Inspection·September 8, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 09/06/23 at 10:10 a.m. and on 09/06/23 at 11:57 a.m. in Resident #4's room revealed the call light both times was connected to the light string hanging behind the resident's bed on the opposite side of the bed in which the resident was sitting. When this surveyor told the resident where the call light was, the resident turned and looked but, the resident did not respond. During an interview on 09/06/23 at 10:22 a.m. with the DON, confirmed Resident #4's call light was attached to the light string on the opposite side of the bed and not within Resident #4's reach. Record review of Resident #22's face sheet dated 09/07/23 revealed the resident was admitted on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance (can be feelings of distress, sadness or symptoms of depression, and anxiety), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), cerebral palsy (abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles), depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Review of Resident #22's quarterly MDS dated [DATE] revealed the resident has a BIMS score of 07 indicating the resident has severe cognitive impairment. The MDS indicated their ADL's to include walking did not occur during the 7 day period. Review of Resident #22's comprehensive care plan dated 01/20/23 with revision date of 09/06/23 revealed the call light to be kept within reach for urinary incontinence. There were no other problems addressing call lights. Observation on 09/07/23 at 11:30 a.m. during Resident #22's peri care revealed the call light was clipped to the privacy curtain and not within the resident's reach. Further observation of Resident #22 after peri care the call light continued to remain out of reach for the resident. CNA A and CNA B did not replace the call light within Resident #22's reach. During interview on 09/07/23 at 11:30 a.m. with CNA A and CNA B after completing peri care for Resident #22, both CNAs said they had finished with Resident #22. This surveyor took both CNA A and CNA B back into Resident #22's room and both CNA A and CNA B confirmed the call light was attached to the privacy curtain and the call light was not within Resident #22's reach. CNA A then took the call light and unclipped it from the privacy curtain and placed the call light beside Resident #22 so she could reach it. When this surveyor asked what might happen if Resident #22 was not able to reach the call light CNA A and CNA B stated she may fall out of the bed. Review of Resident #36's face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), kidney disease stage 3 (your kidneys are damaged and can't filter blood the way they should), glaucoma- bilateral (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 2 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nerve), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), muscle weakness, unsteadiness on feet. Review of Resident #36's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 08, indicating moderate impairment of cognition and ADL's to include walking which requires extensive assistance of 1 person. Review of Resident #36's comprehensive care plan revised on 07/26/23 revealed falls, visual function and urinary incontinence were addressed and one of the approaches was to keep the call light within reach. Observations on 09/05/23 at 11:50 a.m. of Resident #36 reclining in his recliner revealed call light was stretched across the bed but, not within resident #36's reach. Observation on 09/06/23 at 10:00 a.m. of Resident #36 was reclined in his recliner and the call light was observed on the opposite side of the bed next to the upper bed rail and was not within the resident's reach. The DON was observed taking the call light from behind the resident's bedside dresser and stretching the cord over to the resident and attaching the call light to the side of the recliner within the resident's reach. During an interview and observation on 09/06/23 at 10:20 a.m. the DON confirmed Resident#36's call light was not within reach. During the interview on 09/06/23 at 10:24 a.m. with the DON, when asked what could happen if the resident could not reach the call light, the DON stated the resident could fall or something worse could happen to them. Review of the facility Policy and Procedure for Answering the Call Light dated 2001 and revised on 2021 sated in part: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of the Facility Policy and Procedure for Perineal Care (incontinent care) dated 01/20/23 revealed on page 2, numbers 14. and 15., States reposition the bed covers. Make the resident comfortable. Place the call light within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 3 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0583 Keep residents' personal and medical records private and confidential. 