Health inspection·December 22, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some draped which did not completely cover his body. She stated it was not very dignified and she felt it was demeaning to Resident #54. She stated she believed that the staff should treat residents like they would want their family treated and she did not think this was appropriate. In an interview on 12/19/23 at 10:30 AM, LVN H stated she had not thought about #54transferring in the shower chair back and forth down the hall to his room partially clothed, but she could see that it could be considered a dignity issue. In an interview on 12/20/23 at 2:00 PM with the DON, stated it was her expectation that residents should be fully clothed when in the hallways and not transported in a shower chair. She stated this would be a dignity issue and it should not happen. She stated she was not aware that it was occurring, and her expectation was that a resident be transported in their wheelchair fully clothed to provide privacy. She stated charge nurses should monitor these activities. Review of Resident #75's quarterly MDS assessment, dated 09/10/23, revealed she had clear speech, was understood by others, and was able to understand others. Resident #75 was cognitively intact. Her diagnoses included: dementia (loss of memory and cognition), hypertension (high blood pressure), and congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). In an observation on 12/19/23 at 11:50 AM RN I took Resident #75's blood sugar at the table. This Resident sat at a table by herself. On 12/21/23 at 11:45 AM in an interview with Resident #75, she stated she preferred to have her fingerstick done in privacy, rather than in the dining room. She said, I would rather have them do it in my room. In an interview on 12/21/23 at 7:25 AM Resident #75 stated, this AM they checked her blood sugar and gave insulin in the dining room again. On 12/21/23 at 07:30 AM in an interview with the DON and the RN Regional consultant present they both stated it was their expectation that procedures such as insulin administration and obtaining blood sugars should be done in privacy. Record review of the policy titled Rights of the Elderly Human Resources Code, Chapter 102 not dated, which stated in part: An elderly individual is entitled to privacy while attending to personal needs and a private place for receiving visitors or other individuals. This right applies to medical treatment, written communications, telephone conversations, meeting with family, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 provide both a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS-10055) and a Notice of Medicare Non-coverage (Form CMS-10123 general notice) for 2 of 3 residents (Residents #3 and #83) reviewed for Medicare Beneficiary Protection Notification when discharged from Medicare Part A Services with benefit days remaining. Residents Affected - Some 1. The facility failed to ensure Resident #3's representative was given a NOMNC (Form CMS-10123 general notice) and a SNF ABN (Form CMS-10055) when he was discharged from skilled services. 2. The facility failed to ensure Resident #83's representatiive was given a NOMNC form and a SNF ABN form when she was discharged from skilled services. These failures could place residents and their representatives at risk of not being fully informed about services covered by Medicare. The findings included: 1. Resident #3 Review of Resident #3's admission Record, dated 12/22/23, revealed a [AGE] year-old male who was originally admitted to the facility on [DATE]. The resident's diagnoses included: dementia; type 2 diabetes mellitus (insufficient production of insulin causing high blood sugar); chronic obstructive pulmonary disease (lung disorder); hypothyroidism (thyroid disorder); hypertension (high blood pressure); gastro-esophageal reflux disease (stomach acid backs up into the esophagus); major depressive disorder; hemiplegia and hemiparesis affecting right side following cerebral infarction (right sided weakness after having a stroke); hyperlipidemia (high cholesterol); hypokalemia (low potassium); peripheral vascular disease (abnormal narrowing of the arteries outside of the heart); and intellectual disabilities. Review of Resident #3's electronic health record census report revealed his most recent hospitalization had been from 7/17/23 to 7/20/23. Review of the Beneficiary Protection Notification Review worksheet for Resident #3 revealed he had received Medicare Part A Services from 7/20/23 through 9/05/23. The resident remained in the facility. The form documented the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. The form documented Unable to locate - See plan of correction in the sections for SNF ABN (CMS-10055) and NOMNC (CMS 10123). 2. Resident #83 Review of Resident #83's admission Record, dated 12/22/23, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE]. The form documented the resident was hospitalized on [DATE] and was re-admitted to the facility on [DATE]. The resident's diagnoses included: dementia; history of falling; fracture of left lower leg; anxiety disorder; malignant neoplasm of left female breast (breast cancer); hypothyroidism (thyroid disorder); heart disease; hypertension (high blood pressure); gastro-esophageal reflux disease (stomach acid backs up into the esophagus); and chronic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0582 kidney disease (kidney failure).A Level of Harm - Minimal harm or potential for actual harm Review of the Beneficiary Protection Notification Review worksheet for Resident #83 revealed she had received Medicare Part A Services from 8/21/23 through 10/17/23. The resident remained in the facility. The form documented the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. The form documented Unable to locate - See plan of correction in the sections for SNF ABN (CMS-10055) and NOMNC (CMS 10123). Residents Affected - Some In an interview on 12/20/23 at 2:30 PM, the Social Worker stated she was responsible for sending notification to residents or their representatives when Medicare A benefits were going to end. In an interview on 12/20/23 at 2:47 PM, the Social Worker stated the only form she had used when notifying residents or their representatives when skilled benefit days would end was the NOMNC. She had not used the SNF ABN form. In an interview on 12/21/23 at 12:18 PM, the Social Worker returned the completed SNF Beneficiary Protection Notification Review forms for Resident #3 and Resident #83. She stated she did not have the copies of the notification forms that had been used, signed, and provided to the residents' representatives. The Social Worker stated she reviewed the NOMNC (CMS-10123) with the resident or their representative and had it signed. She then gave the form to the MDS Coordinator to scan into the electronic health record and place the copy in a notebook binder. The Social Worker stated she only used the NOMNC form (CMS-10123) and had not used the SNF ABN form (CMS-10055). She stated the prior MDS Coordinator had been responsible for scanning the forms into the residents' electronic health records and keeping a copy in a binder notebook. The prior MDS Coordinator had left employment during the end of October 2023, and it was discovered she had not scanned the forms into the electronic health records and a binder notebook with copies of the forms was not found. She stated the facility staff had developed a Plan of Correction to address the problem. