Inspection·October 26, 2022

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident #7 on 5/26/22 at 8:06 AM Resident #7 stated she reported an incident in September 2022 about two CNAs speaking Spanish while providing care to her. Resident #7 stated it was better for about a week and then it was right back to where it started. Resident #7 stated CNAs during the night shift were still speaking Spanish while providing care for her. Resident #7 stated the last time it happened was on the night of 10/24/22. Resident #7 stated she did not tell anyone about the CNAs speaking Spanish in front of her, because she did not want to get anyone in trouble. Resident #7 stated it made her feel sad, angry, and like they were talking about her. Resident #7 stated she did not feel the grievance was resolved. Resident #7 stated the facility did not discuss the grievance with her after she reported it. Resident #7 stated a reasonable time frame to her for a grievance to be resolved would be about a week. Record review of resident council minutes for 8/4/22, 9/6/22, and 10/6/22 indicated Call lights are being answered and residents told I'll be back, and never return. Record review of grievance logs for May 2022 - September 2022 indicated no grievances for call lights being answered, turned off, and staff not returning. Record review of a grievance report dated 9/14/22 indicated Resident #7 reported two night shift CNAs were only speaking Spanish when in her room and she was unable to understand them. Grievance report indicated staff were educated to speak appropriate language when providing patient care. Record review of in-service dated 9/14/22 indicated staff was educated on the use of foul language or inappropriate conversation during patient care. During an interview on 10/26/22 at 3:38 PM The Activity Director stated she believed that complaints during resident council were considered grievances. The Activity Director stated grievances were started by the person who took the complaint and then given to the Social Worker. The Activity Director stated the failure for unresolved grievances could make the residents believe nothing ever got solved and it hurts them because they must continue to deal with the problem. During an interview on 10/26/22 at 3:43 PM the Social Worker stated some complaints made during resident council would be considered a grievance. The Social Worker stated that answering the call lights, turning them off and saying they will return, and not returning would be considered a grievance. The Social Worker stated grievances were started by the person taking the grievance, then they discussed it in the morning meeting or with the Administrator. The Social Worker stated they would talk to residents, staff, or supervisors to resolve the complaint. The Social Worker stated they follow up on grievances by talking to residents to see if they are satisfied or if it is resolved. The Social Worker stated they follow up for a few days after the grievance and then periodically afterward. The Social Worker stated Resident #7's grievance was resolved by having the CNAs relocated to another area and those CNAs were educated on the use of appropriate language during resident care. The Social Worker stated the failure to resolve grievances for residents would make them feel disrespected, unheard, and not cared about. During an interview on 8/26/22 at 3:54 PM the DON stated anyone could take a grievance. The DON stated it was usually documented by a department head and the form is turned into the Social Worker, then it is discussed in the morning meeting. The DON stated the department in which the grievance originated would then perform the investigation, corrective action, and follow-up. The DON stated she was unaware of the grievance report for Resident #7 and the resident council complaints. The DON stated the residents could feel disrespected, unheard, and dehumanized when grievances are not resolved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 2 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0585 or reported. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/26/22 at 4:06 PM the ADMIN stated that complaints during resident council were absolutely considered grievances. The ADMIN stated he expected department heads to document grievances and then discuss them during the morning meeting. The ADMIN stated the investigation, corrective action, and follow up would be completed as an interdisciplinary team. The ADMIN stated he was unaware of Resident #17's grievances or the resident council complaints. The ADMIN stated the residents would not feel cared for or disconnected and could lead to physical needs not being met or the environment not being secured. Residents Affected - Few Record review of Grievances Standard of Practice policy revised on November 2017 revealed Standard of Practice: . The facility will make prompt efforts to resolve grievances. Record review of Grievances Standard of Practice policy revised on November 2017 revealed Standard of Practice Explanation and Compliance Guidelines: 6. C An initial response is expected within 72 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 3 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse for 1 of 20 residents reviewed for abuse. (Resident #24) Residents Affected - Few The facility failed to follow their policy on abuse and reportable events by not reporting allegations of abuse to the administrator for Resident #24. This failure could place residents at risk of not having incidents of abuse, being reviewed, and investigated which could place residents at risk of continued and/or unrecognized abuse. Findings Included: Record Review of Resident #24's face sheet (no date) indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #24 had diagnoses of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record Review of the progress note dated 09/29/2022 at 4:01 pm by LVN C indicated Resident #24, was hit on the head by another resident. No injuries noted, no complaints of pain or discomfort. The Administrator, nursing management and MD were notified. Progress note at 6:28 pm by LVN C indicated the responsible party had been called and LVN C had left a voicemail to return call. LVN C was not available for interview. Record review of Resident #24's chart indicated no incident report was completed on 09/29/2022 for a resident-to-resident altercation. Record Review of Resident #24's MDS dated [DATE] indicated a BIMS score of 2 indicating severe impairment. Section I of the MDS for active diagnosis indicated Resident #24 had Non-Alzheimer's dementia, anxiety, and psychotic disorder. Record Review of Resident #24's care plan dated 8/29/2022 indicated Resident #24 was in the secure unit related to dementia. The Approach dated 8/29/2022 indicated to keep environment free of possible hazards and monitor to assure residents safety. Record Review of Resident #24's care plan indicated on 4/21/2022 that Resident #24 exhibits verbally abusive behavioral symptoms. The approach (dated 3/1/2021) indicated to allow distance in seating other residents around resident and to assess whether the behavior endangered Resident #24 and others. Another approach indicated to avoid over-stimulation of other physically aggressive residents. During an interview on 10/26/22 at 2:08 p.m. LVN A stated, The Charge nurse was responsible for filling out incident reports when resident altercations had occurred and notifying the Administrator. Incident reports were important because they had the correct steps to follow to make sure the residents were safe. During an interview on 10/26/22 at 3:07 p.m. with the MDS Coordinator and the DON interim, the interim DON stated, the charge nurse was responsible for filling out an incident report for any resident altercations and the Administrator was the abuse coordinator. Resident to resident altercations should have been reported because the resident could have continued with an aggressive pattern and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 4 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few state needed to know that steps had been followed to prevent future incidents. The interim DON was not aware of the alleged incident involving Resident #24. During an interview with the Administrator on 10/26/22 at 2:45 p.m., the Administrator stated he was never notified of the resident-to-resident altercation on 9/26/22 or he would have completed an investigation. The Administrator stated he should have been notified immediately to investigate and the violator should have been determined for possible interventions. The Administrator stated he made daily rounds in the unit and the charge nurses were responsible for notifying him of any incidents that had happened. The Administrator stated if the incident was not investigated, the possible violator could have endangered another resident. Record review of the policy dated September 2020 on Abuse/Reportable Events indicated all residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents should not be subjected to abuse by anyone, including facility staff, other residents, consultants or volunteers, or staff of other agencies serving the resident. It was everyone's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, or mistreatment of resident's property abuse and situations that may constitute abuse or neglect to any resident in the facility. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. Comprehensive investigations will be the responsibility of the administrator. The administrator will report cases to HHSC. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 5 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure an accurate MDS was completed for 3 of 20 residents reviewed for MDS assessment accuracy. (Resident #24, #8 and #13). Residents Affected - Some The facility failed to accurately reflect Resident #24, #8 and #13's medications on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1.Record Review of Resident #24's face sheet indicated a [AGE] year-old female admitted on [DATE]. Resident #24 had a diagnosis of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record Review of Resident #24's physician orders (9/1/2022-9/20/2022) indicated Resident #24 was taking buspirone 10mg daily from 8/23/2022 until 10/20/2022. No indication that Resident #24 was taking Seroquel, Lexapro, Abilify and Mirtazapine were found on the orders. Record Review of Resident #24's care plan dated 4/25/2022 indicated she was taking Lexapro and Mirtazapine for depression. Care plan dated 4/21/2022 indicated Resident #24 was taking psychotropic drugs Xanax, Abilify and Seroquel. Record Review of Resident #24 MDS dated [DATE] indicated she had a BIMS score of 2 indicating mildly impaired. Section I of the MDS indicated Resident #24 had an active diagnosis of anxiety and psychotic disorder. Section N of the MDS indicated Resident #24 had received antipsychotic medications for the last 7 days and antidepressants for the last 7 days. Section N0450 indicated that a GDR had been documented from the physician as clinically contraindicated. 2. Record Review of Resident #8 indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #8 had a diagnosis of stage 3 chronic kidney disease, dementia (brain disorder) and hypertension (high blood pressure). Resident #8 did not have a diagnosis of diabetes. Record Review of the physician orders dated 7/15/22 until 8/5/22 indicated Resident #8 was not taking any insulin. Record Review of Resident #8's care plan did not indicate she was taking insulin or have a diagnosis of diabetes. Record Review of the MDS dated [DATE] indicated Resident #8 had a BIMS score of 2 indicating mildly impaired. Section I of the MDS for active diagnosis did not indicate a diagnosis of diabetes. Section N0300 of the MDS under medications indicated Resident #8 had 4 days of injections in the last 7 days. Section

N0350 indicated she had insulin injections 4 of 7 days since admission. 3. Record Review of Resident #13's face sheet indicated a [AGE] year-old male admitted on [DATE]. Resident #13 had a diagnosis of HTN (high blood pressure), Alzheimer's (brain disorder) and chronic pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 6 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0641 Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #13's Physician orders dated 8/31/22 indicated Resident #13 was taking clopidogrel 75mg po qd. Physician orders did not indicate Resident #13 was taking anticoagulants. Record Review of care plan dated 08/10/2022 indicated Resident #13 was taking Plavix for clot prevention. Care plan did not indicate Resident #13 was taking anticoagulants. Residents Affected - Some Record Review of the MDS dated [DATE] indicated a BIMS score of 1, indicating mildly impaired. Section N of the MDS under medications indicated Resident #13 had taken anticoagulants 7 of 7 days. Interview on 10/26/22 at 2:08 pm with LVN A, LVN A stated the MDS nurse is responsible for completing the MDS. LVN A stated the MDS nurse will ask the nurses if there are any changes in resident's conditions. LVN A stated the charge nurses will list resident changes in their 24-hour report and the day shift charge nurse will notify the MDS nurse. Interview on 10/26/11 at 1:32 pm with the ADON. The ADON stated the charge nurses are responsible for notifying the MDS nurse of any changes that need to be updated on the MDS. Interview on 10/26/22 at 3:07 pm interview with the MDS coordinator, the MDS coordinator stated she is responsible for completing the MDS's accurately. MDS coordinator stated if it was not done correctly it could result in false information and inaccurate care planning. Interview on 10/26/22 at 2:45 pm with the Administrator. Administrator reported it was the responsibility of the MDS nurse to complete the MDS's. Stated he expected the MDS to be completed correctly. The policy on Nursing Policy and Procedures dated 10/2020 under #4 concerns and problems indicated to review care Area Assessment triggers on the MDS and list the problems. Sources include diagnosis, problems related to physician orders, and all problems identified on all assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 7 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 of 20 residents (Resident #24) reviewed for PASRR. Residents Affected - Few The facility failed to review Resident #24's PASRR level 1 assessment for accuracy. Resident #24 was diagnosed for psychosis on 02/16/2022 prior to his diagnosis of dementia on 10/18/2022. This failure could place resident at risk of not receiving needed assessments (PASRR Evaluation), individualized care and specialized services to meet their needs. Findings include: Record Review of Resident #24's face sheet (no date) indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #24 had a diagnosis of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record review of Resident #24's care plan dated 4/25/2022 indicated on 8/29/2022 the resident resided in the secure unit related to dementia. The care plan indicated on 4/25/22 that Resident #24 had a diagnosis of depression and was at risk for mood decline and side effects of medication. The care plan dated 4/21/2022 indicated Resident #24 was taking psychotropic drugs Xanax, Abilify and Seroquel for psychotic disorder with delusions. Record Review of Resident #24 MDS dated [DATE] indicated Resident #24 had a BIMS score of 2 indicating severe cognitive impairment. Section I of the MDS indicated Resident #24 had an active diagnosis of anxiety, non-Alzheimer's dementia, and psychotic disorder. Section N of the MDS indicated Resident #24 had received antipsychotic medications for the last 7 days and antidepressants for the last 7 days. Record Review of Resident #24's PASRR Level 1 Screening completed on 10/31/2020 indicated in Section C0100 resident had no mental illness. During an interview on 10/26/22 at 3:07 p.m. with the MDS nurse, who was also the interim DON, stated the PASRR was completed by the MDS nurse, so it would have been her responsibility to review the PASRR. The MDS nurse stated she was not aware that the PASRR should have been marked yes on the mental illness section (C0100) because the resident had a diagnosis of dementia. The MDS nurse stated the failure could have resulted in Resident #24 not receiving the correct services or it could have impacted her quality of life. During an interview on 10/26/22 at 2:45 p.m. the Administrator stated he expected the MDS nurse to notify the state authority when residents had a mental illness. During an interview on 10/26/22 at 1:32 p.m., a policy for PASRR was requested from the ADON but was not provided upon exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 8 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 4 of 20 residents reviewed for care plans. (Resident #14, Resident #47, Resident #4, and Resident #24) The facility failed to ensure Resident #14 received his daily showers as ordered by the physician. The facility failed to ensure Resident #47 received oxygen at rate ordered by the physician and the facility failed to develop and implement plan of care for oxygen therapy. The facility failed to update Resident #4's care plan to indicate he no longer was receiving hospice services. The facility failed to ensure Resident #24's care plan was updated and revised to reflect she was not taking any antidepressant medications. The facility failed to ensure Resident #24's care plan was updated and revised to reflect she was not taking any antipsychotic medications. These failures could place the residents at increased risk of injury or infection and not having their individual needs met. The findings included: 1. Record review of the face sheet (undated) indicated Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of COVID-19 (Contagious disease caused by severe acute respiratory syndrome coronavirus 2), dyspnea (difficult or labored breathing), and vascular dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.) Record review of Resident #47's