Inspection·December 27, 2023

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #7's clinical record revealed there was no documentation Resident #7, or their RP had been given a written notice of room change. Resident #15: Record review of Resident #15's face sheet dated 12/27/2023, revealed a [AGE] year-old female who was admitted on [DATE] with diagnoses including fracture of lumbar vertebra, rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), and osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). Record review of Resident #15's Quarterly MDS dated [DATE] revealed a BIMS score of 08, indicating moderate cognitive impairment. During an interview on 12/27/2023 at 9:15 a.m., Resident #15 said she had been moved into her current bedroom a few weeks ago. Resident #15 said she did not like the bedroom she was currently in because her personal items like her television does not fit in the room on top of the dresser. Resident #15 said that every time someone comes into the room the room entrance door bangs against the dresser, and she does not like it. Resident #15 said she moved into her current room because she did not get along with her former roommate who kept her up at night. Resident #15 said she was moved into the room without given a written notice or given an opportunity to ask any questions about the room she was being moved to. Resident #15 said she was not happy with the room and would like to go back to her old room in the 200-hall that fit her personal items. Resident #15 said her RP knows about the room change but was not sure if the facility provided a written notice of the room change or reason for the change before they moved her. During a phone interview on 12/27/2023 at 10:10 a.m., Resident #15's RP said she was Resident #15's POA. The RP said she was contacted by the facility regarding Resident #15's room move. The RP said she had not received anything in writing regarding any room changes or reason for the room change. Record review of Resident #15's clinical record revealed there was no documentation that Resident #15 or their RP had been given a written notice of room change. During an interview on 12/27/2023 at 9:35 a.m., the Administrator said resident room changes in the facility should be documented. The Administrator said she would look for documentation regarding Resident #7 and Resident #15's room change and provide the facility policy. During an interview on 12/27/2023 at 9:45 a.m., the ADON said Resident #15's RP called and asked the ADON to move Resident #15 in with her past roommate (Resident #7) because Resident #15 was not happy with her roommate at the time. The ADON said it was not documented. The ADON said during the call she told the RP that she would put the residents together but at the time the ADON had Covid. The ADON said a room became available and both residents were moved into the room. The ADON said she moved Resident #7 into the room after speaking with the POA. The ADON said she forgot to document the conversations she had with the RPs of both residents. The ADON said she was responsible to document the room move and there was no documentation regarding the room move. The ADON said Resident #15 started at the facility in a room in the 400-hall shared with Resident #7. The ADON said there was an outbreak of Covid and Resident #15 was transferred to the 100-hall. The ADON said Resident #15 was cleared from Covid and moved into her current room on 12/13/2023. The ADON said the process for room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675522 If continuation sheet Page 2 of 8 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 675522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Monahans 1200 W 15th St Monahans, TX 79756 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some moves was, the facility notifies the resident and family if they have an RP of the move. The ADON said room moves were usually documented. The ADON said there was no documentation regarding Resident #7's and Resident #15's moves because it was a quick thing. During an interview on 12/27/2023 at 11:30 a.m., the Administrator said that policy shows that room transfers should be recorded in the resident's medical record. The Administrator said an advance notice of room transfer should have been provided. The Administrator said she was unable to locate any documentation related to the room transfers for Resident #7 and Resident #15. Review of the facility policy titled Transfer, Room to Room, dated 12/2012, reads in part, Where feasible the facility will make room to room transfers when requested by the resident or as may become necessary to meet the resident's medical and nursing care needs. Notice of Room Change: Unless medically necessary or for the safety and well-being of the resident9s), a resident will be provided with an advance notice of the room transfer. Such notice will include the reason(s) why the move is recommended. Prior to the room transfer, the resident, his or her roommate (if any), and the resident's representative (sponsor) will be provided with information concerning the decision to make the room transfer. Documentation of a room transfer is recorded in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675522 If continuation sheet Page 3 of 8 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 675522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Monahans 1200 W 15th St Monahans, TX 79756 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #15) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #15's bedroom entrance door and door to the restroom were not partially blocked by a dresser. This failure could place the resident at risk of decreased quality of life due to the lack of a well-maintained environment. Findings included: Record review of Resident #15's face sheet dated 12/27/2023, revealed a [AGE] year-old