Inspection·September 15, 2023

F 0690 buttocks area. CNA A rolled resident back on to brief and fasten brief. Level of Harm - Minimal harm or potential for actual harm Interview on 09/14/23 at 11:30 AM, CNA A stated she should have cleaned penis head and shaft. She stated she knew she forgot to clean residents' buttocks and that was why she rolled him back over. CNA A stated she should have changed the brief since resident was not clean. CNA A stated she got nervous and forgot the steps. She stated she just completed CNA training and knew the steps. CNA A stated she had been trained on proper incontinent care technique. CNA A stated the potential negative outcome for improper incontinent care could be rash and bed sores. Residents Affected - Some Resident #40 Record review of face sheet for Resident #40, dated 09/13/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: epilepsy (seizure disorder), major depressive disorder (mental illness), diabetes (high blood sugar), muscle weakness, hypertension (high blood pressure), and heart failure. Review of Resident #40's MDS, dated [DATE] revealed Resident #40 had a BIMS of 07 which indicated the resident's cognition was severely impaired. He required extensive two person assist with bed mobility, personal hygiene and dressing. He required total dependence of one person for toilet use. Record review of Resident #40's Comprehensive Care Plan dated 09/06/23 revealed the resident requires total dependence x 1 with toileting and personal hygiene. The interventions included assist with ADL's. The resident has a foley catheter in place. The resident was at risk for pressures ulcers related to bedfast/mobility and neuropathy. The interventions included check incontinence pads frequently (every 2-3 hours) and change as needed. If stool incontinence and toileting after meals. Observation of incontinent care on 09/22/23 at 10:30 AM, TNA B performed incontinent care for Resident #40 and used same wipe multiple times across resident's lower abdomen and buttocks area. TNA B took a wipe and made a swipe accross resident #40's abdomen and then made several back and forth swipes with the same wipe. When TNA B turned resident to side she cleaned the buttocks. TNA B took a wipe and swiped back and forth on buttocks area using the same wipe. Interview on 09/14/23 at 10:45 AM, TNA B stated she knew she wiped the lower abdomen area using the same wipe several times and the buttock area several times. She stated she should have wiped the area and folded wipe once and then discarded wipe in trash. She stated she got nervous and forgot. TNA B stated she had been trained on proper incontinent care technique, but she got nervous. TNA B stated the potential negative outcome for improper incontinent care could be mild infection and skin irritation. Interview on 09/15/23 at 09:14 AM, the DON stated CNA A and TNA B were trained on incontinent care and skill check offs done quarterly. The DON stated the DON, ADON and CN were responsible for monitoring the CNA's regarding incontinence care. She stated CNA A just passed her certification exam and further stated that CNA A reported to her Resident #28 was being inappropriate was why she hurried through incontinent care. She stated TNA B just completed the CNA classes and was nervous because this was her first time with a state surveyor. She stated the penis should have been cleaned and wipes are to be used with one swipe. She stated the potential negative outcome could be infection or skin issues. Interview on 09/15/23 at 09:30 AM, the ADM stated the DON was responsible for monitoring and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 2 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 - Some training the nursing staff. He stated he was not familiar with the steps of incontinent care, but he relied on the DON for incontinent care training and monitoring. He stated the staff was trained on incontinent care. He stated the potential negative outcome could be infection and possible UTI if not done correctly. Record review Incontinent Care for the Male Resident dated 07/18/23 revealed CNA A completed skills checkoff for incontinent care. Record review Incontinent Care for the Male Resident dated 08/08/23 revealed TNA B completed skills checkoff for incontinent care. Record review of facility policy and procedure titled, Perineal Care with a revised date of 08/19 revealed the following: Purpose: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . For a Male Resident: . b. Clean perineal area starting with urethra and working outward . e. Clean and rinse urethral area using a circular motion. f. Continue to clean the perineal area including the penis, scrotum and inner thighs. g. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. h. Thoroughly clean perineal area in same order, using a new cleansing wipe as needed . m. Clean the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks, change the cleansing wipe as needed. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. n. Dry area thoroughly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 3 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 9 of 30 days (08/13/23, 08/19/23, 08/20/23, 08/26/23, 08/27/23, 09/02/23, 09/03/23, 09/09/23, and 09/10/23) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 08/13/23, 08/19/23, 08/20/23, 08/26/23, 08/27/23, 09/02/23, 09/03/23, 09/09/23, and 09/10/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster dated 08/04/23 revealed there were one RN employed at the facility. Record Review of the employee roster update provided by the ADM dated 09/13/23 revealed RN A termination date 07/20/23 and had written on document No RN time sheet for last 30 days. During an interview on 09/13/23 at 11:45 AM with the ADM he stated there were no RN times for the last 30 days. During an interview on 09/13/23 at 11:50 AM with the DON she stated she was currently the only RN employed. She stated she worked Monday through Friday 08:00 AM to 05:00 PM unless she covered a shift on the floor. She stated the facility can use telehealth 24/7 on the weekends and after 07:00 PM on the weekdays. She stated the medical director was also available 24/7. She stated they currently have an ad out for weekend RN through there corporation and have planned a job fair for 09/14/23. During an interview on 09/13/23 at 11:58 AM with the ADM, he stated they were posting ads all around the area on Facebook job sites, indeed, and the corporate office was posting as well. He stated he currently does not have any contract with agency. He stated they have a corporate nursing pool that was like agency, but they currently have no RN available to send. During an interview on 09/15/23 at 09:14 AM with the DON, she stated she and the ADM were responsible for RN coverage. She stated if staff needs an RN, staff could call her 24/7. She stated the nurse consultant was also available by phone if needed. She stated the facility policy was to have RN coverage 8 hours a day 7 days a week. She stated it was important to have an RN to add clinical assessments and supervision. She stated there was treatments and assessments that only the RN could do. She stated if the resident was acutely ill the nurse would send resident to the hospital. She stated the potential negative outcome could be the resident would not get the services required by an RN. She stated the facility does not use outside agencies. She stated she had requested an RN for the corporate pool but there was not an RN available. During an interview on 09/15/23 at 09:30 AM with the ADM, he stated he was responsible for RN coverage. He stated if the staff needed and RN they were to work with the DON. He stated the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 4 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many policy was to have an RN 8 hours a day 7 days a week. He stated it was important to have an RN to manage the whole aspect of the building. He stated LVN's were only allowed to do certain things. He stated the potential negative effect would be depending on the certain need of the resident and general overall care of resident. He stated the agency he had spoken with stated they could not provide him with an RN they only had LVN's, so he does not need an agency if they cannot provide an RN. He stated RN's have a higher level of education and can perform certain duties like PICC lines and various procedures. He stated his expectations were to have coverage 8 hours a day 7 days a week to meet the regulation in place. Record review facility ad dated 09/13/23 revealed an ad for weekend RN. Record review [name] Bulletin Board Print Document dated 09/08/23 revealed job order for registered nurse (RN) - [facility location]. Record review hireology.com dated 09/07/23 revealed ad for weekend RN. During an interview with ADM on 09/15/23 at 10:00 AM surveyor request policy on RN Coverage. During exit conference 09/15/23 at 12:00 PM ADM was asked if there were any additional information, they want to present that was requested, she stated No. During an interview on 09/22/23 at 11:56 AM with the ADM surveyor requested facility policy on RN Coverage. Record review email from ADM on 09/22/23 at 01:23 PM revealed I do not think we have one for just RN coverage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 5 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the menu was followed, for 2 out of 2 residents that received pureed food (Residents #26 & 33), in that: 1. The facility failed to ensure Resident # 26 received pureed bread on 09/13/23 and on 09/14/23. 2. The facility failed to ensure Resident # 33 received pureed bread on 09/13/23 and on 09/14/23 These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. The findings include: On 09/13/23 at 11:31 AM an observation of the pureed process was conducted. Dietary [NAME] A began the process at 11:31 AM. No cornbread was pureed during this process. On 09/14/23 at 10:45 AM an observation of the pureed process was conducted. Dietary [NAME] A began the process at 11:45 AM. No bread was pureed during this process. An observation was made on 09/13/23 at 12:20 PM of Resident #33 lunch tray and it did not have any puree bread on the plate. An observation was made on 09/13/23 at 12:31 PM of Resident #26 lunch tray and it did not have any puree bread on the plate. An observation was made on 09/14/23 at 11:40 AM of Dietary [NAME] A and plated Resident #26 food and did not include bread. All items were runny on the plate with the exception of the mash potatoes. An observation was made on 09/14/23 at 11:50 AM of Dietary [NAME] A and plated Resident #33 plate without any bread on the plate. All items were runny on the plate with the exception of the mash potatoes. Resident #26 Record review of Resident #26's face sheet, dated 09/14/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (defective memory), dysphagia (difficulty swallowing), and gastro-esophageal reflux disease Stomach acid issues). