Health inspection·July 16, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some male who was admitted [DATE] and readmitted [DATE] with diagnosis type II diabetes mellitus, dysphagia , retentions of urine, major depressive disorder, adjustment disorder with mixed anxiety and depressed mood , symptomatic epilepsy, pain in left knee, depression, unspecified convulsions, and chronic kidney disease. Record review of Resident #30's Significant change MDS dated [DATE] revealed: Section C Cognitive Patterns revealed Resident #30 had a BIMS score of 13, meaning resident had intact cognitive status. Section N revealed no use of anti-depressants, or anti-anxiety medications. Record review of Resident #30's physician orders dated 07/01/2024, revealed orders for Bupropion ER (extended release) 150 mg by mouth every day, Escitalopram 10 mg by mouth every day, Mirtazapine 15 mg by mouth at bedtime, Depakote sprinkles 125 mg, 3 tabs by mouth two times a day, Phenytoin 100 mg by mouth four times a day, and Tramadol 50 mg by mouth every four hours as needed for pain. Record review of Resident #30's Care plan dated 06/12/2024, revealed no evidence, goal, or interventions for the following medications: Bupropion (anxiolytic-to treat anxiety), Escitalopram (anti-depressant), Mirtazapine (anti-depressant), Depakote sprinkles (anti-epileptic/seizure), phenytoin (anti-convulsant), and Tramadol (narcotic used for pain relief). Record review for Resident # 37's electronic face sheet dated 07/16/2024, revealed a [AGE] year-old male admitted on [DATE] with diagnoses: Hemiplegia (complete or severe paralysis on one side) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction affecting left non-dominant side, vascular dementia (brain damage caused by multiple strokes) mild, with psychotic disturbance, and psychotic disorder with delusions. Record review of Resident #37's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns revealed Resident #37 had a BIMS score 15 meaning the resident had intact cognitive status. Record review of Resident # 37's Physician orders dated 07/01/2024 revealed: Clopidogrel 75 mg by mouth once a day, Aricept (donepezil) 5 mg by mouth once a day. Record review of Resident #37's Care Plan dated 03/08/2024 revealed: there were no goals, interventions for the diagnosis of Hemiplegia, Hemiparesis, or the use of Aricept (medication for dementia) or clopidogrel (blood thinner) in the care plan. During an interview on 07/15/2024 at 2:30 PM the ADON stated, herself and the DON were responsible to update care plans. The ADON stated a new pressure ulcer should be updated in the care plan upon finding the pressure ulcer. During an interview on 07/15/2024 at 2:40 PM the DON stated her expectation was that care plans should include resident needs and address ways to support their needs. The DON stated, herself and the ADON were responsible for updating the care plans. The DON stated she did not feel there was a negative impact to residents for care plans not being accurate because staff usually go by the orders not the care plan. The DON stated what led to the failure of items not being addressed in the care plan was that she was new to the long-term care process, and she was still learning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675259 If continuation sheet Page 2 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 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 07/16/24 at 12:21 PM, the DON stated not all care plans had been reviewed and updated. The DON stated medications should have been care planned. The DON stated there was no harm to residents, but the care plan does help staff to know interventions planned for resident. The DON stated that she and the ADON were responsible for auditing and ensuring accuracy of care plans. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered dated Revised December 2016: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment 7. The care planning process will: a. facilitates resident and/or representative involvement. b. Include an assessment of the resident's strengths and needs; 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well -being; g. Incorporate identified problem areas . