Health inspection·September 13, 2023

F 0760 Level of Harm - Actual harm Residents Affected - Some Record review of Resident #1's progress notes dated 08/14/2023 at 11:03 AM completed by RN A reflected, I was called to the room by CNA on 300 hall. On entering it was apparent that this patient was having seizures. His face muscle was twitching, his eyes were rolled up and he did respond to my voice calling his name. His [family member] was at his bedside, very emotional. I obtained his V/S (vital signs)-146/68 [blood pressure] P-81, 02 sat of 95% on RA (room air). I stayed with patient and sent word with CNA to have the nurses at the desk call 911 for a patient having seizure. The [family member] apparently was on the phone with 911 operator. She handed me her phone to answer questions that were being asked of regarding his condition. I gave this information including the above V/S. Within a couple minutes the Ems arrived, and they then took V/S again and they were almost identical to those that I had just gotten. [Resident #1] was coming around as they loaded him on the stretcher and whisked him away. Record review of the hospital history and physical dated 08/11/23 for Resident #1 reflected, Seizure 15 minutes. Patient did not get his anticonvulsant medication at nursing home. HPI (history of present illness): Resident is a [AGE] year-old Hispanic male with seizure disorder, developmental delay. Recent fracture of right hip status post a bipolar hip replacement is readmitted to the hospital after he had a 15 minutes seizure at the facility. According to the [family member] the patient was not given his anticonvulsive medications because it ran out, subsequently patient has known seizure disorder. All seizure lasting 15 minutes he presented to hospital ER by PH Z and restarted on his oral medications. [Family member] does not want him to go back to the facility. During interview with the PHY on 09/11/23 at 10:18 a.m., he said he was the primary doctor for Resident #1. He explained Resident #1 had a complex medication regimen. PHY said he completed the history and physical on the resident after transfer to the hospital for seizures on 08/14/23. He stated there was no harm done to Resident #1. He believed the facility tried to get the medication on a weekend. Further interview on 09/13/23 at 10:48 a.m. with the PHY, revealed he was not informed that the facility did not have the seizure medication of Carbamazepine to give Resident #1. The PHY explained Resident #1 had a complex medication regimen and not taking the medicine for 3 days may have caused the seizure or not. He was getting another seizure medication of Phenobarbital 64.8 mg tablet three and one-half (3.5) by mouth once a day at bedtime. Even with the medication the resident had breakthrough seizures sometimes. The PHY stated in some cases pharmacies ran out of ordered meds. The lesson to learn here was the facility should have contacted the family member to get the meds. He said Resident #1 was fine. Review of Resident #1's laboratory values dated 08/08/23 through 08/11/23 (pre and post admission to the facility) for CBC, CMP and UA revealed no concerns. During interview on 09/06/23 at 4:03p.m. with RN A revealed she was present when Resident #1 had a grand mal seizure (unconsciousness and chronic muscle contractions) on 08/14/23 (day Resident #1 was transferred to the hospital). RN A explained she arrived on Monday morning and Resident #1 was a new resident on her hall, admitted on Friday of previous week. At about 8:30 a.m. on 08/14/23, an aide informed her Resident #1 was having a seizure. She immediately ran to the room and observed resident having grand mal seizure. Resident #1's responsible party was at his bedside. The seizure was very intense which made the RP very emotional and hysterical. The RP noted the Resident #1 had small seizures periodically, but he had not had grand mal seizures in over 8 years. RN A stated the RP believed the seizure occurred because Resident #1 did not get his seizure medication of Carbamazepine since admission date of 08/11/23 till 08/14/23 (incident date). RN A said she informed one of the nurses to call 911 but noticed the RP had already called and was on the phone with EMS. The EMS requested to talk to her and she provided the needed information to EMS. Resident #1 was transferred to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 If continuation sheet Page 2 of 7 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at San Angelo 5455 Knickerbocker Rd San Angelo, TX 76904 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 0760 Level of Harm - Actual harm Residents Affected - Some hospital for evaluation and treatment. Meanwhile, RN A checked the MAR and found out the Resident #1 did not get his seizure medication of Carbamazepine as ordered that morning. RN A asked MA D who was supposed to give medication and why Resident #1 did not receive the scheduled medication. CMA D said the medication was not available. RN A asked CMA D why she did not tell her or the ADON or DON. CMA D stated she forgot to inform them. RN A explained she was shocked that staff members did not contact the pharmacy, doctor, and administration starting on 08/11/23 (admission) till 08/14/23 (incident date). RN A stated it was the facility policy for the CMA or the nurses to call the pharmacy to inquire why a medication was not available. RN A noted what happened was avoidable and should not have happened. She stated it appeared the staffs involved did not take responsibility to call and find out why the medication was not available. RN A mentioned that