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate the assessment of one (Resident #72) of two residents with the pre-admission screening and resident review (PASRR) program. The facility did not identify Resident #72 as having a newly evident mental illness with a primary diagnosis of dementia after she acquired a new diagnosis that would require a new PASRR Level 1 (PL1) form or PASSR 1012 form be completed. This failure could affect residents with psychiatric diagnoses who may not be evaluated for PASRR services and place them at risk of not receiving services for care and treatment. The findings were: Review of Resident #72's Face Sheet and Orders dated 12/20/23 revealed she a was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #72's diagnoses included: dementia (thought process that interferes with daily function) which was added on 04/2/21, delusional disorder (altered reality), psychotic mood disorder with hallucinations (mental condition that causes you to lose touch with reality, main symptoms are delusions and hallucinations), major depressive disorder recurrent and severe (severe altered mood), and post-traumatic stress disorder ( mental condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). All added to her diagnoses on 08/31/22. Review of Resident #72's's Physician Orders dated 12/20/23 revealed an order for Sertraline 50 mg by mouth daily for major depressive disorder. Review of Resident #72's Quarterly MDS dated [DATE] revealed Resident #72 had a moderate cognitive impairment with a BIMS score of 12 (moderately impaired). No mood or behavior concerns were indicated. Section N revealed the resident was currently taking the following high-risk medications: antipsychotics, an antidepressant, and antiplatelet. Review of Resident #72's PASRR Level One Screening Forms was dated 03/19/21, (before the resident's initial admission into the facility) was completed by the transferring entity and revealed Resident #72 had no diagnosis of mental illness, intellectual disability, or developmental disability. Review of Resident #72's electronic medical record revealed there was not a second PL1 form, or a 1012 form (dementia/Alzheimer's) completed. In an interview on 12/22/23 at 10:30 AM, the MDS coordinator stated she was responsible for the PASSR's in the facility. She stated that Resident #72 should have had a new PL1 form completed when she was diagnosed with the psychotic mood disorder, and major depressive disorder. She stated she will check with her consultant and have her help to see what she can find out regarding a facility policy on PASRR. She stated she was still learning. She stated that she has been there since 11/23 as the MDS coordinator. She stated the diagnoses for #72's Mental illness were added after the original PL1 was done. She stated another PASRR should be completed. She stated a negative outcome for the resident of not having another PL1 completed would be that the resident may not receive needed care and services if he was eligible under PASRR services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy PASRR Policies and Procedures, not dated, revealed the following [in part]: The facility follow THHS Regulatory Regulations, Texas Health and Human Services Commission, and the Texas Administrative Code or screening residents and making referrals to the local authority. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a summary of the baseline care plan was provided to the resident and their representative for 2 of 7 residents (Resident #s 89 and 349) reviewed for baseline care plans following admission into the facility for skilled nursing care services, in that: 1. Resident #89's had baseline care plans dated 11/17/23 and 11/27/23, and a summary had not been provided to her or her representative. 2. Resident #349's baseline care plan was dated 12/14/23 and a summary had not been provided to him. This failure placed the residents at risk for not receiving information regarding the care and services to be provided to meet their needs and to promote their physical and mental health and well-being within their new living environment. The findings included: 1. Resident #89 Review of Resident #89's admission Record, dated 12/22/23, revealed an [AGE] year-old female initially admitted to the facility on [DATE]. The form documented the resident was hospitalized on [DATE] and was re-admitted to the facility on [DATE]. The resident's diagnoses included: fractured left shoulder; malignant neoplasm of anal canal (rectal cancer); hypothyroidism (thyroid disorder); hyperlipidemia (high cholesterol); dementia; depression; hypertension (high blood pressure); chronic kidney disease (kidney failure); and gastro-esophageal reflux disease (stomach acid backs up into the esophagus). Review of Resident #89's electronic health record revealed baseline care plan forms dated 11/17 /23 and 11/27/23. The forms did not document the name of the person who completed the form, the resident's name, or the resident's representative's name in the area for signatures. Review of Resident #89's admission MDS Assessment, dated 11/29/23, revealed a BIMS score of 2 out of 15 (severe cognitive impairment). In an interview on 12/19/23 at 11:47 AM, Resident #89's family member stated he had not had the resident's baseline care plan reviewed with him and he had not been provided with a copy of it. The family member stated he had not attended a meeting to discuss the resident's care. 2. Resident #349 Review of Resident #349's admission Record, dated 12/22/23, revealed a [AGE] year-old male initially admitted to the facility on [DATE]. The resident's diagnoses included: osteomyelitis left ankle and foot (bone infection); cellulitis left lower limb (bacterial infection of the skin); type 2 diabetes mellitus (insufficient production of insulin causing high blood sugar); hyperlipidemia (high cholesterol); hypokalemia (low potassium level in the blood); major depressive disorder, recurrent; and hypertension (high blood pressure). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #349's electronic health record revealed a baseline care plan form dated 12/14 /23. The form documented it had been completed by ADON BB. The form did not document the resident's name or the resident's representative's name in the area for signatures. In an interview on 12/20/23 at 11:57 AM, Resident #349 stated he had not had his care discussed with him since had been here [admitted to the facility]. In an interview on 12/22/23 at 3:25 PM, the DON stated the admitting nurses completed the baseline care plans for new admissions and should provide a copy to the resident or the resident's representative. In an interview on 12/22/23 at 3:41 PM, RN I stated she did admit residents as the charge nurse for the rehabilitation hall. She stated she did not complete baseline care plans. She stated, They don't make us do that. RN I stated the MDS nurse did them, and if a resident was admitted during the weekend on Saturday or Sunday, the MDS nurse did them on Monday. RN I stated she thought the staff had 72 hours to complete a baseline care plan. In an interview on 12/22/23 at 6:56 PM, the DON stated the charge nurses were supposed to have completing the baseline care plans during the past. She stated she was going to take over completing the baseline care plans. The DON stated the ADONs had been doing chart audits for the completion of baseline care plans and had been completing the ones that had not been done. In an interview on 12/22/23 at 8:44 PM, the ADONs stated they did not do baseline care plans unless needed. ADON BB stated the admitting nurse did the baseline care plan. She stated the MDS nurse did not do the baseline care plan. ADON BB stated the nurse completing the baseline care plan was supposed to print a copy of the baseline care plan and give it to the resident or representative. ADON BB stated she did the baseline care plan for Resident #349. She stated she did not print a copy of the baseline care plan and did not give a copy to Resident #349. Review of the facility's Baseline Care Plan Policy, not dated, documented [in part]: Policy: It is the policy of the facility to develop a baseline care plan within 48 hours of admission. Along with the baseline care plan is a summary of care plan that is provided to the resident and representative in a language that can be understood. Procedure: 1. Upon admission, the facility will begin the process of developing a baseline care plan and this care plan will be completed within 48 hours of admission. 