Health inspection·March 26, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm administrator also made aware no other injury noted will continue to monitor patient closely and staff as to how to handle brittle patient. A record review of the TULIP website accessed 03/22/2023, revealed no report for Resident #13's injury of unknown origin. Residents Affected - Few During an interview on 03/22/2023 at 01:22 PM LVN A stated she was alerted by CNA E to a bruise on Resident #13. LVN A stated she assessed Resident #13 with a large bruise from Resident #13's chest to around her back. LVN A stated she immediately reported the injury to the ADON. LVN A stated she reported to the ADON that Resident #13 could not state how she developed the bruise and no one had reported witnessing an event to produce the injury. During an interview on 03/22/2022 at 02:15 PM CNA E stated she discovered a large bruise on Resident #13 on Monday 03/20/2023 when she was providing incontinent care for Resident #13. CNA E stated Resident #13 was not able to state how she came to have the bruise. CNA E stated she reported the bruise to the charge nurse LVN A. During an interview on 03/24/2023 at 02:14 PM the ADON stated she was alerted to a bruise on Resident #13 by LVN A and CNA E. The ADON stated she initiated an accident incident report and reported the injury to the Administrator. The ADON sated the injury was unwitnessed and the source was unknown, but the ADON believed she could speculate how the injury came to be. The ADON stated she believed the injury came from a caregiver not properly utilizing the Hoyer lift and thus bruised Resident #13. The ADON stated she did not report the injury to the state and/or the Administrator as an injury of unknown origin. During an interview on 03/24/2023 at 04:45 PM the Administrator stated he received a report of Resident #13's bruise on 03/20/2023 and the source of the bruise was due to a caregiver, possibly a can, not properly utilizing the Hoyer lift. The Administrator stated he believed the ADON had direct knowledge of the source of the bruise and not speculation. The Administrator stated it was the facility's policy to report all injuries of unknown origin. The Administrator stated he had not reported the injury of unknown origin for Resident #13 to the state agency . A record review of the facility's policy Reporting Abuse to Facility Management, dated February 2014, revealed, it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etcetera, to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source . policy interpretation and implementation . to help with recognition of incidents of abuse, the following definitions of abuse are provided: injury of unknown source is defined as an injury that meets both of the following conditions: the source of the injury was not observed by any person or the source of the injury could not be explained by the Resident: and the injury is suspicious because of the extent of the injury; or the location of the injury, for example the injury is located in an area not generally vulnerable to trauma; or the number of injuries observed at one particular point in time; or the incidence of injuries overtime. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 2 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 observations, interviews, and record reviews, the facility failed to ensure the Resident's assessment accurately reflected the resident's status, for 1 of 24 residents (Resident #2) reviewed for lack of assessment for dentures, in that: Residents Affected - Few 1. Resident #2 was admitted and assessed without documenting her need for dentures after a hospitalization where Resident #2 was treated for having swallowed her dentures. This failure could have placed residents at risk for harm by unidentified dentures and lack of care and support for the dentures. The findings included: A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 11/22/2022 and 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care. A record review of Resident #2's hospital discharge records, dated 02/26/2023, revealed history of present illness; chief complaint; altered mental status, low oxygen level, and foreign body (dentures) in esophagus . this is a [AGE] year-old white female brought by emergency medical services 2[name of hospital] emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. the patient is unable to provide any history due to cognitive impairment at baseline . the patient was sent 2 . emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. the patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. her second episode was more severe and associated with significant coughing and choking. care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation . the patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, and elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia . X-ray of the soft tissues of the neck performed at the emergency room showed a U-shaped foreign body noted within the cervical esophagus [back of the throat] consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for, but the patient's lower dentures were not. because of these findings, the patient . has been transferred to a higher-level of care for further medical management and evaluation, including an ear nose and throat specialist consultation findings of foreign body and cervical esophagus . foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx [back of the throat] and extending into the cervical esophagus . A record review of Resident #2's re-entry and quarterly MDS's, dated 02/27/2023 revealed the Regional MDS LVN documented in section A0310 type of assessment 99 which indicated none of the above. Further review of section A0310 revealed the choices were 01. Admission, 02. Quarterly, 03. Annual, 04. Significant Change in Status, 05. Significant Correction to prior comprehensive assessment, 06. Significant correction to prior quarterly assessment, and 99. None of the above. Further review revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 3 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 the MDS assessment was not signed by a RN. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #2's quarterly MDS's, dated 03/01/2022, revealed the Regional DON assessed Resident #2 as returned from an acute care hospital on [DATE]. The MDS assessment revealed Resident #2 was severely impaired for cognition and was assessed as needing limited assistance and supervision during meals. Resident #2 was diagnosed with pneumonia, loss of liquids/solids from mouth when eating or drinking and required a change in textures of food and liquids. Review of the MDS Section L revealed no documentation for the assessment broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose). Residents Affected - Few A record review of Resident #2's physical paper chart revealed a Care Plan worksheet, dated 01/11/2023, which reflected the attendees as the AD and the DOR. The document revealed there was a concern made by Resident #2's representative for Resident #2's bottom dentures. Further review revealed no documents to reveal any subsequent care plan meetings. A record review of Resident #2's Care Plan, dated, 01/13/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. Further review of Resident #2's medical records evidenced no further care plans other than the 01/13/2023 care plan. During an interview on 03/23/2023 at 01:55 PM, the Regional MDS LVN stated she was the MDS coordinator for the facility intermittingly. The Regional MDS LVN stated she had been helping periodically per the facility's needs with resident assessments and would be alerted by the facility of the need for an MDS assessment. The Regional MDS LVN stated she had completed the MDS assessment for Resident #2 on 02/27/2023 and documented the assessment section as 99 and did not document the assessment as a change of status . The Regional MDS LVN stated she was not aware of Resident #2's change of status and her hospitalization for swallowing her dentures with a diagnosis of sepsis pneumonia. The Regional MDS LVN stated she was not assigned to follow the MDS with care plans and the duty was assigned to someone at the facility by the Administrator possibly ADON S [ADON S from another facility] who helped at the facility or the Regional DON. During an interview on 03/24/2023 at 04:50 PM, the Regional DON stated a care plan was prepared by the IDT per the MDS assessment within 14 days of the completed MDS assessment. The Regional DON stated she had completed the quarterly MDS for Resident #2 on 03/01/2023 and did not document an assessment for Resident #2's oral/dental status under Section L, broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose) mouth or facial pain, discomfort or difficulty with chewing. The Regional DON stated she did not know if Resident #2's dentures were or were not loose fitting and after her discharge from the hospital there were no reports of Resident #2 having swallowing issues. The Regional DON stated she was responsible for 5 other facility's and was on call for all 5. The Regional DON stated she was not in the facility for 40 hrs. a week. The