Health inspection·February 18, 2023

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 that was palatable, attractive, and appetizing for residents who consumed foods orally from 1 of 1 lunch meals from 1 of 1 kitchen. Residents Affected - Some The facility failed to provide food that was palatable for 1 of 1 lunch meal observed on 2/16/2023. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. Findings include: During an interview on 02/15/2023 at 11:20 AM Resident # 15 stated the food was bad. During an interview on 02/15/2023 at 11:25 AM Resident # 42 stated the food was bad. During an interview on 02/15/2023 at 02:48 PM Resident # 35 stated the food here is awful. Resident stated even the alternative food is bad most of the time. During an interview on 02/15/2023 at 03:00 PM Resident # 22 stated the food was so, so. During confidential interviews on 02/16/2023 at 10:05 AM, four residents, stated food sometimes is good at other times is not good. Observation of the test tray on 02/16/2023 at 12:40 PM revealed the food tray consisted of a bowl of beans with sausage, side of corn bread, side of steamed white rice, and side of tomatoes with zucchini. The food was not attractive and did not have an appearance, and taste was not palatable. The bowl of beans with sausage tasted bland. Visually was not attractive as the bowl of beans was mixed with circular pieces of sausage which did not project a palatable food to eat. The beans and sausage gave the impression of being over cooked as the beans were dark in color and the sausage seemed dry. The corn bread was dry and lacked taste. The steamed white rice could be chewed but there was no flavor. The tomatoes with zucchini were also bland On 02/18/2023 at 02:30 PM Interview with the ADM, ADON, and MDS the issues found with the food were explained. Record review of the USDA Food code, dated 2017, revealed: Ready-to-Eat Food. (1) Ready-to-eat food means FOOD that: (a) Is in a form that is edible without additional preparation to achieve FOOD safety, as specified under one of the following: 3-401.11(A) or (B), § 3-401.12, or § 3-402.11, or as specified in 3-401.11(C); or (b) Is a raw or partially cooked animal FOOD and the consumer is advised as specified in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675055 If continuation sheet Page 2 of 9 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 675055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Childress 1200 7th St NW Childress, TX 79201 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 Subparagraphs 3-401.11(D)(1) and Level of Harm - Minimal harm or potential for actual harm (3); or (c) Is prepared in accordance with a variance that is granted as specified in Subparagraph 3-401.11(D) Residents Affected - Some (4); and (d) May receive additional preparation for palatability or aesthetic, epicurean, gastronomic, or culinary purposes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675055 If continuation sheet Page 3 of 9 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 675055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Childress 1200 7th St NW Childress, TX 79201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards of food safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to make sure expired foods were disposed and open food items labeled. This deficient practice could place residents at risk of causing food-born illness, weight loss, and a diminished meal experience. Findings include: In an observation on 02/15/2023 at 10:05 AM on initial kitchen rounds revealed the following: 1. The Walk-in cooler had a plastic container, which contained sweet potatoes with an open date of 2/8/2023 use by date of 2/11/2023. 2. The Walk-in cooler had a plastic container, which contained spiced apples with prep date of 12/2/2022 and use by date of 12/10/2022. 3. The dry storage area had a plastic bag which contained four open bags of bread with no open date or use by date listed on any of the bags of bread. Each of the bags of bread contained approximately four to five pieces of bread. On 02/16/2023 at 08:25 AM, a follow-up kitchen observation revealed the following: 1. The Walk-in cooler had A plastic bag which contained several biscuits with a due date of 02/15/2023. There was no open date listed or documented on the bag. 2. The pantry area had the same plastic bag found which contained four open bags of breads with no use by date. On 02/15/2023 in an interview and walk through with [NAME] A, and AD (providing assistance in kitchen operations), stated the walk-in cooler contained the expired sweet potatoes, expired spiced apples. [NAME] A, and AD stated the pantry area contained an un-labeled plastic bag with four bags of bread inside of a plastic bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675055 If continuation sheet Page 4 of 9 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 675055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Childress 1200 7th St NW Childress, TX 79201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 02/16/2023 at 09:00 AM [NAME] A stated the cooks and kitchen staff were responsible for throwing away all the expired food. [NAME] A stated if expired food was not thrown away, it could be given to residents and people could get sick. [NAME] A stated if food was cooked/prepared without proper handwashing and wearing gloves, then this could be cross contamination. On 02/16/20213 at 11:01 AM, [NAME] B stated all kitchen staff were responsible for throwing away