Inspection·September 7, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some linen on the floor. The sharps container had the front portion of the lid broken and pulling away from the container. The shampoo/body wash gallon jug was on the floor with no cap and the container was full. On 9/7/23 at 9:25 AM the Hall 3 bath was observed with a dirty unlabeled hairbrush in the door storage bin. On 9/7/23 at 10:57 AM an interview with the Acting DON, , she stated the CNA and DON was responsible for ensuring the baths were orderly and clean. The Acting DON stated she expected names to be on resident hairbrushes, and if not, should be disposed. She added staff should take the linens in the shower at the time of the shower. Linens should not be on the floor. She stated if this was her facility, the condition of the showers would be monitored at least one time a shift. She stated the baths needed better storage and organization which was why the cleaning and orderliness of the bathrooms were not maintained. The Acting DON stated, sanitation problems, infections, and dignity due could result from being in an unclean area. On 9/7/23 at 12:00 PM an interview with the Maintenance Supervisor, he stated he was not aware the shields were missing on the bathroom lights. He stated he made rounds in the facility and staff submitted work orders for needed repairs. He stated staff place work orders requests into the TELS online maintenance system. He stated he also received verbal repair requests from staff. He stated staff normally make requests verbally. Record review of the Work Orders Report dated 9/7/23 for Closed Work Orders from the TELS online maintenance system revealed from 3/23/23 through 9/7/23, there were nine work orders documented. The most recent documented work order was dated 5/31/23. Since 5/31/23, there were no documented work orders initiated in the facility in the electronic system. On 9/7/23 at 2:04 PM an interview with the Acting Administrator, he stated he expected items in the bathroom to be repaired. He added staff should have cleaned the bathroom areas immediately after use and they needed cabinetry. He stated CNAs and maintenance are doing weekly rounds. He stated cross-contamination could be the result for unkept bath areas. On 9/7/23 at 2:54 PM, an interview with CNA D regarding the bath on Hall 4. She stated the other baths have shelves and that was why things were on the floor. She added she was not sure where to store the shampoo bottles, but they should have had lids; they could spill. She stated, as far as the responsibility of the shower chair, staff cleaned them between resident uses. She added sometimes staff get busy. , she stated she was not sure if any deep cleaning of the shower chairs was done. She further stated housekeeping sprays and cleans the baths really good. She stated residents using the baths and unclean hairbrushes , could result being in an unclean place and infection control problems. Record review of the facility policy titled, Cleaning and Disinfection of Resident Care Items and Equipment, Revised October 2018, revealed the following documentation, Policy Statement. Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for the disinfection, and the OSHA, blood-borne pathogen standard. Policy Interpretation and Implementation . 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 2 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 - Some Record review of the facility policy titled Maintenance Service, revised November 2021, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards . Providing routinely scheduled maintenance service to all areas. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 3 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 3 of 24 residents (Residents #9, #19, and #32) reviewed for PASRR screening, in that: Residents Affected - Some Residents #9 and #32 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. Resident #19 had an accurate, positive PASRR Level 1 screening; however, no subsequent PASRR Level 2 Evaluation. These failures could place residents with an inaccurate PASRR Level 1 Evaluation and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs. The findings were: Resident #9 Record review of Resident #9 electronic face sheet revealed an [AGE] year-old female most recently admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, Bi-polar II. Record review of Resident #9's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Bi-polar II. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 7 indicating the resident was moderately cognitively impaired. Record review of Resident #9 most recent care plan, undated, revealed a focus area and diagnosis of Bi-polar II, this problem started 04/21/2021. Resident #9 was prescribed Risperidone .5mg once a day to assist with this area of need. Record review of Physician progress notes for Resident #9 dated 09/07/2023 revealed under current medications, Resident #9 was prescribed Risperidone .5mg once a day for Bipolar II Disorder. Record review of Resident #9's Preadmission Screening and Resident Review Level One (PL1) form dated 1/21/2020 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #19: Record review of Resident #19's electronic face sheet revealed an [AGE] year-old female most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnosis of Bipolar II Disorder. Record review of Resident #19's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Bipolar II Disorder. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 10 indicating the resident was moderately cognitively impaired. Record review of Resident #19's most recent care plan, undated, revealed a focus area and diagnosis of Bipolar II Disorder, this problem started 08/09/2023. Resident #19 was prescribed Depakote Sprinkles 125mg once a day and Wellbutrin XL 125mg once a day to assist with this area of need. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 4 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Physician progress notes for Resident #19 dated 09/07/2023 revealed under current medications, Resident #19 was prescribed Depakote Sprinkles 125mg once a day and Wellbutrin XL 125mg once a day to assist with Bipolar II Disorder. Record review of Resident #19's Preadmission Screening and Resident Review Level One (PL1) form dated 10/6/2020 revealed under section C0100 Mental Illness an answer of Yes, indicating the resident does have a mental illness. The Resident does not have a PASRR Level 2 Evaluation. Resident #32: Record review of Resident #32's electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnosis of schizoaffective disorder, bipolar type. Record review of Resident #32's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of schizoaffective disorder, bipolar type. