Health inspection·January 11, 2023

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #32's Physician Orders dated 6/23/22 reflected Novolog Solution (insulin aspart), inject 15 units subcutaneous before meals for diabetes. Review of Resident #34's Face Sheet dated 1/9/23 reflected that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Diabetes Mellitus, Hypertension, Hyperlipidemia, Left-sided partial paralysis, falling, contracture of left foot. Resident #34's MDS assessment dated [DATE] reflected that he scored a 10 of 15 on the mental status exam (indicating moderate cognitive impairment), was diabetic, and had injections 5 of 7 days. Review of Resident #34's Care Plan, created 12/15/22 reflected the focus is resident is at risk for hyperglycemia/ hypoglycemia episodes related to of Diabetes Mellitus. The goal is that resident will have no complications related to diabetes through the review date. The interventions will be to monitor fasting serum blood sugar as ordered by doctor and administer diabetes medications as ordered by doctor. Review of Resident #34's Physician Orders dated 9/10/21 reflected Humalog Kwikpen Solution Injector 100 Unit/ml (insulin lispro), inject as per sliding scale subcutaneous before meals. Review of Resident #35's Face Sheet dated 1/9/23 reflected that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Diabetes Mellitus, Hypertension, Parkinson's, Dementia, falling, and lack of coordination. Resident #35's MDS assessment dated [DATE] reflected she scored a 13 of 15 on the mental status exam (indicating minimal cognitive impairment), was diabetic, and had injections 5 of 7 days. Review of Resident #35's Care Plan, created 11/15/22 reflected the focus was resident is at risk for hyperglycemia/ hypoglycemia episodes related to of Diabetes Mellitus. The goal is the resident will have no complications related to diabetes through the review date. The interventions are to monitor fasting serum blood sugar as ordered by doctor; administer diabetes medications as ordered by doctor. Review of Resident #35's Physician Orders dated 12/30/22 reflected Humalog Kwikpen Solution Injector 100 Unit/ml (insulin lispro), inject 10 Units subcutaneous before meals. Observation on 01/09/23 at 12:04 PM revealed LVN D checked Resident #35's blood sugar via fingerstick. LVN D pulled up Resident #35's shirt, cleaned Resident #35's abdomen with alcohol pad and injected the insulin subcutaneously to abdomen in the public dining area during lunch in the immediate presence of other residents. Observation on 01/09/23 at 12:12 PM revealed LVN D checked Resident #32's blood sugar via fingerstick. LVN D pulled up Resident #32's sleeve, cleaned Resident #32's left arm with alcohol pad and injected the insulin subcutaneously to left arm in the public dining area during lunch in the immediate presence of other residents. Observation on 01/09/23 at 12:24 PM revealed LVN D checked Resident #34's blood sugar via fingerstick. LVN D pulled up Resident #34's shirt, cleaned Resident #34's abdomen with alcohol pad and injected the insulin subcutaneously to abdomen in the public hall adjacent to the dining room in the immediate presence of other residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 2 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 01/11/23 at 09:27 AM LVN D stated that she chooses to give medications in the Dining Room because she was told that the residents should be treated as they would be treated at home and at home, the residents' would get medications anywhere in their home. LVN D stated I know the policy stated that staff is supposed to take residents to their bedroom to administer medications but the residents do not mind. When surveyor asked LVN D if she asked residents their preference regarding the location of the medication administration, LVN D stated, no she did not ask Resident #32, Resident #34, or Resident #35 if they preferred to go to their room. When surveyor asked LVN D if she would check blood sugars and administer insulin to the residents in a restaurant setting, LVN D stated, no she would not. Interview 01/11/23 at 09:00 AM ADON stated that staff was never supposed to check blood sugars or give insulin in the dining area. ADON stated that on 01/9/23 he observed LVN D passing medication in the Dining Area and told LVN D not to give Residents medications in the Dining Room. ADON stated that he instructed LVN D to take all residents to the Medication Room or the resident rooms to administer medications. ADON stated that on 1/9/23 during lunch service he observed LVN D administering insulin to residents. ADON stated that he will have to monitor LVN D more closely and do additional training with her. ADON stated that he did think that LVN D understood the facility policy. Review of facility's policy and procedure titled Quality of Life- Dignity, revised August 2009 read in part: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation: -Residents shall always treated with dignity and respect. -Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 3 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 (Residents #1) reviewed for indwelling catheters. The facility failed to ensure Resident #1 indwelling catheter was secured to prevent pulling or tugging. The failure could place residents at risk for discomfort, urethral trauma and urinary tract infections. Findings included: Review of Resident #1's admission Record dated 01/09/23, indicated he was admitted to the facility on [DATE] with diagnosis of benign prostatic hyperplasia (Age-associated prostate gland enlargement that can cause urination difficulty). Resident #1 was [AGE] years of age. Review of Resident #1's MDS dated [DATE] indicated in part: Brief Interview Mental Status = 6 indicated resident had severe impairment. Urinary incontinence = not rated, resident has a catheter. Review of Resident #1's care plan dated 01/04/23 indicated in part: Focus: the resident has foley catheter and is at risk for increased urinary tract infections. goal: the resident will show no signs/symptoms of urinary infection through review date. Interventions: change catheter every month, position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks each shift, monitor/document for pain/discomfort due to catheter. Review of Resident #1's physician order report dated 12/10/2022 - 01/10/2023 indicated in part: Check Foley catheter placement, ensure Foley is secured via velcro strap to reduce friction/pulling. Start date 09/27/2022 Observation and interview on 01/09/23 at 03:02 PM CNA C performed incontinent care for Resident #1, CNA C sanitized her hands, donned gloves and explained to the resident what she was going to do. CNA C pulled Resident #1's pants down and the resident was noted to have an indwelling urinary catheter. The urinary catheter was not secured to the resident's leg and when CNA C turned Resident #1 on his side the catheter tube pulled on his penis. Resident #1 told surveyor that the catheter tube would hurt his penis when they changed him because it would tug his urethra. Resident #1 said he did not recall the staff securing the catheter to his leg. CNA C said she had just started working at the facility last week and was not aware of the resident's catheter not being secured to his leg. Interview on 01/11/23 at 02:24 PM DON said her expectations for residents with urinary catheters was for them to be checked by the nurse and the aides for any loops or kinks and for the nurse to make sure it was anchored to the resident. DON was made aware by the surveyor that during an observation Resident#1's urinary catheter was not secured to the resident and the resident had voiced that it caused him discomfort. DON said Resident #1 did not like for the catheter to be secured but that that it did have to be secured. DON said if the catheter was not secured that it could cause trauma and discomfort to the resident's penis. DON said the failure occurred because the staff did not check to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 4 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0690 see that the catheter was secured. Level of Harm - Minimal harm or potential for actual harm Interview on 01/11/23 at 02:48 PM the Administrator was made aware of the observation of the catheter not secured for Resident #1. The Administrator said the catheter should have been secured as that could lead to injury and discomfort to the resident. Residents Affected - Few Review of the facility's policy titled Catheters - insertion and care dated 04/2021 indicated in part: It is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications. Attach catheter strap to leg to assist in securing tubing. Review of Lippincott Manual of Nursing Practice 9th Edition 2009, page 783 indicated the following in regards to securing a urinary catheter: General Considerations: .Secure the indwelling catheter to patient's thigh using tape, strap, adhesive anchor, or other securement device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 5 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 store all drugs and biologicals in locked compartments for 1 of 2 medication carts reviewed for medication storage and to meet the needs of 2 residents (Resident #1, Resident #40), 1 of 2 Medication Carts and 1 of 1 Medication Rooms (Medication Room) reviewed for compliance. 1. The facility failed to ensure Medication Cart #1 was locked when unattended. 2. The facility failed to ensure the Medication Cart #1 did not include an opened and undated Lantus pen (insulin medication used to treat Diabetes Mellitus) for Resident #40. 3. The facility failed to ensure the Medication Storage Room did not contain an opened and undated Ozempic pen (medication used to treat Diabetes Mellitus) for Resident #1. This failure could place residents at risk of having access to unauthorized medications and unauthorized lab and medical supplies and/or lead to possible harm or drug diversions and also placed residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings included: UNDATED MEDICATIONS Review of Resident #1's face sheet dated [DATE] revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: Type 2 Diabetes Mellitus, Alzheimer's disease (a progressive disease that destroys memory), Dementia ( a condition characterized by progressive loss of intellectual functioning, impairment to memory, and thinking), Schizoaffective disorder (a mental health condition with a combination of symptoms), Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anemia (condition in which blood does not have enough healthy red blood cells). Review of Resident #1's care plan dated [DATE] revealed, Focus- Resident #1 will have no complications related to Diabetes through the review date, interventions- administer