Regional DON stated she had not coordinated a care plan for Resident #2's change of status for her needs with dentures and assistance supervision during meals within 14 days of the 02/27/2023 re-admission from the hospital or within 14 days of the 03/01/2023 quarterly MDS assessment . The Regional DON stated there should have been care instructions in Resident #2's care plan to reflect Resident #2's needs for support with her dentures and assistance with meals to include diet textures and swallow studies as assessed by the SLP who was an IDT member. During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, the Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 4 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 with the facility's nursing services while the search for a replacement DON ensued. The administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The administrator stated the facility policy is to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which do not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed. A record review of the facility's policy admission Assessment and Follow Up: Role of the Nurse, dated December 2012, revealed, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the Resident, initiating the care plan, and completing required assessment instruments, including the MDS . steps in the procedure . conduct a physical assessment, including the following systems: eyes, ears, nose, throat; teeth and gums . contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtained admission orders that are based on these findings . notify the supervisor and the attending physician of immediate needs that the resident may have . report other information in accordance with facility policy and professional standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 5 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 8 residents (Resident #2, #32, #28, and #7) reviewed for care plans in that: Residents #32 and #7 did not have a comprehensive person-centered care plan in their resident file. Residents #2 and #28 did not have a comprehensive care plan that met a resident's medical needs. These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs. The findings were: Record review of Resident #32's face sheet dated 3/23/23, revealed an [AGE] year-old female admitted on [DATE] with diagnosis that include malignant neoplasm of brain (a fast-growing tumor in the brain), gastro-esophageal reflux disease (a condition where acidic gastric fluid flows backward into the esophagus), and depression. Record review of Resident #32's most recent MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #32's EHR reflected no evidence of a comprehensive person-centered care plan. Record review of Reside #7's face sheet dated 3/23/23, revealed a [AGE] year-old female admitted on [DATE] with diagnosis that include Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves), Stage 3 pressure ulcer (an injury to skin resulting from prolonged pressure), and Dysphasia (impairment in speech due to brain disease or damage). Record review of Resident #7's most recent MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 6 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0656 Record review of Resident #7's EHR reflected no evidence of a comprehensive person-centered care plan. Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Some Record review of Resident #28's face sheet dated 3/23/23, revealed an [AGE] year-old male admitted on [DATE] with diagnosis that include Gout (a form of arthritis), Oropharyngeal dysphagia (swallowing problems occurring in the mouth/throat), Aphasia (language disorder that affects the ability to communicate) and open wounds to forearm and left ankle. Record review of Resident #28's most recent MDS dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #28's care notes from the dietician dated 9/19/22 indicate that the resident had lost 8.1% of their total body weight in 1 month. Stated there were current orders for protein shakes. Record review or Resident #28's care notes from the dietician dated 315/23 indicate that the resident had lost 7.8% of their total body weight in 1 month. The care note also states that the resident should be on a fortified meal plan. Record review of Resident #28's comprehensive person-centered care plan revealed there were no interventions present for the resident's weight loss as recommended by the dietician. Record review of facility policy on care planning revealed that comprehensive care plans for each resident must be developed within seven days of completion of the MDS. Record review of facility policy on care planning revealed that a change in condition that will not resolve itself without intervention is required to be reviewed by an interdisciplinary team and revised on the care plan. In an interview on 3/24/23 at 10:55 AM, ADON stated she is teaching herself the facilities EHR system and has recently taught herself how to do Care Plans in the system. The ADON stated that she was not aware Resident #32 and Resident #7 did not have record of a care plan in the EHR. The ADON also stated that she was not aware that Resident #28's care plan did not accurately reflect his medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 7 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0656 needs. Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Some In an interview on 3/24/23 at 1:06 PM, Administrator stated he was not aware care plans were not being completed adequately. Administrator stated there were care plan meetings but that there were not RNs at these meetings. The administrator stated he does not know why Residents #32, #7, and #28 do not have accurate care plans. Resident #2 A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care. A record review of Resident #2's hospital discharge records, dated 02/26/2023, revealed history of present illness; chief complaint; altered mental status, low oxygen level, and foreign body(dentures) in esophagus . this is a [AGE] year-old white female brought by emergency medical services 2[name of hospital] emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. the patient is unable to provide any history due to cognitive impairment at baseline . the patient was sent 2 . emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. the patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. her second episode was more severe and associated with significant coughing and choking. care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation . the patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, and elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia . X-ray of the soft tissues of the neck performed at the emergency room showed a U-shaped foreign body noted within the cervical esophagus consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for but the patient's lower dentures were not. because of these findings, the patient . has been transferred to a higher-level of care for further medical management and evaluation, including an ear nose and throat specialist consultation findings of foreign body and cervical esophagus . foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx and extending into the cervical esophagus A record review of Resident #2's re-entry and quarterly MDS's, dated 02/27/2023 revealed the Regional MDS LVN documented in section A0310 type of assessment 99 which indicated none of the above. Further review of section A0310 revealed the choices were 01. Admission, 02. Quarterly, 03. Annual, 04. Significant Change in Status, 05. Significant Correction to prior comprehensive assessment, 06. Significant correction to prior quarterly assessment, and 99. None of the above. Further review revealed the MDS assessment was not signed by a RN. A record review of Resident #2's quarterly MDS's, dated 03/01/2022, revealed the Regional DON assessed Resident #2 as returned from an acute care hospital on [DATE]. The MDS assessment revealed Resident #2 was severely impaired for cognition and was assessed as needing limited assistance and supervision during meals. Resident #2 was diagnosed with pneumonia, loss of liquids/solids from mouth when eating or drinking and required a change in textures of food and liquids. Review of the MDS Section (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 8 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some L revealed no documentation for the assessment broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose). A record review of Resident #2's physical paper chart revealed a Care Plan worksheet, dated 01/11/2023, which documented the attendees as the Activities Director [AD] and the Director of Rehabilitation [DOR]. The document revealed there was a concern made by Resident #2's representative for Resident #2's bottom dentures. Further review revealed no documents to reveal any subsequent care plan meetings. A record review of Resident #2's Care Plan, dated, 01/13/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. Review of Resident #2's care plan revealed 1 care instruction, Resident [#2] is at risk for falls due to amputation and weakness . Resident [#2] will be free of falls through