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675259 If continuation sheet Page 3 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #28) reviewed for accidents and supervision. The facility failed to ensure CNA-E and CNA-F locked the Resident wheelchair during the Hoyer transfer of Resident #28. This failure could place residents at risk of injuries. Findings included: Review of Resident # 28's face sheet dated 07/16/2024 revealed an [AGE] year-old female admitted on [DATE]. Review of Resident #28's diagnosis revealed: hypertension (high blood pressure), disorder of muscle, degenerative disease of the nervous system, muscle wasting, and atrophy. Review of Resident # 28's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 12 (moderately impaired). Section GG-Functional Abilities and Goals, Mobility Devices-uses Wheelchair (manual or electric), Mobility- E. Chair/bed-to chair transfer: Dependent-Helper does ALL the effort. Resident does none of the effort to complete the activity. Review of Resident #28's Care Plan dated 06/27/2024 revealed, Problem-I am limited in ability to transfer self R/T (related to) muscle weakness. Goal-Resident will be transferred with use of Hoyer lift. Approach-Use Hoyer lift for transferring. During an observation on 06/12/2024 at 10:15 AM, CNA-E and CNA-F did not lock the wheelchair while Resident #28 was being transferred from her bed to her wheelchair during a Hoyer Lift transfer. During an interview on 07/15/2024 at 2:45 PM, CNA-F stated they were not taught to lock the brakes on the Hoyer or the wheelchair during a transfer, although she was trained. She stated she did not know what the policy revealed. During an interview on 07/15/2024 at 3:30 PM the DON stated the Hoyer lift was not supposed to be locked during a transfer of residents, but the wheelchair was. She stated the DON monitored. The DON stated the failure was that some policies were confusing on when to lock the Hoyer lift and/or wheelchair. She stated the negative impact in not locking the wheelchair during a transfer was the possibility of injury to residents. She stated her expectations were that they would review the facility transfer policy, re-educate, and make sure it did not happen again. Review of facility Hoyer lift manual, https://www.manualslib.com/manual/2889017/Invacare-Reliant-450.html?page=13#manual on 07/15/2024 revealed; Invacare does not recommend locking the rear casters of the patient lift when lifting an individual. Wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675259 If continuation sheet Page 4 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 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 0689 Level of Harm - Minimal harm or potential for actual harm Review of facility policy Lifting Machine, Using a Portable dated December 2013 revealed; Purpose-The purpose of this procedure is to help lift residents using a manual lifting device. Steps in the Procedure-To transfer a resident from a bed to a chair, you should: 1. Position the chair. If it is a wheelchair, be sure the wheels are locked. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675259 If continuation sheet Page 5 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 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 Residents Affected - Many 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 record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 100 of 403 (June 8, 2023 to July14, 2024) days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 06/09/2023, 06/10/2023, 06/11/2023, 06/16/2023, 06/17/2023, 06/18/2023, 06/24/2023, 06/25/2023, 07/01/2023, 07/02/2023, 07/05/2023, 07/06/2023,07/07/2023, 07/08/2023,07/09/2023, 07/10/2023, 07/11/2023, 07/12/2023, 07/13/2023, 07/14/2023, 07/15/2023, 07/16/2023, 07/17/2023, 07/18/2023, 07/19/2023, 07/20/2023, 07/21/2023, 07/22/2023, 07/23/2023, 07/24/2023, 07/25/2023, 07/26/2023, 07/27/2023, 07/28/2023, 07/29/2023, 07/30/2023, 07/31/2023, 08/01/2023, 08/02/2023, 08/03/2023, 08/04/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/02/2023, 09/03/2023, 09/09/2023, 09/10/2023, 09/16/2023, 09/17/2023,09/24/2023, 09/30/2023, 10/01/2023, 10/07/2023, 10/08/2023, 10/14/2023, 10/15/2023, 10/21/2023, 10/22/2023, 10/28/2023, 10/29/2023, 11/04/2023, 11/05/2023, 1/11/2023, 11/12/2023, 11/18/2023, 11/19/2023, 11/25/2023, 11/26/2023, 12/02/2023, 12/03/2023, 12/09/2023, 12/10/2023, 12/16/2023, 12/17/2023, 12/23/2023, 12/24/2023, 12/28/202, 12/29/2023, 12/30/2023, 12/31/2023, 01/06/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/20/204, 01/21/2024, 05/04/2024, 05/05/2024, 05/12/2024, and 06/23/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of the facility's RN coverage tracking from 06/08/2023 to 07/14/2024 revealed 06/09/2023, 06/10/2023, 06/11/2023, 06/16/2023, 06/17/2023, 06/18/2023, 06/24/2023, 06/25/2023, 07/01/2023, 07/02/2023, 07/05/2023, 07/06/2023,07/07/2023, 07/08/2023,07/09/2023, 07/10/2023, 07/11/2023, 07/12/2023, 07/13/2023, 07/14/2023, 07/15/2023, 07/16/2023, 07/17/2023, 07/18/2023, 07/19/2023, 07/20/2023, 07/21/2023, 07/22/2023, 07/23/2023, 07/24/2023, 07/25/2023, 07/26/2023, 07/27/2023, 07/28/2023, 07/29/2023, 07/30/2023, 07/31/2023, 08/01/2023, 08/02/2023, 08/03/2023, 08/04/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/02/2023, 09/03/2023, 09/09/2023, 09/10/2023, 09/16/2023, 09/17/2023,09/24/2023, 09/30/2023, 10/01/2023, 10/07/2023, 10/08/2023, 10/14/2023, 10/15/2023, 10/21/2023, 10/22/2023, 10/28/2023, 10/29/2023, 11/04/2023, 11/05/2023, 1/11/2023, 11/12/2023, 11/18/2023, 11/19/2023, 11/25/2023, 11/26/2023, 12/02/2023, 12/03/2023, 12/09/2023, 12/10/2023, 12/16/2023, 