expired food. The negative consequence of not throwing away expired food was it could be given to residents and could make them sick. [NAME] B stated if food was being cooked without handwashing or the use of gloves it could be considered cross contamination and could make a person sick. On 02/17/2023 at 07:27 AM, the DM stated all kitchen staff were responsible for making sure the expired food were thrown away. The DM stated if expired food were not thrown away then there was a potential residents could be served the expired foods and may get sick. The DM responded he spoke to kitchen staff about throwing away expired food. On 02/17/2023 at 07:41 AM, the ADM stated the DM was responsible for making sure expired food was thrown away. The ADM stated if expired food was not thrown away it had the potential of giving it to the residents and could make them sick. Record review of the facility's Food Storage Policy, dated 2018, revealed the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to state, federal, and US Food Codes and HACCP guidelines. Procedure 1. Dry Storage rooms. # d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. # f. Where possible, leave items in the original cartons placed with the date visible. Procedure 2. Refrigerators. # d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. # e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675055 If continuation sheet Page 5 of 9 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 675055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Childress 1200 7th St NW Childress, TX 79201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four out of twelve staff members (ADON, LVN A, CNA B and OTA) reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure LVN A doffed gloves and performed hand hygiene appropriately during wound care. 2. The facility failed to ensure OTA, ADON and CNA B performed hand hygiene appropriately during lunch with residents requiring feeding assistance. These failures could place residents at risk for transmissible diseases or slow wound healing due to cross contamination. Findings include: 1. During dining observation on 02/15/23 at 12:30 PM, OTA (Occupational Therapy Assistant) was observed walking around the dining room when Resident #41 dropped his fork. OTA retrieved a new fork for Resident #41, touching him on his shoulder while speaking with him. OTA then turned to another table and began rubbing Resident #43 back and shoulders. OTA then took Resident #43's fork and began feeding him. No ABHR or hand washing was observed between these direct contacts. OTA stopped feeding Resident #43 and turned around to Resident #16, where she bent down and began rubbing Resident #16 feet. OTA did not wash her hands or utilize ABHR after touching resident's feet and then she picked up Resident #16 fork and began feeding him. OTA stopped feeding Resident #16 turned to Resident #43 and began feeding him without utilizing ABHR or washing hands between residents. OTA stopped feeding Resident #43 turned back to Resident #16 and began rubbing his hands and then picked up Resident #16 fork and began feeding him. Observation on 02/15/23 at 12:30 PM revealed the ADON did not wash her hands or utilize ABHR prior to picking up Resident #18 fork and began feeding her. The ADON put the fork down and Resident #18 picked up her own fork and began feeding herself. The ADON did not utilize ABHR or wash her hands before turning to Resident #43 and begin feeding him. Observation on 02/15/23 at 12:30 PM revealed CNA B did not wash her hands or utilize ABHR prior to picking up Resident #18 fork and began feeding her. CNA B handed the fork to Resident #18 to feed herself. CNA B did not wash her hands or utilize ABHR before picking up Resident #19 fork and begin feeding her. During an interview on 12/15/23 at 4:06 PM with OTA was asked when she should wash her hands OTA stated she was supposed to wash her hands after touching every resident and when her hands were soiled. When asked when you are supposed to wash your hands during lunch, OTA stated she should be washing her hands between each resident after touching one resident then another at lunch. OTA stated a negative outcome of touching a resident's feet then touching their food could put bacteria in their food. During an interview on 12/15/23 at 4:20 PM with CNA B, she stated she was supposed to wash her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675055 If continuation sheet Page 6 of 9 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 675055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Childress 1200 7th St NW Childress, TX 79201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hands before, during and after entering a resident's room and doing anything with a resident. CNA B stated she should use ABHR between residents during mealtime. CNA B stated a negative outcome of feeding one resident then going to another without washing hands, was the residents could get sick, and they could catch a virus. 