consolidated physician orders dated 10/26/22 indicated an as needed order for oxygen at 2 liters per minute via nasal cannula for shortness of breath which started on 12/7/21. Record review of the comprehensive MDS dated [DATE] indicated Resident #47 had a BIMS score of 14 and was cognitively intact. The MDS revealed no shortness of breath. The MDS revealed no oxygen in the last 14 days while a resident. Record review of the comprehensive care plan, last revised 10/25/22, indicated no comprehensive care plan for Resident #47's oxygen therapy. During an observation on 10/24/22 at 10:48 AM Resident #47 was receiving oxygen at 3 liters per minute via nasal cannula. Resident #47 was non-interviewable. During an observation on 10/25/22 at 8:20 AM Resident #47 was receiving oxygen at 3 liters per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 9 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0656 minute via nasal cannula. Level of Harm - Minimal harm or potential for actual harm During an observation on 10/26/22 at 8:00 AM Resident #47 was receiving oxygen at 3 liters per minute via nasal cannula. Residents Affected - Some During an interview on 10/26/22 at 4:19 PM LVN F indicated the charge nurses were responsible for monitoring and checking oxygen concentrators. LVN F stated the charge nurses must sign off on residents receiving oxygen therapy on the electronic health record one time per shift. LVN F stated Resident #47 had an order for oxygen at 2 liters per minute via nasal cannula. LVN F stated the charge nurses were responsible for putting the orders in the electronic health record. LVN F stated receiving a higher dose of oxygen than ordered can be bad for your brain. During an interview on 10/26/22 at 2:20 p.m. the ADON stated it was the charge nurse's responsibility for entering orders. The ADON said she verified orders after the charge nurse enters the orders. The ADON said the charge nurse could update the care plan, but it was the MDS Coordinator responsibility to update the care plans. The ADON said if oxygen was being administered at a higher rate than ordered the nurse should notify physician a. Running to and receive an order to administer the oxygen at a higher rate. The ADON said oxygen being administered at a higher rate than ordered could inadvertently damage the lungs. The ADON said it was important to have supplemental oxygen on the care plan so the nurses would know what the resident's oxygen fluctuation was, whether the resident had a diagnosis of COPD, or determine if the resident needed a diagnosis changed. The ADON said the care plan ensured proper interventions were in place to care for residents. 2. Record review of the consolidated physician orders dated 10/26/2022 indicated Resident #14 was a [AGE] year-old male, admitted on [DATE] with diagnoses including pressure ulcer of the sacral region, local infection of the skin, muscle wasting and atrophy, pilonidal cyst with abscess (an abnormal pocket in the skin at the tailbone that usually contains hair and skin debris that drains pus or blood), and rash. The physician orders indicated Resident #14 was to have a daily shower as part of his wound care starting 10/09/2022. Record review of the most recent MDS dated [DATE] indicated Resident #14 understood others and was understood by others. The MDS indicated Resident #14 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #14 was not resistive to evaluation or care. The MDS indicated Resident #14 required total dependency with bed mobility, transferring, dressing, personal hygiene, and toileting. Record review of the care plan updated on 8/29/2022 indicated Resident #14 had an activities of daily living (ADL) deficit. The care plan interventions included total assistance with showers. The care plan indicated Resident #14 was at risk for skin breakdown related to amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function) and quadriplegia (paralysis of all four limbs). The care plan interventions included to keep the resident clean and dry as much as possible. Record review of Resident #14's shower sheet for October 2022 indicated he was provided a shower on 10/10/2022, 10/12/2022, and 10/19/2022. Record review of a progress note dated 10/13/22 at 12:30 p.m. indicated Resident #14 had gone out on pass with family. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 10 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0656 Level of Harm - Minimal harm or potential for actual harm Record review of a progress noted dated 10/17/22 at 12:19 a.m. indicated Resident #14 has returned to the facility on [DATE] at 11:30 p.m. During an observation and interview on 10/24/22 at 10:55 a.m. Resident #14 was clean and without offensive odor. Resident #14 said he was not receiving his showers as often as he should. Residents Affected - Some During an interview on 10/25/22 at 9:28 a.m. Resident #14 said he had not been receiving his showers. Resident #14 said it depended on what staff member was working as to whether or not he received his showers. Resident #14 said he had only been receiving his showers once a week. 3. Record review of the consolidated physician orders dated 10/26/2022 indicated Resident #4 was [AGE] year-old male, re-admitted [DATE] with diagnoses including acute respiratory failure, COPD, alcohol dependence in remission, bipolar disorder, shortness of breath, and muscle weakness. Record review of the most recent MDS dated [DATE] indicated Resident #4 usually understood other and was usually understood by others. The MDS indicated Resident #4 was severely cognitively impaired with a BIMS of 06. The MDS indicated Resident #4 required total assistance with bed mobility, transferring, eating, and toileting. Record review of the most recent care plan updated on 7/13/2022 indicated Resident #4 required hospice as evident by terminal illness of COPD. Record review of a progress note dated 5/23/2022 indicated Resident #'s wife had requested him to be taken off hospice services. Record review of a progress note dated 5/30/2022 indicated the Nurse Practioner would have been notified on 5/31/2022 when making rounds of Resident #4 no longer receiving hospice services. During an interview on 10/25/22 at 3:20 p.m. LVN D said Resident #4 was not receiving hospice services. LVN D said she was unsure when Resident #4 discharged from hospice services. 4. Record Review of Resident #24's face sheet (no date) indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #24 had a diagnosis of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record Review of Resident #24's physician's orders (no date) indicated Resident #24 was taking buspirone 10mg daily from 8/23/2022 until 10/20/2022. There was no indication Resident #24 was taking Seroquel, Lexapro, Abilify and Mirtazapine were found on the orders. Record Review of the Care plan dated 4/21/2022 indicated Resident #24 was taking psychotropic drugs Xanax, Abilify and Seroquel. The goal included Resident #24 will remain free of drug related complications. The approach included to administer medications as ordered, pharmacy consult, and discuss with the MD and family the need for use of medication. Record Review of Resident #24's care plan dated 4/25/2022 indicated the problem was taking Lexapro and Mirtazapine for depression. The goal indicated Resident #24 would remain free of signs or symptoms of distress, symptoms of depression, anxiety, or sad mood. The approaches included administering medications as ordered, pharmacist consultant, and monitor and report to the MD risk for harming others. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 11 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident #24's MDS dated [DATE] indicated she had a BIMS score of 2 indicating mildly impaired. Section I of the MDS indicated Resident #24 had an active diagnosis of anxiety and a psychotic disorder. During interview on 10/26/22 at 2:08 p.m. LVN A stated the charge nurses were responsible for updating the care plan when medications were discontinued. LVN A stated the MDS nurse was responsible for updating the care plan when residents are discharged from hospice services. LVN A stated the charge nurses should document resident changes on their 24-hour report and notify the MDS nurse the next morning or the MDS nurse would ask the nurses if there were any changes to update the MDS. LVN A stated care plans should be updated for medication changes to prevent mistakes or confusion. LVN A stated if care plans were not complete, nurses might think the care plan was ongoing. During an interview on 10/26/11 at 1:32 p.m. the ADON stated the charge nurse was responsible for updating the care plan if medication or hospice services had been discontinued. The ADON stated the care plans were important to ensure resident changes in medications and when to monitor for side effects. During an interview on 10/26/22 at 2:47 p.m. the DON/MDS Coordinator said the charge nurse should input orders and the ADON ensured the orders are input correctly. The DON/MDS Coordinator