Inspection·January 31, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure expired medications were removed from the over-the-counter medication supply cabinet in the medication storage room. This failure placed residents at risk of not receiving the intended therapeutic effects of their medications. Findings included: An observation on 01/30/24 at 12:35 PM, revealed five bottles of Saccharomyces Boulardii Probiotics (a nutritional supplement used for gut health), with an expiration date of 12/23, in the cabinet of the medication storage room. During an interview on 01/30/24 at 12:35 PM, the DON stated, MRD was just there the other day, and she cleared all the expired medication. When the medication was found, she was shocked as she stated the MRD supposedly had pulled all the expired medications. After all other medications were checked, that appeared to be the only medication that was expired in the med room. During an interview on 01/31/24 at 08:10 AM, RN A stated the MRD was responsible for ordering and stocking the OTC medications in the med room. She stated the MRD checked expiration dates on the medication bottles. She stated the pharmacist is responsible for getting in the electronic medications that has expired. She stated it is the nurse's responsibility to check the expiration date when they take a bottle of medication from the medication room. She stated the nurses were responsible for monitoring the prescription medications that were stored in the medication room. She stated whoever is using the med cart is responsible for getting rid of the expired medications. She stated she checks them herself. She stated the additives in expired medications could cause adverse reactions. She stated expired meds could not be potent or have no effect, or they could be too strong. She stated residents may not get the desired effectiveness from expired medications. During an interview on 01/31/24 at 08:36 AM, the DON stated, the MRD was responsible for ordering over-the counter-medications. She stated the MRD rotated the stock and checked expiration dates routinely. She stated the pharmacy consultant was in monthly and completed checks of the medication room and medication carts. She stated if the meds are expired or DC, they put the meds in a box. The DC control meds are placed in a lock box in her office and when the pharmacist come in, they destroy them together. She stated there should not have any expired medication in the med room. The nurses are responsible for meds in the fridge. She stated ultimately the nursing staff was responsible for checking expiration dates on all medications. She stated the ADON does a spot check randomly. She stated expired medications may have lost their effectiveness and the resident may not receive the therapeutic benefits of the medication, the medication can be too strong, and the medication can have a reverse reaction, and the resident can die. The DON stated having expired medication in the cabinet did not meet her expectations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 2 of 8 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 01/31/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy titled, Medication Storage - in the Home dated 10/20, reflected in part, It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure, or misuse . 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of per procedures for medications destruction, and reordered from the pharmacy, if a current order exists. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 3 of 8 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 01/31/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident with pureed diet orders receivedfood that was palatable, attractive, and at a safe and appetizing temperature for 11 of 11 residents on pureed diets and 1 of 1 lunch meal tested for nutritive value, flavor, and appearance. Residents Affected - Some The facility failed to provide palatable food served at an appetizing temperature to residents. The facility failed to ensure residents received their meals according to the menu. This deficient practice could place the residents who ate food from the facility kitchen by placing them at risk of poor food intake, weight loss and/or dissatisfaction of the meals served. Findings include: During an observation and interview with CK 1 on 01/29/2024 between 11:15 a.m. to 12:05 p.m. revealed CK 1 she was going to prepare pureed food for 11 residents that were getting pureed Diets. CK 1 prepared by getting her fried chicken patties for the residents. She stated she normally puts an extra 1 or 2 in just to make sure there is enough. CK 1 did not measure portions of chicken patties according to the recipe. CK 1 broke the patties up in the blender and added chicken broth/stock to the blender. CK 1 poured the liquid into the blender, and she let it blend for one to two minutes. She then took the top off the blender to check the consistency and stated she needed a little more stock to thin the chicken out a little more. She took the measuring cup and added some hot water from the coffee maker, and then she put some powder broth/stock mix into the water and stirred it. She added the stock to the chicken and let it blend for another one to two minutes or until it was the consistency she wanted. CK 1 was satisfied with the consistency, so she placed the puree chicken in a metal container and put it on the stem table to keep it hot. She tempted the chicken, and it was at 155 degrees. CK 1 took apart the blender and she brought it over to the washing station and she washed it then placed it in the dishwasher. Once that was done, she got the blender and brought it back and assembled it. The next item she prepared was carrots. She again got the measuring cup and eye-balled how much she thought would be enough for the 11 residents. She placed the carrots in the blender and blended them about two and a half to three minutes. She then checked the consistency of