2. Information for the baseline care plan will be based upon admission orders, information from the transferring provider and discussion with the resident representative if applicable and the resident so chooses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #45) reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #45 after the resident was admitted with an order for oxygen. This failure could place residents at risk of not receiving care that is thoughtful, planned, and relevant to their condition(s) which could lead to complications in resident health and quality of life and care. The findings include: Record review of Resident #45's face sheet, dated 12/22/2023, revealed a [AGE] year-old female with an initial admission date of 03/16/2023 and the latest return date of 11/03/2023. The resident had diagnoses which included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation) and acute and chronic respiratory failure with hypoxia (lungs cannot provide enough oxygen to the blood and the organs). During an interview and observation on 12/19/23 at 10:48 AM during initial rounds, Resident #45 was lying in bed receiving oxygen therapy. She said she has COPD and required oxygen continuously. Record review of Resident #45's Care plan, last reviewed 10/15/2023, revealed no documentation of resident receiving oxygen therapy. Record review of Resident #45 Order Summary Report revealed an order for oxygen at 2 liters per minute continuous with a start date of 03/16/2023. Record review of Resident #45's Medication Administration Record for the month of December 2023, revealed the resident received oxygen continuously. Record review of Resident #45's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15 (cognitively intact) and in Section O - Oxygen therapy was coded as not in use. In an interview on 12/22/23 at 3:10 PM, the MDS Coordinator said she was responsible for resident care plans. She said Resident #45 should have had a care plan for oxygen under the problem for COPD. She said, it was just missed. She said a potential negative outcome would be a resident might not receive the right treatment if it was not listed in the care plan. In an interview on 12/22/23 at 3:22 PM, the DON said Resident #45's oxygen therapy should have been addressed in the resident's care plan. A potential negative outcome would be the resident would not receive needed care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0656 Record review of the facility policy Updating Care Plans, not dated, revealed the following [in part]: Level of Harm - Minimal harm or potential for actual harm 1. Care plans are modified between care plan conferences when appropriate to meet the resident's current needs, problems and goals. Residents Affected - Few 3. The Care Plan will be updated and/or revised for the following reasons: a. Significant change in the resident's condition. b. A change in planned interventions. c. Goals are obtained, and new goals established to meet current resident needs and/or goals. d. New diagnosis, new medications, abnormal labs or new behaviors, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 residents who were unable to conduct activities of daily living received the necessary services to maintain good personal hygiene for 3 of 26 residents (Resident's #3, #34, #54), reviewed for activities of daily living. Residents Affected - Some -The facility failed to provide nail care for Resident #3. -The facility failed to provide oral care for Resident #3, #34 and #54. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, skin breakdown, dental pain and cavities, and a decreased quality of life. Findings included: Resident #3 Record review of Resident #3's MDS r evealed he was a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses: Diabetes (high level of sugar in the blood), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), hemiplegia (muscle weakness or partial paralysis on one side of the body), Pulmonary Disease (a group of diseases that cause air-flow blockage and breathing - related problem). He had a BIMS score of 11 which indicated moderate cognitive impairment. In an interview and observation on 12/20/23 at 11:16 AM Resident #3 stated his teeth need brushing. He stated they do not assist him to brush his teeth or cut his fingernails. His fingernails on both hands were about 1/4 inch long and he stated he would like them clipped and filed. His teeth had food and tarter in his lower teeth. He stated he has asked the nurses to help brush his teeth, trim his nails, and bath him, but they say they don't have the time to do it. He stated, They don't have enough help and have a had a large turnover. In an interview on 12/19/23 at 2:38 PM, LVN G stated she was the 100 hall charge nurses. She stated residents should have their fingernails cut, shave, etc. on shower days. She stated staff should assist residents to perform oral care if needed every shift. She stated Nurses cut diabetic resident's nails and monitored to see that CNA's provided assistance with ADL's and other personal care. During an observation on 12/20/23 at 11:35 AM, LVN G entered Resident #3's room to perform a fingerstick and noticed the resident's fingernails were long and dirty. She asked him if he wanted them cut and he replied he did. LVN G cut Resident #3's fingernails. Resident #34 Review of Resident #34's Face Sheet, dated 12/22/23, revealed a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included: quadriplegia (paralysis of all four limbs), absence of left leg above knee and polyneuropathy (damage to multiple peripheral nerves). Review of the Annual MDS for Resident #34 dated 11/10/23 reflected a BIMS score of 15 (cognitively (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0677 intact). Resident #34 was assessed as dependent with toilet use and personal hygiene. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #34's Care Plan, last revised on 08/01/23, revealed the intervention Personal/Oral Care: The resident is totally dependent on 1-2 staff for personal hygiene and oral care. Residents Affected - Some Record review of the ADL's sheets for Resident #34 failed to document oral care. In an interview and observation on 12/21/23 at 11:46 AM, Resident #34 said staff does not brush his teeth every day. He said if he wants his teeth brushed, he must ask for it to be done. He did not state how many days out of the week his teeth were brushed. Resident #54 Review of Resident #54's face sheet dated 12/19/23, revealed he was an [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #54's quarterly MDS assessment, dated 11/10/23, revealed he had clear speech, was understood by others, and was able to understand others. Resident #54's cognition was moderately impaired. The assessment reflected Resident #54 was dependent and performed none of the activity for personal hygiene, bathing, and dressing, it stated he was able to perform the activity of oral care with set up assistance. Record review of the ADL's sheets for Resident #54 failed to document oral care. In an interview on 12/20/23 at 03:09 PM Resident #54's family member stated no one brushes his teeth. She stated she has asked in care plan meetings that staff brush his teeth, and it still does not get done. She stated she told a staff member Unknown Staff O in the care plan meeting. She stated she did not know what position she holds; she just knows her name was Unknown Staff O. In an interview on 12/21/23 at 2:30 PM, the DON stated the CNAs should assist residents with oral care each shift. She stated the charge nurses should monitor to see that it is done. She stated failure to do so could result in dental problems. A policy for ADL's was requested but not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to maintain an environment that was free from accidents and hazards for 31 (All resident on 100 Hall) of which 5 of 31 (Resident #81,82, 20, 40, and 77) had cognitive decline that could still access their sinks, of 90 residents. -Temperature readings for the public restroom on the 100 hall were 128 degrees Fahrenheit. -The temperature reading in the restroom to Resident room [ROOM NUMBER] on the 100 hall was 128 degrees Fahrenheit. -5 residents on the 100 hall had cognitive decline and could access their sinks. An Immediate Jeopardy to residents' health or safety was identified on 12/21/23. The Immediate Jeopardy template was provided to Administrator on 12/21/23 at 7:23PM. While the Immediate Jeopardy was removed on 12/22/23 at 7:38PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a severity level of a pattern as the facility began lowering water heater temperature for 100 hall, testing water temperatures in resident rooms on the 100 hall and in-servicing staff. These failures placed residents at risk of potential 3rd degree burns. Findings include: In an observation on 12/21 2023 at 12:30 PM, water in the sink of 100 hall public restroom was extremely hot. In an observation and interview on 12/21/2023 at 12:46 PM, the Maintenance Director was observed checking water temperature in 100 hall public restroom. He used 2 plastic cups, one inside of another, and at 1 minute the temperature was observed to be 128 degrees Fahrenheit . The Maintenance Director went to room [ROOM NUMBER] and used 2 plastic cups, one inside of another, and within 1 minute the restroom sink water was observed at a temperature of 128 degrees Fahrenheit. The Maintenance Director said, that's too hot. The Maintenance Director said that water temperature would affect all Resident's on hall 100. He said this water temperature could burn the residents. In an interview on 12/21/2023 at 12:51 PM, the Maintenance Director said they cranked up the hot water on hall 100 due to fluctuation in temperature outside and request from staff for cold showers down hall 100. The Maintenance Director said his thermometer for checking water temperatures was one year old. In an interview on 12/21/2023 at 1:40 PM with both the Maintenance Director and the Maintenance Assistant. The Maintenance Director said he spoke with the Maintenance Assistant and said he had changed the water temperature on 12/18/2023 at approximately 10AM and did not notify the Maintenance Director. The Maintenance Assistant said he did not know the staff's name, but she had requested him to turn water temperatures up on hall 100. The Maintenance Assistant said that travel Staff notified him at approximately 8 AM on 12/18/2023. The Maintenance Assistant said he never notified the Maintenance Director that he had increased the water temperatures by 15 degrees to 130 degrees Fahrenheit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0689 The Maintenance Assistant said he did not check water temperatures before or after changing water temperature. Level of Harm - Immediate jeopardy to resident health or safety Resident #81 Residents Affected - Some Record review of Resident #81's Quarterly MDS, dated [DATE] revealed an [AGE] year-old male, admitted to the facility on [DATE]. Resident #81 had an active diagnosis of dementia . He had a BIMS score of 8 (moderately impaired). During an observation on 12/19/23 at 3:20pm, Resident #81, who resided on 100 hall, was propelling himself down the hallway in his wheelchair. Resident #82 Record review of Resident #82's Quarterly MDS, dated [DATE] revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #82 had an active diagnosis of dementia. She had a BIMS score of 3 (severe impairment). During an observation on 12/19/23 at 3:22pm, Resident #82, who resided on 100 hall, was ambulating herself down the hallway in her wheelchair. Resident #20 Record review of Resident #20's Quarterly MDS, dated [DATE] revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #20 had an active diagnosis of dementia. She had a BIMS score of 2 (severe impairment). During an observation on 12/19/23 at 12:46pm, Resident #20, who resided on 100 hall, was sitting in her wheelchair in her room. Resident #40 Record review of Resident #40's Quarterly MDS, dated [DATE] revealed an [AGE] year-old female, admitted to the facility on [DATE]. Resident #40 had an active diagnosis of dementia. She had a BIMS score of 5 (severe impairment). During an observation on 12/19/23 at 3:52pm, revealed Resident #40, who resided on 100 hall, was laying in bed asleep with a Wander Gard on her right foot. Resident #77 Record review of Resident #77's Quarterly MDS, dated [DATE] revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #77 had an active diagnosis of dementia. She had a BIMS score of 5 (severe impairment). During an observation on 12/19/23 at 11:00 am, Resident #77, who resided on 100 hall, was sitting up in a chair in her room, stating she had just received a bath. In an observation and interview on 12/21/23 at 1:47 PM, the Maintenance Director checked hot water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some heater for hall 100 that was inside a locked closet inside the locked medication room. The hot water heater was a dial temperature in which Maintenance Supervisor said he reduced temperature immediately after checking water temperatures earlier. He said the water temperature was 130 degrees Fahrenheit. He said he checked for 1 to 2 minutes regularly when checking temperatures. He said he, starts at beginning of hall and works way to end of halls. The Maintenance Director said he checks random rooms and point of care areas on halls and different rooms each week. He said he knew which rooms to check and said, I just remember from week to week. In an observation and interview on 12/21/23 at 1:48 PM with Charge Nurse F said she does not have a key to the hot water heater closet in the medication room. In an interview on 12/21/2023 at 02:16 PM the Maintenance Director said his expectations were that staff wrote requests in maintenance logbook and water temperature checks would be performed before and after temperature change. He said he had no knowledge of the Temperature change. In an interview with DON on 12/22/2023 at 2:45 PM she said, Only Maintenance has keys to hot water heater closets. Record review of the facility's