female who as admitted on [DATE] with diagnoses including fracture of lumbar vertebra, rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), and osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). Record review of Resident #15's Quarterly MDS dated [DATE] revealed a BIMS score of 08 indicating moderate cognitive impairment. Section Functional Abilities and Goals revealed Resident 15's oral and toilet hygiene were supervision or touching assistance; partial/moderate assistance with toilet transfer. During an observation and interview on 12/27/2023 at 9:15 a.m., Resident #15 was observed lying in bed. Resident #15 said the bathroom entrance door bounces against the dresser. Observation revealed a crack on the wooden door of the restroom. Resident #15 said she could not really get in to use the restroom comfortably as there was a narrow entrance. Observation revealed approximately 3-foot opening to enter into the restroom, but bathroom door partially blocked by dresser in the bedroom. Resident #15 said she was incontinent, and staff change her in bed but that she sometimes used the restroom to wash her hands. Resident #15 said it makes her feel bad because she would not be able to get in the restroom comfortably. Resident #15 said when staff open the bathroom door, they bang against the dresser holding her television. Resident #15 said the main room entrance door also does not open all the way and bumps against the dresser every time someone opens the door. Observation revealed entrance opens wide until approximately a foot and a half from the wall where the door bumps into the dresser holding the television. Resident #15 said she was moved into the room without given a written notice or given an opportunity to ask any questions about the room she was being moved to. Resident #15 said she was not happy with the room and would like to go back to her old room in the 200-hall that fit her personal items. Resident #15 said she had not been injured. During an interview on 12/27/2023 at 9:35 a.m., the Administrator said she did not know about the dresser partially blocking the entrance into the restroom. The Administrator said Resident #15 was moved to the room a few weeks ago and she had not received any complaints about the room. The Administrator said she does not think Resident #15, or her roommate Resident #7 used the restroom as they were both incontinent and are assisted by staff, but the partial blocked door to the restroom was not acceptable and should be fully open and accessible for residents and staff. The Administrator said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675522 If continuation sheet Page 4 of 8 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 675522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Monahans 1200 W 15th St Monahans, TX 79756 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the risk was someone could bump into the door or the side of the entry way into the restroom resulting in injury. During an interview on 12/27/2023 at 9:45 a.m., the ADON said Resident #15 had a very large television that sits on a long dresser. The ADON said that Resident #15 was moved into the room as she requested a room change due to issues with her previous roommate. The ADON said the dresser partially blocks the entrance to the restroom. The ADON said Resident #7 and Resident #15 do not use the restroom and receive incontinence care by staff. The ADON said Resident #15 does not get out of bed without the use of a mechanical lift. The ADON said the restroom does not get used by the residents in the room although staff access the room to empty the bed pan and wash their hands. The ADON said staff were able to fit in the partial opening to dispose of the bed pan and wash their hands. The ADON said the facility gives Resident #15 a basin with water to wash her hands or they use baby wipes to wash her hands. The ADON said several staff members including maintenance and herself moved Resident #15's personal items into the room. The ADON said the move was to only be temporary. Review of facility policy titled Maintenance Services, dated 2009, reads in part: Functions of maintenance personnel include, but are not limited to: Maintaining the building in good repair and free from hazards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675522 If continuation sheet Page 5 of 8 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 675522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Monahans 1200 W 15th St Monahans, TX 79756 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 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Based on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA K) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide in that: The facility failed to ensure CNA K had a current nurse aide certification while employed at the facility while actively providing care for residents. This failure could place residents at risk for receiving care from someone unqualified to provide care. Findings included: Review of a staff roster dated 12/20/2023 reflected CNA K had a hire date of 3/31/2023. During an interview and record review on 12/22/2023 at 10:45 a.m., the BOM reviewed CNA K's employee file which revealed CNA K's certification expired 11/08/2023, and she had worked since the expiration dated. The BOM said she was unaware that the certification was expired and did not know why CNA K had not renewed her certification. The BOM said the facility did not have a system to track the expiration dates and it was the responsibility of the department head to ensure certifications were up to date. Timecard report revealed that CAN K had been working routinely as a CNA since 11/08/2023. During an interview on 12/22/223 at 10:55 a.m., the BOM said she spoke with CNA K who had been working at the time and was informed that CNA K had