said the showers sheets and point of care system was how CNAs were aware of showers needing to be done. The DON/MDS Coordinator checked shower sheets to ensure resident showers were done as ordered or scheduled. The DON/MDS Coordinator said residents with orders for showers daily with a wound and not receiving them were at risk for infection, odor, and maceration (occurs when the skin is in contact with moisture for too long. The skin becomes soft, wet, soggy, wrinkly, and lighter in color). The DON/MDS Coordinator said the nurses should monitor to ensure the oxygen was being administered at the correct rate. The DON/MDS Coordinator said oxygen administered at too high of a rate could affect the resident's eyes and hyperventilate them. The DON/MDS Coordinator said she was responsible for ensuring care plans were updated. The DON/MDS Coordinator said acute issues and a new onset of chronic issues for a resident was reported on the facility activity report. The DON/MDS Coordinator said the facility activity report triggered what needed to be added to the resident's care plan. The DON/MDS Coordinator said chronic issues that a resident was admitted with would be triggered by the MDS to put on the care plan. The DON/MDS Coordinator said oxygen therapy should be care planned. The DON/MDS Coordinator said oxygen therapy should be care planned intervention and should be accessible for the nurse to review and apply necessary interventions to aid the resident receiving oxygen. During an interview on 10/26/22 at 3:07 pm interview with the MDS coordinator/Interim DON, the DON stated she should have updated the care plans and she was responsible for making sure the changes were made. The DON stated the charge nurses were responsible for updating the care plan when medications were discontinued and the MDS nurse was responsible for updating the care plan when hospice care was discontinued. The DON stated if care plans were not correct, the nurses could get false information. During an interview on 10/26/2022 at 4:45 p.m. the ADON said the facility's Chart-readmission policy was the policy to refer to for physician orders. Record review of the facility's Care Plan-Resident policy dated 10/2022 indicated, .Resident Care Plan Documentation and Use of The Plan .a. The resident care plan is used to plan and assign care for all disciplines .c. The resident care plan must be kept current at all times . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 12 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's Chart-readmission policy dated 10/2022 indicated, .New physician orders will be completed .Update medication administration record (MAR)/treatment administration record (TAR) as appropriate .Update MAR/TAR with med/treatment changes . The policy on Nursing Policy and Procedures dated October 2020 under #8 (b) the care plan must be reviewed and revised at least every 90 days. Problems, goals, and approaches may be reviewed and revised when appropriate and necessary. When the goal is resolved the date should be entered in the appropriate are on the care plan. #12 (d) indicated all residents receiving Hospice are to have care plans developed in conjunction with the organizations. Event ID: Facility ID: 676035 If continuation sheet Page 13 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 facility reviewed for Activity Director. Residents Affected - Some The facility did not ensure the Activity Director was qualified to serve as the director of the activities program. This failure could place residents at risk of not receiving a program of activities that meets their assessed activity needs. Findings include: Record review of a Personnel File Review Sheet, undated, revealed a staff member listed as Activity Director with a hire date 8/12/2022. Record review of the Activity Director employee file revealed no documentation of certification or CEU's as an Activity Director. During an interview on 10/26/2022 at 1:30 p.m., the Activity Director stated she had been in the position for the past two months. The Activity Director stated she was responsible for providing activities in room and in a group setting. The Activity Director stated she did not have a certification or license to qualify as an Activities Director. The Activity Director stated her background was as a caregiver. The Activity Director stated she was not aware that a certification was needed. The Activity Director stated she thought she had up to a year to become certified. The Activity Director stated she was told by the previous Administrator she did not have to be certified prior to her taking the position. The Activity Director stated the failure of not being certified was residents not receiving activities that meet their activity needs. During an interview on 10/26/2022 at 4:51 p.m., the Interim Administrator stated he had only been at the facility for seven weeks. The Interim Administrator stated the Activity Director did not have a certification or license to qualify as an Activity Director. The Interim Administrator stated he was not aware that the Activity Director was not certified until the surveyor brought it to his attention. The Interim Administrator stated it was important for the Activity Director to be certified to ensure she was following a plan that would be conducive to residents. When asked how residents could be negatively affected, he said, I do not see a potential harm since the residents were being provided activities. Record review of an undated Job Description Activity Director sheet, indicated will be responsible for the planning, developing, organizing, implementing, evaluating, and directing of Activity Programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to ensure that the spiritual development, emotional, recreational and social needs of the patient/resident are maintained on an individual basis . Certificates, Licenses, Registrations: Activity Professional Certification required . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 14 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a gradual dose reduction was attempted for 1 of 5 residents (Resident #31) reviewed for unnecessary medications. The facility failed to do a gradual dose reduction or document contraindication for a gradual dose reduction for Resident #31's Seroquel 25 mg at bedtime started on 06/09/21. This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Record review of the face sheet for Resident #31 revealed a [AGE] year-old-female admitted on [DATE] with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), Aphasia following other cerebrovascular disease (loss of ability to understand or express speech, caused by brain damage), dysphagia following other cerebrovascular disease (difficulty swallowing foods or liquids), Fall from bed, and essential (primary) hypertension (force of the blood against the artery walls is too high). Record review of the most recent MDS dated [DATE] revealed Resident #31 was unable to complete the BIMS interview, and staff assessment indicated cognitive skills for daily decision making were severely impaired. The MDS revealed Resident #31 sometimes understood. The MDS revealed Resident #31 required limited to extensive assistance with ADLS. The MDS revealed Resident #31 had no hallucinations, delusions, behavior, rejection of care or wandering. The MDS revealed in section N0410 medications received Resident #31 received an antipsychotic 7 days. Record review of the care plan last revised 06/15/21 revealed Resident #31 required psychotropic drugs for the treatment of depression, behavior management. The short-term goal target date of 07/21/22 indicated Resident #31 will reduce the use of psychoactive medication through the review date. Record review of Resident #31 physician order report dated 09/26/22-10/26/22 revealed an order for Seroquel 25 mg 1 tab by mouth at bedtime with start date of 06/09/21 for diagnosis of Dementia. Record review of Resident #31 medical records revealed no record of a gradual dose reduction or documentation of a contraindication for gradual dose reduction. During an observation and interview on 10/24/22 at 1217 Resident #31 sitting up in bed with eyes open. Resident #31 was alert, pleasant and voiced no concerns. During an interview on 10/26/22 at 1:33 PM, the pharmacy consultant indicated she did not know why the gradual dose reductions for Resident #31 were not done. The pharmacy consultant indicated she provided the facility the recommendations for gradual dose reductions for Resident #31 on the dates of 06/25/21, 08/25/21, 02/23/22, and 09/22/22. The pharmacy consultant provided surveyor with copies of the previously provided recommendations for Resident #31. Record review of the pharmacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 15 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few recommendation dated 06/25/21 for Resident #31 indicated, Please consider a trial dose reduction to assess continued need for treatment and check one of the following: () Medication