next review . encourage call light usage . increased staff supervision with intensity based on Resident [#2] need. Further review of Resident #2's medical records evidenced no further care plans other than the 01/13/2023 care plan. During an interview on 03/22/2023 at 02:15 PM CNA D and CNA E, who were the CNAs for Resident #2 revealed the CNAs stated they were not aware Resident #2 had top and bottom dentures and believed she only had top dentures. The CNAs stated they had no care instructions for Resident #2 in their version of the care plan, the [NAME] . The CNA's stated they had no training or care instructions for Resident #2's denture care. During an interview on 03/23/2023 at 01:55 PM, the Regional MDS LVN stated she was the MDS coordinator for the facility intermittingly. The Regional MDS LVN stated she had been helping periodically per the facility's needs with Resident assessments and would be alerted by the facility for the need for an MDS assessment. The Regional MDS LVN stated she had completed the MDS assessment for Resident #2 on 02/27/2023 and documented the assessment section as 99 and did not document the assessment as a change of status. The Regional MDS LVN stated she was not aware of Resident #2's change of status and her hospitalization for swallowing her dentures with a diagnosis of sepsis pneumonia. The Regional MDS LVN stated she was not assigned to follow the MDS with care plans and the duty was assigned to someone at the facility by the Administrator possibly ADON S [ADON S from another facility] who helped at the facility or the Regional DON. During an interview on 03/24/2023 at 04:50 PM, the Regional DON stated a care plan is prepared by the Interdisciplinary Team [IDT] per the MDS assessment within 7 days of the completed MDS assessment. The Regional DON stated she had completed the quarterly MDS for Resident #2 on 03/01/2023 and did not document an assessment for Resident #2's oral / dental status under section L, broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose) mouth or facial pain, discomfort or difficulty with chewing. The Regional DON stated she did not know if Resident #2's dentures were or were not loose fitting and after her discharge from the hospital there were no reports of Resident #2 having swallowing issues. The Regional DON stated she was responsible for 5 other facility's and was on call for all 5. The Regional DON stated she was not in the facility for 40 hrs. a week. The Regional DON stated she had not coordinated a care plan for Resident #2's change of status for her needs with dentures and assistance supervision during meals within 7 days of the 02/27/2023 re-admission from the hospital or within 7 days of the 03/01/2023 quarterly MDS assessment . The Regional DON stated there should have been care instructions in Resident #2's care plan to reflect Resident #2's needs for support with her dentures and assistance with meals to include diet textures and swallow studies as assessed by the Speech Language pathologist [SLP] who was an IDT member. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 9 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, the Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The administrator stated the facility policy is to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which do not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed. A record review of the facility's policy Care Planning - Interdisciplinary Team, dated February 2014, revealed, policy statement: our facilities care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each Resident. a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment MDS. the care plan is based on the residence comprehensive assessment and is developed by a care planning interdisciplinary team which includes but is not necessarily limited to the following personnel: the residents attending physician; the registered nurse who has responsibility for the Resident; the activities director coordinator; therapist speech; occupational; recreational; etcetera as applicable; consultants; the director of nursing; the charge nurse responsible for the Resident; nursing assistants responsible for residents care; others as appropriate. the Resident, the residents family and or the residents legal representative guardian are encouraged to participate in the development of and revisions to the residents care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 10 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 9 residents (Resident #2) reviewed for reviewed for neglect for denture care and supervision at meals, in that: Residents Affected - Few The facility failed to identify care or support for Resident #2's dentures. During 3 meals, on 02/20/2023 and 02/21/2023, Resident #2 choked on food and aspirated food. Resident #2 swallowed her lower dentures which became lodged in the back of her throat during the 2nd meal and was served the third meal in this condition. [Choking occurs when the airway is blocked by food, drink, or foreign objects. Aspiration occurs when food, drink, or foreign objects are breathed into the lungs (going down the wrong tube).] An IJ was identified on 03/24/2023. The IJ template was provided to the facility on [DATE] at 05:15 PM. While the IJ was removed on 03/25/2023, the facility remained out of compliance at a scope of IJ and a severity level of J because of the facility's need to evaluate the effectiveness of the corrective systems. This failure placed Residents at risk for death by a blocked airway and secondary pulmonary infection by aspirated food/vomit. The findings included: A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 11/22/2022 and 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care. A record review of Resident #2's admission notes, 11/22/2022 to 02/20/2023, failed to reveal any assessments for dentures or oral dentition. A record review of Resident #2's admission MDS, dated [DATE], revealed the Regional MDS LVN prepared the assessment and failed to assess Resident #2 was admitted with and used dentures. Further review revealed Regional DON I signed the MDS. A record review of Resident #2's Care Plan, dated, 03/22/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. A record review of Resident #2's nursing progress notes revealed LVN H documented on 02/20/2023 at 06:30 PM, Approximately 1730 [05:30 PM] resident was eating dinner in the dining room when she aspirated [inhaled food and/or vomit into lungs] while eating her meal. Writer and staff acted quickly and was able to assist Resident to clear what was caught in her throat. Writer contacted the physician and was told to monitor resident for fever and shortness of breath. Resident [family member] was contacted and let known of the situation. Resident vitals are stable and Resident has been placed back in her bed in high fowlers position to prevent any further aspiration. will continue to monitor. A record review of Resident #2's nursing progress notes revealed LVN A documented on 02/21/2023 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 11 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0684 Level of Harm - Immediate jeopardy to resident health or safety 01:53 PM, To dining room for meals for supervision. Pureed diet served today due to sore and hoarse throat. Resident began coughing on first bite of food. Resident able to clear and then slowly ate pureed food. X-ray ordered with two views. A record review of Resident #2's final X-ray Report, dated 02/21/2023 , revealed, examination: chest . findings: . a metallic foreign body projects over the neck Residents Affected - Few A record review of Resident #2's nursing progress notes revealed the ADON documented on 02/21/2023 at 06:11 PM, Patient presenting increased SOB using ABDM muscles, cold, clammy to touch, pale, diaphoretic [excessive sweating], speech therapist here tried to feed patient at this time patient did not tolerate but one bite of mashed potatoes. Drooling and discharge from nose called. [Resident #2's representative] and doctor [name] on call for [Resident #2's doctor] send to ED for evaluation and treatment . A record review of Resident #2's hospital medical records revealed a History of Present Illness, dated 02/22/2023, authored by Dr. T, chief complaint: altered mental status, low oxygen level, and foreign body (dentures) in esophagus [throat] . is a [AGE] year old white female brought by EMS to [local hospital] hospital emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. The patient is unable to provide any history due to cognitive impairment at baseline. As a result, history is obtained exclusively from review of hard copy medical records provided by the transferring facility. The patient was sent to the outside emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. The patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. Her second episode was more severe and associated with significant coughing and choking. Care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation. Her shortness of breath was worse if she laid flat and improves if she sat up. At the outside emergency room, the patient's initial vital signs were remarkable