the pharmacy received the medication on 08/11/23 and claimed to have called the facility and no one answered. The pharmacy did not call the facility again until 08/13/23 (2 days after initial contact) and talked to LVN E. RN A said there was no record LVN E informed anyone. In an interview with LVN E on 09/07/23 at 2:56p.m., he said he did not remember receiving a call from the pharmacy. He said If he did the information was passed down to the nurse on that hall. He was working on hall 200 and not hall 300 where Resident #1 was residing. LVN E was asked who he passed the information onto and he said he did not remember. In an interview on 09/08/23 at 1:06p.m. with CMA D, she said she has employed in the facility about 3 years. On 08/14/23 she looked at the MAR and saw an order for seizure medication for Resident #1. She looked but could not find the medication. She wrote on the MAR that the medication was not available. CMA D said she did not talk to RN A who was the charge nurse on duty. CMA D explained the facility policy was to notify the nurse, ADON or DON. She said she forgot to notify the nurse or follow the facility policy and took responsibility for what happened. She said she should have done everything to ensure Resident #1 received such significant medication including calling the RP to see if she had it. She was asked if she talked to any staff member that worked on the weekend regarding the medication not being available. CMA D said she had not. She said LVN F worked on the weekend. Review of the MAR for Resident #1 dated August 2023 revealed LVN F signed that ordered seizure medication of Carbamazepine on 08/13/23 was not available. During interview with LVN F on 09/07/23 at 4:06 p.m , he said he worked on 08/13/23 as confirmed by the electronic sign-in sheet. LVN F stated he signed the medication was not available because it was not in stock. He said he did not remember the exact incident. LVN F explained the facility policy was to contact the pharmacy or the ADON to inform them that the medication was not available. LVN F did not remember calling the pharmacy or the ADON. LVN F said his phone did not show any correspondence about the medication. Review of the MAR for Resident #1 dated August 2023 revealed LVN G signed that ordered seizure medication of carbamazepine on 08/11/23 through 08/14/23 was not available. Attempted interviews with LVN G on 09/07/23 at 9:00 a.m., 09/07/23 at 2: 00 p.m., 09/09/23 at 4: 01 p.m. and 09/13/23 at 1:00 p.m. but did not receive a response. During interview on 09/06/23 at 10:12a.m. with DON, she said she was not notified that Resident #1 did not have her seizure medication until 08/14/23 when the Resident #1 was having the seizures. The DON explained it was the facility policy for the staff members (nurses and medication aides) to call the pharmacy to find out why a medication was not available. She said the staff involved did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 If continuation sheet Page 3 of 7 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at San Angelo 5455 Knickerbocker Rd San Angelo, TX 76904 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 0760 follow the facility policy. Furthermore, she noted the pharmacy did not contact the facility again after the initial attempt till 2 days later. The DON said she talked to pharmacy to avoid a repeat of what happened. Level of Harm - Actual harm Residents Affected - Some Review of E-Rx new prescription from the pharmacy dated 09/12/23 for the medication Carbamazepine reflected, over max dose (1600 mg) calls for 2000 mg per day. No answer on 08/11/23 at 4:00p.m. On 08/13/23 at 3:08a.m. LVN E will have dayshift clarify with the Doctor During interview on 09/07/23 at 3:14 p.m. with PM Z, she said she was the pharmacist for the facility. PM Z said she was familiar with the medication for Resident #1. She explained the pharmacy received an order for Carbamazepine oral tablet extended release-give 5 tablets by mouth two times a day. On 08/11/23, she contacted the nursing station because she wanted to clarify the dosage which was more than the normal recommended max dose, and no one answered. PM Z said she did not contact the facility again until 08/13/23 at 3:08a.m. She talked to LVN E. She stated LVN E inform her he would inform Resident #1's charge nurse. PM Z did not hear from the facility. PM Z was asked why it took 2 days to contact the facility after the initial call. She said the pharmacy shouldn't have taken that long to request information from the facility regarding the seizure medication. Review of the facility policy undated 01/09/2014, titled Medication ordering and receiving from Pharmacy reflected: Policy: Medication and related products are received from dispensing pharmacy on a timely basis. The facility maintains accurate records of medication and receipt. Procedures: Ordering medication from the dispensing pharmacy . 