Maintenance Log from 09/01/23 through 12/21/23 revealed there were no issues noted to hot water, nor that Maintenance had addressed any issues regarding hot water. Record review of facility policy Test Water Temperatures, undated, revealed the following [in part]: It is suggested that you review or watch the TELS Masters Training video that accompanies the task. Test water temperatures . Let the hot water run from 3 to 5 mins. . Insert the stem into the stream of running water, so that the sensor is fully immersed. . As the temperature of the water is taken, hold your hand under the running water at about the same time to assess how the water feels on your skin. 1. Ensure patient room water temperatures are between 105 degrees F. and 115 degrees F. (or as specified by state requirements) . Texas 100 degrees F to 110 degrees F. 5. Common area bathrooms, public bathrooms and any other areas having sinks should be checked and recorded as well. This was determined to be an Immediate Jeopardy on 12/21/23 at 7:23PM. Administrator was notified. Administrator was provided the Immediate Jeopardy template on 12/21/23 at 7:23PM. The following Plan of Removal submitted by the facility was accepted on 12/22/23 at 11:38AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0689 Timeline: Level of Harm - Immediate jeopardy to resident health or safety 12/21/23 at 12pm, the Maintenance Director lowered the temperature on the hot water heater. At approximately 3pm, the Maintenance Director checked all the water temperatures from 100 hall and they were all logged at safe range of 110 degrees. Residents Affected - Some At approximately 4pm, the Maintenance Director checked water temperatures in resident rooms in the facility. At 7:38PM, the Maintenance Director checked room [ROOM NUMBER] water temperature and it was within safe range, logged at approximately 110 degrees under running water for 3 minutes. 1. Immediate Response: Water temperatures have been checked on 100 hall and rooms logged a safe water temperature range (see attached log). 31 of 90 residents on hall 100 are not at risk. Skin Assessments completed on all residents on hall 100 with no negative findings. AdHoc meeting with Administrator and DON to review issue and community's response plan implemented. 2. Risk Response: Resident/Residents on hallway 100 that received a shower or used thing sink for hand hygiene may potentially be affected by the alleged deficient practice. o Skin audit (sweep) was conducted by the administrative nurses (DON/ADONS/WCN) on current residents with no significant findings identified. Initial skin audit commenced on the evening of 12/21/23 once the concern was identified prior to the immediacy being implement@ 746PM. o Conducted 100% skin sweep of all active residents on hallway 100. There were no adverse effects identified. See above Date Completed: Initial skin sweeps on: 12/21/23 o ADMINISTRATOR and MAINTENANCE DIRECTOR received re-education on the importance ensuring that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0689 temperatures of hot water must be maintained less than 110 degrees and that if water temperatures are adjusted that they must be rechecked before and after doing so. Level of Harm - Immediate jeopardy to resident health or safety ? Residents Affected - Some Maintenance director were re- educated on running water for 3 minutes prior to any temperature check that is completed as per policy. ? Maintenance director was re-educated on holding the thermometer into the stream of running water so that the sensor is fully immersed and allowing the thermometer to register the correct temperature. o Date Completed: 12/21/23 at 8:30pm. o All management staff received education on the expectation hot water temperatures and that they are to be maintained below 110 degrees and if believed to be too hot to notify the Administrator or maintenance director immediately. Date Commenced: 12/21/23 1. ADMINISTRATOR AND MAINTENANCE DIRECTOR received education prior to exiting the facility. 2. All Management staff received education on the staff received education on the hot water temperatures and that they are to be maintained within safe rage 110-115 degrees and report immediately to Administrator and Maintenance Supervisor while preventing use of hot water until temperatures can be checked for safe temperatures. 3. Reviewing the temperatures and temperature logs to identify elevation or deviation from below 110 during the daily clinical meeting held 5 times weekly as well as random checks on weekends to ensure the temperatures are maintained at the appropriate temperature. 4. IDT will review the system & will update appropriate interventions to address the prevention of hot temperature injury. 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety ADMINISTRATOR and or Designee will conduct weekly rounds to ensure that temperature logs, monitoring logs and QA are being conducted on this system. Date commenced:12/21/23 Date completed: Residents Affected - Some 4. Monitoring Response: The administrator or Designee will make daily temperature checks 5 days per week and then random temperature checks on the weekend to ensure the hot water temperatures are below the 110 degree to validate the compliance. Findings will be reported to the ADMIN and reviewed with the QAPI committee for the next 2-3 months to determine compliance or to identify further education and oversight is needed. Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from 12/21/2023 at 6:00pm to 12/21/2023 at 7:00pm revealed: In an interview on 12/22/23 at 6:00pm, the Administrator and Maintenance Director said the plumber came at 11:30am on 12/22/23 and looked at all 4 hot water heaters. They were ordering digital regulators that were tamper proof and maintain a continuous temperature. Checked a sample of rooms, 2 on each hallway, and all were within limits with a range of 100-105 degrees. The sample of rooms would be rotated each day and documented. The Administrator said he and only the Maintenance Director had access to hot water heaters. They were the only 2 that can test the water daily. The procedure was for the water to run for 3 minutes and hold the digital thermometer under running water. This will be done daily for 4 weeks, testing different rooms daily, and logging results. In-services started yesterday and were on-going until all staff have been in-serviced. Staff will not be able to pick up their paycheck until they were in-serviced to assure all staff are in-serviced. Record review of Water Temperature Log for 12/22/23 revealed all temperatures on the 100 hall within 100 degrees F to 104.6 degrees F. Record review of In-services started on 12/21/23 revealed: -Hot Water Heater Adjustments and Water Temps are on-going. -Safe Water Temps and Testing by the Administrator and Maintenance Director completed on 12/21/23. Record review of Skin Sweep for Hallway 100 dated 12/21/23 did not reveal any concerns relating to burns from hot water. Record review of AdHoc QAPI meeting completed on 12/21/23 with all required members in attendance. The meeting addressed the facility's POR needs. In interviews on 12/22/23 at 6:00 pm of sample staff from both shifts were completed with 2 RNs, 6 LVNs, 4 CNAs, 1 CMA, Housekeeping Supervisor, Human Resource Director, Medical Records, Dietary Manager and Social Worker. They all stated they had been in-serviced. They all said if the water was too hot, they would notify immediately either the Maintenance Director, Administrator, or the DON. They would