the carrots and figured it needed some more liquid to thin them out and make them smoother. She took the measuring cup, and she got some water and placed into the blender. She blended it for about two minutes, and she still was not satisfied with the consistency. DM got a plate and spoon and advised her to put a spoon of the carrots on the plate and slide it across the plate and see if it still not grainy or do you think its smooth enough for someone who cannot swallow can eat it without having to chew? CK 1 said she thought so. DM then retrieved another spoon and had her to taste it. DM asked her was she able to just swallow it? CK 1 stated she could, but it still felt a little grainy. CK 1 stated she felt it was not going to get any smoother. DM advised her blended a little more and then see how it comes out. CK 1 was headed to get some more water when DM stated I would have used the juice from the carrots to make sure the food still had its nutritive value. CK 1 got the juice from the carrots, and she poured it in the blender and let it go for about two to three minutes pouring the liquid in the blender. CK 1 checked the carrots again and she stated it appear to be the same texture to her. DM them advised CK 1 to use the other blender and see if it smooths out the texture. CK 1at this time was agitated. She poured the carrots into the other blender and blended it for about two minutes. Once again, CK 1 stated that blender still didn't change the texture. DM advised her to throw the carrots out and prepare the squash for the puree diet. DM took and dumped the carrots and advised CK 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 4 of 8 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 01/31/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she needed to hurry up because they were falling behind. CK 1 brought the dishes over to the washing station and DS washed it out and placed in the dishwasher. CK 1 got a towel from the sanitizer bucket, and she wiped the counter off. Once the blender finish washing, DS brought it to her. CK 1 gathered the squash and placed it into the blender and blended for about a minute until she thought the texture was right for the pureed diet. The squash appeared to be loose, but CK 1 and the DM figured it was fine. DM advised her she would use a thickener to thicken it up. CK 1 stated the temp was reading at 122 degrees and it needed to be hotter. DM advised CK 1 to warm it up. CK 1 placed the squash in a bowl and warmed it up. And then it read 160 degrees. CK 1 then placed the squash in the metal pan and placed on the steam table. It was already pass serving time which trays started going out in the hall at noon. Carrots was on the board, and it was not updated due to the change. There were rolls on the steam table and they were supposed to be served with lunch. DM stated the rolls were not proofed so she changed to bread. The bread however was update on the menu board. DM placed the first pan of rolls on the counter and the second pan of rolls on a cart by the little hallway. Dining observation was observed by Surveyors, and it was revealed several residents stated the food was horrible. While Surveyors did interviews with residents in their rooms along with residents in a confidential meeting, they complained about the food also. In an interview with CK 2 on 01/31/2024 at or around 9:55 a.m., CK 2 stated her expectations for the quality of the food must taste good. She stated she tasted her food and the texture must be right. She stated she gets a spoonful of puree item, and she tries to swallow it and if she can chew it, it is not the right texture and it is not ready for a puree resident. CK 2 stated she also checks the puree to see if it ready by lifting the food through the spaces in the fork, and if it does it is ready. CK 2 stated she gets feedback from the residents the DM. CK 2 stated DM talks about concerns in the morning meetings. Also, the residents will ring the bell and let them know. CK 2 stated they have gotten complaints about a month ago regarding the food being cold. She stated they were not using the hot plate. She stated when the temps were taken for the food in the kitchen, the temps it was hot, but by the time the residents received their food on the last hallways the food is called. She stated she was advised to not put the hot plate when she started. She stated she was just as she was told. CK 2 stated she has not received any complaints regarding her food being nasty. She stated she tastes her food She stated she cannot speak for the other cooks. She stated she follows the menu. If they do not have an item, they sign a sheet of paper and use an alternate item if it is approved. In an interview on 1/31/2024 at 1:10 p.m. the DM stated she follow the menus per the guidelines. For puree diets she will add the stock from the food if that is available. If not, she will use a broth and a thickener if it is to lose. She tells her employees that you can always add but you cannot take out. She checks the quality and palatability of the food by getting a spoon and tasting it. She stated if it is good to her, it is good to them. She stated her expectations is for the food to be [NAME] and for the staff to follow the recipes. She stated she talks with the residents to find out about their likes and dislikes and to see how she can change the menu. She stated when the resident is admitted into the facility, she will go to their room and introduce herself and talk with them. The dietician makes sure the diets are correct for residents with special diets. Review of the facilities diet manual unknown date provided 3.1 D-1 Pureed Texture. The Pureed texture is a mechanical modification of the Regular Diet or any therapeutic diet, designed for people with moderate to severe swallowing difficulty and a poor ability to protect their airway. This texture allows pureed food (pudding like consistency) that is smooth and easily stays together. Food