Health inspection·July 23, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 07/22/2024 at 1:23 PM, Resident #1's bathroom door had numerous small, brown, dried stains. The floor in front of the door was sticky, as the surveyor's shoes were sticking to the ground. Resident #1 granted permission for the surveyor to view his bathroom. Upon entrance to the bathroom, there was a strong urine odor. The toilet had a gray bedside commode frame that was over the toilet seat. The gray bedside commode frame and toilet seat underneath had brown substances that looked like dried poop splatters. The brown substances covered the back of the toilet bowl, the sides of the toilet, the walls beside the toilet, the floor in front of the toilet, and covering the seat and frame of the bedside commode frame over the toilet. The inside of the toilet bowel was stained a grayish brown and the water was a light yellow-brown color. There was a pair of green pants in the corner of the bathroom floor. Resident #1 stated no one had been in to clean his bathroom. Resident #1 stated it bothered him and he did not want to use it. Resident #1 stated there were several toilets further down the hallway that were cleaner. During an observation on 07/23/2024 at 8:46 AM, Resident #1's bathroom door had numerous small, brown, dried stains. The floor in front of the door was sticky, as the surveyor's shoes were sticking to the ground. Upon entrance to the bathroom, there was a strong urine odor. The toilet had a gray bedside commode frame that was over the toilet seat. The gray bedside commode frame and toilet seat underneath had brown substances that looked like dried poop splatters. The brown substances covered the back of the toilet bowl, the sides of the toilet, the walls beside the toilet, the floor in front of the toilet, and covering the seat and frame of the bedside commode frame over the toilet. The inside of the toilet bowel was stained a grayish brown and the water was a light yellow-brown color. There was a pair of green pants in the corner of the bathroom floor. During an interview on 07/23/2024 beginning at 8:49 AM, Housekeeper A stated she had worked 07/22/2024 and 07/23/2024 as a housekeeper on Resident #1's hallway. Housekeeper A stated when she worked as a housekeeper, she was supposed to clean every room and every bathroom. During an interview on 07/23/2024 beginning at 8:50 AM, the Housekeeping Supervisor stated Resident #1's bathroom was unacceptable and unsanitary. The Housekeeping Supervisor stated she expected the housekeeping staff to clean every room, every day, including the bathroom. The Housekeeping Supervisor stated she was responsible for monitoring to ensure the rooms and bathrooms were cleaned, but she was short staffed and had been working in laundry. The Housekeeping Supervisor stated it was important to ensure the bathrooms were cleaned every day for the health of the residents. The Housekeeping Supervisor stated it was important to ensure the residents had a sanitary environment. During an interview on 07/23/2024 beginning at 8:56 AM, Housekeeper A stated Resident #1's bathroom always looked dirty. Housekeeper A stated she cleaned Resident #1's bathroom on 07/22/2024 at approximately 10:40 - 10:45 AM. Housekeeper A stated she only cleaned the bathroom once a day. Housekeeper A stated she was not responsible for making sure the dirty clothing was picked up, that was a CNA's responsibility. Housekeeper A stated it was important to ensure the bathrooms were adequately cleaned because it was nasty and unsanitary. Housekeeper A stated the residents should have had a clean space. During an interview on 07/25/2024 beginning at 5:13 PM, the Administrator stated he expected the housekeepers to clean each room and bathroom daily. The Administrator stated Resident #1's bathroom should had been cleaned on 07/22/24 by the housekeeping staff. The Administrator stated department heads were responsible for monitoring to ensure the cleaning was completed each day. The Administrator stated it was important to ensure the bathroom was cleaned every day to maintain a sanitary environment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675668 If continuation sheet Page 2 of 6 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 675668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mineola 320 Greenville Highway Mineola, TX 75773 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 Record review of the Homelike Environment policy, dated February 2021, revealed The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment .pleasant natural scents . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675668 If continuation sheet Page 3 of 6 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 675668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mineola 320 Greenville Highway Mineola, TX 75773 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so that facility is free of pests and rodents for the 1 of 3 bathroom's reviewed for pests. Residents Affected - Few The facility did not maintain an effective pest control program to ensure the facility was free of roaches in Resident #2's bathroom on C Hall. These findings could place residents at risk for an unsanitary environment and a decreased quality of life. The findings included: Record review of the face sheet, dated 07/23/2024, revealed Resident #2 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Record review of the admission MDS assessment, dated 06/28/2024, revealed Resident #2 had clear speech and was understood by others. The MDS revealed Resident #2 was able to understand others. The MDS revealed Resident #2 had a BIMS score of 13, which indicated no cognitive impairment. The MDS revealed Resident #2 had no behaviors or refusal of care. Record review of the comprehensive care plan, created 07/09/2024, revealed Resident #2 had a limited ability to maintain grooming and personal hygiene related to bipolar disorder. The care plan's goal was for Resident #2 to groom self with assistance as needed. Record review of the work order, dated 02/21/2024, revealed Roaches are extra bad in the kitchen. The work order had a check for in progress and was initialed and signed on 02/21/2024. Record review of the pest control log, between May 2024 and July 2024, revealed the following: 05/06/2024 - Roaches in med cart, hallways, patient rooms, C-hall. 05/07/2024 6:00 AM - 6:00 PM - RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], shower room - roaches. 05/22/2024 - building closets, halls, etc. - roaches. 06/10/2024 - the whole building - roaches everywhere. 06/12/2024 - C-Hall - roaches. 06/14/2024 - West/east - roaches. 06/15/2024 - in rooms C-Hall - roaches. 