also document it in the Maintenance Log that was at the nurse's station. They would protect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0689 the residents from being burned by hot water. Level of Harm - Immediate jeopardy to resident health or safety After the POR and Monitoring, Administrator was informed the Immediate Jeopardy was removed on 12/22/23 at 7:38PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a severity level of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 4 residents (Resident #3 and Resident #88) reviewed for respiratory care. Residents Affected - Some A. Resident #3's and #88's nebulizer mask and tubing were not kept in a plastic bag when not in use. B. Resident #3's oxygen cannula and tubing were not kept in a plastic bag when not in use. This failure could place residents requiring oxygen at risk for respiratory infections due to the potential for microorganisms infiltrating their oxygen, nebulizer equipment and supplies causing a decline in physical health. The findings Included: Resident #3 Record review of Resident#3's MDS revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following diagnosis of Pulmonary Disease (a group of diseases that cause air-flow blockage and breathing - related problem). He had a BIMS score of 11 which indicated moderate cognitive impairment. Review of Resident #3's care Plan dated 09/08/2021 revealed the following problem: Resident has a history of altered respiratory status/difficulty breathing with chronic obstructive pulmonary disease and asthma, history of hospitalization for acute respiratory failure with low blood oxygen. Dated revised on: 09/08/2021. o Administer medication/inhalers as ordered. Monitor for effectiveness and side effects. o Monitor for respiratory distress and report to as needed: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. In an observation on 12/19/2023 at 9:36 AM, during initial rounds, Resident #3's nebulizer mask was laying on his bedside table open to air and not bagged. In an interview and observation on 12/20/2023 at 10:00 AM, Resident #3's oxygen tubing and nasal cannula was laying on the floor in his room. The resident said he was supposed to wear the oxygen all the time but removed it because he thought they were going to come and take him for a bath. He stated he took off the tubing himself. His nebulizer mask and tubing were laying on his bedside table to open air and not bagged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0695 Resident #88 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #88's face sheet, dated 12/22/2023, revealed resident was a [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation) and acute and chronic respiratory failure with hypoxia (lungs cannot provide enough oxygen to the blood and the organs). Residents Affected - Some Record review of Resident #88's admission MDS, dated [DATE] revealed the resident had BIMS score of 13 (cognitively intact) and Section P revealed he received oxygen therapy. In an observation on 12/19/23 at 12:49 PM, during initial rounds, Resident #88 was sitting in his room eating. His nebulizer mask and tubing were laying out on his nightstand and not bagged. In an observation on 12/19/23 at 3:24 PM, Resident #88 was asleep in bed. His nebulizer mask and tubing were laying out on his nightstand and not bagged. In an interview and observation on 12/20/23 at 9:04 AM, Resident #88 said he has COPD and gets breathing treatment 4 times a day. His nebulizer mask and tubing were laying out on his nightstand to open air and not bagged. Record review of Resident #88's Order Summary Report revealed the resident has an order for Ipratropium Bromide Inhalation Solution 0.02%, 2.5 ml, inhale orally four times a day for chronic obstructive pulmonary disease with a start date of 12/08/2023. Record review of Resident #88's Care Plan, dated 12/19/2023 revealed the following: Problem - The resident has asthma related to COPD. Intervention - Give nebulizer treatments and oxygen therapy as ordered. In an interview on 12/22/2023 at 3:28 PM, the DON said nebulizer masks and oxygen tubing should be stored in a zip lock bag at bedside when not in use. Potential negative outcomes would be the mask and tubing could get dirty and possible infection control concerns. Record Review of the facility's policy Nebulizer Treatment, not dated, revealed the following [in part]: Procedures: 12. Storage of apparatus in plastic bag is to prevent possible contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to review the work of each Certified Nurse Assistant (CNA) at least once every 12 months, for 4 (CNA A, CNA B, CNA C and CNA D) of 4 CNAs reviewed for annual competency evaluations (there were only 4 CNAs that had worked at the facility longer than a year). Residents Affected - Many This deficient practice could affect 90 residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings include: Record Review of Personnel Files revealed the following: - Employee record for CNA A revealed a hire date of 04/02/2021, with no evidence of a competency evaluation in the past 12 months. There was no record of a previous competency evaluation. - Employee record for CNA B revealed a hire date of 04/01/2019, with no evidence of a competency evaluation in the past 12 months. The last competency evaluation was completed on 04/25/2022. - Employee record for CNA C revealed a hire date of 04/01/2019, with no evidence of a competency evaluation in the past 12 months. The last competency evaluation was completed on 04/25/2022. - Employee record for CNA D revealed a hire date of 08/10/2019, with no evidence of a competency evaluation in the past 12 months. There was no record of a previous competency evaluation. In an interview conducted on 12/22/2023 at 5:07 PM, the Human Resource Director stated there was no documentation for the 4 CNAs annual proficiency exams completed at least once every 12 months. In an interview conducted on 12/22/2023 at 5:17 PM, the Regional RN Consultant said the DON has not been at the facility very long and was currently in training. There was no documentation for the 4 CNAs annual proficiency exams being completed at least once every 12 months. Potential negative outcomes would be the DON would not be aware where the nurses would need further education and to see if shortcuts were being taken in providing patient care. Record review of the facility policy titled Nursing Services, undated, revealed the following in part: Policy: 7. The facility will ensure that nurse aids are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with currently accepted professional principles for 1 of 4 med carts reviewed. -The 300-hall medication cart was left unlocked. -CMA E left Resident #32's medication in a pill cup on her bedside table unattended. This failure could place residents who receive medications in the facility and place them at risk of receiving incorrect medications or ineffective therapeutic doses or drug diversion. The findings include: 1.Record review of Resident #32's face sheet revealed an [AGE] year-old female with an admission date of 10/20/2023. Diagnoses including dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities), type 2 diabetes (high blood sugar), schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal), and hypertensive chronic kidney disease (is a long-standing kidney condition that develops over time due to persistent or uncontrolled high blood pressure). Record review of Resident #32's Quarterly Assessment, MDS, dated [DATE], revealed the resident