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 protect the confidentiality of personal health care information for 1 of 42 [Resident #7) residents reviewed for confidentiality of records during the survey in that: Residents Affected - Few The facility failed to ensure RN C locked and closed the laptop during the medication pass exposing Resident #7's personal information to include some of her medications. This failure could affect residents by placing them at risk for loss of privacy and dignity. The Findings included: Review of Resident #7's face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior with episodes of mania and sometimes depression), diabetic neuropathy (a nerve damage that is caused by diabetes), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions) and depression ( A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) Observation on 09/07/23 at 8:27 a.m. of RN C's medication cart revealed the medication cart was left unattended for approximately 3 minutes while RN C went into Resident # 10's bathroom to wash his hands. RN C was setting up medications for Resident #7. The screen showed Resident #7's picture, name and medications RN C was about to setup. Interview on 09/07/23 at 9:26 a.m. with RN C stated he did not remember leaving the laptop open. When asked what could have happened if someone sees the information? RN C stated well, I guess someone could use the information against the resident. Interview on 09/07/23 at 10:25 a.m. with the DON revealed she was not aware of the issues found during medication pass. She stated no one else was supposed to see the meds or issues of the resident. When asked what could have happened if the resident's information was open and no one around. She stated the information could be used against the resident or they could sell the information to someone else Record review of a facility's policy and procedure titled Resident Rights dated 2001 and revised in February 2021 revealed in part: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: f. Privacy and confidentiality. 3. The unauthorized release, access, or disclosure of resident information is prohibited. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 4 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure nursing staff was able to demonstrate competency in skills and techniques for 1 of 2 (RN C) RNs observed during medication pass. The facility failed to prevent RN C from following: 1. Established Infection Control Procedures while passing medications to Resident #5 and Resident #10. 2. HIPAA privacy requirements to lock and close the laptop while passing medications to Resident #7. 3. The procedure to lock the medication cart before walking away during the medication pass. 4. The procedure to prime an Insulin Pen before administering the medication to Resident #7. These deficient practices could affect residents who were receiving medications leaving them at risk for infection, not receiving the proper amount of insulin and exposure of confidential information. The findings were: Review of Resident #7's face sheet dated 09/07/23, revealed Resident #5 was admitted on [DATE] and diagnoses which include type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), Schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior with episodes of mania and sometimes depression), diabetic neuropathy (nerve damage that is caused by diabetes), Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), Congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), anxiety ( a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #7's quarterly MDS assessment dated [DATE], revealed Resident #7 had severely impaired cognition skills for decision making and a BIMS score was 99 indicating unable to complete the interview. Further review of the quarterly MDS revealed ADL's for Resident #5 required supervision of 1 staff person. Review of Resident #7's care plan dated 04/04/23 and revision dated 08/29/23 revealed the care plan addressed the resident's medications including monitoring the side effects and to administer the medications as ordered. Review of Resident#7's Physician's Order Report dated from 08/07/23 to 09/07/23 revealed Resident #7 was to receive Lantus Solostar (insulin glargine) U 100, 100 units/ml (3ml) give 42 units subcutaneous and give twice a day 8:00 a.m. and 8:00 p.m. Further review revealed Resident #7 was to also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 5 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some receive Divalproex 125 mg capsule, 2 po tid.; Famotidine 20 mg tab give 1 po bid; Furosemide 20mg tab, give 1 po qd;, Metformin 500mg tab 1 po qd; Quetiapine 300 mg extended release tab, give 1 po qd; Docusate Na 100mg tab give 1 po qd; D3 2000IU capsule, give 1 po qd; Farxiga 10 mg tab give 1 po qd; Lisinopril 5 mg tab, give 2 (10mg) po qd; Lorazepam o.5mg tab give 1 po tid. Review of Resident #10's Face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), cardiomegaly (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), glaucoma, bilateral, severe stage (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), depression with psychotic symptoms (mood disorder). Review of Resident #10's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 11, indicating moderate impairment and ADL's required supervision with setup by 1 person. Review of Resident #10's