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 7 indicating the resident was moderately cognitively impaired. Record review of Resident #32's most recent care plan, undated, revealed a focus area and diagnosis of schizoaffective disorder, bipolar type, this problem started 08/29/2023. Resident #23 was prescribed Depakote 125mg twice a day, Seroquel 50mg 2 tablets twice a day, and Escitalopram 20mg once a day to address this diagnosis. Record review of Physician progress notes for Resident #32 dated 09/06/2023 revealed under current medications, Resident #32 was prescribed Depakote 125mg twice a day, Seroquel 50mg 2 tablets twice a day, and Escitalopram 20mg once a day to address his diagnosis of schizoaffective disorder, bipolar type. Record review of Resident #32's Preadmission Screening and Resident Review Level One (PL1) form dated 5/26/2023 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. During an interview conducted on 09/7/23 at 12:07PM with the Acting Administrator, he verified Residents #9, #19, and #32 had a diagnosis of mental illness. The Acting ADM verified Residents #9, and #32 did not have PASRR 2 Evaluations as all their PASRR 1 Evaluations were negative. The Acting ADM verified Resident #19 had a positive PASRR 1 Evaluation, but no subsequent PASRR 2 Evaluation. The Acting ADM stated the purpose of the PASRR 1 Evaluation was to identify if a Resident required additional services. He said if the PASRR 1 Evaluation was positive then it gets put into an online system and they reach out to the necessary people to ensure a PASRR 2 Evaluation was done. He said the MDS nurse was responsible for entering the PASRR 1 Evaluation into the system. The Acting ADM stated the potential harm if a resident with a diagnosis of a mental illness who had a negative PASRR 1 Evaluation, and no subsequent level two evaluation was the residents could potentially go without services. During an interview with the Acting DON on 09/7/23 at 12:52PM, she verified Residents #9, #19, and #32 had diagnosis of mental illnesses. The Acting DON confirmed Residents #9 and #32 did not have PASRR 2 Evaluation as their PASRR 1 Evaluations were negative after review. The Acting DON stated Resident #32 had a positive PASRR 1 Evaluation; however, the resident did not have a subsequent PASRR 2 Evaluation. The Acting DON stated it was the MDS nurses' responsibility to ensure every resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 5 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted to the facility has an accurate PASRR 1 Evaluation. The Acting DON also stated it was the MDS nurses' responsibility to ensure PASRR 1 Evaluation are completed accurately by comparing them to the residents' medical records. The Acting DON stated positive PASRR 1 Evaluations should be referred to the local mental health authority for completion of a PASRR 2 Evaluation. The Acting DON stated she did not know Residents #9, #19, and #32 had a mental illness as she was the Acting DON. The Acting DON stated the potential harm to a resident without an accurate PASRR 1 Evaluation and a subsequent PASRR 2 Evaluation was the residents will not receive the services they need. During an interview with the MDS nurse on 9/7/23 at 1:25pm, she stated Residents #9, #19, and #32 did not have PASRR 2 Evaluations. The MDS nurse stated Residents #9 and #32 do not have accurate PASRR 1 Evaluations as both residents have a diagnosed mental illness. The MDS nurse verified Resident #19 had a positive PASRR 1 Evaluation; however, Resident #19 did not have a subsequent PASRR 2 Evaluation. The MDS nurse stated it was her responsibility to ensure every resident entering the facility had a completed and accurate PASRR 1 Evaluation. The MDS nurse also stated it was her responsibility to ensure any new mental health diagnosis added after entry to the facility that warranted a new PASRR 1 Evaluation were completed. The MDS nurse stated she did not know why #9 and #32 did not have positive PASRR 1 Evaluation due to having had a mental illness diagnosis. The MDS nurse stated the potential negative outcome for residents not having an accurate PASRR 1 Evaluation and subsequent PASRR 2 Evaluation are the residents may not be offered the services they may need for their diagnosis. [NAME] Oaks Preadmission Screening and Resident Review (PASRR) Policy Revised 2/1/2023: The facility policy for PASARR states all applicants to a Medicaid-certified nursing facility are evaluated for mental health prior to admissions and offered the most appropriate setting for their needs. If the PASARR level one screening indicated the individual may have an Intellectual Disability or a Mental Illness diagnosis the facility will confer with local mental health providers to complete a PASARR level two screening. Following the completion of the level two screening a care plan will be developed by the facility in order to meet the needs of a resident with an Intellectual Disability or a Mental Illness diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 6 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 - Some 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 observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 4 resident halls (Halls 3 and 4) observed for bathroom sink water temperature in that: 4 resident rooms (Rooms 30, 31, 33 and 40) temperatures were not held between the state regulated water temperature of 100-110 Fahrenheit (F) degrees. This failure could place residents at risk for diminished quality of life, injury and burns. The findings included: Observation on 09/05/23 at 10:17 AM in room [ROOM NUMBER] revealed the water temperature from the resident-use sink was 119.1 degrees F checked with surveyor's digital thermometer. Observation on 09/05/23 at 10:19 AM in room [ROOM NUMBER] revealed the water temperature from the resident-use sink was 119 degrees F checked with surveyor's digital thermometer. Observation on 09/05/23 at 10:22 AM in room [ROOM NUMBER] revealed the water temperature from the resident-use sink was 118.1 degrees F checked with surveyor's digital thermometer. Observation on 09/05/23 at 12:22 PM in room [ROOM NUMBER] revealed the water temperature from the resident-use sink was 123.3 degrees F checked with surveyor's digital thermometer. During an interview on 09/05/23 at 12:45 PM the Maintenance Supervisor was asked about the hot water temperatures in some of the resident rooms. He stated previously that the water heater boxes had gone out. He stated that he checked water temperatures in the facility every week. He added there was no particular time that he checked the hot water, but it was whenever he had time. He stated that he checked the hot water in every room. He also stated that the last time and he had checked water temperatures in resident rooms was last week. He also stated that he looked for 105 to 110°F as the correct temperature range for resident use hot water. He stated that the water heater that controlled these halls (Halls 3 and 4) was set at 120 degrees F and he had just now adjusted it down. He added that he turned it down to 110°F. During an interview on 09/06/23 at 2:09 PM, the Maintenance Supervisor stated that he does not know why the water temperature was set so high. He stated that they had plumbers working in the facility last week and they may have turned up the temperature that controls the water heater on accident. He stated the residents have a potential negative outcome of getting burned by the hot water. During an interview on 09/07/23 at 11:42 AM, the Acting Administrator stated he was unaware of the high water temperatures on Halls 3 and 4. The Acting Administrator stated he did not know why the water heater was turned up that high and stated the Maintenance Supervisor was responsible for checking water temperatures weekly via the facilities TELS system. The Acting Administrator stated the potential negative outcome to the residents is a possible rash or blister on their skin. Record review water temperature logbook for dates 06/01/22 through 09/05/23 revealed no