1) New medications, except for emergency or stat medications, are as follows: a) If needed before next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery within (4) hours. b) Timely delivery of new orders is required so that medication administration is not delayed. The emergency kit is used when the resident needs medications prior to pharmacy delivery. The facility completed the following corrective actions to address the non-compliance after incident occurred but prior to the surveyor entering. Review of in-services 08/14/23 and 08/23/23 revealed the charge nurses from 2 shifts (6:00a.m. to 6:00p.m. and 6:00p.m. to 6:00a.m. were in-serviced related to medication administration, transcribing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 If continuation sheet Page 4 of 7 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at San Angelo 5455 Knickerbocker Rd San Angelo, TX 76904 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 0760 Level of Harm - Actual harm Residents Affected - Some physician's orders, rights of medication, reviewing the MAR prior to administering medication, reviewing orders and clarifying with the physician if needed, medication ordering and contacting the pharmacy immediately. Interview with 5 charge nurses and the DON (RN A, LVN E, LVN F, LVN M, LVN N) on the 2 shifts from 09/12/23 at 2: 00p.m. to 09/13/23 at 4: 00p.m. revealed all staff members reported being recently in-serviced on medication ordering, medication administration, notifying the physician, reviewing new orders and ensuring residents were receiving the required and ordered medications. They were able to explain in-services related to notifying the pharmacy immediately if the medication was not available and communicating to the physician or the resident's representative. Review of record revealed there were 3 residents taking seizure medication of Keppra (Residents #4, #5 and #6) from 09/11/23 at 11: 00a.m to 09/13/23 at 3:25p.m. They said they were receiving Keppra and have been receiving their medication without any problem. The residents explained they had not had a seizure and received their medication on time as ordered. During interview with the DON on 09/07/23 at 10:00a.m., she revealed all residents on high-risk medications including seizure meds were reviewed without concerns. She conducted in-services and reeducated nurses on the need to contact the pharmacy and the physician to clarify orders. The DON told the nurses to contact her anytime if there was a problem with any medication issues. She stated she performed cart audits to match medication with administration. The DON explained she designated an ADON to review medication orders (particularly new admission) daily and discuss during the daily meetings with the administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 If continuation sheet Page 5 of 7 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at San Angelo 5455 Knickerbocker Rd San Angelo, TX 76904 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 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #2) of two residents reviewed for infection control practices. Residents Affected - Few CNA H failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #2. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #2's face sheet dated 09/12/22, revealed an 81- year- old female admitted to the facility on [DATE] with diagnoses including overactive bladder, epilepsy, and dementia. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 required limited assistance with most activities of daily living and one-person physical assistance with bed mobility and transfer. Resident #1 was always incontinent of bladder and frequently of bowel. Review of Resident #2's Care Plan dated 02/01/23 revealed Resident #2 had frequent bladder incontinence related to overactive bladder. Observation of incontinence care for Resident #2 on 09/7/23 at 4:34p.m. revealed CNA H did not wash her hands prior to donning gloves. CNA H removed Resident #2's brief that was soiled with urine and fecal matter which was sipping through Resident #2's clothing. CNA H wiped the resident from front to back. CNA H did not change her gloves but continued to clean Resident #2 with soiled gloves. CNA H's gloves were visibly soiled with urine and fecal matter. CNA H did not wash her hands, change gloves or perform hand hygiene before retrieving Resident #2's clean brief and placing it underneath the resident and fastening it. CNA H again, did not wash her hands before exiting Resident #2's room. In an interview on 09/7/23 at 4:38p.m. with CNA H, she revealed she should have washed her hands before starting care and changed her gloves during care. CNA A also revealed she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #2. CNA H stated she had been at the facility since September 2023 and received infection control training during orientation. CNA H said the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. During an interview with the DON on 09/13/23 at 1:07p.m., he revealed he was aware of some of the concerns raised about infection control. He stated he expected the aides to wash their hands before and after giving care to a resident and change their gloves at appropriate times. Review of the facility's hand washing policy, undated, reflected the following: Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 If continuation sheet Page 6 of 7 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at San Angelo 5455 Knickerbocker Rd San Angelo, TX 76904 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 0880 Policy: Level of Harm - Minimal harm or potential for actual harm Hand washing is required before and after a procedure that involves direct or indirect contact with a resident, after contact with wastes or contaminated materials, before handling any food or food receptacle, or at any time hands are soiled. Residents Affected - Few Procedure: When hands are visibly dirty or contaminated with proteinaceous material, are visibly soiled with blood or other body fluids, and in case of a resident with spore-forming organisms (e.g., C. difficile). Perform hand hygiene with either a non-antimicrobial soap and water or an antimicrobial soap and water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 If continuation sheet Page 7 of 7