for blood pressure 131/72, heart rate 106, respiratory rate 18, temperature 101.4, and 90% oxygen saturation on room air. Labs were remarkable for white blood cell count 25.4, hemoglobin 13.1, hematocrit 40.2, platelet count 270, sodium 138, potassium 4.3, creatinine 0.73, glucose 170, lactic acid 1.35, negative troponin, BNP 37, lipase 22, phosphorus 3.5, magnesium 1.7, TSH 1.06, PT 12.4, INR 1.1, PTT 30.4, and negative urinalysis. The patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, an elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia. CTA of chest was negative for PPE but did show acute findings consistent with bilateral aspiration pneumonia. CT of abdomen and pelvis with IV contrast performed at the outside emergency room showed fecal impaction with wall thickening and adjacent stranding. X-ray of the soft tissues of the neck performed at the outside of emergency room showed a U-shaped foreign body noted within the cervical esophagus consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for, but the patient's lower dentures were not. As a result of these findings, the patient has been transferred to [out of town specialty hospital] to a higher-level care for further medical management and evaluation, including ear nose and throat specialist consultation. A record review of Resident #2's hospital records revealed a patient assessment document Bedside Swallowing Evaluation, dated 02/22/2023, authored by Dr. U, medical history diagnosis, date of onset: patient is a [AGE] year-old female admitted with hypoxemia, concern for aspiration pneumonia, findings of foreign body and cervical esophagus. her are in, history of renal cancer. chest X-ray 02/22: segmental atelectasis vs RRL pneumonia. foreign body dentures removed by medical doctor and ear nose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 12 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and throat specialist this morning after locating object in hypopharynx and extending into the cervical esophagus. per emergency medical record documented dysphasia at nursing facility. During an interview on 03/22/2023 at 10:23 AM, the ADON stated on her 2nd day of employment at the facility, Resident #2 aspirated during the evening dinner on 2/20/2023. The ADON stated LVN H was assigned to supervise the residents at the evening meal and was absent from his duty. The ADON stated she heard the commotion and calls from the dining room when she ran to the dining room and assessed Resident #2, pale, cyanotic [blue skin], cold, tearing eyes and anxiously attempting to breath. The ADON stated she performed the Heimlich maneuver [performed by wrapping your arms around a person, making a fist with one hand and clasping it with the other. You place your fists between the person's ribcage and belly button and thrust your hands into their abdomen until the object is freed], swept Resident #2's oral cavity and expelled food from Resident #2's oral cavity. The ADON stated she was not familiar with Resident #2 and did not know Resident #2 had dentures. The ADON stated she did not feel or visualize Resident #2's dentures in her mouth. The ADON stated she could not access Resident #2's care plan due to her lack of training on the facility's electronic record. The ADON stated she now understood, even if she had access to Resident #2's care plan there were no interventions to alert anyone to Resident #2's dentures. The ADON stated Resident #2 was assessed with vital signs within normal limits, her physician was given a report and was assisted to bed for the evening. The ADON stated the physician was not given any report regarding her dentures. During an interview on 03/22/2023 at 02:15 PM CNA D and CNA E, who were the CNAs for Resident #2 to include the dinner meal on 02/20/2023 and 02/21/2023, the CNAs stated they were not aware Resident #2 had top and bottom dentures and believed she only had top dentures. The CNAs stated they had no training or care instructions for Resident #2's denture care. During an interview on 03/23/2023 at 02:00 PM, LVN H stated he was the nurse on duty on 02/20/2022 and that Resident #2 had aspirated and had recovered. LVN H stated he called the on-call physician, gave report of the incident, and received new orders for monitoring Resident #2 for signs and symptoms of aspiration complications . LVN H stated he did not document the SBAR or the new orders received. LVN H stated he was not aware Resident #2 had dentures. LVN H stated Resident #2 was assisted to bed for the evening and was not in distress. LVN H stated he had no knowledge if Resident #2 had her lower dentures lodged in her airway that evening. LVN H stated there was a miscommunication as to his duty to supervise the dining room meal that evening. During an interview on 03/23/2023 at 02:05 PM the ADON stated Resident #2 refused the breakfast meal on 02/21/2023. The ADON stated Resident #2 was receiving mechanical soft diet and the diet was discontinued on 02/21/2023 and a pureed diet was ordered . The ADON stated Resident #2 was assisted with the lunch meal by LVN A and Resident #2 began to aspirate on pureed foods. The ADON received the report of the 2nd aspiration episode and SBAR'ed the physician and received a new order for a chest x-ray. The ADON stated the image was captured shortly afterward, and the facility awaited the results of the image. The ADON stated Resident #2 was assisted by the SLP with the evening meal on 02/21/2023 when Resident #2 began to aspirate a 3rd time and was sent to the hospital for treatment and evaluation. The ADON stated the facility received the image result of the x-ray at 10:00 PM. The ADON stated the x-ray revealed a foreign object in the airway. During an interview on 03/23/2023 at 02:00 PM the NP stated he was a NP who worked for the PCP responsible for Resident #2. The NP stated he had reviewed Resident #2's medical records to include her admitting nursing assessments and was not aware of Resident #2 using dentures. The NP stated if the nursing staff had assessed and documented Resident #2's dentures he could have had an opportunity to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 13 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few review her assessments, he may have possibly ordered a referral for Resident #2 to see a dentist to assess for Resident #2's dentures for proper fit. The NP stated often, as people age, the lower jaw changed shape and dentures became loose fitting. The NP stated Resident #2 could have died when she was not provided support while eating with dentures, such as proper care for dentures, instructions for wearing dentures, proper supervision for proper fitting dentures prior to meals. The NP stated the danger for aspiration was still in place due to the floor staff not having access to a complete and accurate care plan developed to support Resident #2's nutritional needs, and assistance with meals and dentures. During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The Administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The Administrator stated the facility policy was to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which did not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed . A record review of the facility's policy admission Assessment and Follow Up: Role of the Nurse, dated December 2012, revealed, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the Resident, initiating the care plan, and completing required assessment instruments, including the MDS . steps in the procedure . conduct a physical assessment, including the following systems: eyes, ears, nose, throat; teeth and gums . contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtained admission orders that are based on these findings . notify the supervisor and the attending physician of immediate needs that the resident may have . report other information in accordance with facility policy and professional standards of practice. This was determined to be an Immediate Jeopardy (IJ) on 03/24/20223 at 05:17 PM. The Administrator was notified. The Administrator was provided with the IJ template on 03/24/2023. The following Plan of Removal was accepted on 03/25/2023 at 3:00 PM. Plan of Removal Verification 03/26/2023 Resident # 2 assessed by the RN for any s/s of discomfort/pain or changes in condition, physician was notified of the alleged deficiency on 3/24/23. There were no new orders obtained. The affected resident's responsible party was notified by the Administrator of alleged deficiencies and plan of correction. Resident was evaluated by SLP, clarification on diet received, new orders for speech treatment and swallow study ordered by physician. A record review of Resident #2's medical record revealed a progress note authored by the Regional DON, dated 03/24/2023, revealed, resident in the dining room without dentures, oral cavity without signs and symptoms of pain or discomfort. no redness or irritation noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 14 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few A record review of the facility's ad-hoc QAPI attendee sign in log, dated 03/24/2023, revealed attendees to include