had a BIMS score of 12 (moderately impaired). Record review of Resident #32's Physician Order Summary, dated 12/22/2023, revealed the resident received the following oral medications: Amlodipine Besylate 5mg 1 time a day, Aspirin 81mg 1 time a day, Buspirone 10mg 4 times a day, Calcium Carbonate wafer 500mg as needed, Cholecalciferol capsule 125mg 1 time a day, Cranberry capsule 425mg 2 times a day, Furosemide 40mg 1 time a day, Gabapentin 600mg 3 times a day, Levothyroxine 25mg, Loperamide 2mg as needed, Potassium Chloride 20meq 1 time a day, Reglan 10mg as needed, Senna Plus 8.6-50mg as needed, Tylenol with Codeine #3 300-30mg every 4 hours as needed, Xarelto 10mg 1 time a day, and Zofran 4mg every 8 hours as needed. In an observation and interview during initial rounds on 12/19/2023 at 9:45 AM, Resident #32 was sitting up in bed in her room with her medications in a pill cup on her bedside table. The resident said that was her medications and she had not taken them yet. She said the CMA leaves her medications with her all the time. In an observation and interview during initial rounds on 12/19/2023 at 9:47 AM, CMA E was observed outside of Resident #32's room at her medication cart getting putting another resident's medication in a pill cup. CMA E was asked how she assures Resident #32 takes all of her medications since it was left at her bedside, she said, I watch her and then locked her medication cart and left the area and went into another resident's room, leaving Resident #32 unattended with medications at bedside. At that time, Charge Nurse F came into the room and said she would stay with the resident until she took her medications, since she was left unattended. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 12/19/2023 at 12:04 PM, Charge Nurse F stated, all residents have to be observed taking all of the medications, that is a rule. That was why I came into Resident #23's room. She said potential negative outcomes could be the resident did not take all their medications, they might drop one on the floor or another resident could take them. In an interview on 12/21/2023 at 8:27 AM, the DON said medication aides and nurses are required to stay with residents until they have taken all their medications. If a resident does not want to take the medication, they should not leave them with the resident. The DON said potential negative outcomes could be the resident did not get their medications or gets a partial dose, the nurse did not know what the resident has taken, the resident could spill the medications on the floor, or another resident could take them. 2.In an observation and interview on 12/21/2023 at 07:30 AM the 300 hall nurses' medication cart was left unlocked. LVN G was in a resident room and the unlocked cart was left in front of the closed door of the resident's room. The nurse consultant came down the hallway and immediately locked the cart. She stated it was her expectation that medication carts be kept locked at all times. She stated this was a failure on the Nurses part to keep the med cart secured. She stated it could result in a drug diversion or a resident getting the wrong medication. LVN G came out of the room and stated it was her first time at the facility, and she was an agency nurse. She stated she did not realize she had left the cart unlocked. She stated this could result in a drug diversion. She stated she was oriented to the facility this morning by the ADON. In an interview on 12/21/2023 at 9:30 AM with the DON she stated she expected her nurses to keep the med room door locked and the medication cart locked at all times when not in use. She stated failure to do so could result in a drug diversion. Record review of the facility policy Medication, Administration of Drug, not dated, revealed the following [in part]: Procedure: 13. Be sure resident has swallowed all medications. The facility provided a policy titled Storage of Medications, not dated which stated in part: Medications and biologicals are stored safely, securely, and properly. The medication supply is to be accessible to only licensed nursing personnel or staff members authorized to administer medications. Medication rooms and carts are to be kept locked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 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 service safety in 1 of 1 kitchen, in that: Residents Affected - Some 1. Opened food items were not placed in sealed containers and were not fully dated. 2. Floors and walls throughout the dietary department were soiled with food, grease, dust. 3. Shelf units were soiled with spilled spices, food, and had rusting surfaces. 4. The microwave oven and electric mixer were soiled with splattered food. 5. The low temperature dish machine did not have water temperatures and sanitizer levels consistently documented. 6. Cooking utensils and pans were stored with their sanitized surfaces exposed to contaminants in the air. 7. Ceiling air duct vent covers were soiled with dust build-up. This failure could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated. The findings included: Observations and interview during the initial tour of the facility kitchen on 12/19/23, starting at 9:00 AM, revealed the following: - The staff locker room had a white towel soiled with a dark colored substance on the floor beneath a shelf with paper products and supplies, and an N95 mask was on the floor in corner. - The non-perishable food storage room had a plastic bulk storage container with a dust soiled lid; the container held flour. - The wall behind the beverage refrigerator and ice machine was soiled with dust build-up. - The spice shelf soiled with spilled spices; spice containers were not dated when opened or only dated with the month and day and did not include the year (10 ounce container with parsley flakes was dated 11/28, an open 57 ounce carton of potato pearls (instant mashed potatoes) was dated 12/8 and not resealed, an open package of peppered gravy mix was in a plastic bag that was not sealed closed and was not dated). - The exterior surface of the electric mixer stand was soiled with white power/dust and dried food splatters. - The interior surface of the microwave oven was soiled with splattered food; door handle was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0812 greasy. Level of Harm - Minimal harm or potential for actual harm - The walk-in refrigerator contained an open package with raw hot dogs in a plastic storage bag that was not sealed closed and was open to the air, the bag was not labeled and not dated; egg salad was in a container dated 12/14; mixed vegetables (cauliflower and broccoli) were in a container dated 12/12. Residents Affected - Some - The door to the walk-in freezer unit did not close completely in the door frame; the walk-in freezer was accessed from inside the walk-in refrigerator. - Metal shelves throughout the kitchen had rusting surfaces. - The floor tiles were soiled with grease and food crumbs near food preparation counter. In an interview and record review on 12/19/23 at 9:30 AM, Dishwasher K stated she checked the low temperature dish machine water temperatures and chlorine sanitizer level before starting to wash the dishes. Review of the daily dish machine temperature log revealed the water temperatures and sanitizer levels for the breakfast, lunch, and dinner meals for 12/19/23 (current day) had been documented and initialed by Dishwasher K. She stated she had not documented yet today and had documented on wrong date line. Observation on 