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #26 was usually understood. The MDS revealed Resident #26 had a BIMS of 05 which indicated the resident's cognition was severely impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 07/24/23 for Resident #26 revealed the following: Category: Nutritional Status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 6 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 Resident is on regular PUREE diet. large portions - Level of Harm - Minimal harm or potential for actual harm honey thickened liquids- weight loss Edited: 08/14/2023 Residents Affected - Few Record review of Resident #26's order summary report dated 09/14/23 revealed the following orders: Diet ordered 05/05/22: Regular Puree Record view of Resident #26 weight log, June-September 2023, indicated there was no significant weight loss at the time of survey. Resident #33 Record review of Resident #33's face sheet, dated 09/14/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (defective memory), pneumonitis due to inhalation of food and vomit (inflammation in the lungs), oropharyngeal phase (difficulty swallowing), abnormal weight loss and dysphagia (difficulty swallowing). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #33 was sometimes understood. The MDS revealed Resident #33 had a BIMS of 99 which indicated the resident's was unable to complete the interview. Section K Mechanically altered diet: Require change in texture of food or liquids Record review of a care plan, dated 06/07/23 for Resident #33 revealed the following: Category: Nutritional Status Resident has experienced weight loss - Hospice Care - do not force feed- Regular - Puree -large portions/ fortified- thin liquids Edited: 09/05/2023 Record review of Resident #33's order summary report dated 09/14/23 revealed the following orders: Diet Order 03/13/23: Regular Diet and Texture Puree. Record view of Resident #33 weight log, June-September 2023, indicated there was no significant weight loss at the time of survey. Record review of Resident #26 diet card dated Wednesday 09/13/23 revealed he should have received 1/4 cup of pureed cornbread. Record review of Resident #33 diet card dated Wednesday 09/13/23 revealed he should have received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 7 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 1/4 cup of pureed cornbread. Level of Harm - Minimal harm or potential for actual harm On 09/13/23 at 11:31 AM an observation of preparing the pureed lunch meal prepared by Dietary [NAME] A revealed she did not make the pureed cornbread. Residents Affected - Few Record review of Resident #26 diet card dated Thursday 09/14/23 revealed he should received 1/4 cup of garlic biscuit. Record review of Resident #33 diet card dated Thursday 09/14/23 revealed he should have received 1/4 cup of garlic biscuit. On 09/14/23 at 10:45AM an observation of preparing the pureed lunch meal prepared by Dietary [NAME] A Revealed she did not make the pureed bread. During an interview on 09/14/23 at 11:24 AM Dietary [NAME] A said she had pureed everything that she had to for the meal. During an interview on 09/15/23 at 09:13 AM, Dietary [NAME] A said the residents may not receive all the nutrients that they need if they do not follow the menu. She said the menu helped guide them on what nutrients the residents needed. She said the resident paid to live at the facility and should have all their food that they paid for. She said she was unaware she did not give the two residents the pureed bread at the time of serving. She said sometimes she tried to put the bread in the food rather than place it on the side like she did for the remainder of the residents. She said she did not know if the residents preferred to have their bread on the side of their other dishes like the remainder of the residents or if incorporating the bread within the food was a preference. She said she should have pureed all of the items that were on the menu. She said she had been trained to puree all menu items. During an interview on 09/15/23 at 09:49 AM, the DM said he knew Dietary [NAME] A did not provide bread on the tray for the residents that required pureed on 09/13 and 09/14/23. He said he thought using bread in the mixture was okay. He said he thought Dietary [NAME] A used bread in her puree meal preparation both days. He said he was unaware she had not used bread the second day. He said any residents on a pureed diet should receive all items on the menu like the rest of the residents. He said the residents could lose nutrition if they are not getting all that was on the menu. He said he did not have a policy specifically on pureed foods. He said all of the policy provided was what he had. During an interview on 09/15/23 at 10:19 AM, the ADM said DM was responsible for all activity that occurred in the kitchen. He said he was not aware of any of the identified deficient practices. He said he had been in the kitchen many times and had not noticed that the residents receiving pureed were not receiving all the items on the menu. He said he expected the dietary staff to follow the policies and guidelines for the kitchen. He said the majority of the kitchen staff had been employed at the facility for years and should have known the expectations of the kitchen. During an interview on 09/15/23 at 10:33 AM Resident #33 said that he liked bread but was unable to tell the surveyor if he preferred cornbread or light bread. He stared at the surveyor when she asked him multiple questions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 8 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 During an interview on 09/15/23 at 10:35 AM Resident #26 said the food was good and the texture was ok with him. He said he liked cornbread but did not like white bread as much. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Menu Planning, revised 06/01/19 revealed: Residents Affected - Few Policy The facility believes that nutrition is an important part of maintaining the well-being and health of its residents and is committed to providing a menu that is well balanced nutritious and meets the preferences of the resident population. A standardized menu which meets the nutritional recommendations of the residents in accordance with the recommended dietary allowances of the food and nutrition board of the National Research council, national academy of sciences will be used. Modifications for the resident population and preferences may be made as appropriate. 2 Alternates may include a comparable entree vegetable and starch. And always available menu may also be offered as an alternative menu option in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 9 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 puréed meals (9/13/23 - Lunch and 09/14- Lunch) observe for 2 of 2 residents with orders for puréed diet (Residents #26 and 33); in that: The facility failed to provide food that was in a form to meet resident needs Residents #26 and #33 with the orders for puréed diets. This failure could place residence at risk of decreased food intake and choking. The findings include: On 09/13/23 at 11:31 AM an observation of the pureed process was conducted. Dietary [NAME] A began the process at 11:31 AM. The following steps were taken: Entrée: dietary cook a use two cups of mechanical soft pork chop. She added three scoops of juice from the mechanical soft pork chop. She blended it and added two scoops of thickener. She blended then added two slices of white bread. She blended then added two more slices of white bread. She added one more scoop of thickener and blended. She presented the Entrée for the surveyor to taste. The texture of the pork chop contained grit and lumps. The form was runny and the color was a peach color. Starch: She scooped three cups of black eyed peas into the machine and 7 cups of juice from the peas into the pureed machine. She blended it and added three scoops of thickener. She blended it and presented the mixture for surveyors to taste. The black eyed pea mixture was had a liquid texture, runny form and was a light brown color. Vegetable: She scooped three cups of greens and 5 cups of juice from the greens. She blended the mixture. She added 3 scoops of thickener. She blended the mixture. She presented the green mixture to the surveyor to taste. The mixture texture was liquid, the form was runny and it was a dark green in color. No cornbread was pureed during this process. On 09/14/23 at 10:45AM an observation of the pureed process was conducted. Dietary [NAME] A began the process at 10:45 AM. The following steps were taken: Entrée: She placed two scoops of cubed chicken in the puree machine. She added 5 scoops of white gravy. She blended the mixture. She presented the mixture to the surveyor to taste. The mixture was liquid and runny in form and texture. The mixture was white and appeared to be more gravy than chicken. Vegetable: She used 2 cups of green beans and 4 cups of juice from the green beans. She blended the mixture. She presented the mixture for the surveyor to taste. The green bean mixture was runny and liquid in form and texture. It was green in color. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 10 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 0805 No bread was pureed during this process. Level of Harm - Minimal harm or potential for actual harm An observation was made on 09/14/23 at 11:40 AM of Dietary [NAME] A and plated Resident #26 food and did not include bread. All items were runny on the plate with the exception of the mash potatoes. Residents Affected - Few An observation was made on 09/14/23 at 11:50 AM of Dietary [NAME] A and plated Resident #33 plate without any bread on the plate. All items were runny on the plate with the exception of the mash potatoes. Resident #26 Record review of Resident #26's face sheet, dated 09/14/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (defective memory), dysphagia (difficulty swallowing), and gastro-esophageal reflux disease Stomach acid issues). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #26 was usually understood. The MDS revealed Resident #26 had a BIMS of 05 which indicated the resident's cognition was severely impaired. Section K Mechanically altered diet: Require change in texture of food or liquids Record review of a care plan, dated 07/24/23 for Resident #26 did revealed the following: Category: Nutritional Status Resident is on regular PUREE diet. large portions honey thickened liquids- weight loss Edited: 08/14/2023 Record review of Resident #26's order summary report dated 09/14/23 revealed the following orders: Diet ordered 05/05/22: Regular Puree Record view of Resident 26 weight log, June- September 2023, indicated there was no significant weight loss at the time of survey. Resident #33 Record review of Resident #33's face sheet, dated 09/14/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (defective memory), pneumonitis due to inhalation of food and vomit (inflammation in the lungs), oropharyngeal phase (difficulty swallowing), abnormal weight loss and dysphagia (difficulty swallowing). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #33 was sometimes understood. The MDS revealed Resident #33 had a BIMS of 99 which indicated the resident's was unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 11 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 0805 complete the interview. Level of Harm - Minimal harm or potential for actual harm Section K Mechanically altered diet: Require change in texture of food or liquids Residents Affected - Few Record review of a care plan, dated 06/07/23 for Resident #33 did revealed the following: Category: Nutritional Status Resident has experienced weight loss - Hospice Care - do not force feed- Regular - Puree -large portions/ fortified- thin liquids Edited: 09/05/2023 Record review of Resident #33's order summary report dated 09/14/23 revealed the following orders: Diet Order 03/13/23: Regular Diet and Texture Puree. Record view of Resident 33 weight log, June-September 2023, indicated there was no significant weight loss at the time of survey. Record review of Resident #26 diet card dated Wednesday 09/13/23 revealed he should have had the following: Entree: three fourth cups of pureed fried pork chop starch: three fourth cups puree Black Eyed Peas vegetable: half a cup of pureed mixed green bread: 1/4 cup of pureed cornbread dessert: half a cup of pudding with whip topping condiment: one margin, one salt and pepper packet beverage: 8 fluid ounces of milk thicken to honey 8 fluid ounces of water thickened to honey Record review of Resident #33 diet card dated Wednesday 09/13/23 revealed he should have had the following: Entree: three fourth cups of pureed fried pork chop starch: three fourth cups puree Black Eyed Peas vegetable: half a cup of pureed mixed green bread: 1/4 cup of pureed cornbread (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 12 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 0805 dessert: half a cup of pudding with whip topping Level of Harm - Minimal harm or potential for actual harm condiment: one margin, one salt and pepper packet beverage: 8 fluid ounces of milk and 8 fluid ounces of water Residents Affected - Few Record review of Resident #26 diet card dated Thursday 09/14/23 revealed he should have had the following: Entree: three fourth cups of puree chicken fried chicken South: 2 fluid ounces of cream gravy starch: three fourth cups of mashed potatoes Vegetable: 1/2 cup of puree green peas bread: 1/4 cup of garlic biscuit dessert: 1/4 cup of puree frosted cake condiment: one margin, one salt and pepper packet beverage: 8 ounces of milk (thickened to honey consistency) and eight ounces of water (thickened to honey consistency) Record review of Resident #33 diet card dated Thursday 09/14/23 revealed he should have had the following: Entree: three fourth cups of puree chicken fried chicken South: 2 fluid ounces of cream gravy starch: three fourth cups of mashed potatoes Vegetable: 1/2 cup of puree green peas bread: 1/4 cup of garlic biscuit dessert: 1/4 cup of puree frosted cake condiment: one margin, one salt and pepper packet beverage: 8 ounces of milk and eight ounces of water During an interview on 09/15/23 at 09:13 AM, Dietary [NAME] A said the fried chicken was a tough meal, and she was focused on making sure the chicken was cooked properly. She said she had been trained regarding pureed foods. She said pureed food should hold its form. She said pureed food was not supposed to be thin. She said it should have been either pudding or nectar. She said that it should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 13 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have had the consistency of baby food. She said she did not taste the food. She said she did not have a reason to taste the food. She said she was aware the pureed meals both days was runny because she specifically saw the green beans drip. She said she had not had any recent training on pureed food. She said she takes responsibility for actions that occur in the kitchen. During an interview on 09/15/23 at 09:49 AM, the DM said he was responsible for all activity that went on in the kitchen. He said pureed foods should have the thickness of mashed potatoes. He said the meals on 09/13 and 09/14/23 could have been thicker based on observing the pureed food from Dietary [NAME] A. He said he believed the first-day Dietary [NAME] A was nervous. He said he talked to her about the pureed process. He said if the pureed was not prepared properly, it could strangle the residents and place them at risk for pneumonia. He said he did not have a system in place to monitor the pureed process