policy entitled Antimicrobial Stewardship, dated 2019, revealed the following: .Policy: Treatment with antibiotics is only appropriate when the practitioner determines, on the basis of an assessment, that the most likely cause of the patient's symptoms is a bacterial infection. Antibiotics will be used only for as long as needed to treat infections, minimize the risk of relapse, or control active risk to others. Antibiotics are generally not used to treat colonization and will be avoided when treating viral illnesses such as colds, influenza, and viral gastroenteritis .9. When a culture and sensitivity (C&S) is ordered, it should be performed before the initiation of an antibiotic/anti-infective. Facility staff should perform the following actions: a. Treat results of C&S as a high priority, b. Communicate C&S results to the physician/prescriber as soon as available to determine if current antibiotic/anti-infective therapy should be continued, modified, or discontinued. C. Changes in antibiotic/anti-infective orders should be communicated to the pharmacy as soon as recorded in the resident's medical records. D. Changes to antibiotic/anti-infective orders based on C&S will be reviewed by the facility infection control specialist or a pharmacist . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675037 If continuation sheet Page 31 of 31