to be continued as ordered. Discontinuation of therapy likely will be harmful to resident and/or others or it will interfere significantly with the provision of care for others. () reduce the current order to Seroquel 12.5 mg at bedtime x 1 week, then dc. () Other: Record review of the pharmacy recommendation dated 08/25/21 for Resident #31 indicated, Please consider a trial dose reduction to assess continued need for treatment and check one of the following: () Medication to be continued as ordered. Discontinuation of therapy likely will be harmful to resident and/or others or it will interfere significantly with the provision of care for others. () reduce the current order to Seroquel 12.5 mg at bedtime x 1 week, then dc. () Other: Record review of the pharmacy recommendation dated 02/23/22 for Resident #31 indicated, The resident has been taking the antipsychotic Seroquel 25 mg at bedtime since 6/2021. Please evaluate the current dose and consider a dose reduction. () Condition stable: attempt dose reduction to () Resident with good response, maintain the current dose () Previous dose reduction failed: Date of failed GDR: _____ () Condition is not well controlled. Record review of the pharmacy recommendation dated 09/22/22 for Resident #31 indicated, The resident has been taking the antipsychotic Seroquel 25 mg at bedtime since 6/2021. Please evaluate the current dose and consider a dose reduction. () Condition stable: attempt dose reduction to () Resident with good response, maintain the current dose () Previous dose reduction failed: Date of failed GDR: _____ () Condition is not well controlled. The pharmacy consultant indicated after performing the medication reviews, she would send the recommendations to the facility email and the DON would provide the recommendations to the facility doctor. During an interview on 10/26/22 at 2:51 PM, the corporate nurse indicated if pharmacy recommendations for gradual dose reduction for Resident #31 were not in the binder the facility did not have them. The corporate nurse indicated it was the DON's responsibility to ensure gradual dose reductions were being attempted or contraindication for gradual dose reductions was documented. During an interview on 10/26/22 at 4:31 PM, the ADON indicated she had started in September 2022, and she did not know why the gradual dose reductions had not been attempted. The ADON indicated she is currently working with the corporate nurse to develop a monitoring system to ensure gradual dose reductions are attempted or contraindications for gradual dose reductions are documented. The ADON indicated not attempting gradual dose reductions could cause residents to have dizziness, memory loss and negatively affect them. During and interview on 10/26/22 at 4:41 PM, the DON indicated the DON's office was responsible for gradual dose reductions or documentation of contraindication for gradual dose reductions. The DON indicated the pharmacist gave recommendations for gradual dose reductions and these were then given to the doctor to see if he agreed. The DON indicated 5 months ago she was monitoring the gradual dose reductions with a binder, but she had moved to be the MDS nurse and had not been following through with the pharmacist recommendations. The DON indicated she assumed the ADON took over the gradual dose reductions. The DON indicated a gradual dose reduction not being attempted was part of a system failure. The DON indicated not attempting gradual dose reductions placed the residents at risk for being over medicated and keeping them more sedated than they needed to be. Record review of the facility's policy and procedure for Medication-Drug Regimen Review with effective date of 10-2020 revealed, .5. The Pharmacy Consultant drug regimen review and nursing medication documentation review reports are processed as follows: a. Drug Regimen Review recommendations to physician: The report is provided by the Pharmacy Consultant upon exit from the home, the physician provides a written response to the home after the report is sent, a copy of the report is kept by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 16 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0758 Level of Harm - Minimal harm or potential for actual harm home until the physician's signed response is returned, the physician's response is provided to the Pharmacy Consultant for review and then filed by the home, the home maintains copies of signed reports on file for at least two years . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 17 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 20 residents reviewed for laboratory services. (Resident #157 and Resident #16) Residents Affected - Few The facility did not ensure Resident #157's electrolyte panel was drawn daily for five days. The facility did not obtain a physician's ordered CBC (test that measures red blood cells, white blood cells, and platelets), CMP (test that measures different substances in blood), Hemoglobin (test that measures for low or high levels of red blood cells), Lipid Panel (test that measure the amount of fats in blood), TSH (test that measures the thyroid gland), and Vitamin D levels for Resident #16. These failures could place the residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level. Findings Include: 1. Record review of the consolidated physician orders dated 10/26/2022 indicated Resident #157 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including hyponatremia (decreased sodium level), cardiac pacemaker, atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). The physician orders did not indicate Resident #157 had an order for an electrolyte panel to be drawn. The physician orders indicated Resident #157 had an order for sodium chloride 1 gram by mouth twice a day starting 10/20/2022 Record review of the baseline care plan completed by LVN D dated 10/22/2022 indicated Resident #157's diagnosis that contributed to admission was low sodium. Record review of the comprehensive care plan dated 10/25/2022 indicated Resident #157 was at risk for alteration in sodium levels/abnormal lab values related to hyponatremia with an intervention of monitor labs per physician orders. Record review of the hospital discharge orders dated 10/20/2022 indicated Resident #157 had a discharge order to draw an electrolyte panel (A blood test that measures if there is an electrolyte imbalance in the body. Electrolytes such as sodium, potassium, chloride, and bicarbonate are found in the blood.) daily for five days. Record review of the hospital lab results dated 10/17/2022 indicated Resident #157's sodium level was 128 milliequivalent/Liter (meq/L). The hospital lab results indicated Resident #157's sodium level of 128 meq/L was low, but did not provide a reference range. During an interview on 10/25/22 at 8:17 a.m. the Regional Reimbursement Consultant Nurse said Resident #157 had not had a lab drawn since she admitted to the facility on [DATE]. The Regional Reimbursement Consultant Nurse said the nurse practioner would be making rounds on 10/25/2022 and would order labs for Resident #157. The Regional Reimbursement Consultant Nurse viewed the discharge lab orders with the surveyor. The Regional Reimbursement Consultant Nurse said the lab order was not carried over at the facility. The Regional Reimbursement Consultant Nurse said she was unsure why the lab (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 18 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few order was not carried over. The Regional Reimbursement Consultant Nurse said she did not enter the primary diagnosis of hyponatremia, but had saw that was Resident #157's primary diagnosis in the electronic medical records. The Regional Reimbursement Consultant Nurse said the hospital documentation indicated the resident had not been maintaining her sodium levels. The Regional Reimbursement Consultant Nurse said it was important to have drawn the labs to monitor her sodium levels. The Regional Reimbursement Consultant Nurse said decreased sodium levels could lead to cardiac issues and muscle cramps. Record review of the lab results dated 10/25/2022 indicated Resident #157's sodium level was 135 meq/L. The lab results indicated the refence range for sodium was 136-145 meq/L. During an interview on 10/26/22 at 1:33 p.m. LVN D said she no longer worked at the facility. LVN D said she had been the nurse who put in the admission orders for Resident #157. LVN D said she had not been given the complete set of discharge orders from the nursing management for Resident #157. LVN D said the orders were supposed to be verified by a second nurse and the ADON. LVN D said the orders were not verified by a second nurse or the ADON. LVN D said she could not remember who the second nurse was that day. LVN D said not having sodium levels drawn as ordered could result in having cramps, dehydration, lethargy, and weakness. During an interview on 10/26/22 at 2:20 p.m. the ADON said the charge nurse was responsible for entering admission orders. The ADON said she verified admission orders after the charge nurse entered the orders initially. The ADON said the negative effect for labs not being drawn as order on Resident #157 could be not monitoring for signs and symptoms of hypo-natremia such as low blood pressure, cramps, or dehydration. 