12/17/2023, 12/23/2023, 12/24/2023, 12/28/202, 12/29/2023, 12/30/2023, 12/31/2023, 01/06/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/20/204, 01/21/2024, 05/04/2024, 05/05/2024, 05/12/2024, and 06/23/2024 there was no evidence of RN coverage. During an interview on 07/16/24 at 2:23 PM the DON stated she was responsible for scheduling RN coverage and her expectation was to have 8 hours RN coverage daily. The DON stated she was hired August 2023 and she monitored RN coverage by the schedule she made. The DON stated she did not feel there was a negative effect on residents not having 8-hour RN coverage. The DON stated RN coverage was to help oversee and support the LVN's. The DON stated she was available by phone and could have come to facility. The DON stated whet led to the failure were RN's not wanting to work full shifts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675259 If continuation sheet Page 6 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 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 Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 07/16/24 at 2:41 PM the ADMN stated his expectation was to have appropriate RN coverage as required. The ADMN stated he did not think there had been a negative affect to residents because staff had access to an RN and the DON. The ADMN stated the DON was responsible to create the schedule and he assisted in monitoring. The ADMN stated what led to the failure of not having 8-hour RN coverage was a shortage of RN 's in the area, and not being able to cover when staff called in and the DON was out for surgery. The ADMN stated between sister facilities staff always had the resource of contacting a RN. The ADMN did not think they had a policy for RN coverage, they followed the federal guidelines. Event ID: Facility ID: 675259 If continuation sheet Page 7 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 4 medication carts reviewed for storage. The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion. Findings included: During an observation on 07/14/2024 at 8:38 PM, there was an unlocked medication cart on the south hallway of facility with LVN-B out of line of site. The unlocked cart contained all prescription and Over the Counter medications that included, but not limited to eye meds, stool softeners, antipsychotics, insulins, blood pressure medications, and narcotics. During an interview on 07/14/2024 at 8:40 PM LVN-B stated, she was in charge of the medication cart. She stated she was passing medications to a resident and the cart should have been locked at all times when out of sight. She stated there were 19 resident medications stored in this medication cart. LVN-B stated the residents had the potential to obtain medications that were not theirs and possibly cause an allergic reaction. During an interview on 07/14/2024 at 8:49 PM the DON stated residents had the potential to obtain medications that were unsafe for them and cause possible harm such as an overdose or an allergic reaction if the medication cart were left unlocked. She stated the charge nurses, and the Nursing Department heads were to monitor the medication carts. She stated she was unsure where the failure was as this nurse was the charge nurse at this time. The DON stated her expectations were for the medication carts to be locked at all times when not in use or out of sight. Review of facility policy Security of Medication Cart dated April 2007 revealed: Policy Statement- The medication cart shall be secured during medication passes. Policy Interpretation and Implementation; 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3. Then it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675259 If continuation sheet Page 8 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that each resident received food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, appearance, and temperature. Residents Affected - Many The facility failed to ensure that 38 of 38 residents who received meals from the kitchen received food that was palatable, attractive, and at a safe and appetizing temperature. This failure place residents at risk of poor food intake and/or dissatisfaction of meals served. The findings were: During an observation on 07/14/2024 at 12:40 PM, the kitchen staff were plating the lunch meal and placing lids on top of meals that do not fit and some were cracked. The plated meals placed on the rolling cart were to be delivered to the residents who chose to eat in their rooms. This state surveyor monitored the test tray from the kitchen to last meal served to residents and proceeded to take the test tray to the conference room for other state surveyors to sample. During an observation on 07/14/2024 at 12:44 PM, the sample meal tray temperatures of the food were taken by the Cook. The temperatures were: pork roast was 85 degrees and was cold and tough, stuffing was 90 degrees and cool to the touch, green