the Regional DON, Medical Director, Administrator, ADON, and RDO A record review of Resident #2's order summary revealed new orders on 03/25/2023, for: the mechanical soft diet to be discontinued and for a pureed diet with thin liquids to begin, denture care to include monitoring daily for comfort and fit, an order for a modified barium swallow test, and an order for speech language to evaluate and treat. A record review of Resident #2's speech therapy notes, dated 03/25/2023, revealed Resident #2 was evaluated by the SLP, clarification on diet received, new orders for speech treatment and a swallow study was ordered by the physician. A record review of Resident #2's progress notes revealed a note authored by the ADON on 03/25/2023, [family member] called and informed there was an active and investigation from state surveyors on the incident with his [Resident #2's] dentures . Residents with dentures were assessed by the RN (Regional DON) on 3/24/2023, the plan of care was updated and POC was updated to reflect patients' dentures utilization. A record review of the facility's daily census report revealed 9 residents (Residents #2, #5, #6, #10, #16, #20, #21, #28, and #88) were assessed for their needs for dentures. A record review of Resident #2's care plan, dated 03/26/2023, revealed a focus on denture care with interventions for denture supports, Problem: Resident has dental concerns AEB: (x ) resident without dentures currently, pt refuses to wear. A record review of Resident #5's care plan, dated 03/26/2023, revealed a focus on denture care with interventions for denture supports, Problem: Resident has dental concerns AEB: (x ) resident without dentures currently, pt refuses to wear. Residents will be identified on admission, by the charge nurse, if dentures are in place. The ADON will enter the information in the Matrix EMR and Point of Care mechanism. The ADON will also initiate dental care plan. During an interview on 03/26/2023 at 10:33 AM the ADON stated she had reviewed all residents for needs for dentures and has assessed 9 residents with dentures to include Residents #2, #5, #6, #10, #16, #20, #28, and #88. The ADON stated she reviewed their care plans for accurate assessment and nursing interventions for the residents related to their needs for dentures. Staff have been educated on abuse and neglect, changes in condition by the Administrator and ADON starting on 3/24/2023. IDT has been in-serviced starting on 3/24/2023 by the RNC on Care Planning, MDS completion, and communication with staff on interventions/Point of care EHR documentation. Nursing staff has been educated on denture care, refusals, instructions for wearing dentures and notification of any issues with dentures/missing dentures starting on 3/24/2023 by ADON. Staff will not be allowed to work until they receive training. A record review of the facility's in-service titled Change of Condition, dated 03/24/2023, revealed 43 employees were educated for, facility policy title change in the residence condition or status policy statement our facility shall promptly notify the Resident, his or her attending physician, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 15 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few representative of changes in the Resident's mechanical, mental condition and or status . policy interpretation and implementation; the nurse surveyor charge nurse will notify the resident's attending physician or alcohol physician when there has been . discovery of injuries of unknown source, . a significant change in the residence physical, emotional mental condition . A record review of the facility's in-service titled Abuse and Neglect, dated 03/24/2023, revealed 43 employees were educated for, abuse and neglect clinical protocol the nurse will assess the individual and document related findings, assessment data will include injury assessment, all current medications, vital signs . the nurse who report findings to the physician as needed the physicians well let's ask the resident to verify or clarify such finding . reporting abuse to the facility management, policy statement, it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etcetera, to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to the facility management. A record review of the facility's in-service titled Care Planning IDT, dated 03/24/2023, revealed 43 employees were educated for, policy statement her facilities care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each Resident . policy interpretation and implementation . a comprehensive care plan for each resident is developed within seven days have a completion of the resident assessment MDS. the care plan is based on the resident's comprehensive assessment and is developed by care planning introducing [NAME] team which includes, but it's not necessarily limited to the following personnel: the resident attending physician: the registered nurse who has responsibility for the Resident: the dietary manager dietitian: the social services worker responsible for the Resident: the activity director coordinator: therapist speech, occupational, recreational, etcetera, as applicable: the charge nurse responsible for resident care: nursing assistants responsible for the residents care: and others as appropriate or necessary to meet the needs of the Resident. comprehensive care plan . policy statement; an individualized comprehensive care plan that includes measurable objective objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each Resident. policy interpretation and implementation; are facilities care planning in the disciplinary team in coordination with the Resident, is her family or representative, develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning and resident may be expected to attain . the comprehensive care plan is based on a thorough assessment that includes, but it's not limited to the MDS. A record review of the facility's in-service titled denture Cleaning and Storing, dated 03/24/2023, revealed 43 employees were educated for, the purpose of this procedure are two cleans and freshen the residents mount, to clean the residence dentures, to prevent infections of the mouth, to protect the residents dentures from breakage when dentures are out of the residents mouth, and to store dentures at bedtime . review the residents care plan to assess for any special needs of the Resident. assemble the equipment and supplies needed loose or poor fitting dentures can cause gum sores and prevent the resident from chewing his or her food properly. if a resident is not chewing his or her food thoroughly report it to your supervisor. encourage the resident to keep dentures in his or her mouth as much as possible. when dentures are left out of the mouth for several days, the bone structure to the mouth changes and the gums will shrink causing the dentures to fit improperly . During an interview on 03/26/2023 at 11:10 AM the Human Resources Manager stated she reviewed the employee roster and compared the roster to the in-service roster and stated it was accurate for all of the facility's employees, to include employees who worked during the IJ up to midnight on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 16 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0684 03/25/2023. Level of Harm - Immediate jeopardy to resident health or safety Nursing staff received in-service training on documenting physician team contact in the progress notes for each resident as appropriate. Notification to physician of any changes of condition will be noted on the 24-hour report and the facility activity report and will be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends. Residents Affected - Few During an interview on 03/26/2023 at 10:33 AM the ADON stated she received in-service education from the facility's Regional DON to include reporting to the physician and documenting in residents' medical records, the 24- hour report, the facility activity report, any notification to physicians of any changes of conditions, and would be noted on the 24-hour report and the facility activity report, and would be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends. The ADON stated she and the Regional DON provided in-service training education for all of the facility's, 43 staff, to include reporting to the physician and documenting in residents' medical records, the 24- hour report, the facility activity report, any notification to physicians of any changes of conditions, and will be noted on the 24-hour report and the facility activity report, and will be reviewed by the IDT team at the morning meetings Monday-Friday, and by the Manager on Duty on weekends. The ADON stated the weekend RN and the ADON would in-service staff as needed, new staff, since all staff had been in-serviced by 03/25/2023. Upon reporting to work the appropriate in-service will be given to staff before they can begin work. All staff will complete Abuse/Neglect in-service by the Administrator and verified by the RDO. Nursing staff will also complete denture care, requirement for a nurse to be in dining room during meals, physician notification of change of condition, access