2. Record review of Resident #16's physician order report, dated 09/26/2022-10/26/2022, indicated Resident #16 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included acute respiratory disease, essential hypertension (high blood pressure), and Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of Resident 16's physician order report, dated 09/26/2022-10/26/2022, indicated Resident #16 had a one-time order for CBC, CMP, Hemoglobin, Lipid Panel, TSH, and Vitamin D levels to be drawn with a start date of 09/22/2022. Record review of Resident #16's annual MDS, dated [DATE], indicated Resident #16 understood others and made herself understood. The assessment indicated Resident #16 was moderately cognitively impaired with a BIMS score of 7. The assessment indicated Resident #16 did not reject care or evaluation. The assessment indicated Resident #16 did not require help or staff oversight at any time with bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Record review of Resident #16's care plan, dated 06/07/2022, did not address physician lab orders. During an interview on 10/25/2022 at 10:05 a.m., the ADON stated Resident #16 had not had her labs drawn that was ordered on 09/22/2022. During an observation and interview on 10/26/2022 at 9:15 a.m., Resident #16 stated she did not know how often her lab work should be drawn. She was unable to recall the last time her labs were drawn. Resident #16 did not have any negatives outcomes from the labs not being done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 19 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/26/2022 at 2:07 p.m., the DON stated the ADON was responsible for ensuring labs were drawn and ordered were completed. The DON stated the ADON walked out around 09/30/2022. The DON stated she was not aware that Residents #157 and #16 had orders for labs until surveyor intervention. The DON stated Resident #157 admission nurse was responsible for inputting all new lab orders. The DON stated the ADON should had done an audit to ensure all orders were placed in the computer. The DON stated she was responsible for checking/monitoring orders. The DON stated she monitors by pulling a facility activity report every morning. The DON stated she was depending on the ADON to assist with completion of lab orders by reviewing the activity report because the DON was also fulfilling the role of a MDS nurse. The DON stated the important of having labs drawn was so that the values could be monitored on a more consistent basis. The DON stated the failure of not knowing the lab values could potentially be critical and life threating. Record review of the facility's Lab Order policy, dated 10-2020, indicated, It is the policy of this home to provide or obtain laboratory services to meet the needs of its resident . 2. The DON/designee will be responsible to monitor lab orders to assure that all ordered labs have been drawn as ordered by the physician. 3.The DON/designee will be responsible to input all new lab orders as they were received. 7. Laboratory results will be maintained in the resident's clinical record Record review of the facility's Lab Monitoring-Therapeutic Levels policy, dated 10-2020, indicated It is the policy if this home that physician ordered laboratory services will be provided and monitored . 4. All lab result will be reviewed by a nurse. The nurse will date and document the time the result was received FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 20 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 - Some 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 food was prepared in a form designed to meet individual needs for 3 of 20 residents (Resident #24, Resident #12, and Resident #50). Resident #24, who required a mechanical soft diet with ground meat was served wavy lays potato chips at lunch. Resident #12 who required a mechanical soft diet with ground meat was served a chopped pork chop at lunch and cornbread. Resident #50 who required a mechanical soft diet with ground meat was served diced pork chop with rice at lunch. These failures could place residents on a mechanical soft ground meat diet at risk for poor intake, weight loss, not meeting their nutritional needs and choking. The findings included: 1. Record Review of Resident #24's face sheet (undated) indicated a [AGE] year-old female admitted on [DATE]. Resident #24 had a diagnosis of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record Review of Resident #24's physician orders (no date) indicated a mechanical soft diet with thin liquids, avoid all milk products lactose intolerance. Interventions included offering substitutes if less than 75% is eaten and monitoring intake. Record Review of Resident #24's care plan dated 10/25/2022 indicated a mech soft diet with thin liquids Record Review of Resident #24's MDS dated [DATE] indicated a BIMS score of 2 indicating the resident was cognitively impaired. Section I of the MDS indicated a diagnosis of dysphagia. Section K0510 for swallowing/nutritional status indicated a mechanically altered diet. Section G of the MDS for functional status indicated Resident #24 required supervision for eating and setup help only. During observation/interview on 10/25/2022 at 12:06 pm, Resident #24 was given a tray with a grilled cheese sandwich and wavy lays potato chips. Interview was attempted and resident was not interviewable. Resident #24 was eating the potato chips with her hands and no choking or coughing occurred. The meal ticket indicated Resident #24 was on a mech soft diet with thin liquids. During an interview on 10/26/22 at 2:08 pm LVN A stated the charge nurses were responsible for checking trays before they give them to the residents. LVN A stated giving the wrong texture of meat could cause choking or aspiration. LVN A stated she skimmed over the meal ticket and did not realize she gave Resident #24 the wrong tray. 2. Record Review of Resident #12's face sheet (undated) indicated he was a [AGE] year-old male admitted on [DATE]. Resident #12 had a diagnosis of depression, HTN (high blood pressure) and dysphagia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 21 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 (difficulty with swallowing). Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #24's care plan dated 4/14/2022 indicated a problem with nutritional status. Approach included mechanical soft, chopped/moistened meats. Residents Affected - Some Record Review of Resident #12's MDS dated [DATE] indicated he had a BIMS score of 4 indicating severely impaired cognition. Section K0510 of the MDS under Nutritional Approaches indicated Resident #12 received a mechanically altered diet. Section G of the MDS under function status indicated Resident #12 required supervision with eating and one-person physical assist. During observation on 10/26/2022 at 1:18 pm, Resident #12 was given a chopped pork chop with rice, greens, and cornbread. Meal ticket read mech soft diet. Interview was attempted and resident #12 was not interviewable. 3. Record review of Resident #50's face sheet (undated) indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #50 had diagnoses of Dementia (impaired ability to remember), dysphagia (difficulty with swallowing), and aphasia (affects a person's ability to express and understand written and spoken language). Record review of Resident #50's consolidated physician order for diet dated 10/18/22 indicated Regular, Mechanical soft diet with thin liquids and fortified food with all meals. Special instructions revealed ice cream with lunch and dinner. Record review of the comprehensive MDS dated [DATE] indicated Resident #50 was usually understood and usually understands others. The BIMS was 00 which indicated severe cognitive impairment. The MDS revealed Resident #50 required set up help with eating. Record review of the comprehensive care plan last revised on 8/17/22 revealed Resident #50 would receive a mechanical soft diet with thin liquids and fortified foods with breakfast for problem with nutritional status. During observation, interview, and record review on 10/24/22 at 12:50 PM Resident #50 received smothered pork chop that was cut in approximately 1 - 2-inch cubes on top of regular rice. There was no ice cream. The meal ticket with tray indicated Resident #50 should have received ground smothered pork chop, pureed rice, and ice cream with lunch and supper meals. Resident #50 was observed in her room eating the pork chops and rice with no coughing, eyes watering, or nose running. Resident #50 was able to use utensils without any difficulty observed. Resident #50 stated she does not usually get ice cream with her meals, but she doesn't like it much anyways. Resident #50 stated