beans were 80 degrees and cold to taste, the roll was soggy on the bottom, and the vanilla pudding had clumps of pudding mix and did not have a smooth texture. During an interview on 07/14/2024 at 12:44 PM the [NAME] stated that she had cooked the food and did not want to test it. During an interview on 07/14/2024 at 12:48 PM the DM stated she believed the food was at the correct temperature and declined trying anything on the test tray. The DM stated her expectation was that the food temperature would be at 100 degrees or above. The DM stated all residents eat meals from the kitchen. During an interview on 07/14/2024 at 11:26 AM, Resident #37 stated vegetables were too mushy to eat and most of it was boiled, canned vegetables with no taste. During an interview on 07/14/2023 at 03:10 PM, Resident #30 stated the food was not hot, or warm. Resident #30 stated he was on a mechanical soft diet and the food did not taste good. Resident #30 stated he would have liked his food to be hot and he would put ketchup or something on it so he could eat the food. During an interview on 07/16/2024 at 12:21 PM, the DON stated she expected food to be served at the correct temperatures. The DON stated the failure occurred due to not having plate warmers and lids for the plates did not fit correctly and caused food to cool down. The DON stated residents could lose weight if not eating meals because the food was not warm or hot. During an interview on 07/16/24 at 02:46 PM the ADM stated his expectation was food served to the residents be warm, palatable, and timely. The ADM stated the effect on residents were if the food was cold residents would not eat the food. The ADM stated the DM monitors food temperatures and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675259 If continuation sheet Page 9 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete timeliness of food being served. The ADM stated food not being served in a timely manner caused the food to be cold when served to residents. Review of facility's policy titled and dated: Food Preparation and Service-Policy Statement-Food service employees shall prepare and serve in a manner that complies with safe food handling practices. Revised July 2014 Food Preparation, Cooking and Holding Temperatures and Times .2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese .5. The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms. a. poultry and stuffed foods-165 degrees. b. Ground meat, ground fish and eggs held for service-at least 115 degrees. c. fish and other meats- 145 degrees for 15 seconds. d. Fresh, frozen, or canned fruits/vegetables-135 degrees . Event ID: Facility ID: 675259 If continuation sheet Page 10 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 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 interviews, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 of 14 (Resident #29) residents reviewed for resident records. The facility failed to ensure Resident #29 had orders for weekly skin assessments. This failure could place residents at risk of having errors with their care and treatment. The findings included: Record review of Resident #29's electronic face sheet, dated 07/16/2024, revealed an [AGE] year-old female who admitted [DATE] with diagnoses: unspecified dementia, repeated falls, depression, hypertension (high blood pressure) heart failure, type ii diabetes mellitus with diabetic nephropathy (kidney disease), and pain disorder with related psychological factors. Record review of Resident #29's admission MDS dated [DATE], Section C-Cognitive Pattern revealed resident #29 had a BIMS score of 8, meaning the resident had moderately cognitively impaired. Section M Skin Conditions revealed no pressure ulcers. Record review of Resident #29's MAR (May 2024 MAR, June 2024 MAR, and July 2024 MAR) revealed no evidence that skin assessments were completed until 07/03/2024. During an interview on 07/16/24 at 10:30 AM LVN A stated that skin assessments should have been done weekly, starting at admission. LVN A stated the admitting nurse would have been responsible to add the order for skin assessments. LVN A stated if there was an order then it would have populated on a specific day and shift weekly to be completed on the nurses MAR. During an interview on 07/15/2024 at 2:40 PM the DON stated her expectation was skin assessments were to be completed weekly, starting at the time of admission. The DON stated she did not think there was a negative effect to residents because staff were doing daily foot soaks and the resident was receiving showers, so staff were looking at her skin, it was just not documented. The DON stated there should have been an order for weekly skin assessments written at admission. The DON stated what led to failure was that the admission nurse did not follow the facility's admission Checklist and she thought she must have used the orders from the previous