2. Record review of Resident #16 face sheet, dated 2/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and a readmission on [DATE]. Resident #16 had diagnoses which included pressure ulcer of sacral region stage 4 (deep wound reaching the muscles, ligaments or bones), quadriplegia (affected by or relating to paralysis of all four limbs), metabolic encephalopathy (chemical imbalance in the brain), muscle wasting and atrophy (thinning of muscle mass), dysphagia (difficulty swallowing), cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs). Record review of Resident #16's, quarterly MDS, dated [DATE], revealed a BIMS score of 13 out of 15, which indicated his cognition was moderately impaired. He was total dependence and required 2 persons assist for bed mobility and transfers with Hoyer lift. He utilized a power wheelchair. He required one person assist for locomotion, dressing, eating, toileting, personal hygiene and bathing. Record review of Resident #16's care plan, dated 12/19/22, revealed: Problem: Resident has a pressure ulcer to coccyx .Approach: Assess and document skin and wounds weekly including wound measures. Treatment of wound with collagen and hydrogel and calcium alginate. Cover with foam dressing. Turn resident every two hours as tolerated by resident . Problem: Resident has a pressure ulcer to right ischium .Approach: Assess and document skin and wounds weekly including wound measurements. Treatment of wound with calcium alginate and collagen flakes and hydrogel. Cover with foam dressing. Turn resident every two hours as tolerated by resident . Record review of Resident #16's physician's orders revealed, in part: Wound to coccyx: Cleanse with wound cleanser, pat dry, apply collagen and calcium alginate rope with silver, cover with silicone foam dressing once a day dated 01/18/23. Cleanse areas to right ischium with wound cleanser, pat dry, apply collagen and calcium alginate rope with silver, then silicone foam dressing once a day .dated 01/18/23 Weekly wound measurements to be done on Wednesday. This will ensure wound are updated weekly outside of United Wound Healing measurements .dated 02/07/23 During an observation on 12/15/23 at 09:05 PM, LVN A provided wound care for Resident #16 with assistance from CNA C. Resident #16 was lying in his bed. Resident #16 has a Stage IV to right ischium and right coccyx (right buttock). LVN A and CNA C washed their hands and donned gloves. LVN A removed the foam dressings disposing them in trash bag taped to bedside table. LVN A removed gloves and donned new gloves without utilizing ABHR or handwashing. LVN A cleansed wounds with wound cleanser. LVN A removed gloves and donned new gloves without utilizing ABHR or handwashing. LVN A measured wounds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675055 If continuation sheet Page 7 of 9 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 675055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Childress 1200 7th St NW Childress, TX 79201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with paper tape measures disposing them in trash bag taped to the bedside table. LVN A removed gloves and donned new gloves without utilizing ABHR or handwashing. LVN A applied collagen, then calcium alginate with silver to wound. LVN A removed gloves and donned new gloves without utilizing ABHR or handwashing. LVN A placed foam dressings to wounds. CNA C repositioned Resident #16 removed gloves and washed hands. LVN A removed gloves, removed trash bag off bedside table and secured it, and then washed hands. During an interview on 12/15/23 at 9:22 PM with LVN A, she stated hand hygiene should be done after every second glove change. LVN A stated she was to wash her hands when she went from dirty to clean. LVN A stated she receives quarterly in-service training on hand hygiene or monthly. LVN A stated a negative outcome for doing wound care without hand hygiene between removing soiled dressing to applying clean would be transferring soiled to clean. During an interview on 12/16/23 at 9:12 AM with the ADON, she stated all direct care staff should be washing their hands prior to entering resident's room, when providing care, and exiting resident's room. During mealtimes, ADON stated hand hygiene needed to be performed in between every tray, and prior to entering the dining room. The ADON stated a negative outcome for feeding two residents at the same time could be transferring infections to other residents. The ADON stated she was new, and she was going to be doing education with everyone on infection control and hand hygiene. Record review of the facility provided policy titled, Handwashing/Hand Hygiene, dated 01/20/23, revealed, in part: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .1 All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. .4. Use an alcohol-based hand rub containing at least 60% to 95% ethanol alcohol or isopropyl alcohol. .5 Hand hygiene must be performed prior to donning and after doffing gloves. Record review of the facility provided policy titled, Wound Care, dated June 2022, revealed, in part: Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. .Steps in the Procedure .2. Perform hand hygiene (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675055 If continuation sheet Page 8 of 9 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 675055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Childress 1200 7th St NW Childress, TX 79201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 .5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene. Level of Harm - Minimal harm or potential for actual harm .6. Put on clean gloves .7. Use no-touch technique. Residents Affected - Some .13. Discard disposable items into the designated container .Perform hand hygiene. There was no mention in policy regarding paper rulers or measuring the wound or procedures to take if an object touched the wound after it was cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675055 If continuation sheet Page 9 of 9