because he was typically in the front help serving. He said he knew the pureed was not in the correct form. He said Dietary [NAME] A should not have used as much juice, and then she would not have to use bread or thickener. He said when additional items such as thickener and bread are used, more food should be added so the serving size and nutrients are not altered. He said he did not have any policies specific to pureed food outside of pureed snacks. During an interview on 09/15/23 at 10:19 AM, the ADM said the DM was responsible for all activity that occurred in the kitchen. He said he was not aware of any of the identified deficient practices. He said he had been in the kitchen many times and had not identified any concerns with food form. He said he had been trained but not in detail. He said he understood what was expected in general in the kitchen. He said he expected that his dietary staff would follow the policies and guidelines for the kitchen. He said the majority of the kitchen staff had been employed at the facility for years. No policy was provided for pureed foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 14 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 to date and label all food. 2) Dietary staff failed to store foods in a manner to prevent contamination. 3) Dietary staff failed to clean two vents observed in the kitchen area and the inside dry storage area. 4) Dietary Staff stored dented cans with the remaining cans used for resident consumption (. 5) Dietary Staff used 1 of 2 dented cans for resident consumption on 09/13/23. 6) Dietary Staff failed to properly thaw chicken 7) Dietary staff failed to cover food that was not actively being served. These failures could place residents at risk for food contamination and foodborne illness. The findings include: The following observations of the kitchen was made on 09/13/23: -At 8:58 AM - a partially used bottle of water and a personal cup with a lid and straw was on the food prep area. Tray [NAME] A remove the items and place them on the bottom shelf. -At 9:00 AM In the outside storage two cans of Roma tomatoes with dents along the side. They were dated 06/20/23. -At 9:03 AM in the large white freezer was an undated cubed turkey, A gallon of undated strawberry and vanilla ice cream , and there was a bag of 14 popsicle also undated. -At 9:14 AM the vent in the dry storage dirty with built up debris. -At 11:28 AM until 12:06 the cornbread was uncovered. Observed multiple dietary staff passing back and forth. -At 11:44 AM the vents on the window unit in the kitchen area with debris built up on the vents. The AC was on and blowing. -At 3:08 PM Dietary [NAME] C used one of the dented cans of Roma Tomatoes. -At 3:11 PM an opened Big Red soda was on the shelf with food items for the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 15 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 -At 3:15 PM the DM wrapped potatoes (x13) in foil with his bare hands. Level of Harm - Minimal harm or potential for actual harm -At 3:16 PM Dietary [NAME] C touch the coleslaw with her bare hands. After mixing the lettuce she poured the lettuce into a large mixing bowl and reach in to remove the blade out of mixing machine touching the contents in the machine. Residents Affected - Many -At 3:18 PM the DM cell phone ring he reached in his pocket, looked at his cell phone, silenced it and then continued to wrap potatoes in foil never washing his hands. The following observations of the kitchen was made on 09/14/23: -At 9:43 AM observed a large piece of frozen diced chicken sitting in a pan of shallow water thawing. Vent on the AC unit in the window was still dirty. The remaining dented can of roma tomatoes was no longer on the shelf but had been moved down to the bottom right shelf in the outside pantry. A sign that read damaged cans was taped to the shelf. In the large white freezer was an undated cubed turkey, a gallon of undated strawberry and vanilla ice cream, and a bag of 14 popsicle also undated. -At 9:40 AM observed 4 large bottles of dish detergent on the same shelf as food thickener, mayonnaise and sweet relish. Observed a large tube of ground beef on the floor under the dented can area. -At 11:06 AM the DM made 2 sandwiches without gloves. He touched the bread, cheese and meat. He placed each sandwich in a plastic bag and placed them in the fridge. -From 11:06 AM to 11:36 AM two pans of rolls (36 rolls) were uncovered. -At 11:12 AM observed personal hand lotion on the same shelf with seasonings. Above the handwashing sink. -At 11:23 AM observed Dietary [NAME] A using a spatula during the pureed process. She placed the spatula part of the utensil in her bare hand and on the handle of the puree machine and used it to stir the food. -At 11:31 AM the ground beef was still on the floor under the damage cans in the outside dry storage room. -At 11:37 AM observed Dietary [NAME] A use a pair of gloves and grab the pan of rolls. The tongs touched the bread and the bottom of the pan. She used the same tongs to grab the rolls. -At 11:40 AM observed Dietary [NAME] A used the same tongs that she grabbed the tray with to grab eight rolls, 3 bake potatoes and 4 pieces of chicken. -At 11:44 AM observed Dietary [NAME] grab one of the sandwiches prepared with the DM bare hands and plate to serve. -At 11:46 AM observed the