12/21/23 at 11:20 AM, during the puree diet food preparation, revealed [NAME] L removed the cap from a one-gallon jug container of milk to add to food in the food processor. She dropped the cap on the floor, picked it up, rinsed it under running water from the faucet in the food preparation sink, and replaced the cap on the jug container of milk. Observations on 12/21/23 at 11:25 AM of kitchen food preparation area revealed mesh shelf liner had been placed to cover the rusted metal surface of the shelf beneath the steam table and meal tray line counter; ceiling air duct vent covers were soiled with dust build-up; cooking utensils, pans, and a colander were hanging from hooks on a metal frame suspended from the ceiling with the sanitized surfaces exposed to potential contaminants in the air; the floor tile grout was soiled with a dark colored build-up and dried pieces of food and small pieces of paper. During an observation, interview and record review on 12/21/23 at 11:40 AM, [NAME] M was washing dishes. He stated he did not check the low temperature dish machine water temperatures and sanitizer level. [NAME] M stated it was only his second day back in the dish room and he had never checked the dish machine water temperatures and sanitizer before. [NAME] L entered the dish room and explained what [NAME] M needed to do. Review of the daily low temperature dish machine log revealed no water temperatures or sanitizer levels had been documented since 12/19/23. In an interview on 12/21/23 at 12:00 PM, the Dietary Manager stated there were cleaning schedule forms that the dietary staff used for guidance. She stated the staff did not document on the forms when cleaning tasks were completed. Review of the facility's Dietary Services Policy, not dated, revealed the following [in part]: Dietary staff: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0812 Cleaning and work schedules will be available to ensure that all equipment and work areas of the kitchen are being cleaned and maintained on a regular basis. Level of Harm - Minimal harm or potential for actual harm The Food and Drug Administration Food Code 2022 specified [in part]: Residents Affected - Some Chapter 3 Food 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Chapter 4 Equipment, Utensils, and Linens 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 diseases and infections for 2 of 2 residents (Resident #'s 3 and 183) reviewed for infection control practices, in that: Residents Affected - Some -LVN G failed to disinfect her glucometer between residents when doing fingerstick blood sugars. -LVN G failed to perform hand hygiene after glove changes and between residents when doing fingerstick blood sugars. These failures could place residents at risk for the spread of infection. The findings included: Resident #3: Record review of resident# 3's Quarterly MDS dated revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following diagnosis of Diabetes (high level of sugar in the blood), He had a BIMS score of 11 which indicated moderate cognitive impairment. Resident #79: Record review of resident #79 's admission MDS dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Diabetes (elevated level of sugar in the blood), and high blood pressure. In an observation on 12/20/23 at 11:29 AM LVN H supplies into Resident #79's room in after placing it in small red box when she took it out of the medication cart. She did not clean glucometer or wash hands before entering the room. She applied gloves and did the fingerstick after the procedure she removed her gloves, left the room, went to the med cart, and documented Resident #79's blood sugar. She then went directly to Resident #3's Room to perform his fingerstick. She did not clean glucometer before she entered Resident #3's room and did not perform hand hygiene between residents. She used the same uncleaned glucometer to perform a fingerstick on Resident #3. She noticed Resident #3's fingernails were long and had brown dirt underneath them and she asked him if he wanted them cut. She placed the glucometer on the resident's bedside table without a barrier. She placed it back into the red basket after picking it up from his bedside table without disinfecting it and applied new gloves. She did not perform hand hygiene hand and proceeded to cut his fingernails. She then removed her gloves and left the room without performing hand hygiene. In an interview on 12/20/23 at 12:00 noon LVN H stated she should have disinfected the glucometer between resident with a germicidal cleaner and washed her hands. She stated her failure to do so could cause infection. She stated the failure occurred because it made her nervous for someone to watch her perform a procedure. In an interview on 12/20/23 at 1:00 PM an interview with the DON revealed she expected glucometers to be disinfected with the purple top germicidal cleaner that was on the medication cart. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the glucometer should be disinfected between use on each resident. She stated hands should be washed or hand hygiene performed after glove changes and before and after resident contact. Review of the facilities undated policy titled Hand Hygiene stated in part: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease control and Prevention. The centers for Medicare and Medicaid services state operations manual indicates that hand hygiene should be performed when coming on duty, before and after performing any invasive procedure (e.g., fingerstick blood sugar) After caring for a resident including after removing gloves. Event ID: Facility ID: 676100 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 676100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to develop and implement an infection prevention and control program to include antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for antibiotic stewardship. Residents Affected - Many The facility failed to utilize an antibiotic tracking log for the months of September 2023 through December 2023. This failure could place residents at risk for inappropriate antibiotic use. The findings include: In a record review of facility's antibiotic tracking log , the last month the tracking and trending on antibiotic usage was completed in August of 2023. The tracking logs for September 2023, October 2023, November2023, and December 2023 were not completed. In an interview on 12/21/23 at 11:59 AM, the DON provided a Policy for Infection Control and said the facility used the Policy and Procedure but it does not meet the standards of tracking and antibiotic stewardship. She said she was new in the DON position and has not received training for infection prevention and tracking. In an interview on 12/21/23 at 5:15 PM with the Regional RN Consultant and DON, The DON stated the potential outcome of not having an antibiotic stewardship program was not getting rid of infections. The Regional RN Consultant replied, not protecting residents from unnecessary usage of antibiotics. In a Record Review of Facility's policy INFECTION CONTROL POLICY CFR 483.65, undated, revealed the following [in part]: The facility has established and maintains an infection control program designed to provide safe, sanitary, and comfortable environment. Infections are investigated, controlled, and prevented through implementation of the infection control program. A record is maintained of incidents and corrective actions related to infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676100 If continuation sheet Page 30 of 30