Health inspection·November 14, 2023

F 0580 Disorientation, unspecified-new onset confusion Level of Harm - Minimal harm or potential for actual harm Personality disorder, unspecified Unspecified intellectual disabilities Residents Affected - Few Unspecified psychosis not due to a substance or known physiological condition. An interview with Resident #1 on 11/13/23 at 12:22PM revealed she had approached Resident #2 in the dining room and without provocation, hit her with a closed fist to the top of her right hand which was resting on the table. Resident #1 could not explain why she hit Resident #2. Resident #1 indicated that Resident #2 had pain to her right hand, which nursing staff assessed, while still in the dining room. Resident #1 stated that she had spoken with Resident #2 and the two were working on becoming friends. Record review of Accident and Incident Reports for 8/13/23 through 11/13/23 indicated that the incident had occurred between Resident #1 and Resident #2 on 9/30/23 at 5:33PM. The Event Type was listed as Aggressive/Combative Behavior. The Description for was Aggressive Behavior. The Notifications for Resident #1 was as follows: Physician: No Family Notified: No Resident is own MPOA (Medical Power of Attorney) Resident #2 Record review of Resident #2's admission records revealed an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Other Alzheimer's disease Need for assistance with personal care. Unsteadiness on feet, Other abnormalities of gait and mobility Other lack of coordination Muscle wasting and atrophy, not elsewhere classified, unspecified site. Other symbolic dysfunctions Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety Schizoaffective disorder, bipolar type-clarified (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 11/14/2023 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 0580 Adjustment disorder with anxiety-clarified Level of Harm - Minimal harm or potential for actual harm Muscle wasting and atrophy, not elsewhere classified, multiple sites. Repeated falls Residents Affected - Few Difficulty in walking, not elsewhere classified. Weakness Anxiety disorder, unspecified Repeated falls Adjustment disorder with mixed anxiety and depressed mood Schizoaffective disorder, unspecified At the time of this investigation, Resident #2 was quarantined to her room with active Covid-19 and was too unwell to be interviewed. The Notification for Resident #2 was as follows: Physician: Yes Family: No The Evaluation was: No delayed injuries noted. The Incident and Accident Report also revealed that Resident #2 had also sustained falls on 9/21/23 at 2:30PM, 10/7/23 at 3:51PM and 10/27/23 at 10:17AM, respectively. The Notifications for Resident #2 on 9/21/23 were as follows: Physician: No Family: No The Event Type was: Fall. The Notifications for Resident #2 on 10/7/23 were as follows: Physician: No Family: No The Event Type was: Fall. The Notifications for Resident #2 on 10/27/23 were as follows: (continued on next page) 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 11/14/2023 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 0580 Physician: No Level of Harm - Minimal harm or potential for actual harm Family: No Residents Affected - Few The Event Type was: Skin Tear/Laceration with a Description of skin tear to the right 3rd toe which was 1 centimeter by 1 centimeter. It was treated with normal saline and triple antibiotic ointment, and a bandage was applied to the site. A phone interview with the Resident Representative for Resident #2 on 11/13/23 at 12:28PM revealed she had not been notified of the incident between Resident #1 and Resident #2 on 9/30/23. She also had not been notified that Resident #2 had sustained falls on 9/21/23 and 10/7/23 and 10/27/23. She stated she had no complaints or concerns for Resident #2's care or safety and was surprised that she had not been notified of the incident and falls, because the facility informed her that Resident #2 currently had Covid. An interview with the DON on 11/14/23 at 10:57AM revealed that families were always notified of a fall or incident involving their Resident, as soon as possible. She stated that she did not know why Resident #2's physician and family had not been notified of the falls on 9/21/23, 10/7/23 and 10/27/23, especially since the fall on 10/27/23 resulted in an injury. The DON stated both the physician and the family should have been notified of all three falls, even if they did not result in injury. The DON stated that she did not know why the physician was notified of the incident that took place between Resident #1 and Resident #2 on 9/30/23, but Resident #2's family had not been notified. Record review of the facility's policy for Change in a Resident's Condition or Status, dated 4/20/23 revealed: 1. The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a(an): (a) Accident or incident involving the resident. 2. The nurse/designee will notify the resident's representative when: (a) The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. Record review of the facility's policy for Assessing Falls and Their Causes, dated March 2018 revealed: (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 11/14/2023 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 0580 Steps in Procedure After a Fall: Notify the resident's attending physician and family in an appropriate time frame. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 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 11/14/2023 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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, at the time of admission, have physician orders for the resident's immediate care for 1 of 6 (Resident #3) residents reviewed for admission orders. Residents Affected - Few Resident #3's clinical record did not contain physician orders for care of Resident #3's surgical incision. This failure could place residents at risk of not receiving essential care consistent with the resident's physical and psychosocial well-being upon admission to the facility. Findings included: An interview and observation with Resident #3 on 11/13/23 at 3:14PM revealed that she had been admitted to the facility on [DATE] with a surgical site to the bottom of her left foot, resulting from surgical debridement of a diabetic foot ulcer. She stated the dressing to the bottom of her foot had only been changed once since her admission. The date observed on the dressing was noted as 11/11/23. Resident #3 thought the dressing was to be changed daily. Record Review of Resident #3's admission orders dated 11/2/23 revealed that there were no orders for the care of the surgical site. There was an order for PRN podiatry consult. Record Review of Resident #3's baseline care plan dated 11/2/23 revealed the following: Problem Category: General Goal: The Resident will perform the following tasks at their highest practicable level. Approach: Weekly head to toe skin check Q (every) Friday, Licensed Nurse, 6AM-6PM. Record review of Resident #3's Progress Notes dated 11/8/23, six days after Resident #3 was admitted to the facility, revealed that facility staff had assessed the bottom of Resident #3's feet. An incision was noted to the left lateral sole of the foot from debridement of a diabetic ulcer. There were no signs and symptoms of infection noted. There were sutures x 5. The surgical site was left open to air. A call was placed at 4:44PM, by the DON, to the surgeon's office for treatment orders, but a return call had not been received. No other calls were noted to have been placed to the surgeon's office until it was brought to the attention of the DON by this surveyor on 11/14/23 at 8:40AM. The DON stated she did not know there were no treatment orders in Resident #3's chart. She stated she performed the dressing change to the surgical site on 11/11/23, because it was requested by Resident #3. She placed another call on 11/14/23 for treatment orders and dressing changes to the surgeon's office but did not receive a return call. Record review of the facility's policy for Following Physician Orders, which was not dated, revealed the following: Policy: It is the policy of the facility to follow the orders of the physician. At the time of admission, the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and (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 11/14/2023 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 0635 physical status upon admission. Level of Harm - Minimal harm or potential for actual harm Procedure: The facility must have orders from the physician upon admission for: 1. Residents Affected - Few Dietary 2. Drugs (if necessary) 3. Routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary plan. 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 11/14/2023 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 Based on observation, interview and record review the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 CNAs (CNA B and CNA C) reviewed for infection control. Residents Affected - Some CNA B and CNA C failed to don appropriate PPE when delivering meals to Covid positive residents. This failure could place well residents who took meals in their rooms, at risk of sickness due to the transmission of Covid-19 which could lead to a reduction in resident's quality of life and psychosocial well-being. Findings included: An interview with LVN A on 11/13/23 at 12:02PM revealed the Dietary Manager was at home with Covid-19. She stated there were currently 10 residents who had Covid-19. They were sequestered to their rooms with droplet precaution signs on the doors and bins with full PPE (Personal Protective Equipment) outside of the rooms for nursing staff use. She stated all staff should don full PPE before entering a Covid-positive resident's room. An observation of lunch service to Covid positive residents was conducted on 11/13/23 at 12:42PM and revealed CNA B delivering lunch trays with only an N95 face mask and a face shield used as protection from Covid. An interview with CNA B on 11/13/23 at 1:05PM revealed she had been told both that she had to wear and that she did not have to wear full PPE any time she entered a Covid positive resident's room to deliver food. She stated the DON and ADON had told the CNAs conflicting stories. She stated she wore an N95 face mask and face shield for her own protection but did not wear gloves or a gown as she delivered food. CNA B stated that she did not understand why Covid positive residents were housed on two hallways and felt that they all should have been moved to one hall, so that limited staff had access to Covid positive residents. Observation of CNA C on 11/13/23 at 1:29PM revealed that she delivered a lunch tray to a Covid positive resident's room without performing hand hygiene before entering. CNA C was observed wearing only an N95 face mask. An interview with CNA C at 1:31PM revealed some staff told her they were supposed to gown up and use all the PPE from the bin outside of the resident's room and others had not. She was confused about what she was to do. CNA C stated that she forgot to perform hand hygiene and don PPE before entering the room and just wanted to make sure the sick residents got their lunches on time. Review of facility policy for Transmission-based Precautions revealed that full PPE was to be worn whenever a Covid positive resident's room was entered. All PPE was to be removed before exiting the room and new PPE was to be donned. Doors were to be always closed and Droplet Precautions were to be posted on each door. On 11/13/23 at 1:39PM the DON stated that the procedures for donning and doffing of PPE are posted on each Covid positive resident's door. She stated she had told the CNAs to use ABHR (Alcohol-based (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 11/14/2023 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 Hand Rub) and wear an N95 face mask when delivering food but was unsure if they had to wear full PPE. She did not know that facility policy for Transmission-based Precautions was to don full PPE before entering a Covid positive resident's room if the CNA was only delivering food. The DON stated that she would in-service the CNAs immediately. A phone interview with the Corporate Compliance Nurse at 2:43PM revealed Covid positive residents could be placed on the same hall as negative residents as long as contact precautions were posted on doors, the doors remained closed, and staff wore full PPE when entering rooms. She stated CNAs who were moving from Covid positive to Covid negative rooms while delivering food, needed to don full PPE before entering with a tray and doff everything before leaving a Covid positive room. CNAs were to perform hand hygiene and don new N95 face masks before entering a Covid negative room. The DON stated she was not aware of the policy and didn't know the CNAs had to don full PPE to deliver food or that a new N95 face mask needed to be donned before delivering food to a Covid negative resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675055 If continuation sheet Page 9 of 9