not renewed her certification because she thought the facility would do it. The BOM said CNA K had been taken off the floor on 12/22/2023 to work on renewing her certification. During an interview on 12/22/23 at 1:42 p.m., the Administrator said the prior ADON told CNA K that she would work on and take care of CNA K recertification. The Administrator said that this process did not occur. The Administrator said she did not know that CNA K had been working as a CNA with the expired certification. The Administrator said that CNA K had been taken off direct care when she learned of the expired certification. During an interview on 12/27/2023 at 11:15 a.m., CNA K said she was hired on 03/31/2023 as a certified nursing aide. CNA K said the previous ADON back in September said she would get her CNA certification renewed for her. CNA K said there had been issues logging into Tulip (an online system for submitting long-term care licensure applications) to get the certification updated. CNA K said she was first certified back in 2020 and the facility had paid for her certification and school. CNA K said she had since 12/22/2023 she had been working as an NA by passing out water, taking food trays and answering call lights until she was able to renew her certification. CNA K said she was up to date on her trainings at the facility. CNA K said she had her competencies reviewed about three weeks ago by the new ADON. During an interview and record review on 12/27/2023 at 1:11 p.m., the ADON said she oversaw performing competencies on staff. The ADON said CNA K's competencies and trainings at the facility were up to date. The ADON presented the competencies for review verifying competencies were current. The ADON said on 12/20/2023 she learned CNA K's certification was expired. The ADON said she was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675522 If continuation sheet Page 6 of 8 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 675522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Monahans 1200 W 15th St Monahans, TX 79756 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 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few previously aware of the expired certification and did not have a system on tracking certifications of staff. The ADON said since then CNA K has been working 8 hours as an NA instead of 12 hours as a CNA. The ADON said NA duties include passing out water to the residents, answer call lights, making beds, and passing out snacks as long as she does not have to feed any residents. The ADON said CNA K could assist with activities within the 8-hour period until her certification was updated. The ADON said that the BOM was taking care of HR duties. The ADON said the facility failed to ensure CNA K's certification was renewed because of previous ADON failing to follow-up with the process. The ADON said the risk was residents receiving services from an unqualified staff member. Review of facility policy titled Licensure, Certification, and Registration of Personnel, dated 2007, reads in part A copy of recertifications must be presented to the Human Resources Director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675522 If continuation sheet Page 7 of 8 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 675522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Monahans 1200 W 15th St Monahans, TX 79756 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 (12/20/2023) of 4 days reviewed for nurse staffing information. Residents Affected - Many The facility failed to post the required staffing information for 12/20/2023. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. Finding include: During observation on 12/20/2023 at 1:00 p.m., of the public access area nursing station located outside of the DON office, revealed a daily sheet posting information which included facility name, census, total hours for RNs, LVNs, CNAs, MAs, and shift times that was dated 12/18/2023. During observation on 12/20/2023 at 2:45 p.m., of the public access area nursing station located outside of the DON office, revealed a daily sheet posting information which included facility name, census, total hours for RNs, LVNs, CNAs, MAs, and shift times that was dated 12/18/2023. During an interview on 12/27/2023 at 9:45 a.m., the ADON said that the night staff were responsible for posting the nurse staffing information which included information on staff scheduled and total work hours. The ADON said she does not know why the information for 12/20/2023 was not posted that day and the information posted was from 12/18/2023. The ADON said she learned of this after observing the Surveyor looking at the information. The ADON said that night shift staff post the information at the end of their shift in the morning with the day's schedule staff and total hours. The ADON said the facility currently does not have a DON who would be responsible for overseeing the process. The ADON said currently she was responsible for monitoring the posting of nurse staffing information until a full time DON is hired. Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, dated 2006, reads in part, Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The information rec recorded on the form shall include: a. The name of the facility; b. The date for which the information is posted; c. The resident census at the beginning of the shift for which the information is posted; d. Twenty-four (24) hour shift schedule operated by the facility; e. The shift for which the information is posted; f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift; g. The actual time worked during that shift for each category and type of nursing staff; and h. Total number of licensed and non-licensed nursing staff working for the posted shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675522 If continuation sheet Page 8 of 8