high-water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 7 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 temperatures. Level of Harm - Minimal harm or potential for actual harm Record review grievance report from May 2023 through September 2023 revealed no hot water concerns. Record review of facility document titled, TELS Masters, undated, reflected the following: Residents Affected - Some F-689 Accidents - Water Temperatures Description - The facility must ensure that the resident environment remains free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Purpose - The purpose of recording your water temperatures is to assure the Surveyor that your facility is remaining as free from accidental burns and scalds as possible and that any issues are addressed in a prompt and consistent manner. Surveyors will often test water temperatures at hand sinks and bathing tubs with a thermometer if they hold their hand under the water and feel it is too hot or note their skin turning red. Common Causes - A common cause of tap-water burns to the elderly include slipping and falling in the bathing tub and not being able to get back up. Residents may also not check the water before touching it. Other causes could come from mechanical issues such has temperature changes that occur when the water is being used in other areas of the building or a plumbing malfunction that causes a sudden burst in scalding water. Please note that Long Term Care residents may be more susceptible to burns than other individuals due to several factors. These include decreased skin sensitivity, communication abilities, and the inability to react quickly when exposed to hot water Review of the current American Burn Association Scald Injury Prevention Educator ' s Guide provided the following information. The basis of the information is from research conducted by [NAME], AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and Stone, M, [NAME] J, [NAME] J. The continuing risk of domestic hot water scalds to the elderly. Burns 2000; 26:347-350.: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree burns in 1 minute and water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third degree burns within 5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 8 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 seconds. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 9 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 2 medication carts (Med cart B) and 1 of 1 treatment cart, in that: The facility failed to ensure that medication and treatment carts were secured when unattended. These failures could result in the theft or misuse of medications. The findings include: Treatment cart On 9/5/23 at 2:39 PM, the treatment cart was observed near Hall 4 unlocked and unattended and contained ointments. This treatment cart was located outside of the nurse's station, but the nurse's station was unattended. On 9/5/23 at 5:33 PM the treatment cart was observed unlocked and unattended near Hall 3 at the nurse's station. The nurse station was unattended. On 9/6/23 at 8:12 AM, an observation of the treatment cart and interview revealed the treatment cart was unlocked and unattended in the corridor between rooms #26 and #27. The cart contained nystatin powder, triple antibiotic creams, and other ointments. The nurse was not present and could not be found on the corridor. The Acting DON was made aware of the unattended cart and stated, Where is she (nurse)? On 9/6/23 at 8:25 AM an interview was conducted with LVN A, who was the wound care nurse. She stated, she usually locked the cart and had left it unlocked. She added she did not know why the cart was unlocked yesterday (9/05/23). She further stated other staff had keys to the treatment cart and it should be locked. She stated, residents could get into it, if it was left unlocked and she and the DON was responsible for ensuring that the medication and treatment carts were secure. Medication cart On 9/5/23 at 7:15 PM an observation was made on Hall 4 and Medication cart B was unlocked and unattended in the corridor outside of room [ROOM NUMBER]. LVN D was in room [ROOM NUMBER] talking to a resident and a visitor in the room. On 9/5/23 at 7:16 PM an interview was conducted with LVN D, he stated, he had just walked into room [ROOM NUMBER]. He added he should have locked the cart before he went in the room. He stated he had not received any known medication security in-services and that there had been lots of staff turnover. LVN D stated people could steal medications if the medications care was unlocked. Observation on 09/07/23 at 10:42 AM revealed Medication cart B was unlocked and unattended in Hall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 10 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 3. Level of Harm - Minimal harm or potential for actual harm Interview on 09/07/23 at 10:44 AM, LVN E stated the medication cart should have been locked when it was unattended. LVN E stated she forgot to lock the cart before she walked away from it. LVN E stated the potential negative outcome could be residents getting into medications they should not be into. Residents Affected - Some On 9/7/23 at 10:57 AM an interview with the Acting DON, she stated staff got busy and distracted which was why the carts were not locked. She stated she expected staff to lock the carts, so the residents could not get the medications. She stated she would [NAME]-service the staff. On 9/7/23 at 2:04 PM an interview with the Acting Administrator revealed he expected staff to have locked the carts. He stated the DON and ADON are responsible for the cares, and they should check the carts randomly. He stated residents could get in the medications and get something they should not have if the cart was not locked. Record review of the facility policy titled Administering Medications, Revised April 2019, revealed the following documentation, Policy Statement. Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 16. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aid. It may be kept in the doorway of the resident's room, with open drawers, facing inward, and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by . Record review of the facility policy, titled Nursing Care Center Pharmacy Policy and Procedure Manual, 2007, Section 4.1, Medication Storage, Storage of Medications, revealed the following documentation, 4.1 Storage of Medication. Policy. Medication and biologicals are stored properly, following manufactures, or provider pharmacy recommendations, to maintain their integrity, and to support safe effective drug administration. The medication supplies shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures. 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aids) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. Record review of the facility policy titled in Nursing Care Center Pharmacy Policy and Procedure Manual, 2007, Section 7.1, Medication Administration General Guidelines, revealed the following documentation, 7.1 General Guidelines. Policy. Medications are administered as prescribed in accordance with manufacture specifications, good nursing practice principles and practices and only by persons legally authorized to do so . Procedures. Medication Administration. 17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 11 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 visible to the personnel, administering medications when unlocked . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 12 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 in 1 of 1 kitchen reviewed for dietary services, in that: 1)The facility failed to ensure foods were processed under sanitary conditions during puree preparation, 2) The facility failed to ensure Dietary staff dated and labeled foods as required, 3) The facility failed to ensure Dietary staff maintained quaternary sanitizer levels within acceptable ranges in wiping cloth solutions. 4) The facility failed to ensure Dietary staff ensured food and non-food contact surfaces were clean, 5) The facility failed to ensure foods were stored in a sanitary manner, 6) The facility failed to ensure Dietary staff used good hygienic practices, 7) The facility failed to ensure foods were retained within manufacturer's recommended timeframes, and 8) The facility failed to ensure Dietary staff maintained chlorine sanitizer levels within acceptable ranges in the 3 compartment sink. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observations and interviews on 9/05/23 from 11:00AM to 11:59AM revealed the following during a kitchen tour: During an interview on 9/05/23 at 11:00 AM, the Dietary Manager stated they were not using the dishwasher at this time. The Dietary manager stated the disposal had backed up into the dishwasher and the issue had started on Sunday night (9/03/23). She also stated the dishwasher vendor was coming today to work on the dishwasher. The Dietary Manager checked the quaternary sanitizer in the three-compartment sink. The sanitizer test strip indicated the solution was between 0 and 100 ppm . She checked it a total of four times in the three-compartment sink basin and from the quaternary sanitizer dispenser directly. On 9/5/23 at 11:08 AM the Dietary Manager was interviewed regarding the quaternary sanitizer. She stated she checked the level briefly that morning (9/05/23). During an interview on 9/5/23 at 11:12 AM the Dietary Manager was asked what range she looked for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 13 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 as correct for the quaternary sanitizer. She stated, it should be 100 ppm or 200 ppm. Level of Harm - Minimal harm or potential for actual harm In the white refrigerator there were 11 uncovered drinks. There was also rusted areas on the interior of the refrigerator. Residents Affected - Many The milk chest refrigerator was soiled with dried spills on the interior and also had dirt and mold buildup along the lid trim. There was 1 gallon of milk that was a labeled Best by August 31. The large freezer in the kitchen had a missing light shield. Cottage cheese in the front large refrigerator was labeled, Best By 8/26/23. There was also an opened bag of mozzarella cheese in this refrigerator that was not dated and labeled. On 9/5/23 at 11:20 AM temperatures of the food items were taken by the Dietary Manager on the service line using a dial thermometer with the following results: -Pork 160°F -Potatoes 180°F. -Carrots 150°F -Puréed carrots 149°F. -Cornbread no temperature taken -Brown gravy no temperature taken -Ground pork 200°F -Puréed pork 170°F On 9/5/23 at 11:28 AM an interview and observations were conducted with the Dietary Manager. She stated the last time the staff calibrated the dial thermometers last Friday (9/01/23). The two dial thermometers from the facility and the surveyor's digital thermometer were placed in ice water to check their accuracy. The surveyor's digital thermometer was 33.3°F and both of the dial thermometers for the facility was 40°F. The facility dial thermometers were reading 6 degrees too high. The Dietary Manager was observed placing scoops potatoes into the processor. Prior to that the surveyor asked and checked the interior of the processor and blade and the blade was wet. There were seven sets of fluorescent lights in the kitchen and three sets had no caps on the fluorescent lights, and two were not shielded. The lower cabinetry had dried spills on the shelves. There were cartons of milk and thickened liquids stored in a tub of undrained ice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 14 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 The drink gun had a buildup of syrup. Level of Harm - Minimal harm or potential for actual harm On 9/5/23 at 11:35 AM an interview and observation were conducted with Dietary staff A. She stated that the solutions in the red and green buckets were all sanitizers. Dietary staff A then attempted to test the sanitizer in the green bucket with a chlorine test strip. There was no reaction indicated on the test strip since the sanitizer in the bucket was quaternary. At 11:38 AM Dietary staff A asked the Dietary Manager if there were different test strips used for the quaternary sanitizer and where they were located. At 11:40 AM Dietary staff A was observed dipping the test strip in the green bucket for one second. The green bucket tested at 100 ppm quaternary sanitizer instead of the required 200-400 ppm. This green bucket was at the front counter. She then tested the red bucket that was on the rear counter, and it tested at 0 ppm quaternary sanitizer, and the water was dirty and had wiping cloths in it. Residents Affected - Many In the pantry, there were bottles of [NAME] Designer Dessert Sauces that were beyond the manufactures recommended use by date. The caramel flavored two bottles were labeled Best if used by June 2022, cinnamon flavor was labeled, Best if used by April 2023, key lime flavor was labeled Best if used by January 2023. There was also no cap on the key lime flavor. The mango flavor was labeled Best if used by January 2023. Observation and on 9/5/23 at 11:49 AM revealed there were nine drinks still uncovered in the white refrigerator. On 9/5/23 at 11:50 AM, an interview and observation were conducted with Dietary staff A. She stated, she just placed lids on two of the uncovered drinks in the white refrigerator. She added the other 9 uncovered drinks were juices for meals, but they were frozen now. Observation revealed that these were glasses of orange juice and cranberry juice. She further stated this refrigerator was ancient. The can opener had a buildup of dried food on the blade. The microwave exterior had gummy grease Observations on 9/05/23 from 4:45PM to4:48PM revealed the following during a kitchen tour: There was a tub of milk cartons and thickened tea, stored in a tub of undrained ice. The dishwasher vendor had not come to repair the dishwasher, or the three-compartment sink quaternary sanitizer dispensing unit. observations on 9/06/23 from 10:40 AM to 10:51 AM revealed the following during a kitchen tour: There was a bottle of Equate Hand Sanitizer stored on the counter next to the ice scoop, and the drink gun. The label revealed the following, .Warning. For external use only: Hands. Flammable. - The following observations were made, and interviews conducted during a kitchen tour on 9/06/23 that began at 11:38 AM and concluded at 11:59 AM: On 9/6/23 at 11:38 AM purée preparation was observed, and an interview was conducted with Dietary staff B. She stated that she had seven purées, and she was pureeing burritos. Observation of the interior of the processor pot revealed that it was wet, and the blade was wet. Dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 15 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 