Diabetes medications per MD order. Review of Resident #1's admission MDS dated [DATE] revealed, insulin as necessary. Review of Resident #1's Physician's Order dated [DATE] revealed, Ozempic Solution Pen Injector, inject 0.25mg subcutaneous one time a day every Friday. Review of Resident #40's Face Sheet dated [DATE] revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: Type 2 Diabetes Mellitus, Dementia, Long term use of insulin, Hyperlipidemia, and Upper Respiratory Infection. Review of Resident #40's admission MDS dated [DATE] revealed, insulin as necessary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 6 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 Record review of Resident #40's Care Plan dated [DATE] revealed, Focus- Resident #1 will have no complications related to Diabetes through the review date, interventions- administer Diabetes medications per MD order. Record review of Resident #40's Physician's Order dated [DATE] revealed, Lantus Solostar Solution Pen Injector, inject 25 Units subcutaneous at bedtime. Observation and interview on [DATE] beginning at 10:50 AM, inventory of Medication Cart #1 with LVN D revealed an opened and undated Lantus pen (insulin medication used to treat Diabetes Mellitus) for Resident #40. LVN D stated that insulin pens should be dated upon opening and she was unsure who opened it. LVN D stated that she usually checks her cart at the beginning of her shift but had not done it today. LVN D stated that Resident #40 only receives Lantus (insulin medication used to treat Diabetes Mellitus) on night shift so she had not looked at his pen. Observation on [DATE] at 11:12 AM, inventory of the Medication Room with ADON revealed one (1) open and undated Ozempic pen (insulin medication used to treat Diabetes Mellitus) for Resident #1. Interview on [DATE] at 10:30 AM DON stated that herself and ADON are responsible for checking the medication room for expired or undated medications and discarding them. DON stated that medication room was checked last on [DATE]. DON stated that nurses and medication aides are instructed to bring medications and narcotics to Me (DON) or ADON. Then the medications are locked in the safe that is inside the locked cabinet that is located in the locked DONs office. DON stated the pharmacist comes monthly to do drug destruction. Interview on [DATE] at 10:30 AM ADON stated that he checked the med room on [DATE], and was due to check it again on [DATE]. ADON stated that he was distracted when surveyors walked in the door so he never got around to checking the medication room. ADON stated that the Ozempic pen (insulin medication used to treat Diabetes Mellitus) was discarded. ADON stated that since Resident #1 only receives injection once a week, on Fridays, and there was likely no harm to resident. ADON stated that the medications found in Medication Cart #1 belonged to resident #40. The family provides his medication from their own pharmacy, and it doesn't come with a label, so staff forgets to label the Lantus pen (insulin medication used to treat Diabetes Mellitus) appropriately. ADON stated that this has occurred before and he has educated staff. ADON stated that the pen will be removed and replaced and labeled appropriately. ADON stated that Resident #40 only gets Lantus (insulin medication used to treat Diabetes Mellitus) at bedtime, an in-service to reeducate nightshift staff will be done. Record Review of Pharmacy Consult book revealed last audit by the consultant pharmacist reflected the following: Medication room report stated Yes expired meds, and no open date found on meds on [DATE]. Medication room report stated Yes expired meds, and no open date found on meds on [DATE]. Record review of the facility policy titled Administering Medications revised [DATE] reads in part: The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Record review of the facility policy titled Labeling of Medication Containers revised [DATE] reads (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 7 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 in part: Level of Harm - Minimal harm or potential for actual harm Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. Labels shall include the date the medication was dispensed and the expiration date when applicable. Residents Affected - Some UNLOCKED MEDICATION CARTS Observation on [DATE] at 11:54 AM revealed an unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol, vitamins) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All of the drawers of the Medication Cart (#1) were unlocked and were easily accessible. Observation revealed the DON walked up to LVN D and told her to lock her cart. Surveyor over- heard LVN D respond to DON I am still passing meds. Observation on [DATE] at 12:23 PM revealed an unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. No staff or residents were present in the area. Observation on [DATE] at 1:46 PM revealed an unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. Observation on [DATE] at 3:40 PM revealed an unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. Observation on [DATE] at 09:35 AM revealed unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. Observation on [DATE] at 10:13 AM revealed unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. Observation on [DATE] at 5:02 PM revealed unlocked Medication Cart (#1) with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer and canister of purple wipes in third drawer. All drawers of the medication cart were unlocked and were easily accessible. Interview on [DATE] at 9:27 AM LVN D stated that she was nervous and has no excuse for leaving the Medication Cart (#1) unlocked while unattended. LVN D stated that she knows that medication cart should be locked, because someone could get in and get the medications. LVN D stated the medication cart has medications like insulin, vitamins, OTC medications, Tylenol and narcotics that could be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 8 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 dangerous. LVN D stated she is sorry for leaving the Medication Cart unlocked. Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 9:00 AM ADON stated that he told LVN D several times to lock her cart. ADON states that LVN D knows better than that and she has been working at the facility for a few years. ADON stated that he will do an in-service on locking Medication Carts. Residents Affected - Some Review of the facility's policy, titled Security of Medication Cart, revised [DATE], reflected (in part): Medication carts must be locked at all times when out of nurses view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 9 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure that menus were served per with adequate or appropriate nutritional items the menus reflected for the noon time meal (lunch) to meet the nutritional needs of residents. 1. [NAME] A did not serve residents on a regular or mechanical soft diet, the correct portion size of salad when served at (lunch or dinner meal). 2. [NAME] A failed to provide residents on a puree diet a starch food at lunch . These failures placed residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. Findings included: Review of the residents food menu to be served on 01/10/23 revealed items to be served were: 1. Regular diet and mechanical soft diet: 2/3 cup of lasagna; 8 oz of salad, 1 garlic bread stick. 2. Puree Diet: 1/2 cup of puree lasagna; 4 oz of puree soft-cook vegetable; garlic bread stick . Observation of the noon meal preparation on 01/10/23 at 11:30 AM revealed [NAME] A plating the food. [NAME] A served lasagna and a bread stick to residents on the regular diet however, [NAME] A provided residents on the regular diet a (yellow handled scoop) equal to three tablespoons serving of salad instead of a full 8 oz of salad list on the menu. The residents on a puree diet did not receive a bread stick (a starch item) or equivalent with their meals. Interview on 01/10/23 at 12:19 PM the DM confirmed [NAME] A used a yellow-handled scoop (three tablespoons) when serving the salad to resident on the regular diet at meal preparation. Interview on 01/11/23 at 09:16 AM [NAME] A stated she had been the cook for six months. [NAME] A stated she was trained to use a grey scoop (1/2 cup) for all puree dishes. [NAME] A said the casserole on the regular trays the staff used a white scoop (2/3 cup). [NAME] A said she normally used a spoon with holes in it for vegetables and did not know how large that was. [NAME] A on the lunch meal for 1/10/23 she used the yellow scoop for the salad , and she thought the yellow scoop was three table spoons big. She said with the corporation switchover, the facility just got (received) new recipes , so she used the same serving sizes as she did under the old corporation. [NAME] A was shown the menu with serving sizes by diet. [NAME] A said she was unaware of the portion sizes. She said she normally would put bread in with the lasagna. She thought back and stated, she did not. Interview on 01/11/23 at 09:44 AM the DM stated she worked as the DM for 3 months. The DM said in hindsight the lunch meal preparation was a disaster. She said [NAME] A was nervous and the previous DM instructed the staff to use a grey scoop for everything. The DM looked at the menu for 1/10/23 with the serving size and said the residents should have received 8 oz of salad and did not. The DM explained the facility just returned to the corporation (Change of management) , so the menu was brand new to us. The DM was informed the residents on a puree diet did not receive a bread portion. She said she was informed not to use bread for puree because it turned back into dough but said there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 10 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 0803 should be mashed potato or rice as a starch. Level of Harm - Minimal harm or potential for actual harm Interview on 01/11/23 at 10:34 AM the Administrator was informed of the menu documenting 8 oz of salad for residents with regular diets and the residents on a puree diet not getting a bread or starch portion at the noon meal. She nodded her head and did not have any additional information. Residents Affected - Some Interview on 01/11/23 at 1:19 PM the DM stated she could not find policies about dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 11 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: Residents Affected - Many 1.The facility failed to label and date food items. 2.The facility failed to discard expired food items. 