Health inspection·March 27, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm there for a couple of weeks but stated that the facility does clean the toilet. Resident #78 was indifferent to the stained toilet when asked about it. Resident #78 was the lone occupant of the room, which had a large area of textured ceiling missing and hanging down over the area of the bed opposite of his closest to the door. Resident #78 stated that the ceiling sustained water damaged approximately six months ago, which was why he did not have a roommate. Residents Affected - Some In a follow up interview on 03/27/2024 at 1:50 PM, Resident #78 stated that the facility has offered for him to switch rooms on more than one occasion, but he declined because he did not want to have to leave his room and move everything. B. Review of Resident #54's Face Sheet dated 03/27/24 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Myocardial infarction (happens when one or more areas of the heart muscle do not get enough oxygen) and Pneumonia (infection that inflames the air sacs in one or both lungs). Review of Resident #54's MDS PPS (Medicare Prospective Payment System) Assessment, dated 02/22/2024 revealed Resident #54 had a BIMS Score of 15 indicating cognition was intact. Observation and interview on 03/27/2024 at 9:52 AM, Resident #54 was in his room lying across his bed and stated that his bathroom could be checked. Resident #54's toilet had a brownish yellow stain with debris in it that ran down the toilet from the bowl to the bottom of the pedestal. Resident #54's toilet was also not properly secured to the floor, which allowed the base of the bowl to move some for side to side. Resident #54 stated that he had not noticed either of the observations made by surveyor while using the bathroom. C. Review of Resident #96's Face Sheet dated 03/27/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Cerebral infarction of unspecified vertebral artery (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, which can result in parts of the brain dying off) and Obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). Review of Resident #96's Optional State MDS Assessment, dated 11/18/2023 revealed Resident #96 had a BIMS Score of 15 indicating cognition is intact. Observation and interview on 03/27/2024 at 10:05 AM, Resident #96 was in his room lying down in his bed. Resident #96's room was painted in a violet color and had two sections of paint missing beside his bed that appeared as large white spots. Resident #96 stated that the paint has been missing for approximately 2 months and would not be that way if he was in his own house. Interview on 03/27/2024 at 12:25 PM, the ADM stated that she did not currently have a maintenance supervisor or full-time maintenance employee for the facility and has not since late November of 2023. The ADM stated that she has a maintenance employee from another facility who comes in on the weekend and fixes what they can. The ADM stated that anything urgent or critical they would immediately contact contract help to have the issue resolved. The ADM was advised that she had maintenance issues in the facility, which she stated she knew and was working to get someone hired to address. Observation and interview on 03/27/2024 at 1:10 PM, the Housekeeping Supervisor stated that all resident rooms and toilets were to be cleaned thoroughly daily. The Housekeeping Supervisor stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 2 of 4 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she tells her staff clean to what you would want your home to look like. The Housekeeping Supervisor stated that failure to properly clean a resident room could make them not feel at easy and could pose a dignity issue. At 1:17 PM, the Housekeeping Supervisor was shown Resident #78's toilet and stated that it was unacceptable and should have been completely cleaned all the way around the toilet down to the base on the floor. At 1:19 PM, the Housekeeping Supervisor was shown Resident #54's toilet and stated that the toilet was not properly cleaned, and that maintenance needed to ensure the toilet was properly secured to the floor. Observation and interview on 03/27/2024 at 1:25 PM, Housekeeper A stated that all resident rooms were to be cleaned daily and that they were to ensure toilets were clean. Housekeeper A stated that they were to make sure that all resident rooms are kept in good condition and homelike. Housekeeper A stated that failure to do so could result in emotional issues for the resident because the facility was their home. Housekeeper A was shown the toilet of Resident #78, which she stated was not cleaned properly and that she would not want a toilet in her house to look like it. Housekeeper A stated that Housekeeper B was responsible for cleaning Resident #78's room and toilet on 03/27/2024. Housekeeper A was shown the toilet of Resident #54, which she stated she was responsible for on 03/27/2024. Housekeeper A stated that she must have missed the stain and looseness of the toilet because she was focused on the inside and top portions of the toilet. Observation and interview on 03/27/2024 at 1:32 PM, Housekeeper B stated that all four corners and the bathroom of resident rooms were to be cleaned daily. Housekeeper B stated that he did not want a resident on a dirty toilet. Housekeeper B was shown the toilet in Resident #78's room, which he stated was cleaned by him. Housekeeper B stated that he failed to observe the stains and properly clean the toilet of Resident #78. Housekeeper B stated that they were to ensure that all resident rooms were homelike. Observation and interview on 03/27/2024 at 1:36 PM, the ADM stated that rooms were to be cleaned daily and that toilets should be cleaned well in order to disinfect them for infection control. The ADM was shown Resident #78's toilet, which she stated was not homelike and could pose a dignity issue for him. The ADM stated that the ceiling in Resident #78's room has been damaged for a while and that they are waiting for repairs to be finished. The ADM stated that Resident #78 has been asked on more than one occasion to switch rooms, but he did not want to move. The ADM was shown Resident #54's toilet and stated that it was not properly cleaned and needed to be secured better. The ADM was shown the missing paint from two locations in Resident #96's room and stated that they are working on remodeling the rooms and pointed out to surveyor that they recently replaced the flooring in the room. The ADM was unable to provide an exact date of when the repair by [remodeling company] of Resident #78's room would take place, but did provide a invoiced for the repairs made to the other locations. Interview on 03/27/2024 at 2:48 PM, the DON stated that failure to properly clean a resident's room / toilet could result in contamination issues and would not be homelike. Record Review of the billing invoice from [remodeling company] reflected that the kitchen and main lobby areas were repaired for water damage on 11/17/2023. Record Review of the facility's Housekeeping Procedures, with a revision date of 03/03/2023 revealed, Bathroom Cleaning .Wet Steps: 5. Sanitize commode, tank, bowl & base. Use a brush for inside of bowl. Additional Information .Proper cleaning technique prevents the spread of infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 3 of 4 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record Review of the facility's undated, Maintenance Polices & Procedures revealed, The Policies related to maintenance and plant operations are: A. This Center shall properly maintain the building, its fixtures, systems, and equipment in good working order to ensure that the entire Center is clean, free of environmental pollutants, and in good repair at all times. Additionally, the Center shall employ a competent, adequate maintenance staff and maintain and update the maintenance manual in order to provide a healthy and safe environment for residents. G. This Center shall maintain a clean, adequate water supply, properly maintain water fixtures and plumbing in good operating condition, and maintain a water heating system to ensure clean, hot water at the correct temperature for both resident and facility use as prescribed by law. Event ID: Facility ID: 675101 If continuation sheet Page 4 of 4