facility. Review of facility document titled, admission Checklist, not dated, revealed Add orders into Matrix Review of the facility policy titled; Pressure Ulcer Risk Assessment dated September 2013 revealed Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis . Once inspection of skin is completed proceed to the admission Assessment or Weekly Skin Integrity tool and completed documentation of findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675259 If continuation sheet Page 11 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for halls 1 of 3 halls. Residents Affected - Some The facility staff (CNA C) failed to place dirty linens in a sealed bag before being transported from resident room. The facility staff failed (CNA D) to place dirty briefs after peri-care in a sealed back before being transported from resident room. These failures could place residents at risk for the spread of infection and skin complications. Findings included: During an observation on 07/14/2024 at 8:36 PM, CNA-D was carrying unbagged dirty briefs through the hallway to the dirty bins. During an interview on 07/14/2024 at 8:36 PM, CNA-D stated she was carrying dirty briefs unbagged from resident room to the dirty bin because she had not taken an extra trash bag to place them in. She stated all dirty linens and briefs should be bagged and sealed before transporting them outside of resident rooms. She stated in doing so, she could have caused cross contamination between residents and/or staff members. During an observation on 07/15/2024 at 10:00 AM, CNA-C was carrying unbagged dirty resident sheets through hallway to the dirty bins. During an interview on 07/15/24 at 11:13 AM, CNA-C stated she was carrying linens from a resident room to the dirty linen closet that was un-bagged. She stated she had training on infection control and how to properly transport them from resident rooms to the dirty laundry. CNA-C stated she sat them down on the floor outside of the laundry room door to obtain a bag to put them in and stated she knew that was not the correct way to transport linens. She stated the linens should have been bagged and sealed before leaving resident room. CNA-C stated, carrying the unbagged linens from a resident room this way could have caused cross contamination from resident to resident. During an interview on 07/15/2024 at 4:03 PM the DON stated, all staff were to bag dirty linens and briefs before leaving rooms. She stated anything from resident's rooms should not be un-bagged when coming out to their room. The DON stated all staff should have been monitoring, but the ADON monitors most of the time. She stated the negative impact would have been cross contamination which would lead to the spreading of infection and/or germs. The DON stated the failure occurred with the CNA's rushing and hurrying to get their duties finished, that led to forgetting what was needed to finish the task properly. She stated her expectations were to have staff reeducated with infection control and the proper way of transporting linens and dirty briefs when it came to leaving resident rooms. The DON stated if linens were clean or dirty, they were to be bagged in and bagged out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675259 If continuation sheet Page 12 of 13 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 675259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cisco 1404 Front St Cisco, TX 76437 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 07/16/2024 at 2:48 PM the ADON stated it was unacceptable to carry dirty briefs down the hallway without being bagged. She stated in-services were provided to all staff in May 2024 on Infection Control. She stated the negative impact to residents to residents transferring bacteria, which would lead to residents getting sick. She stated residents were immunocompromised and they could get sick easier. The ADON stated the DON and herself monitored, and the failure occurred with staff not following through with in services and competencies. She stated her expectations were to follow the policies. Record review of facility policy titled Infection Prevention and Control Program dated 1/1/2024 revealed: Policy: this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program. 3. Standard precautions; a. All staff shall assume that all residents are potentially infected or colonized with an Organism that could be transmitted during the course of providing resident care services 12. Linens: a. Laundry and direct staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linen shall be separated from soiled linen at all times. c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linens shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. f. Environmental services staff shall not handle soiled linen unless it is properly bagged. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675259 If continuation sheet Page 13 of 13