comprehensive care plan dated 12/01/23 with revision date of 08/30/23 under medications reveals an approach of administer medications as ordered. Review of Resident #10's Physician Order Report date from 08/07/23 to 09/07/23 revealed the following medications to be given Buspirone 5 mg tab give 1 po bid; D3 1000 IU 25mg cap give 1 po qd; Eliquis 5 mg tab give 1 tab po bid; Lisinopril 10mg tab give 1 po qd; metoprolol tar 25 mg tab give 1 po bid; lactulose solution 10 mg/15ml give 30 ml po qd; dorszao/tinol Sol 22.3-4.68 1 gtt o.u. bid; alphagn p sol 1% give 1 gtt o.u. tid; terbinafine hcl 1% cream on toenails qd; lorazepam 0.5mg give 0.25mg tab po bid. Observations from 09/07/23 at 8:15 a.m. to 9:10 a.m. for Resident #7 and #10 during the medication pass revealed RN C placed his finger in the medication cup then took the blister packs and either popped the resident's medications into his thumb and index finger or popped the pill(s) into the palm of his hand and then placed the medication into the medication cup. When asked how many pills he was giving, he would pour the medication into the palm of his hand and take his thumb and index finger and pick up each pill and place back into the medication cup. Resident #10 refused her eye drops and her toenail cream. As RN C was setting up the medication for Resident #7, RN C left the keys in the lock on the medication cart and went into Resident #10's bathroom to wash his hands. Later as RN C was setting up Resident #5's medications he walked away from the medication cart without locking and closing the top on the laptop, exposing Resident #7's picture, name and some of the medications Resident #7 was taking. Observation on 09/07/23 at 9:10 a.m. for Resident #7 revealed RN C was preparing to give Resident #7 her insulin with an insulin pen. RN C picked up the new insulin pen, placed the needle on the end of the barrel and dialed up the 42 units he was to give. RN C did not prime the insulin pen prior to setting the dosage in which the resident might have not received all her insulin as ordered. Interview on 09/07/23 at 9:20 a.m. to 9:26 a.m. with RN C revealed he did not wear gloves as he setup the medications for Resident #7 and #10 or ensure his hands were clean while picking up blister (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 6 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some packs, opening drawers on the medication cart and while opening over the counter medications used on multiple residents. Stated he did not remember if he left the keys in the medication cart or leave the laptop open exposing Resident #7's picture, name, and some of her medications. RN C stated he did not know he was handling the medications incorrectly and thought he could pick the pills up with his thumb and index finger and place them into the palm of his hand. When asked what could happen in the different situations, RN C stated he could have caused the resident to develop an infection. RN C stated, the keys anyone could have come along and opened the medication cart and taken the medications. RN C stated the personal information of Resident #7 could have been taken and used against the resident. Interview on 09/07/23 at 12:25 p.m. with RN C concerning the insulin given to Resident #7 stated he was not aware of priming the insulin as long as there were no bubbles in the insulin barrel. Interview on 09/07/23 10:20 a.m. to 10:25 a.m. with the DON revealed she was not aware of the medication pass with RN C but, when asked about his training, the DON stated RN C was trained and also had the pharmacist consultant do medication passes with the nurses and medication aides. When asked what could have happened in each of the incidents with RN C during the medication pass, the DON stated, infection control- not cleaning his hands and using proper procedure to handle pills could lead to infection. The keys left in the lock on the medication cart- the DON stated someone could have come along and gotten into the medication cart and taken medications. The laptop not locked and lid closed-the DON stated no one else was to see the medications or issue of the resident and the information could be used against the resident or they could sell the information to someone else. The insulin pen- the DON stated it was an infection control issue and also not primed Resident #7 might not have gotten the right dose. Review of RN C's Clinical Nursing Validation Review Checklist revealed on 02/28/23, RN C was checked off for his skills by the DON. The checklist included hand washing and on 07/16/23 handwashing and F tags for infection control with the facility Core Clinical Compliance 2023. Review of the facility Policy and Procedure dated 2001 with a revision on 04/19 for Administering Medications revealed in part the following: 16. During administration of medications, the medication cart is to be kept closed and locked when out of sight of the medication nurse or aide a. When using a tablet or laptop, maintain HIPAA privacy requirements by covering or closing the computer screen 21. Staff follows established infection control procedures (e.g. handwashing, antiseptic technique, gloves, ) for the administration of medications, as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 7 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #7 and #10) out of 5 residents reviewed for medication administration in that: The facility failed to ensure RN C ensured the Insulin Pen was purged before giving Resident #7 her insulin. The facility failed to prevent RN C from giving Resident #10 Lorazepam 0.5mg tab instead of 0.25mg tab. These deficient practices could affect residents with medications and place residents at risk for not receiving the proper dosage. The findings included: Review of Resident #5's face sheet dated 09/07/23, revealed Resident #7 was admitted on [DATE] and diagnoses which include type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), Schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior with episodes of mania and sometimes depression), diabetic neuropathy (nerve damage that is caused by diabetes), Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), Congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), anxiety ( a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident#7's Physician's Order Report dated from 08/07/23 to 09/07/23 revealed Resident #7 was to receive Lantus Solostar (insulin glargine) U 100, 100 units/ml (3ml) give 42 units subcutaneous and give twice a day 8:00 a.m. and 8:00 p.m. (Start date was 08/18/23) Review of Resident #7's Medication Administration Sheet dated 08/07/23 to 09/07/23 revealed the Lantus Solostar (insulin glargine) pen was started on 08/18/23 and the resident was receiving the insulin twice a day at 8:00 a.m. and 8:00 p.m. Observation on 09/07/23 at 9:10 a.m. RN C was observed taking a new Lantus Solostar pen for Resident #7 and placing a new needle on the barrel. RN C dialed up 42 units of insulin and did not purge the pen before ensuring Resident #7 was given the insulin and receiving the dose on the left side of the abdomen. Interview on 09/07/23 at 12:25 p.m. with RN C after the medication pass concerning not priming the Lantus Solostar pen before dialing the correct dosage and giving the insulin to Resident #5, stated he was not aware of priming the insulin as long as there were no bubbles in the insulin barrel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 8 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/07/23 from 10:20 a.m. to 10:25 a.m. with the DON revealed she was not aware of the issues found with the Medication Pass with RN C. She stated concerning the insulin pen for Resident #5 should have been primed before dialing up the dosage for Resident #7. Stated Resident #5 may have not gotten the correct dosage of insulin. Review of Resident #10's Face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), cardiomegaly (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), glaucoma, bilateral, severe stage (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), depression with psychotic symptoms (mood disorder). Review of Resident #10's Physician Order Report date from 08/07/23 to 09/07/23 revealed the Lorazepam order reflected Lorazepam - Schedule IV tablet; 0.5mg. Special instructions: administer 0.25 mg tablet by mouth two times a day; 08:00 a.m.- 10:00 a.m., 08:00 p.m. - 10:00 p.m. (Starting on 08/17/23). Review of Resident #10's Controlled Substance Administration Record from 07/19/23 to 09/08/23 revealed the resident was to receive from 07/19/23 to 08/16/23 ½ tab of Lorazepam once a day. The order description was Lorazepam- Schedule IV 0.5 mg tablet and to give 0.25 mg (1/2 of the 0.5mg tablet) by mouth once a day. Then on 08/16/23 the order for ½ mg tablet of Lorazepam was to be given twice a day starting on 08/17/23 and had continued to 09/08/23. Observation on 09/07/23 at 8:15 a.m. during Medication Pass revealed RN C gave Resident #10 Lorazepam 0.5mg tab 1 by mouth, and was to receive twice a day. Observation again on 09/08/23 at 12:45 p.m. of the Resident #10's blister pack of Lorazepam revealed the medication was refilled on 08/20/23 and to take a 0.5mg tablet twice a day. There was nothing on the blister pack indicating the dosage had been changed and further observation of the 0.5 mg tablet revealed the tablet was not scored so as to give ½ (equals 0.25 mg) of the tablet. Completed as part of the medication reconciliation to verify the orders against the medication given and the blister pack medication was taken from. Interview on 09/08/23 at 2:22 p.m. with the DON after informing her of the medication discrepancy with Resident #10's Lorazepam she stated it was called into the Pharmacist. The order was not transcribed electronically. The Lorazepam was originally ordered for a gradual dose reduction (GDR) on 07/19/23 to 0.25 mg. The pharmacy kept sending out 0.5 mg of Lorazepam and the staff continued to give 0.5 mg. The original order from 09/14/22 for Resident #10's Lorazepam was for 0.5 mg to be given twice a day. Interview on 09/08/23 at 4:23 p.m. with the DON confirmed Resident #10 was given the wrong amount of the Lorazepam for 15 days. When asked about what could happen by receiving the wrong amount, she stated Resident #10 could have an adverse reaction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 9 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0755 Record review of the Facility Policy Administering Medications dated 2001 with a revision date of 04/19 stated in part: 4. Medications are administered in accordance with prescriber orders . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 10 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0759 Ensure medication error rates are not 5 percent or greater. 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 it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 6.67%, based on 2 errors out of 30 opportunities, which involved 2 of 5 residents (Resident #7 and #10) reviewed for medication administration in that: Residents Affected - Some The facility to ensure RN C ensured the Insulin Pen was purged to ensure Resident #7 received her insulin as ordered. The facility failed to prevent RN C from giving Resident #10 the wrong dosage of Lorazepam 0.25mg tablet as ordered. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. The findings included: 1. Review of Resident #7's face sheet dated 09/07/23, revealed Resident #7 was admitted on [DATE] and diagnoses which include type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), Schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior with episodes of mania and sometimes depression), diabetic neuropathy (nerve damage that is caused by diabetes), Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), Congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), anxiety ( a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident#7's Physician's Order Report dated from 08/07/23 to 09/07/23 revealed Resident #7 was to receive Lantus Solostar (insulin glargine) U 100, 100 units/ml (3ml) give 42 units subcutaneous and give twice a day 8:00 a.m. and 8:00 p.m. (Start date was 08/18/23) Review of Resident #7's Medication Administration Sheet dated 08/07/23 to 09/07/23 revealed the Lantus Solostar (insulin glargine) pen was started on 08/18/23 and was receiving the insulin twice a day at 8:00 a.m. and 8:00 p.m. Review of Resident #7's comprehensive care plan, dated 04/24/23 and revised 08/19/23 revealed the resident was on Insulin and Administer medication as ordered. Observation on 09/07/23 at 9:10 a.m. RN C was observed taking a new Lantus Solostar pen for Resident #5 and placing a new needle on the barrel. RN C dialed up 42 units of insulin and did not purge the pen before ensuring Resident #7 was given the insulin and receiving the dose on the left side of the abdomen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 11 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/07/23 at 12:25 p.m. with RN C after the medication pass concerning not priming the Lantus Solostar pen before dialing the correct dosage and giving the insulin to Resident #7, stated he was not aware of priming the insulin as long as there were no bubbles in the insulin barrel. Interview on 09/07/23 from 10:20 a.m. to 10:25 a.m. with the DON revealed she was not aware of the issues found with the Medication Pass with RN C. She stated concerning the insulin pen for Resident #7 should have been primed before dialing up the dosage for Resident #7. The DON stated Resident #7 may have not gotten the correct dosage of insulin. Review of Resident #10's Face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), cardiomegaly (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), glaucoma, bilateral, severe stage (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), depression with psychotic symptoms (mood disorder). Review of Resident #10's Physician Order Report date from 08/07/23 to 09/07/23 revealed the Lorazepam order reflected Lorazepam - Schedule IV tablet; 0.5mg. Special instructions: administer 0.25 mg tablet by mouth two times a day; 08:00 a.m.- 10:00 a.m., 08:00 p.m. - 10:00 p.m. (Starting on 08/17/23). Review of Resident #10's Controlled Substance Administration Record from 07/19/23 to 09/08/23 revealed the resident was to receive from 07/19/23 to 08/16/23 ½ tab of Lorazepam once a day. The order description was Lorazepam- Schedule IV 0.5 mg tablet and to give 0.25 mg (1/2 of the 0.5mg tablet) by mouth once a day. Then on 08/16/23 the order for ½ mg tablet of Lorazepam was to be given twice a day starting on 08/17/23 and had continued to 09/08/23, when it was found to be wrong during reconciliation of the Lorazepam for Resident #10. Observation on 09/07/23 at 8:15 am during Medication Pass RN C gave Resident #10 Lorazepam 0.5mg tab 1 by mouth, and the Lorazepam was to be given twice a day. Observation again on 09/08/23 at 12:45 p.m. of the Resident #10's blister pack of Lorazepam revealed the medication was refilled on 08/20/23 and to take a 0.5mg tablet twice a day. There was nothing on the blister pack indicating the dosage had been changed and further observation of the 0.5 mg tablet revealed the tablet was not scored so as to give ½ (equals 0.25 mg) of the tablet. Completed as part of the medication reconciliation to verify the orders against the