to care plan in matrix, and update to Point of Care mechanism for CNA/nurse documentation of denture care from the ADON and verified by the Administrator. During an interview on 03/26/2023 at 10:11 AM, RN K stated she was the facility's weekend RN supervisor and worked from 06:00 AM to 10:00 PM. RN K stated she had received in-service education to include abuse and neglect, residents' changes in condition, care planning, MDS completion, and communication with staff on interventions/Point of care EHR documentation. RN K stated she and nursing staff had been educated on denture care, refusals, instructions for wearing dentures and notification of any issues with dentures/missing dentures starting on 3/24/2023 by ADON. RN K stated staff would not be allowed to work until they received training. RN K stated she and the ADON would in service staff as needed, new staff, since all staff had been in- serviced by 03/25/2023. During an interview on 03/26/2023 at 10:58 AM, the BOM/HR, and MOD as assigned, stated the in-service roster was accurate for employees who worked from the date of the IJ to midnight on 03/25/2023 to include all of the facility's 43 employees. During an interview on 03/26/2023 at 11:18 AM, CNA L stated she assisted residents with dressing, eating, toileting and activities of daily life. CNA L stated she received education/in-services for dentures, clean make sure they have them in, don't fit right, refuse, change of condition, refusal to eat drink, s/s of aspiration, and to report everything. During an interview on 03/26/2023 at 12:30 PM CNA M stated she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA M stated the facility's electronic record for resident care now included an area where CNAs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 17 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0684 could now document denture care for residents. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 03/26/2023 at 3:20 PM LVN N stated she worked the 02:00 PM to 10:00 PM shift and occasionally the 10:00 PM to 06:00 AM shift. LVN N stated she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the ADON and/or DON any complications and or concerns with residents and their dentures. LVN N stated the facility's electronic record for resident care now included an area where CNA's could now document denture care for residents and LVN N would inspect the documentation for accuracy and assess residents with dentures prior to and after meals. Residents Affected - Few During an interview on 03/26/2023 at 04:53 PM CNA O stated she worked the 10:00 PM to 06:00 PM shift, received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA O stated the facility's electronic record for resident care now included n area where CNA's could now document denture care for residents. CNA O stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for resident's skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. During an interview on 03/26/2023 at 04:54 PM CNA P stated worked she worked 02:00 to 10 :00 PM and she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA P stated the facility's electronic record for resident care now included an area where CNA's could now document denture care for residents. CNA P stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for residents' skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. During an interview on 03/26/2023 at 05:01 PM CNA Q stated she worked 06:00 PM to 06:00 AM and she received education/in-service for resident denture care, to check for well-fitting dentures, to document a resident's refusal to wear dentures and to report to the nurse any complications and or concerns with residents and their dentures. CNA Q stated the facility's electronic record for resident care now included an area where CNAs could now document denture care for residents. CNA Q stated she was trained to assess all residents at the beginning of her shift, and throughout the shift for residents' skin conditions, and overall wellbeing, and to focus on residents needs for dentures and denture care to include well-fitting dentures and to report to the nurse any resident's refusal to wear dentures. During an interview on 03/26/2023 at 06:00 PM LVN R stated she has been in serviced for main issue to assess residents for dentures, and to assess residents for refusals to eat and assess for ill-fitting dentures, and to inspect delegation of care to CNAs for resident denture care. LVN R stated she would assess CNAs for assistance with resident care to include eating and oral care. LVN R stated she had worked double shifts from 06:00 AM to 10:00 PM, but usually worked the 06:00 AM to 2:00 PM shift. During an interview on 03/26/2023 at 06:10 PM LVN B stated she had been in service for main issue to assess residents for dentures, and to assess residents for refusals to eat and assess for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 18 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ill-fitting dentures, and to inspect delegation of care to CNAs for Resident denture care. LVN B stated she would assess CNAs for assistance with Resident care to include eating, and oral care. LVN R stated she has worked double shifts from 06:00 AM to 10:00 PM, but usually works the 06:00 to 2:00 PM shift. also, in serviced on documenting SBARS and reviewing residents care plans for accuracy, also to report all allegations of suspected ANE and/or mistreatment. During an interview on 03/26/2023 at 06:16 PM CNA E stated she had been in-serviced for has received education in services any changes of conditions and report to the charge nurse, the ADON, and if ANE, mistreatment, and or injuries of unknown origin to the nurse, ADON, and to include the Administrator. CNA E stated the CNA documentation screen for residents now included a care plan for residents who had dentures. CNA E stated she usually worked the 02:00 PM to 10:00 PM shift and had worked the 10:00 PM to 06:00 AM shift. All in-service and training will be completed by 3/25.[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 19 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 designate a registered nurse (RN) to serve as DON on a full-time basis in that: Residents Affected - Some The facility had no full time Director of Nurses (DON) from October of 2022 through present [3/22/23]. This failure could place all residents at risk for not receiving necessary care and services. The findings included: Record review of facility policy on Director of Nursing Services revealed that the Director is employed full-time at 40-hours per week. In an interview on 3/21/23 at 11:28 AM, the ADON stated there was no DON at the facility, and she believed the regional DON was the acting DON. In an interview on 3/21/23 at 3:20 PM, the Administrator stated the facility had no full time DON and the corporate regional RN's assisted with nursing services. In an interview on 3/24/23 at 1:10 PM the Regional DON stated the facility had no full-time designated DON. The regional DON stated she was not in the facility for 40 hours a week and occasionally was in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 20 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 interviews and record review, the facility failed to employ or contract with 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: In an interview on 3/21/23 at 11:28 AM, the ADON stated that the facility did not have a social worker employed, and she was not aware of a contracted social worker. In an interview on 3/21/23 at 3:20 PM, the Administrator stated the facility did not have a social worker employed or contracted to come to the facility. The administrator stated they do not have a specific policy on social workers or social services, and the facility follows federal and state regulations as policy. In an interview on 3/24/23 at 1:10 PM, the regional DON stated that the facility did not employ or contract a social worker on a full-time or part-time basis. The regional DON stated the facility follows the federal and state regulations as policy. Record review of employee roster, undated, revealed there was not a social worker on staff at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 21 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment requirement, for 1 of 1 kitchen staff (Food Service Manager) reviewed for qualifications, in that: The Dietary Manager did not have the appropriate license, certification, or qualifications to function as the food service supervisor. This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. The findings included: Record review of the certifications obtained by facility kitchen staff revealed that the FSM did not have the certification required for her current position. In an interview on 3/25/23 at 10:20 AM, the FSM revealed she does not have the certification required for her current position. She explained she did not have the time to take the test as she is not able to take time off from the facility due to a staffing shortage. In an interview on 3/25/23 at 11:28 AM, the ADON stated she was not aware the FSM did not have the certifications required for her position. In an interview on 3/25/232 at 11:37 AM, the Administrator stated that he was aware that the FSM did not have the certifications required for her position. The administrator stated that the facility had attempted to hire FSM's but have not had success. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 22 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Some The facility failed to ensure proper food storage of dry goods and fresh produce. This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness. The findings included: Observation on 3/21/23 at 11:09 AM revealed a 10-pound box labeled imitation bacon bits open, undated, in a dry storage area in the kitchen. Upon further investigation, box appeared open with bag full of red flakes approximately 3 cm in diameter, and the bag is open. Observation on 3/22/23 at 9:11 AM revealed a box labeled Idaho potatoes unlabeled and on the floor of a dry storage area in the kitchen. Fresh produce resembling potatoes observed through holes in box. In an interview on 3/25/23 at 10:20 AM, the FSM stated that boxes should be dated with either markers or stickers. She stated that the items in the box labeled imitation bacon bits should have been in a sealed plastic container. She then stated that there should not have been anything on the floor in the kitchen or storage rooms. Record review of Food Storage Policy, undated, stated Food in designated dry storage areas shall be kept off the floor,. The food policy stated on dry foods stated Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 23 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 24 residents (Resident #30) reviewed for accurate medical records, in that: LVN A failed to document an order for a urinalysis laboratory test ordered for Resident #30. This failure could place residents at risk for harm by inaccurate records. The findings included: A record review of Resident #30's Face Sheet, dated 03/22/2023, revealed an admission date of 01/06/2022, with diagnosis which included obstructive and reflux uropathy [a condition when the passage of urine from the kidneys to the exterior is blocked by an obstruction anywhere along the urinary tract]. A record review of Resident #30's quarterly MDS, dated [DATE], revealed Resident #30 was an [AGE] year-old female assessed with severe mental cognition impairment, as evidenced by a Brief Interview for Mental status score of 05 out of 15. Resident #15 was assessed with the need for total assistance with activities of daily life to include toileting. Further review revealed Resident #30 was assessed as always incontinent of bowel and bladder. A record review of Resident #30's care plan, dated 03/22/2023, revealed, problem activities of daily life self-care deficit: requires assistance; total staff performs / provides total assistance; will be clean, dry and free form odors with dignity maintained throughout next quarter; approach document activities of daily life performance staff assistance as per policy, notify charge nurse of change in ability . During an observation on 03/21/2023 at 12:16 PM, revealed an empty 4 oz. specimen cup with Lids & ID Label, on the sink counter of Resident #30's bedroom. Further observation revealed the specimen cup label read, UA [urinalysis] 03/20/2023, [Resident #30], [Dr. T ]. A record review of Resident #30's physician's order summary, dated 03/22/2023, revealed no order for a urinalysis laboratory for Resident #30. During an interview on 03/22/2023 at 01:10 PM, LVN A stated she called Dr. T, on 03/20/2023, and gave a SBAR for Resident #30's change of condition with a fever and altered mental status. LVN A stated Dr. T gave her an order to obtain a urinalysis for Resident #30. LVN A stated she failed to document the order in Resident #30's medical record . LVN A stated the failure placed Resident #30 at risk for inaccurate records. LVN A stated inaccurate records denied interdisciplinary team members information needed for quality care for residents. During an interview on 03/24/2023 at 04:40 PM the ADON stated physician's orders should always be documented in the resident's medical record as soon as the order had been received. The ADON stated the documentation of the order was critical to quality care for residents. The AND stated the nurses needed orders documented to ensure nursing practice within their scope of duty. The ADON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 24 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0842 inaccurate records denied interdisciplinary team members information needed for quality care for residents. Level of Harm - Minimal harm or potential for actual harm A record review of the facility's policy regarding recording/documenting physicians' orders was requested, from the Administrator, on 03/22/2023 at 02:16 PM. As of 03/26/2023 at 04:30 PM a policy was not provided and the Regional DON stated the facility followed the CMS and state regulations/guidelines. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 25 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a minimum of 80 square feet per resident for residents in 9 of 9 multiple occupancy resident rooms (Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317). Rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317 did not have the required 80 square feet per resident. These failures could affect the residents placed in these multiple occupancy rooms and place them at-risk by reducing their living space and posing problems in their activities of daily living. The findings were: Record review of Form 3740 Bed Classifications, completed by the Administrator on 2/26/2020, revealed rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were classified to have 3 resident beds in each room. Observation on 02/26/2020 from 11:00 AM to 11:17 AM with the Maintenance Director revealed the measurements of the rooms 109, 111, 112, 201, 204, 209, 211, 315 and 317 were as follows: 1. room [ROOM NUMBER] (3 person room - 2 residents in room) 14.9 ft x 14.83 ft = 221.7 sq ft / 3 residents = 73.9 sq. ft/resident 2. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.75 ft = 220.9 sq ft / 3 residents = 73.6 sq. ft/resident 3. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.75 ft x 15 ft = 221.3 sq ft / 3 residents = 73.8 sq. ft/resident 4. room [ROOM NUMBER] (3-person room - 1 resident in room) 14.83 ft x 15 ft = 222.4 sq ft / 3 residents = 74.2 sq. ft/resident 5. room [ROOM NUMBER] (3-person room - 2 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident 6. room [ROOM NUMBER] (3-person room - 2 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident 7. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.75 ft = 219.8 sq ft / 3 residents = 73.3 sq. ft/resident 8. room [ROOM NUMBER] (3-person room - 2 residents in room) 14.9 ft x 14.9 ft = 222.0 sq ft / 3 residents = 74 sq. ft/resident 9. room [ROOM NUMBER] (3-person room - 0 residents in room) 15 ft x 14.75 ft = 221.3 sq ft / 3 residents = 73.7 sq. ft/resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 26 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete In an interview on 03/21/23 at 2:27 PM the Administrator stated the facility continues with the room waiver for the rooms less than regulation size. The administrator stated they did not have any plans to increase the number of occupants in each room to 3 at this time. Interview on 3/22/23 at 11:08 AM the maintenance director stated that the facility continues to utilize the room size waiver. The maintenance director stated there have been no changes since last year [2022]. Event ID: Facility ID: 675169 If continuation sheet Page 27 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles, for 1 of 1 Activities Director Care Plan Coordinator, reviewed for training as the care plan coordinator, in that: Residents Affected - Some The facility failed to train the Activities Director in the assigned job as the care plan coordinator. This failure could place residents at risk for harm by not having a complete and accurate care plan to support the residents needs and preferences. The finding included: A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care. A record review of Resident #2's hospital discharge records, dated 02/26/2023, revealed history of present illness; chief complaint; altered mental status, low oxygen level, and foreign body(dentures) in esophagus . this is a [AGE] year-old white female brought by emergency medical services 2[name of hospital] emergency room on the evening of 02/21/2023 for recurrent episodes of aspiration associated with shortness of breath for two days prior to presentation. the patient is unable to provide any history due to cognitive impairment at baseline . the patient was sent 2 . emergency room by care staff at the skilled nursing facility where the patient resides for two episodes of food aspiration for two days prior to presentation. the patient had one episode of food aspiration on 02/20/2023 and a second episode of food aspiration on 02/21/2023. her second episode was more severe and associated with significant coughing and choking. care staff reports gradual onset of worsening shortness of breath for approximately 2 days prior to presentation . the patient was noted to meet criteria for sepsis with elevated heart rate, elevated temperature, and elevated white blood cell count. the patient was found to have a bacterial source in the form of bilateral aspiration pneumonia . X-ray of the soft tissues of the neck performed at the emergency room showed a U-shaped foreign body noted within the cervical esophagus consistent with dentures. upon further inspection of the patient, the patient's upper dentures were accounted for but the patient's lower dentures were not. because of these findings, the patient . has been transferred to a higher-level of care for further medical management and evaluation, including an ear nose and throat specialist consultation findings of foreign body and cervical esophagus . foreign body dentures removed by medical doctor and ear nose and throat specialist this morning after locating object in hypopharynx and extending into the cervical esophagus . A record review of Resident #2's re-entry and quarterly MDS's, dated 02/27/2023 revealed the Regional MDS LVN documented in section A0310 type of assessment 99 which indicated none of the above. Further review of section A0310 revealed the choices were 01. Admission, 02. Quarterly, 03. Annual, 04. Significant Change in Status, 05. Significant Correction to prior comprehensive assessment, 06. Significant correction to prior quarterly assessment, and 99. None of the above. Further review revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 28 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0940 the MDS assessment was not signed by a RN. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #2's quarterly MDS's, dated 03/01/2022, revealed the Regional DON assessed Resident #2 as returned from an acute care hospital on [DATE]. The MDS assessment revealed Resident #2 was severely impaired for cognition, and was assessed as needing limited assistance and supervision during meals. Resident #2 was diagnosed with pneumonia, loss of liquids / solids from mouth when eating or drinking, and required a change in textures of food and liquids. Review of the MDS section L revealed no documentation for the assessment broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose). Residents Affected - Some A record review of Resident #2's physical paper chart revealed a Care Plan worksheet, dated 01/11/2023, which documented the attendees as the Activities Director [AD] and the Director of Rehabilitation [DOR]. The document revealed there was a concern made by Resident #2's representative for Resident #2's bottom dentures. Further review revealed no documents to reveal any subsequent care plan meetings. A record review of Resident #2's Care Plan, dated, 01/13/2023, revealed no focuses, interventions, and/or care instructions for Resident #2's needs for dentures. Review of Resident #2's care plan revealed 1 care instruction, Resident [#2] is at risk for falls due to amputation and weakness . Resident [#2] will be free of falls through next review . encourage call light usage . increased staff supervision with intensity based on Resident [#2] need. Further review of Resident #2's medical records evidenced no further care plans other than the 01/13/2023 care plan. During an interview on 03/24/2023 at 10:40 AM the AD stated she was assigned by the ex-DON to help as a CNA and as a Care Plan Coordinator. The AD stated she had not been trained for the duty as the care plan coordinator and did not understand the care plan coordinator was responsible to invite the IDT to participate in the development of the care plan. The AD stated there were many times she and the DOR] were the only persons involved with preparation of the residents' care plans. The AD stated she was not aware a nurse was responsible to help coordinate the care plan with assessments and care recommendations from different IDT members. The AD stated she was not aware an RN needed to sign off on the care plan. The AD stated she did not know how to update the care plan in residents' records. The AD stated Resident #2's care plan meeting, on 01/11/2023, was attended by Resident #2, her representative, and the DOR only. The AD stated the care plan meeting addressed Resident #2's representative's concern for loose fitting dentures to which she [the AD] reported to the Administrator in the next leadership morning meeting. The AD stated she had no documentation to support her report to the leadership at the morning meeting. The AD stated she was not aware Resident #2 had no care supports in her care plan for dentures. During an interview on 03/23/2023 at 01:55 PM, the Regional MDS LVN stated she was the MDS coordinator for the facility intermittingly. The Regional MDS LVN stated she had been helping periodically per the facility's needs with Resident assessments and would be alerted by the facility for the need for an MDS assessment. The Regional MDS LVN stated she had completed the MDS assessment for Resident #2 on 02/27/2023 and documented the assessment section as 99 and did not document the assessment as a change of status. The Regional MDS LVN stated she was not aware of Resident #2's change of status and her hospitalization for swallowing her dentures with a diagnosis of sepsis pneumonia. The Regional MDS LVN stated she was not assigned to follow the MDS with care plans and the duty was assigned to someone at the facility by the Administrator possibly ADON S [ADON S from another facility] who helped at the facility or the Regional DON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 29 of 30 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 675169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fredericksburg 1117 S Adams St Fredericksburg, TX 78624 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 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/24/2023 at 04:50 PM, the Regional DON stated a care plan is prepared by the Interdisciplinary Team [IDT] per the MDS assessment within 7 days of the completed MDS assessment. The Regional DON stated she had completed the quarterly MDS for Resident #2 on 03/01/2023 and did not document an assessment for Resident #2's oral / dental status under section L, broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or lose) mouth or facial pain, discomfort or difficulty with chewing. The Regional DON stated she did not know if Resident #2's dentures were or were not loose fitting and after her discharge from the hospital there were no reports of Resident #2 having swallowing issues. The Regional DON stated she was responsible for 5 other facility's and was on call for all 5. The Regional DON stated she was not in the facility for 40 hrs. a week. The Regional DON stated she had not coordinated a care plan for Resident #2's change of status for her needs with dentures and assistance supervision during meals within 7 days of the 02/27/2023 re-admission from the hospital or within 7 days of the 03/01/2023 quarterly MDS assessment. The Regional DON stated there should have been care instructions in Resident #2's care plan to reflect Resident #2's needs for support with her dentures and assistance with meals to include diet textures and swallow studies as assessed by the Speech Language pathologist [SLP] who was an IDT member. During an interview on 03/24/2023 at 04:32 PM the Administrator stated the ex-DON resigned in October 2022 and since then the corporate regional nursing support staff, to include the Regional DON, the Regional DON I, the Regional Director of Quality, and the Regional MDS nurse, were all involved with the facility's nursing services while the search for a replacement DON ensued. The administrator stated he relied on the corporate regional nursing support staff for the daily continuation of nursing services. The administrator stated the facility policy is to provide an accurate and comprehensive MDS assessments to include care plan development and implementation upon admission, change in conditions, and at a minimum, quarterly. The Administrator stated this was not done as evidenced by Resident #2's MDS assessments and care plan which do not support Resident #2 with her denture needs. The Administrator stated if he had been given a report from nursing staff, that MDS assessments were incomplete, care plans were not performed as required, he would have ensured gaps in nursing services were addressed. A record review of the facility's policy admission Assessment and Follow Up: Role of the Nurse, dated December 2012, revealed, The purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the Resident, initiating the care plan, and completing required assessment instruments, including the MDS . steps in the procedure . conduct a physical assessment, including the following systems: eyes, ears, nose, throat; teeth and gums . contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtained admission orders that are based on these findings . notify the supervisor and the attending physician of immediate needs that the resident may have . report other information in accordance with facility policy and professional standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675169 If continuation sheet Page 30 of 30