Residents Affected - Many staff B placed burritos and milk in the processor and puréed the mixture and then placed the purée in a pan. The blade to the can opener had a buildup of dried food and was dirty. Dietary staff B washed the processor pot and blade in a three-compartment sink. After the final chlorine sanitizing rinse, the parts were dripping wet. She took the dripping wet processor parts and put it in the processor unit. She then placed 5 cups of rice into the wet processor and puréed it. The Dietary staff A tested the three-compartment sink final chlorine sanitizing rinse and it only had 10 ppm chlorine instead of the required 50-200 ppm range. On 9/6/23 at 11:58 AM an interview was conducted with Dietary staff B. She stated she set up the three-compartment sink chlorine sanitizer rinse at 10:15 AM. Six of 6 cutting boards were dirty and stored with clean food equipment. Dietary staff A was handled the large trashcan lid with her bare hand and then placed the lid on a pitcher of tomato juice. - The following observations were made, and interviews conducted during a kitchen tour on 9/06/23 that began at 12:35 PM and concluded at 1:05 PM: 9/6/23 at 12:35 PM observation was made of temperatures taken by Dietary staff B on the steam table. She used the same dial thermometer as had been used on 9/05/23. The results were as follows: Queso 170°F Corn 180°F Puréed rice, 140°F. Purée burrito 140°F Tomatoes diced and on ice and was 45°F. Salad on ice and was 46°F. Tomato soup was 160°F Burritos were 160°F. Puréed cake at room temperature at 72°F then placed on ice. Observation on 9/6/23 at 12:53 PM revealed the facility dial thermometer and surveyor's digital thermometer were compared in ice water and the surveyor's thermometer was 33.3°F and the dial thermometer for the facility was 40°F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 16 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 On 9/6/23 at 12:54 PM an interview and observation were conducted with a Dietary Manager. Regarding if she had calibrated her thermometer since they were known to be inaccurate the day before (9/05/23). She stated no she had not and had bought new ones. Observation revealed that she had purchased 2 dial thermometers, and these were tested by the Dietary Manager in ice water. The new thermometers were also 40°F and ice. The facility dial thermometers were reading 6 degrees too high. Residents Affected - Many Puréed cake, cartons of milk and thicken tea were in a bin of undrained ice. Dietary staff A retrieved a stack of Styrofoam containers, and they contacted her chest, - The following observations were made during a kitchen tour on 9/07/23 that began at 9:40 AM and concluded at 9:55 AM: A posted sign above the three-compartment sink revealed the following, Dishwashing: three sink method . 3. Sanitize. clean water and sanitizing solution. Food contact surface sanitizing: sodium hypochlorite solution - use dilution 50 to 200 ppm . Observation of the service line, steam table revealed that the area between the shelf and the steam table had an accumulation of dried food and buildup between them. On 9/7/23 at 10:50 AM an interview was conducted with Dietary staff A, she stated, she should have washed her hands in between touching the trash can lid and handling the pitcher. She stated, she was just frazzled which was why she used the incorrect test strips to test the sanitizer. She stated it was an accident that the Styrofoam containers came in contact with her clothing. She added she had only come back to work last week full-time and was part time for five months before. She stated, she needed a dietary training refresher and the lack of training could result in transferring germs to foods. She stated she trained with a co-worker a few days. On 9/7/23 at 11:14 AM an interview with the Dietary Manager, she stated maintenance was supposed to order shields and bulbs and she was unsure how long the lights had not had shields. She stated dietary staff had a cleaning list they signed off on. Regarding the white refrigerator, she stated, the white refrigerator needed to be looked at. She stated, training was usually three days minimum, and she monitored for retraining. The Dietary manger issues were found in the kitchen because of staff nervousness; being in a hurry; and other things happening like the dishwasher was not working. She stated ultimately her, and staff also was responsible to ensure dietary procedures were carried out correctly. She added staff should not have been careless and should have conducted the correct procedures. She stated residents could get contaminated food and infection control problems. Regarding if there was any staff monitoring conducted, she stated did when got a chance she did monitor the staff She added she also had to dietary duties and the dietary department was short staffed. She stated, she did as much as she could. On 9/7/23 at 2:04 PM an interview with the Acting Administrator he stated he expected staff to report needed repairs and dietary issues should be caught in the dietitian's report. He stated the Dietary Manager and Administrator was responsible dietary procedures being carried out correctly,. Regarding what could result from these dietary issues observed, he stated residents could get sick; glass could get broken and contaminate food. Record review of the dietary department in-services from July 2023 thru September 2023, revealed there were two in-services provided for the dietary staff: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 17 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 *On 7/14/23 an in-service was conducted regarding Shelf Life of foods. Level of Harm - Minimal harm or potential for actual harm *The in-service dated 8/1/23 was regarding Full Liquid Versus Clear Liquid Diet. Dietary staff B attended both in-services and Dietary staff A attended, the in-service dated 8/1/23. Residents Affected - Many Record review of the September 2023 Daily Cleaning Schedule for 9/4/23 through 9/10/23, revealed the following documentation, Item - Can opener. When - after each use. Item - Cleaning cloth. When - once a day. Item - Cutting boards. When - after each use . Item - Juice machine. When - once a day . Item - Other equipment. When - after each use. Item - Steam table (wipe out). When - after each meal. Record review of the Auto Chlor QA quat solution label revealed the following, . To Sanitize Pre-Cleaned Public Eating Establishment Surfaces. immersed in 200 to 400 ppm quaternary solution. Drain the use solution from the surface and air dry. Do not rinse . Record review of the Auto Chlor Solution QA Ultra quaternary sanitizer label revealed the following, . Food Contact Surfaces Sanitization . Sanitization. 200 to 400 ppm. Record review of the Test Strip Log for the Three Compartment Sink revealed that on 9/6/23, there was no documentation for the sanitizer being tested on the breakfast or morning test time and for the noon or midday test time. Record review the facility policy, titled Nutrition and Food Service Policies and Procedures. Manual, 2018, Section 4-7, revealed the following documentation, Policy: Cleaning Schedules. Policy Number: 04.004, revealed the following documentation, Policy: the facility will maintain a cleaning schedule, prepared by new the nutrition and food service manager, and followed by employees as scheduled in order to ensure that the kitchen is clean and free of hazards. Procedure: 1. The nutrition and food service manager will develop a cleaning schedule for the daily, weekly and monthly cleaning. 