the food was good and she was not having trouble eating or swallowing. During an interview on 10/25/22 at 11:57 AM CNA E stated charge nurse and dietary staff were responsible for checking the trays. CNA E stated he just passes them out. CNA E stated if something was missing from the meal tray, he goes to kitchen to get it. During an interview on 10/26/22 at 4:19 PM, LVN F stated dietary, charge nurses, then CNAs were responsible for checking meal trays. LVN F stated Resident #50 was on a mechanical soft diet. LVN F stated residents on a mechanical soft diet cannot have chips, bacon, or rice. LVN F stated meat should be ground up not chopped or diced. LVN F stated residents could choke or aspirate if given the wrong diet texture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 22 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 - Some During an interview on 10/26/22 at 4:20 p.m. [NAME] C stated the cook was responsible for checking diets on the tray. [NAME] C stated kitchen staff goes over any plate changes or substitutes together as a group and breaks the trays down together. [NAME] C stated the CNAs were responsible for looking at the trays prior to serving and making sure nothing was missed. [NAME] C stated receiving a plate that was chopped and not mechanical soft can affect the resident's health. [NAME] C stated they use a puree machine on the pulse setting to make a mechanical soft diet and they do not use breaded meats because they turn to mush. [NAME] C stated if the meat was not less than 1 inch thick, it was considered diced and not mechanical soft. During an interview on 10/26/11 at 1:15 PM, The Dietary Manager stated he printed the meal tickets and put them in the daily folder for the cook. The Dietary Manager stated the cook read the meal tickets and prepared the meal tray, then the dietary aid read the meal tickets, then the nurse verified the trays were correct against the meal ticket. The Dietary Manager stated the dietician gave him the recommendation summary report and the nurses gave him communication forms and then he updated the meal tickets with correct diet. The dietary manager said he was responsible for ensuring meal tickets get updated with correct diet. During an interview on 10/26/11 at 1:33 p.m. the ADON stated dietary was responsible for serving the correct trays and the charge nurses were responsible for checking the trays prior to giving them out. The ADON stated the wrong texture of meat could result in aspiration. During an interview on 10/26/22 at 3:07 pm with the DON interim, the DON stated the food trays were dietary's responsibility. The nurses and CNAs were responsible for checking the trays on the floor to make sure they were correct. The DON stated she expected the nurses and CNAs to check the trays prior to giving them out every time. The DON stated giving the wrong texture of meat can cause choking or aspiration. During an interview on 10/26/2022 at 1:32 p.m. the Administrator stated dietary and nursing staff were responsible for checking the dietary trays. The Administrator stated he expected the trays to be checked daily and serving the wrong tray could cause a resident to aspirate. Record Review of the Policy provided on mechanical soft diet (undated) indicated a mechanical soft diet was ground meat with gravy. No chunks or large pieces. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 23 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was provided that accommodated resident allergies, intolerances, and preferences of 1 of 20 residents (Resident #24) reviewed for food allergies. The facility failed to ensure that Resident #24 did not receive a tray that accommodated her allergies or dislikes. This failure could place resident at risk for poor intake, weight loss, and unmet nutritional needs. Findings include: Record Review of Resident #24's face sheet (undated) indicated a [AGE] year-old female admitted on [DATE]. Resident #24 had a diagnosis of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record Review of Resident #24's physician orders (undated) indicated a mechanical soft diet with thin liquids, avoid all milk products lactose intolerance. Record Review of Resident #24's care plan dated 10/25/2022 indicated a mech soft diet with thin liquids. The approach included mechanical soft, chopped/moistened meats. Record Review of Resident #24's MDS dated [DATE] indicated a BIMS score of 2 indicating cognitively impaired. Section I of the MDS indicated a diagnosis of dysphagia. Section K0510 for swallowing/nutritional status indicated a mechanically altered diet. Section G of the MDS under function status indicated Resident #12 required supervision with eating and one-person physical assist. Record Review of Resident #24's meal ticket on 10/25/2022 indicated double portion/mechsoft. Allergies include milk (lactose). Dislikes include cheese, cottage cheese, milk beverages, and cream cheese. Special notes indicated resident is lactose intolerant and avoid all milk products. During observation on 10/25/2022 at 12:06 pm, Resident #24 was given a tray with a grilled cheese sandwich and wavy lays potato chips. Resident interview was attempted and resident #24 was not interviewable. Resident #24 was eating the potato chips with her hands and no choking or coughing occurred. During an interview on 10/26/22 at 4:20 p.m. [NAME] C stated the cook was responsible for checking diets on the tray. Stated kitchen staff they would go over the plate changes or substitutes as a group and break the trays down together. [NAME] C stated the CNAs were responsible for looking at the trays prior to serving and making sure nothing was missed. [NAME] C stated receiving a plate that was chopped and not mechanical soft could affect the resident's health. [NAME] C stated they used a puree machine on the pulse setting to make a mechanical soft diet and they did not use breaded meats because they turn to mush. [NAME] C stated if the meat is not less than 1 inch thick, it was considered diced and not mechanical soft. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 24 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/26/22 at 2:08 p.m. LVN A stated the charge nurses were responsible for checking trays before they give them to the residents. LVN A stated she skimmed over the meal ticket and did not realize she gave Resident #24 the wrong tray. LVN A stated that giving the wrong tray could have caused the resident to have diarrhea due to lactose intolerance. During an interview on 10/26/11 at 1:33 p.m. the ADON stated dietary was responsible for serving the correct trays and the charge nurses were responsible for checking the trays prior to giving them out. The ADON stated receiving the wrong tray could have resulted in the resident having an allergic reaction. During an interview on 10/26/22 at 3:07 p.m. the DON stated the food trays were dietary's responsibility. The nurses and CNAs were responsible for checking the trays on the floor to make sure they were correct. The DON stated she expected the nurses and CNAs to check the trays prior to giving them out every time. The DON stated giving the wrong trays and not following the listed allergies could have resulted in anaphylaxis. During an interview on 10/26/22 at 1:33 p.m. a policy for therapeutic diets was requested from the ADON but was not provided upon exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 25 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure: o food items were dated, labeled, and sealed appropriately. o hair restraints were worn by dietary staff. o expired food item was discarded. o the juice dispenser nozzle was clean. o the toaster was free of food debris. This failure could place residents at risk for foodborne illness. Findings included: During an observation on 10/24/22 starting at 10:22 AM revealed: Freezer #2 large, opened bag of chicken tenders 1/4 full unlabeled and not dated Freezer #3 large box of hamburger patties that were in an unsealed bag inside the box exposed to the air with no open date 36 lb. bag of dinner rolls with no open date Refrigerator #1 12 oz can of cranberry juice cocktail undated, the can was rusted and completely thawed the label (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 26 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 read should be kept frozen Level of Harm - Minimal harm or potential for actual harm 46 oz carton of thickened water with no open date 1 pitcher half full of lemonade undated Residents Affected - Some Refrigerator #2 large piece of ham in a Ziploc bag dated 10/08/22 3 boiled eggs in a Ziploc bag dated 10/17/22 1 gallon Worcestershire sauce approximately 1/4 remaining expired 7/12/22 Refrigerator #3 1 large bag of lettuce dated 10/08/22 the lettuce throughout the bag appeared soggy and the lettuce was brown During an observation in the dry storage room on 10/24/22 starting at 11:04 AM revealed: On the shelves 36 oz box of rice pilaf expired 07/13/21 4 packs of 12 hot dog buns all had green areas and fuzzy white spots 