medication given and the blister pack medication was taken from. Interview on 09/08/23 at 2:22 p.m. with the DON after informing her of the medication discrepancy with Resident #10's Lorazepam she stated it was called into the Pharmacist. The order was not transcribed electronically. The Lorazepam was originally ordered for a gradual dose reduction (GDR) on 07/19/23 to 0.25 mg. The pharmacy kept sending out 0.5 mg of Lorazepam and the staff continued to give 0.5 mg. The original order from 09/14/22 for Resident #10's Lorazepam was for 0.5 mg to be given twice a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 12 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 09/08/23 at 4:23 p.m. with the DON confirmed Resident #10 was given the wrong amount of the Lorazepam for 15 days. When asked about what could have happened to Resident #10 by receiving the wrong amount, the DON stated Resident #10 could of had an adverse reaction to the medication. Record review of the facility policy and procedure titled, Administering Medications dated 2001 and revised on 04/19, revealed in part, . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Event ID: Facility ID: 676288 If continuation sheet Page 13 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 and interview the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions for 1 of 5 residents (Resident #10) reviewed during the medication pass in that: The facility failed to prevent Resident #10 from being given 0.5mg of Lorazepam instead of 0.25mg tab. This deficient practice placed residents receiving medications at risk for receiving the wrong dosage as prescribed. The Findings include: Review of Resident #10's Face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), cardiomegaly (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), glaucoma, bilateral, severe stage (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), depression with psychotic symptoms (mood disorder). Review of Resident #10's Physician Order Report date from 08/07/23 to 09/07/23 revealed the Lorazepam order reflected Lorazepam - Schedule IV tablet; 0.5mg. Special instructions: administer 0.25 mg tablet by mouth two times a day; 08:00 a.m.- 10:00 a.m., 08:00 p.m. - 10:00 p.m. (Starting on 08/17/23). Review of Resident #10's Controlled Substance Administration Record from 07/19/23 to 09/08/23 revealed the resident was to receive from 07/19/23 to 08/16/23 ½ tab of Lorazepam once a day. The order description was Lorazepam- Schedule IV 0.5 mg tablet and to give 0.25 mg (1/2 of the 0.5mg tablet) by mouth once a day. Then on 08/16/23 the order for ½ mg tablet of Lorazepam was to be given twice a day starting on 08/17/23 and had continued to 09/08/23, when it was found to be wrong during reconciliation of the Lorazepam for Resident #10. Observation on 09/07/23 at 8:15 am during Medication Pass RN C gave Resident #10 Lorazepam 0.5mg tab 1 by mouth, and was to receive twice a day. Observation again on 09/08/23 at 12:45 p.m. of the Resident #10's blister pack of Lorazepam revealed the medication was refilled on 08/20/23 and to take a 0.5mg tablet twice a day. There was nothing on the blister pack indicating the dosage had been changed and further observation of the 0.5 mg tablet revealed the tablet was not scored so, as to give ½ (equals 0.25 mg) of the tablet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 14 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 Completed as part of the medication reconciliation to verify the orders against the medication given and the blister pack medication was taken from. Interview on 09/08/23 at 2:22 p.m. with the DON after informing her of the medication discrepancy with Resident #10's Lorazepam she stated it was called into the Pharmacist. The order was not transcribed electronically. The Lorazepam was originally ordered for a gradual dose reduction (GDR) on 07/19/23 to 0.25 mg. The pharmacy kept sending out 0.5 mg of Lorazepam and the staff continued to give 0.5 mg. The original order from 09/14/22 for Resident #10's Lorazepam was for 0.5 mg to be given twice a day. Interview on 09/08/23 at 4:23 p.m. with the DON confirmed Resident #10 was given the wrong amount of the Lorazepam for 15 days. When asked about what could have happened by Resident #10 receiving the wrong amount, the DON stated Resident #10 could have had an adverse reaction to the medication. A facility Policy and Procedure for Medication Storage, Dating and Labeling of all Biologicals requested from the DON was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 15 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #7 and #10) reviewed for infection control practices, in that: Residents Affected - Some The facility failed to prevent RN C from doing the following during medication pass: 1. Setup pills from the blister packs and bottles by using his bare thumb and index finger or palm of his hand to place the medication into the medication cups. 2. Administered by mouth medications for Resident #7 and #10 by placing his bare fingers inside the medication cups These failures could place residents at risk for infection, transmission