DM grab his personal phone look at it and place it back in his pocket. He did not conduct hand hygiene. -At 11:47 AM Dietary cook observed tearing apart 15 rolls with her bare hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 16 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 Observations on 09/15/23 at9:01 AM the ground beef was still on the floor in the storage outside under the damaged can area. Further observation revealed the DM throw the meat away. During an interview on 09/15/23 at 09:13 AM, Dietary [NAME] A said the potential negative outcome of touching food with bare hands was cross-contamination, and the residents could get sick. She said that not thawing the meat correctly could have caused the residents to be potentially exposed to salmonella. She said if the vents were dirty, there was a risk of debris falling into the resident's food, which could make them sick. She said the potential negative outcome of food not being labeled correctly was that staff could not rotate the food properly. She said that residents could get sick if they were given something old. She said that using dented cans could be bad for the residents because something could have been wrong with the can, such as a hole they could not see. She said that she would not use the dented cans. She said the sign observed was placed after the surveyor's entrance. She said a potential negative outcome for having personal items in the food prep area was being written up by the state. She said there was a chance of cross-contamination because they could touch their personal items and then the food. She said she was not aware at the time when she was touching food with her bare hands. She said she thought about it later. She said she had gloves in her pocket. She said her expectation of touching food was not to touch it with her bare hands; instead, she should have had gloves on. She said she knew the way she was thawing the chicken out was incorrect. She said the chicken had not been taken out and she needed to make the meal since the surveyors were watching. She said fried chicken was a tough meal, and she was focused on making sure the chicken was cooked properly. She said she should have placed it in cold water. She said she was unaware of the vents that needed cleaning but tried to do as much as she could. She said the expectation was for the vents to have been cleaned. She said she said all food should be labeled. She said it should have the open date and expiration date. She said the DM typically does the food out in the outside pantry, and she was responsible for the food inside. She said she was unaware of the ground beef left on the floor in the outside pantry. She said the ground beef should have been in the freezer labeled. She said she was unaware of the dented cans before the surveyor entered the facility. She said the expectation for the dented cans to be place at the bottom of the rack for reimbursement. She said she knew there were personal items in the food prep area. She said her phone was in the food prep area, and she realized this after the surveyor was in the kitchen. She said they should follow a cleaning schedule to monitor and identify issues in the kitchen. She said the DM does not offer any correction from his monitoring. She said the dietician would correct it when she came. She said she had received training on her expectations in the kitchen, but it had been a long time ago. She said she was trained by someone else, and the expectations that were expected today might not be the same from a long time ago. She said they are under a new company, and she does not feel like they have a lot of support from the new company. She said she was responsible for all of the identified deficient practices except the dented cans. During an interview on 09/15/23 at 09:42 AM, Tray [NAME] A said their personal items were supposed to be on the bottom rack in the food prep area. She said the reason her personal cups were on the counter was because she was a diabetic and she had to drink a lot of water. She said she had been trained on the expectations when in the kitchen regarding personal items. She said she could not think of a negative outcome of having her personal items in the food prep area. She said she was unaware that personal items could not be in the food prep area. During an interview on 09/15/23 at 09:49 AM, the DM said that he was responsible for all activity that went on in the kitchen. He said he knew he was touching the food with his bare hands. He said he tried to go back and get gloves. He said he knew Dietary [NAME] A was touching the bread with her hands. He said he was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 17 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 aware of Dietary [NAME] B touching the coleslaw. He said he knew Dietary [NAME] A was thawing the chicken incorrectly. He said he was aware of the AC vent that needed cleaning but was unaware of the vent in the dry pantry. He said he was not aware of the unlabeled food identified. He said he was not aware that they had multiple dented cans. He said he thought they only had one can. He said he knew his phone was in the food prep area. He said he was also aware of the personal cups in the food prep area. He did see the lotion on the rack with food items but was unaware that Dietary [NAME] A's phone was also on the rack with food items. He said he knew the cleaning items were in the outside food storage area. He said he was aware of the uncovered rolls. He said he had received training on expectations as a dietary manager. He said he expected he and the other staff should not touch the food with their bare hands. He said the proper way of thawing food should be done at the bottom of the fridge or under running cold water. He said all vents should be clean. He said the ground beef should not have been on the floor, and he takes responsibility for that. He said the dented cans should not be with the remainder of the cans for resident consumption. He said they should be placed where the sign was. He acknowledged that the sign was not present on the first day of the survey. He said the dented cans should be returned to the supplier. He said the rolls should have been covered until ready to serve. He said cleaning items should not be stored with food items. He said he also expected staff not to touch the food with their bare hands. He said residents could get sick if staff touched the food with bare hands. He said improperly thawing meat could place the residents at risk for salmonella. He said the vents not being clean could cause stuff to fly in the food. He said unlabeled food could make residents sick or even staff if they consume the food, not knowing when the food was delivered or opened. He said personal items could carry disease or cause staff to contaminate the food by touching it. He said dented cans can cause residents to get sick because if there was a hole, they may not see it, which could contaminate the food inside the can. He said the exposed rolls could have been exposed to bugs or anything else that could have fallen on the rolls. He said all of the policy provided is what he had. During an interview on 09/15/23 at 10:19 AM, the ADM said DM was responsible for all activity that occurred in the kitchen. He said he was not aware of any of the identified deficient practices. He said he had been in the kitchen many times and only identified deficient practice that he observed was personal items in the food prep area. He said, but it was his understanding that this deficient practice was being addressed. He said he had been trained but not in detail. He said she understood what was expected in general in the kitchen. He said he expected that his dietary staff would follow the policies and guidelines for the kitchen. He said the majority of the kitchen staff had been employed at the facility for years. He said the potential negative outcome for the identified deficient practices was cross-contamination and food-borne illness. Record review of the facility's policy titled Food Preparation and Handling, revised 09/01/18, revealed: Policy To ensure that all foods served by the facility is of good quality and safe for the consumption all booths will be prepared and handled according to the state and US food codes in HACCP guidelines. General Guidelines c. Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 18 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 Thawing foods Level of Harm - Minimal harm or potential for actual harm a. Thaw meat, poultry and fish in a refrigerator at 41 degrees or less. Residents Affected - Many b. This may also be taught using the following procedures: completely submerged under running water at a temperature of 70 degrees Fahrenheit or below with sufficient water velocity to agitate and float off loosen food particles into the overflow: ii. In a microwave oven using the defrost mode and immediately transferred to conventional cooking equipment with no interruption in the process. or is a part of the cooking process. Record review of the facility's policy titled Food Storage, revised 06/01/19, revealed: Policy To ensure that all foods served by the facility is of good quality and safe for the consumption our food will be stored according to the state federal and US food codes and HACCP guidelines. D) who is your freshness store open in both items in tightly covered container. All containers must be labeled in data. G) Use the first in first out rotation method. Date packages in place new items behind existing supplies, so that the older items are used first. I) do not use or store cleaning materials or other chemicals where they might contaminate foods. Label and stores them in their original containers when possible. Store in a locked area away from any food product. Record review of the 2022 US Food and Drug Administration Food Code manual, revealed: Chapter 3 Food 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature (B) Completely submerged under running water: (1) At a water temperature of 70oF (2) With sufficient water velocity to agitate and float off loose particles in an overflow Thawed in a microwave oven and immediately transferred to conventional cooking equipment, with no interruption in the process Preventing Contamination by Employees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 19 of 20 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 675989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Knox City 605 S Ave F Knox City, TX 79529 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 FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675989 If continuation sheet Page 20 of 20