1 loaf of bread with fuzzy white areas During an observation on 10/24/22 at 11:37 AM, the toaster had food particles and the juice dispenser nozzle had gunky dark colored residue. During an observation on 10/25/22 at 11:14 AM, the Dietary Aide G was preparing drinks. Dietary Aide G had hair extending below the collar and freely displayed. Dietary Aide G was wearing a baseball cap with no hair restraint. During an interview on 10/26/22 at 1:21 PM, the Dietary Manager indicated it was his responsibility to ensure the kitchen was clean, staff wore hair restraints, food was labeled, dated and sealed appropriately, and expired items were discarded. The Dietary Manager indicated all food should be labeled and dated when it came in the facility and when it was opened. The Dietary Manager indicated he made rounds every Monday morning to ensure the kitchen was clean, food in the freezers and refrigerator were labeled, dated, and sealed appropriately, and items were discarded if expired. The Dietary Manager indicated he did not do the rounds this past Monday due to being in a hurry to help the kitchen staff to cook. The Dietary Manager indicated it was important for the kitchen to be clean and equipment to be sanitized adequately to prevent cross contamination and prevent food borne illnesses. The Dietary manager indicated it was important to keep food labeled, dated, and sealed appropriately and to discard of expired items to prevent the resident's from getting sick and dying. The Dietary Manager indicated it was his responsibility to ensure all staff in the kitchen wore hairnets. The Dietary Manager indicated he was not aware Dietary Aide G needed to wear a hairnet. The Dietary Manager (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 27 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 - Some indicated he believed a baseball cap would suffice. The Dietary Manager indicated the use of hair nets in the kitchen was important to prevent hair from getting in the food and to prevent particles from contaminating the food. During an interview with the administrator on 10/26/22 at 4:53 PM, the administrator indicated he expected the Dietary Manager to ensure all staff wore hairnets, food was dated, labeled, and sealed appropriately, expired food items were discarded, and the kitchen was adequately cleaned and sanitized. The administrator indicated not doing this could cause food-borne illnesses. Phone interview attempted with the Dietician on 10/26/22 at 4:58 PM with no success. Record review of the facility's policy titled, Sanitizing Equipment In-Place, dated October 1, 2018, revealed . 2. Remove any fallen food particles and scraps. 3. Wash, rinse, and sanitize removable parts using the manual immersion method described in Policy 04.005. 4. Wash remaining food-contact surfaces, and rinse with clean water. Wipe down with chemical sanitizing solution mixed according to the manufacturer's directions . Record review of the facility's policy titled, General Kitchen Sanitation, dated October 1, 2018, revealed . 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food-contact surfaces of equipment . Record review of the facility's policy titles, Food Storage, dated October 1, 2018, revealed . 2. (d) Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. (e) Use all leftovers within 72 hours. Discard items that are over 72 hours old . 3. (e) Store frozen foods in moisture-proof wrap or containers that are labeled and dated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 28 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for 3 of 17 residents (Resident #10, Resident #23, Resident #43) reviewed for clinical records. Resident #10 and Resident #43 had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were missing a date by the physician. Resident #23 had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was missing the physician's signature. This failure could place the residents at risk for not having their end of life wishes honored. Findings included: Record review of an undated face sheet for Resident #10 revealed an [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including viral pneumonia (infection of the lungs caused by a virus), major depressive disorder, recurrent severe without psychotic features (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), Alzheimer's disease with late onset (progressive disease that destroys memory and other important mental functions). Record review of the MDS dated [DATE] revealed Resident #10 was unable to complete the BIMS interview. Resident #10's electronic health record under the miscellaneous tab contained an Out-of-Hospital Do Not Resuscitate form that was not dated by the physician. Record review of Resident #10's care plan last revised on 08/31/22 revealed Resident #10 had an order for Do Not Resuscitate (DNR). Record review of Resident #10's Physicians Orders revealed an active physician's order for Code Status: DNR with start date of 03/04/22. Record review of an undated face sheet for Resident #43 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including 2019-nCoV acute respiratory disease (virus that causes respiratory illness), ischemic cardiomyopathy (disease in which the body cannot pump enough blood to the rest of the body), cerebral infarction (lack of adequate blood supply to the brain which causes parts of the brain to die off) and paroxysmal atrial fibrillation (irregular, rapid heart rate that causes poor blood flow). Record review of the MDS dated [DATE] revealed Resident #43 was unable to complete the BIMS interview. Record review of Resident #43's electronic health record under the miscellaneous tab contained an Out-of-Hospital Do Not Resuscitate form that was not dated by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 29 of 30 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 676035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kingsland 3727 W Ranch Rd 1431 Kingsland, TX 78639 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 0842 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #43's care plan last revised on 06/28/22 revealed Resident #43 had an order for Do Not Resuscitate (DNR). Record review of Resident #43's Physicians Orders revealed an active physician's order for Code Status: DNR with start date of 04/21/22. Residents Affected - Some Record review of an undated face sheet for Resident #23 revealed an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including pathological fracture, right femur, sequela (fracture of the right femur caused by weakened bone), gastro-esophageal reflux disease without esophagitis (disease in which stomach acid or bile flows into the food pipe and irritates the lining), Alzheimer's disease with late onset (progressive disease that destroys memory and other important mental functions), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements) and Dementia in other diseases classified elsewhere with behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the MDS dated [DATE] revealed Resident #23 was unable to complete the BIMS interview. Record review of Resident #23's electronic health record under the miscellaneous tab contained an Out-of-Hospital Do Not Resuscitate form that was not signed by the physician. Record review of Resident #23's care plan last revised on 10/25/22 revealed no indication that Resident #23 had an order for Do Not Resuscitate (DNR). Record review of Resident #23's Physicians Orders revealed an active physician's order for Code Status: DNR with start date of 10/25/22. During an interview with the social worker on 10/26/22 at 4:23 PM, the social worker indicated she was responsible for ensuring DNRs were accurately completed and documented. The social worker indicated she did not know why the DNRs for Residents #10, #43, and #23 were not completed. The social worker indicated she started August 8th and had been working with medical records to get everything organized by looking at all the electronic health records one by one to see who had a DNR. The social worker indicated she was starting a system to monitor the DNRs by keeping a binder with all the residents who were DNR. The social worker stated it was important that all DNRs be accurately documented and completed to ensure the residents and families wishes were honored. The social worker indicated not having the DNRs accurately documented and completed would cause more stress in an already stressful situation and could unnecessarily make end of life care more stressful. During an interview with the Administrator on 10/26/22 at 4:51 PM, the Administrator indicated the social worker was responsible for ensuring the DNRs were accurately completed and documented. The Administrator indicated not having the DNRs accurately completed and documented could cause confusion and the families wishes not to be followed. During an interview with the ADON on 10/26/22 at 4:37 PM, the policy regarding advanced directives was requested and not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 30 of 30