for communicable diseases and or a decline in health. The Findings include: Review of Resident #7's face sheet dated 09/07/23, revealed Resident #7 was admitted on [DATE] and diagnoses which include type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), Schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior with episodes of mania and sometimes depression), diabetic neuropathy (nerve damage that is caused by diabetes), Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), Congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), anxiety ( a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #7's quarterly MDS assessment dated [DATE], revealed Resident #7 had severely impaired cognition skills for decision making and a BIMS score was 99 indicating unable to complete the interview. Further review of the quarterly MDS revealed ADLs for Resident #5 required supervision of 1 staff person. Review of Resident #7's comprehensive care plan dated 04/04/23 and revision dated 08/29/23 revealed the care plan addressed the resident's medications including monitoring the side effects and to administer the medications as ordered. Review of Resident #7's Physician's Order Report dated from 08/07/23 to 09/07/23 revealed Resident #7 was to receive Divalproex 125 mg capsule, 2 po tid.; Famotidine 20 mg tab give 1 po bid; Furosemide 20mg tab, give 1 po qd;, Metformin 500mg tab 1 po qd; Quetiapine 300 mg extended release tab, give 1 po qd; Docusate Na 100mg tab give 1 po qd; D3 2000IU capsule, give 1 po qd; Farxiga 10 mg tab give 1 po qd; Lisinopril 5 mg tab, give 2 (10mg) po qd; Lorazepam o.5mg tab give 1 po tid. Review of Resident #10's Face sheet dated 09/07/23 revealed the resident was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 16 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), cardiomegaly (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), glaucoma, bilateral, severe stage (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), depression with psychotic symptoms (mood disorder). Review of Resident #10's Physician Order Report date from 08/07/23 to 09/07/23 revealed the following medications to be given Buspirone 5 mg tab give 1 po bid; D3 1000 IU 25mg cap give 1 po qd; Eliquis 5 mg tab give 1 tab po bid; Lisinopril 10mg tab give 1 po qd; metoprolol tar 25 mg tab give 1 po bid; lactulose solution 10 mg/15ml give 30 ml po qd; dorszao/tinol Sol 22.3-4.68 1 gtt o.u. bid; alphagn p sol 1% give 1 gtt o.u. tid; terbinafine hcl 1% cream on toenails qd; lorazepam 0.5mg give 0.25mg tab po bid. Review of Resident #10's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS of 11, indicating moderate impairment and ADLs require supervision with setup by 1 person. Review of Resident #10's comprehensive care plan dated 12/01/23 with revision date of 08/30/23 under medications reveals an approach of administer medications as ordered. Observations from 09/07/23 at 8:15 am to 9:10 am for Resident #7 and #10 during the medication pass revealed RN C placed his finger in the medication cup then took the blister packs and either popped the resident's medications into his thumb and index finger or popped the pill(s) into the palm of his hand and then placed the medication into the medication cup. When asked how many pills he was giving he would pour the medication into the palm of his hand and take his thumb and index finger and pick up each pill and place them back into the medication cup. Interview on 09/07/23 at 9:20 a.m. to 9:26 a.m. with RN C revealed he did not wear gloves as he setup the medications for Resident #7 and #10 or ensure his hands were clean before picking up blister packs, popping pills and retrieving them with his thumb and index finger or popping them into the palm of his hand, opening drawers on the medication cart and while opening over the counter medications used on multiple residents. When asked what could happen in this situation, RN C stated he could cause the resident to develop an infection. Interview on 09/07/23 10:20 a.m. to 10:25 a.m. with the DON revealed she was not aware of the medication pass with RN C but, when asked about his training, stated he had been trained (medication pass) and she also had the pharmacist consultant do medication passes with the nurses and medication aides. When asked what could happen in each of the incidents with RN C during medication pass the DON stated, infection control- not cleaning their hands and using proper procedure to handle pills could lead to infection. Review of RN C's Clinical Nursing Validation Review Checklist revealed on 02/28/23, RN C was checked off for his skills by the DON. The checklist included hand washing and on 07/16/23 handwashing and F tags for infection control with the facility Core Clinical Compliance 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 17 of 18 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 Review of the Facility Policy and Procedure for Administering Medications dated 2001 and revised on 04/19 revealed in part: 21. Staff follows established facility infection control procedure (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 18 of 18