should be avoided if they require chewing. Coarse and dry textures, raw fruits and vegetables, breads and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 5 of 8 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 01/31/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete nuts should also be avoided. Beverages should be Thin (regular), Nectar-like, Honey-like, or Pudding-like. It is critical that standardized recipes be followed when preparing pureed foods to ensure nutritional quality is maintained. A record review of the facility's policy titled Menu Substitutions dated 10/2018 reflected the following: The facility believes that a well-balanced menu, planned in advanced and served as posted is important to the well-being of their residents. The menu will be served as planned except emergency situations when a food item is unavailable. Event ID: Facility ID: 676035 If continuation sheet Page 6 of 8 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 01/31/2024 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. FACILITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure CK #1 properly sanitized her hands between tasks. The facility failed to ensure DS used the ice scooper when scooping ice out of the ice machine. The facility failed to ensure DM and [NAME] 1 properly wore a hair restraint while in the kitchen. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: Observation on 01/29/2024 between 11:15 a.m. to 12:05 p.m. revealed CK 1 placed her hand in the sanitizing bucket under the counter and retrieved a towel and wiped the counter down. CK #1 returned the towel back into the sanitizing bucket while another staff brought back her blender. CK #1 was observed placing a glove on her hand without properly washing her hands. She began to puree squash. CK #1 had a hairnet on that was worn inappropriately. CK #1 had hair hanging from under the hairnet. Observation on 01/29/2024 between 11:15 a.m. to 12:05 p.m. revealed the DM was observing along with Surveyor. CK #1 beganto puree the vegetables. Surveyor observed DM wearing hairnet inappropriately, her hair was hanging from under the hairnet. Observation on 01/29/2024 between 11:15 a.m. to 12:05 p.m. revealed the DS scooping ice from the ice machine with a what would be residents drinking cup. It was observed the DS picked up a stack of cups, touching the rims of the cups and scooping the ice out of the ice machine. She did not use the ice scooper. In an attempt to interview CK #1 on 01/30/2024 at and around 9:30, CK #2 stated she knows all hair should be in a hairnet. CK #2 stated she washed her hands frequently and changed her gloves. CK #2 stated she knows while in the kitchen everything should always be sanitized. In an interview with DS on 01/30/2024 at or around 9:55 a.m., the DS stated she knew she should have used the ice scooper. She stated she was just trying to cut the time and get it done. Surveyor asked her if she was aware she also was touching the rim of the cups. She denied putting her hands on the rim of the cups. DS said she was not aware she was touching the rim of the cup. In an interview on 1/31/2024 at 1:10 p.m. the DM stated she thought all her hair was in the hairnet. DM stated DS advised her the Surveyor asked her about taking ice out of the machine with the residents cup and she stated she knew better than to scoop the ice with the cup, but she was trying to save time. DM stated she admitted knowing it was not the proper way to get the ice out of the machine and she should have used the scoop. The DM stated her expectations is for her staff is to operate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 7 of 8 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 01/31/2024 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 the kitchen properly and how they have been trained. Level of Harm - Minimal harm or potential for actual harm A record review of the facility's policy titled Employee Sanitation dated 10/2018 reflected the following: Employee Cleanliness Requirements: Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Residents Affected - Some A record review of the facility's policy titled Employee Sanitation dated 10/2018 reflected the following: Other Practices: Cups, glasses and bowls must be handled so that fingers or thumbs did not contact inside surfaces or lip-contact outer surfaces. A record review of the facility's policy titled Employee Sanitation dated 10/2018 reflected the following: Employee Cleanliness Requirements: Handwashing: Gloves are not a substitute for thorough and frequent hand washing. When using gloves always wash hands before touching or putting on new gloves. A record review of the facility's policy titled Ice Machines dated 10/2018 reflected the following: The facility will maintain the ice machine, scoop, and storage container, in a sanitary manner to minimize to risk of food hazards. The ice machine will be cleaned once per month or more often than needed. The scoop and storage container will be cleaned once each day. Review of the FDA Food Code 2022, Section 2-402 Hair Restraints, 2-402.11 Effectiveness reflected Food employees shall wear hair restraints such as hair coverings or nets, beard restraints . that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service and single-use articles. Review of the FDA Food Code 2022 Section 2-301.14 When to wash reflected Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapped single service and single use articles and: A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; E) After handling soiled equipment or utensils F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Review of the FDA Food Code 2022 Section 4-602.11 Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment. If the manufacturer does not provide cleaning specifications for food-contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those items of equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676035 If continuation sheet Page 8 of 8