3. The cleaning list will be posted weekly and initialed off and dated by each employee upon completion of the task. The nutrition and food service manager or designee will verify that the tasks were completed as assigned. Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures Manual, 2018, Section 4-5, Policy: General Kitchen Sanitation. Policy Number: 04.003, revealed the following documentation, Policy: the facility recognizes this that foodborne illness has the potential to harm, elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary, kitchen facilities, in accordance with the state and US Food Codes in order to minimize the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 18 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 risk of infection and foodborne illness. Procedures: Level of Harm - Minimal harm or potential for actual harm 1. Clean and sanitize all food preparation areas, food contact, surfaces, dining facilities, and equipment. After each use, clean and sanitize, all tableware, kitchenware and food contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. Residents Affected - Many 2. Clean food contact surfaces of grills, griddles, and similar cooking devices in the cavities and door seals of microwave ovens at least once a day; except for hot oil cooking equipment and hot oil filtering systems. 3. Keep food contact surfaces of all cooking equipment free of encrusted grease deposits, and other accumulated soil. 4. Clean and sanitize all multi-use utensils and food contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation period based on food temperature, type of food and amount of food particle accumulation. 5. After cleaning and until use, store and handle all food contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects, and other contaminants. 6. Clean nonfood contact surfaces of equipment at intervals, as necessary to keep them free of dust, dirt, and food particles, and otherwise in a clean and sanitary condition. 7. Store, handle and dispense all single service articles in a sanitary manner and use only once . 9. Clean and rinse immediately prior to use, moist cloth, use for wiping food spills on kitchenware, and food contact surfaces of equipment. Clean frequently during use in a sanitizing solution, and do not use for any other purpose. When not in use, hold in a sanitizing solution of the proper concentration, (100 ppm chlorine, 200 ppm quaternary ammonium, or 25 PPM iodine). 10. Clean and rinse in a sanitizing solution, moist cloths used for cleaning nonfood contact surfaces, of equipment such as counters, dining table, tops, and shelves, and do not use for any other purpose. Record review of the facility policy titled Maintenance Service, revised November 2021, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 19 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 Maintaining the building in good repair and free from hazards . Level of Harm - Minimal harm or potential for actual harm Establishing priorities in providing repair service . Providing routinely scheduled maintenance service to all areas. Residents Affected - Many Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 20 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly in 5 of 5 dumpsters (#1, #2, #3, #4 and #5), in that: Residents Affected - Some The facility failed to maintain the dumpster/refuse disposal container in a manner that effectively prevented the harborage and attraction of pest. These failures could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. The findings include: On 9/5/23 at 12:00 PM an observation was made of the dumpster area. Housekeeping staff A placed trash in dumpster #5 and left 1 of 2 lids open. There were five dumpsters, and the dumpster #2 was leaking and pooling liquid on the cement pad. The leak area was approximately 4 x 4' in the rear of the dumpster which was still wet and approximately 2' x 2' dried area where it had been leaking. The dumpster #3 and dumpster #5 had no plug. On 9/5/23 at 4:47 p.m. an observation was made of the dumpster area. Dumpster #2 was still leaking as observed previously. On 9/6/23 at 10:43 AM an observation was made of the dumpster area. One of the five dumpsters had a lid open and had trash in it. Dumpster #4 had one of two lids open. Dumpster #2 was actively leaking and pooling around the dumpsters. The area was an L-shaped area of leaking that was approximately 3' x 1' wet area and an 18 x 4' area that was dry. On 9/7/23 at 9:26 AM, an interview and observation were conducted with the Maintenance Supervisor regarding the dumpster refuse issue. He stated, the dumpster vendor picked up and emptied the dumpsters approximately every two weeks. He stated staff should have thrown the trash in the dumpster and closed the lid. He added, he had placed signs on the dumpsters reminding staff to close them, but the signs were gone. He stated he placed the signs on them on a couple of months ago but did not put them back up since staff learned to close the lids. He added the last time the signs were on the dumpsters was approximately three months ago. He stated little by little the signs disappeared. He further stated the facility had new staff. He stated dumpster#1 and #2 s are used by the kitchen and dumpster # 3, 4 and 5 are used by housekeeping aides. He added this was how he knew who left them open. Further observation revealed dumpsters #3 and #5 were missing plugs. Dumpster 4 was rusted through the dumpster across the front at an approximately 5-foot long open area. Dumpster #2 was still leaking with pooling liquid. He stated he was not aware the dumpsters were leaking, had no plugs, and dumpster #4 was rusted through in the front. The Maintenance Supervisor further stated the dumpster vendor was the one to call for repair issues and the company was new. He stated lack of communication and new staff was the reason garbage disposal was an issue. He added, his duties included checking to see if the dumpsters were closed. he stated the trash company was responsible to ensure they were repaired. he stated, contamination, spread of germs and contaminating residents in the community could result from garbage disposal issues. On 9/7/23 at 2:04 PM an interview with the Acting Administrator , he stated the vendor company needed to be called to get them replaced. He stated he expected staff to close the dumpster lids if they were open., he stated the Maintenance Supervisor was to maintain the dumpsters and it should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 21 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some part of his rounds. , he stated residents could be exposed to hazards brought in; animals and mice could get into the building. Record review of the facility policy titled Maintenance Service, revised November 2021, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to . Establishing priorities in providing repair service . Maintaining the grounds, sidewalks, parking lots, etc., in good order. Providing routinely scheduled maintenance service to all areas. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 22 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to establish and maintain an effective Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection for all residents in that: Residents Affected - Few -PPE doffing boxes were in the hallway outside the Covid positive rooms. -The Housekeeping Supervisor was observed going in a Covid positive room wearing an N95 mask with no gown, gloves, or face shield on. No handwashing observed before entering Covid positive room or after exiting the Covid positive room. -The facility went from 6 Covid positive residents on 08/28/23 to 33 Covid positive residents on 09/05/23. These failures could place all residents at risk for contracting the COVID 19 virus. Findings included: Interview on 09/05/23 at 9:45 AM, the BOM stated that currently there were 26 residents that were positive for COVID. She stated the positive residents resided all over the building. She also stated that they had tested residents for COVID this morning also. She stated the Administrator and DON were not present due to being positive for COVID. Record review of Resident #1's face sheet, dated 09/05/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of essential hypertension (high blood pressure), personal history of COVID-19 and muscle weakness. Record review of Resident #11's face sheet, dated 9/5/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Major depressive disorder (mental illness), Dysphagia (difficulty swallowing), cerebrovascular disease, and Type 2 Diabetes. Observation on 09/05/23 at 10:06 AM, the Housekeeping Supervisor was observed going in room [ROOM NUMBER] to handle the trash wearing only an N95 mask. Observed signage on room [ROOM NUMBER] stating contact precautions. No hand hygiene observed on entrance into room [ROOM NUMBER] or exit from the room. Observed a PPE disposal (doffing) box in the hallway by room [ROOM NUMBER]. The door to room [ROOM NUMBER] remained open. Resident #1 and Resident #11 resided in room [ROOM NUMBER] and were both Covid positive. Record review of Resident #22's face sheet, dated 09/05/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of muscle weakness, personal history of COVID-19 and arthritis. Record review of Resident #34's face sheet, dated 09/19/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of essential hypertension (high blood pressure), dementia (loss of cognitive functioning), and urinary tract infection. Observation on 09/05/23 at 10:12 AM, room [ROOM NUMBER] was observed with the door open, no signage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 23 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 - Few on door and no PPE storage box outside room. Resident #22 and Resident #34 resided in room [ROOM NUMBER]. Resident #22 was positive for Covid and Resident #34 was negative for Covid. Record review of Resident #8's face sheet, dated 09/19/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (breathing related problems), dementia (loss of cognitive functioning), and personal history of COVID-19. Record review of Resident #23's face sheet, dated 09/19/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of urinary tract infection, muscle weakness and personal history of COVID-19. Observation on 09/05/23 at 10:17 AM, room [ROOM NUMBER] was observed with the door open, no signage on the door and no PPE storage box outside room. Resident #8 and Resident #23 resided in room [ROOM NUMBER]. Resident #8 was negative for Covid and Resident #23 was positive for Covid. Record review of Resident #35's face sheet, dated 09/19/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of unspecified dementia (loss of cognitive functioning), acute respiratory disease (lung problems) and age-related osteoporosis (bone disease). Record review of Resident #25's face sheet, dated 09/19/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), acute kidney failure, and dementia (loss of cognitive functioning). Observation on 09/05/23 at 10:24 AM, room [ROOM NUMBER] was observed with the door open, a contact precautions sign on the door and a box to store PPE outside the room in the hallway. Resident #25 and Resident #35 resided in room [ROOM NUMBER]. Resident #25 was negative for Covid and Resident #35 was positive for Covid. Observation on 09/05/23 at 12:10 PM, room [ROOM NUMBER] was observed with the door closed and signage on the wall stating that contact precautions used and signage for PPE donning and doffing from CDC. There was a PPE storage cart located next to the room and a PPE disposal box for used PPE in the hallway. Record review of Resident #53's face sheet, dated 09/07/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses unspecified dementia (memory problems), constipation and altered mental status Record review of Resident #5's face sheet, dated 09/19/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of parkinson's disease (brain disorder), essential hypertension (high blood pressure), and personal history of COVID-19. Observation on 09/05/23 at 12:30 PM, room [ROOM NUMBER] was observed with signage on the door stating contact precautions should be used. There was a PPE disposal box outside the door in the hallway. Resident #5 and Resident #53 resided in room [ROOM NUMBER]. Resident #5 was negative for Covid and Resident #53 was positive for Covid. Observation on 09/05/23 at 12:50 PM of the small dining room revealed Residents #10, #11, #14 and #16 (all who were Covid positive) were eating their lunch meal. Residents #10, #11 and #16 were being assisted and fed their meals by CNA A and CNA B. CNA A and CNA B were wearing a N95 mask for PPE. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 24 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 - Few Interview on 09/05/23 at 12:51 PM, CNA A stated she and CNA B were from another facility and stated she believed the 4 residents in the small dining room were positive for Covid. Observation on 09/05/23 at 1:17 PM, the Social Worker was observed wearing a N95 mask in the small dining room talking with Covid positive residents. The Social Worker then went to talk with residents in the main dining room with Covid negative residents. The Social Worker did not wear protective clothing or perform hand hygiene. Observation on 09/05/23 at 1:21 PM, Resident #50 (Covid positive) was feeding himself in the small dining room. The Social Worker was observed picking up a food container on the table of Resident #16 with no gloves or gown. CNA A was observed wiping off the clothing from the lap of Resident #16 with a napkin. Resident #16 was not wearing her mask. The Social Worker was observed touching the shoulder of Resident #16. Observation on 09/05/23 at 2:59 PM, CNA C was observed doffing her gown in the hallway outside of room [ROOM NUMBER]. Record review of Resident #33's face sheet, dated 09/07/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), essential hypertension (high blood pressure) and personal history of COVID-19. Record review of Resident #18's face sheet, dated 09/19/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of polyneuropathy (nerve disorder), dementia (loss of cognitive functioning), and personal history of COVID-19. Interview on 09/05/23 at 3:00 PM, CNA C stated there was one resident in room [ROOM NUMBER] who was Covid positive (Resident #33) and one resident who was Covid negative (Resident #18). At this time, CNA C double bagged the soiled PPE and placed the bag on top of the storage cart containing clean PPE. She stated there was supposed to be a box placed in the corridor for the staff to doff their used PPE. Observation on 09/05/23 at 3:29 PM revealed a PPE disposal box outside room [ROOM NUMBER] in the hallway. Interview on 09/05/23 at 3:40 PM, the Acting Administrator stated that now the facility had 33 positive residents, 10 positive staff and 1 positive agency staff. The Acting Administrator stated on 08/28/23, 6 residents tested positive for Covid and no staff members. He stated on 09/01/23, 18 residents tested positive for Covid, 5 staff members and 1 agency staff member. He stated he did not know why Covid was spreading at the facility. Record review of the facility's policy and procedure titled, COVID-19 Infection Prevention, undated, reflected the following: Policy Statement In the event of a suspected or confirmed COVID-19 infection, staff will promptly implement appropriate interventions and a management plan based on the Center for Disease Control's (CDC) guidelines, state and federal regulations, and/or guidance from the local health authority to prevent the spread (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 25 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 of infection. Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation .3. Implement Source Control (masks) Measures Residents Affected - Few -Source control options for HCP include: -A NIOSH approved particulate respirator with N95 filters or higher -A respirator approved under standards used in other counties that are similar to NIOSH approved N95 filtering facepiece respirators (KN95) (Note: These should not be used instead of a NIOSH approved respirator when respiratory protection is indicated); -A barrier face covering that meets ASTM F3502-21 requirements including workplace performance and workplace performance plus masks; or -a well-fitting facemask Any of the above options used solely for source control can be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If using a NIOSH approved particulate respirator with N95 filter or higher during care of a patient with COVID-19 infection, it should be removed and discarded after the patient care encounter and a new one should be donned . 4. Implement Universal Use of Personal Protective Equipment (PPE) Standard precautions should be used for residents if COVID-19 infection is not suspected. Full PPE should be used when: -caring for a resident with suspected or confirmed COVID-19; -performing COVID-19 tests for any individual; or -during times of high transmission in the community, consideration should be given to broader use of respirators and eye protection by HCP during resident care . 7. Placement and Response to Newly Identified COVID-19 Infected Residents -Residents with signs or symptoms consistent with COVID-19 who have had close contact or those who test positive should be placed in a single-person room, if possible. -If limited single rooms are available, or if numerous residents have suspected or confirmed COVID-19 infection, residents should remain in their current location . 8. Environmental Considerations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 26 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 - Few .Management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures Interviews on 09/05/23 at 5:47 PM, LVN C, CNA C and CNA E stated that residents in room [ROOM NUMBER] and room [ROOM NUMBER] were Covid negative. At that time, the surveyor showed them the facility list documenting room [ROOM NUMBER] (Resident #50) was Covid positive. None of the three individuals were aware that Resident #50 was Covid positive. There was no signage on the wall or door at room [ROOM NUMBER] indicating that any type of precautions should be used with Resident #50 since he was Covid positive. Observation on 09/05/23 at 5:54 PM revealed Covid positive rooms #18, #19, #20, and #23 had their doors open. There were PPE disposal bins in the hallway full of used gowns and one that had soiled laundry which had a yellow bag. These bins were in Hall 2 and located between rooms #20 and #21. On 09/06/23 at 8:41 AM an interview and observation were conducted with LVN B regarding which COVID positive residents resided in room [ROOM NUMBER]. She stepped into room [ROOM NUMBER] and was not wearing a gown or gloves. She took her cell phone and shine the light into the resident's face in the A bed. She stated It's Resident #20. She looks bad. She then walked out of the room and stated, she had worked Friday Saturday and Sunday (09/01/23 - 09/03/23) and Resident #20 tested positive on 09/03/23. Regarding She was asked why she had walked into the room without proper PPE, she stated, she was trying to see who the resident was. She added she guessed she should have gowned up. Observation on 09/06/23 at 8:45 AM, PPE disposal boxes were in the hallway at room [ROOM NUMBER] and was full of used gowns. The yellow bag linen bin was in the corridor between Rooms #22 and #23. Observation on 09/07/23 at 8:27 AM revealed there was a large trash bag filled with soiled gowns/used PPE and trash on hall 2. The bag was placed on the floor near room [ROOM NUMBER] and the hall exit door. On 09/07/23 at 8:45 AM an interview was conducted with LVN B and observation. She stated in room [ROOM NUMBER] were Residents #13 and #23 who tested positive today (9/07/23). She further stated that Resident #37 also tested positive today but was left in her room on hall four (room [ROOM NUMBER]). Record review of the Resident Bed List Report dated 9/05/23 revealed Resident #37 had been the roommate to Resident #55 who tested COVID positive on 8/31/23 and was hospitalized on [DATE]. On 09/07/23 at 10:29 AM, the Acting DON stated she will keep the staff informed and updated on their infection control policies via in-services and answering their questions. The Acting DON stated she will be making rounds more frequently to ensure the staff stay compliant and will intervene, in-service and train any staff observed not following the facilities policies. She stated the residents and staff have a potential negative outcome of increasing Covid positive cases at the facility if staff are not following their infection control policies. On 09/07/23 at 11:42 AM, the Acting Administrator stated the facility has monitoring systems in place at this time to check residents, ensure Covid positive room doors are closed, Covid positive residents to remain in their room or encourage a mask if they must leave their room, paper plates and utensils are now being used for Covid positive residents and all Covid positive residents have been isolated to Hall 2, which they have dedicated to be the Covid hallway. The Acting Administrator stated they have been educating all staff regarding droplet/contact precautions, hand washing, disposing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 27 of 28 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 675646 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Snyder 210 E 37th St Snyder, TX 79549 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 of soiled items and expectations for meal times for Covid positive residents. The Acting Administrator stated he thought the Covid outbreak at the facility happened due to lack of education regarding isolating Covid positive residents. The Acting Administrator stated he understood the need for immediate action as a continued outbreak with residents and staff was a potential negative outcome. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675646 If continuation sheet Page 28 of 28