3.The facility failed to ensure staff washed their hands in a manner that prevented cross contamination. These deficient practices could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. Findings include: Observation on 01/09/23 at 10:24 AM revealed: Hand washing sink out of paper towel. DA B washed hands at sink at prep table turn off faucet with bare hands twice. Cook A rinsed hands at the prep table. She did not use soap and turned off the faucet with her bare hands. The preparation sink had a soap dispenser on the wall and a paper towel holder approximately 6 feet away on the next available wall space. Observation on 01/09/23 (at10:24 AM) of the refrigerator contained: - Tupperware container of Pasta dated 1/5/23 - Tupperware container of meat dated 1/5/23 - Zipper bag of ham dated 1/2/23 open to air. - Two bags of bacon dated 12/15/22 open to air. - Zipper bag of hotdogs that were undated. - handful of grilled jalapenos wrapped in plastic wrap and undated. Observation on 01/10/23 between 10:44 AM and 12:19 PM revealed the following: Cook A washed her hands in the food preparation sink and turned off the faucet with her bare hands five times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 12 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 Cook A rinsed her hands at the preparation sink with no soap and turned off the faucet with her bare hands prior to fixing the puree desert. DA B rinsed her hands in the preparation sink with no soap and turned off the faucet with her bare hands three times. Residents Affected - Many DA B washed her hands in the preparation sink and turned off the faucet with her bare hands twice. The DM washed her hands in the preparation sink and turned off the faucet with her bare hands. Cook A rinsed the measuring cup used to make the puree lunch in the preparation sink and not the dish washing sink immediately next to it. Cook A plated the food with her bare hands while touching the food eating surface. Interview on 01/11/23 at 09:16 AM [NAME] A said she was the cook at the facility for six months. She said she was trained how to wash her hands under the previous dietary manager and the manager trained them to turn on the water, soap hands, and turn off the water with a paper towel. [NAME] A said it needed to be turned off with a paper towel because the washer touched the faucet with dirty hands first. [NAME] A said since there was a soap dispenser and paper towels available that it was alright to wash hands in the preparation sink. [NAME] A said the previous DM trained her in serving the food and it was to wear glove if she was touching the food, she said she was told to grab the side of the plate. [NAME] A admitted she was nervous and in a rush because everyone was looking at her. She said left over food was supposed to be labeled. Interview on 01/11/23 at 09:44 AM the DM stated she worked as the DM for 3 months. The DM said in hindsight the lunch meal preparation on 1/10/23 was a disaster. The DM stated the expectation for hand washing was turn on the water as hot as tolerable, wash the entire hand with soap, rinse, dry hands with a paper towel, and turn off the faucet with a clean paper towel. She said this was done to prevent cross contamination. She said she was not sure if the staff were doing it that way. She was informed all dietary staff were observed washing their hands in the preparation sink and turning off the faucet with their bare hands. The DM said the paper towel dispenser by the handwashing sink was broken, The DM said it hat been acceptable so far to wash hands in the food preparation sink. The DM said the left-over storage depended on the dish stored, but usually the expectation was three days for leftovers. She stated she expected leftovers to be labeled, dated, and covered with the date to throw it away. The DM said the other cook was usually the cook that threw out leftovers and she was not on duty. The DM said leftovers dated 1/5/23 were not acceptable. The DM stated she was instructed by her managers to not wear gloves when serving. Surveyor took a plate and showed the DM how [NAME] A handled the plate. The DM stated touching the eating surface with hands gloved or not caused cross contamination. Surveyor requested policies and the DM stated she did not know where they would be but would look. Interview on 01/11/23 at 10:34 AM the Administrator was informed of the findings in the kitchen. She said her expectation for food in zipper bag was to the be sealed but if the person using it was in a rush sometimes it was hard to tell. The Administrator stated her expectation for hand washing was to be done between tasks, using the handwashing sink, and to use a paper towel to turn off the faucet. The Administrator stated she did not know why the staff were using the preparation sink instead of the handwashing sink. The Administrator stated she did sanitization rounds (checked the kitchen for cleanliness) and the kitchen had come a long way from last year. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 13 of 14 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 675881 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pecos 1819 Memorial Dr Pecos, TX 79772 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 Interview on 01/11/23 at 1:19 PM the DM stated she had not done an in-service training on hand washing and the previous DM last had in-service training in the middle of last year. She said she could not find policies about dietary services. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675881 If continuation sheet Page 14 of 14