06/22/2024 - in rooms - roaches/water bugs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675668 If continuation sheet Page 4 of 6 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 675668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mineola 320 Greenville Highway Mineola, TX 75773 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 0925 06/27/2024 - kitchen - roaches. Level of Harm - Minimal harm or potential for actual harm 07/13/2024 - patients rooms Hall C - roaches. Residents Affected - Few Record review of the Pest Control company workorder, dated 05/08/2024, revealed the Pest Control Technician was at the facility and documented the following: Interior service today. Applied perimeter treatment to all entryway doors. Treated full kitchen. No pest activity was observed. Treated nurses' stations through bugs. All of the exterior doors need door sweeps, and that will mitigate the roach access into the building. Record review of the Pest Control company workorder, dated 05/16/2024, revealed the Pest Control Technician was at the facility and documented the following: Exterior service today. Applied water soluble granular to full exterior perimeter. Could not apply liquid due to rain in the forecast. But if you guys need anything, feel free to reach out. Record review of the Pest Control company workorder, dated 06/12/2024, revealed the Pest Control Technician was at the facility and documented the following: Sprayed full interior perimeter of kitchen. Applied perimeter treatment to all doorways leading to the exterior. No pest activity was observed upon inspection but if you guys need anything, feel free to reach out. Record review of the Pest Control company workorder, dated 06/26/2024, revealed the Pest Control Technician was at the facility and documented the following: Applied granular to full exterior perimeter. Treated full exterior perimeter along foundation line. Cleaned and rebated rodent bait stations as needed. No pest activity was observed. Record review of the Pest Control company workorder, dated 07/08/2024, revealed the Pest Control Technician was at the facility and documented the following: Sprayed full interior perimeter of kitchen. Treated all doorways leading to exterior. Treated around nurses' stations. No pest activity was observed. Record review of the Pest Control company workorder, dated 07/18/2024, revealed the Pest Control Technician was at the facility and documented the following: Exterior service today. Applied water soluble granular to full exterior perimeter. Did not treat with liquid due to rain in the forecast. Clean and rebated rodent bait stations as needed. Other than that, you guys should be good to go, but if you need anything, feel free to reach out. During an observation and interview on 07/22/2024 beginning at 1:15 PM, Resident #2 stated he had noticed roaches in his room and bathroom since he admitted to the facility. Resident #2 stated when the facility staff were notified, he was told yeah, the new owner's do not keep it very clean. Resident #2 stated the staff were nice, but the roaches were terrible. Resident #2 granted permission to view his bathroom. No roaches were observed in Resident #2's bathroom. Resident #2 stated there were no roaches now, but they were still terrible. During an observation on 07/23/2024 at 8:42 AM, there were 2 small, brown roaches in Resident #2's bathroom. One roach was coming toward the door from the toilet and the other roach was on the floor near the trashcan. During an interview on 07/23/2024 beginning at 4:22 PM, the Pest Control Technician stated the facility had a history of roach activity in the kitchen area. The Pest Control Technician stated he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675668 If continuation sheet Page 5 of 6 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 675668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mineola 320 Greenville Highway Mineola, TX 75773 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unaware of any roach activity in the hallways or resident rooms. The Pest Control Technician stated the facility's services were for twice monthly. The Pest Control Technician stated during the first visit of the month he treated the exterior, and the second visit he treated the interior. The Pest Control Technician stated during the normal monthly visits he did not treat hallways or resident room. The Pest Control Technician stated he only treated the doors leading to the exterior. The Pest Control Technician stated he normally checked in with the Maintenance Supervisor or Administrator during his visits to see if any concerns needed to be addressed. The Pest Control Technician stated he did have a log at the facility, but it was hard to find most of the time and had not had access to it the last few months. The Pest Control Technician stated the Maintenance Supervisor, or the Administrator had not made him aware of the roach sightings down the hallways and inside the resident's room. The Pest Control Technician stated selective and special treatment were only completed on request. The Pest Control Technician stated the facility has had a problem with American roaches for a while. The Pest Control Technician stated he believed the roaches were coming in through the walls. The Pest Control Technician stated failure to treat or spray for the roaches could have caused a population spike. The Pest Control Technician stated if cleaning was not conducted regularly and properly or food debris was left out then it could have promoted a population growth, which could have caused a health hazard for the residents. The Pest Control Technician stated in severe cases, if the facility was left untreated, it could have caused breathing issues. During an interview on 07/23/2024 beginning at 5:08 PM, the Maintenance Supervisor stated he was unaware of any complaints regarding roaches at the facility. The Maintenance Supervisor stated he and the Pest Control Technician looked at the pest control logs often. The Maintenance Supervisor stated the main purpose of the log was to make the Pest Control Technician of any pest sightings. The Maintenance Supervisor stated he monitored and followed up with the Pest Control Technician to ensure he was looking at the logs. The Maintenance Supervisor stated he was unaware the Pest Control Technician had no access to the pest control logs. The Maintenance Supervisor stated he had not made the Pest Control Technician aware of the roach sightings because he was unaware of the sightings. The Maintenance Supervisor stated it was important to ensure pest control was maintained because it could have led to an infestation. The Maintenance Supervisor stated infestations were not good for the residents. The Maintenance Supervisor stated he did not know why it was not good for the residents. During an interview on 07/23/2024 beginning at 5:13 PM, the Administrator stated he was unaware of any complaints of roaches in the facility. The Administrator stated all staff were responsible for monitoring to ensure there were no bugs or roaches in the facility. The Administrator stated he expected the pest control logs to be reviewed by the Pest Control Technician during his visits. The Administrator stated it was important to ensure pest control was maintained so there were no bugs in the resident's home. The Administrator stated we would not have wanted bugs in our home, so the residents should not have had any in their home. Record review of the Pest Control policy, revised May 2008, revealed this facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .maintenance services assist, when appropriate and necessary, in providing pest control services . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675668 If continuation sheet Page 6 of 6