Inspection·February 15, 2024

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following cerebral infarction (inability to swallow after stroke), acute kidney failure, sepsis (infection in the blood), hypertension (high blood pressure), myocardial infarction (heart attack), dementia, and neuromuscular disfunction of bladder (brain disorder affecting ability to urinate). Record review of Resident #33's quarterly MDS dated [DATE] revealed: Section B- Hearing, Speech, and Vision resident was usually able to make self-understood ; Section C- Cognitive Patterns BIMS score of 9 (moderate cognitive impairment). Record review of the SNF Beneficiary Protection Notification Review indicated Resident #263 received Medicare Part A Skilled Services on 3/22/2023 and her last covered day of Part A services was 4/6/2023. The SNF Beneficiary Protection Notification Review indicated the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Record review of Resident #33's SNF ABN dated 11/02/2023 revealed no evidence that estimated cost was completed. During an interview on 02/15/2024 at 11:37 a.m., the ADMN did not provide an answer to this deficiency. During an interview on 02/15/2024 at 11:39 a.m., the DRC stated MDS coordinators monitored that SNF ABN forms were filled out completely and correctly. She stated the facility did not have an MDS coordinator on staff at the time forms were filled out and their corporate had been filling in and completing the forms. She stated her expectation would be that the estimated cost would be filled in on the ABN form. The DRC stated the effect of not having estimated cost on the ABN form would be that the resident would not have all the information before deciding to continue or discontinue services. She stated that she felt education played a role in forms not being filled out appropriately and that she would make sure newly hired MDS coordinator understood how to fill out the form completely. The DRC stated the facility did not have policy on ABN forms and stated that the facility used the CMS form instructions. Review of CMS.gov accessed on 02/15/2024 at https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-snf-abn revealed: The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A) . Body D. Estimated Cost Section: In this section, the SNF enters the estimated cost of the corresponding care that may not be covered by Medicare. The SNF should enter an estimated total cost or a daily, per item, or per service cost estimate. SNFs must make a good faith effort to insert a reasonable cost estimate for the care. The lack of a cost estimate entry on the SNFABN or an amount that is different than the final actual cost charged to the beneficiary does not invalidate the SNFABN. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 2 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to make sure that the comprehensive care plan is prepared by a team that included the attending physician, a nurse, and a nurse aide with responsibility for the resident for 4 of 13 residents (Residents #1, #9, #25, and #30) reviewed for care plans. The facility failed to ensure that care plan meetings were completed quarterly and within 7 days after completion of the comprehensive assessment. This failure could place the residents at risk for not receiving the care and services to meet their needs. Findings include: Resident #1 Review of Resident #1's electronic face sheet dated 02/14/2024 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that include: dementia, hallucinations, dysphagia (difficulty swallowing), cellulitis (skin infection), hypertension (high blood pressure) and atrial fibrillation (irregular heartbeat). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident had no BIMS and resident was rarely/never understood. Review of Resident #1's care plan conference report on 02/14/2024 revealed no evidence of a care plan meeting being performed since 10/15/2021. Resident #9 Review of Resident #9's electronic face sheet dated 02/14/2024 revealed the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease, muscle wasting, edema (swelling), dysphagia (difficulty swallowing), repeated falls, pain, and diabetes. Review of Resident #9's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 5 (severe cognitive impairment). Review of Resident #9's care plan conference on 02/14/2024 revealed no evidence of a care plan meeting being performed since 09/16/2021. Resident #25 Review of Resident #25's electronic face sheet revealed resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease, dementia, muscle wasting, dysphagia (difficulty swallowing), and atrial fibrillation (irregular heartbeat). Review of Resident #25's quarterly MDS assessment dated [DATE] revealed the resident had no BIMS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 3 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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 0657 and resident is rarely/never understood. Level of Harm - Minimal harm or potential for actual harm Review of Resident #25's care plan conference on 02/15/2024 revealed no evidence of a care plan meeting ever being performed. Residents Affected - Some Resident #30 Review of Resident #30's electronic face sheet dated 02/14/2024 revealed resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: Eisenmenger's syndrome (irregular blood flow in the heart and lungs), lack of coordination, and thoracic aortic aneurysm (a bulge in the part of aorta a major artery that runs through the chest). Review of Resident #30's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 10 (moderate cognitive impairment). Review of Resident 30#'s care plan conference on 02/14/2024 revealed no evidence of a care plan meeting being performed between 01/13/2023 and 07/12/2023. During an interview on 02/15/2024 at 2:38 p.m., the ADMN was present and did not provide an answer to this deficiency. During an interview on 02/14/2024 at 2:38 p.m., the RCN stated her expectation would be for care plan meetings to occur quarterly and as needed when significant change warranted a MDS care plan to be scheduled. She stated she believed the failure occurred from not having an MDS coordinator, full time, in the last six to seven months. She stated facility had a traveling MDS coordinator that came to building on Tuesdays and Thursdays during that time, but no documentation of care plan meetings could be found in electronic medical charts. She also believed that having a new DON that started in October of 2023 and staff transitioning could have led to the failure of care plans to not be performed. The RCN stated the DON should have been monitoring that care plan meetings were being performed and that the RCN was ultimately responsible to monitor that care plan meetings were occurring. She stated that not having care plan meetings could result in residents and their family members not having a say in plan of care. Review of facility policy titled Comprehensive Care Plans dated 01/26/2024 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment and by Day 21 of the patient's stay. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the care plan. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be address in the care plan. The facility's rationale for deciding whether to proceed with care planning will be evidence in the clinical record .Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate .The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan. B. A registered nurse with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 4 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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 0657 responsibility for the resident. C. A nurse aide with responsibility for the resident. D. A member of the food and nutrition services staff. E. The resident and the resident's representative, to the extent practicable. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 5 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for one of one facility reviewed for nursing services. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 7 of 90 days (07/19/2023, 07/25/2023, 07/26/2023, 08/02/2023, 08/04/2023, 08/23/2023 and 09/27/2023) reviewed. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Record review of facility's RN nursing schedules from 07/01/2023-09/30/2023 revealed there was no evidence for at least 8 consecutive hours of RN coverage for the days of 07/19/2023, 07/25/2023, 07/26/2023, 08/02/2023, 08/04/2023, 08/23/2023 and 09/27/2023. During an interview on 02/15/2024 at 01:46 PM, the DRC stated her expectation was that there should be at least 8 consecutive hours of RN coverage on a daily basis. The DRC stated not having the RN coverage could have affected the residents by not receiving appropriate assessment skills needed for resident care. The DRC stated what led to the failure was the lack of RN availability in the community. The DRC stated the DON was responsible for scheduling RNs, and if unavailable, the ADMN was responsible to make sure RN coverage was in compliance. Record Review of facility policy titled Staffing, undated, revealed: Policy Statement: Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation: . .4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 6 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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. Based observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 treatment carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure the treatment cart (#1 of 1) was locked when unattended by LVN-A. This failure could place residents at risk of having access to unauthorized medications, wound care and medical supplies leading to possible harm or drug diversions. Findings included: Observation on 02/13/2024 at 11:08 AM revealed LVN-A retrieved medication cream from treatment cart #1 on the 200 hall. The treatment cart was observed to be left unlocked from 11:08 AM until 11:35 AM and 5 residents were seen walking within 5 ft of treatment cart. Drawer 1 of treatment cart #1 was observed to have contained wound care creams (zinc oxide ointments, calmoseptine ointment, skin protectant ointment, and Vitamin A&D ointment). Drawer 2 of treatment cart #1 was observed to have contained creams (Tacrolimus Ointment 1%, Hemorrhoidal Cream) as well as pain relief Lidocaine Patches and eyedrops. During an interview on 02/13/2024 at 11:35 AM, the DON stated there were creams and supplies for treatments and wound care that were stored in the open treatment cart. She stated with the treatment cart being left open, residents could have easily been able to have access to medications and creams. She stated the negative impact to residents would have been possibly taking medications that did not belong to them, or if ingested, they could have had an adverse reaction. She stated the failure was due to not locking the cart when a medication was retrieved and walking away. The DON stated the nursing staff should have monitored the carts. Her expectations were for all carts to be locked when leaving the cart unattended. During an interview on 02/13/2024 at 11:41 AM, LVN-A stated she left the cart unlocked when she removed a residents medication cream to administer and forgot to lock the cart when she walked away. She stated it was the nurses that monitored the treatment carts. LVN-A stated she did not remember if she had taken any in-services for open medication and/or treatment carts but stated they were to be locked at all times. She stated the negative impact to residents could be that they could eat, possibly poisoning themselves, or put on their skin having an allergic reaction. The LVN-A stated the failure occurred with nursing staff performing too many tasks at once. She stated her expectation was to always make sure the carts were locked when not in use. Record Review of the facility's policy and procedures /Storage of Medications with the revised date of 11/2020 revealed: Policy heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 7 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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 1. Level of Harm - Minimal harm or potential for actual harm Drugs and biologicals used in the facility are stored in locked compartments Only persons authorized to prepare and administer medication have access to locked medication . Residents Affected - Some .6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 8 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 4 of 4 (Resident #1, Resident #6, Resident #7 and Resident #25) residents who received a pureed meal reviewed during the lunch meals served reviewed for food and nutrition services. 1. The facility failed to ensure residents, receiving a puree texture diet, were provided the food according to the menu, including an herb roll and banana cake on 02/14/2024 at 11:50 AM. 2. The facility failed to ensure the recipes for pureed meals were followed for rice and charro beans on 02/13/2024 at 11:00 AM, and frosted banana cake on 02/14/2024 at 11:50 AM. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance, and/or weight loss. Findings included: Record review of Resident # 1's Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 0 (severe cognitive impairment); Section I-Active Diagnosis with following diagnosis of Dementia; Section K- Swallowing/Nutritional Status Resident #1 had a mechanically altered diet. Record review of Resident # 6's Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 0 (severe cognitive impairment); Section I-Active Diagnosis with following diagnosis of Alzheimer and dementia; Section K- Swallowing/Nutritional Status Resident # 6 had a mechanically altered diet. Record review of Resident # 7's Quarterly MDS dated [DATE] revealed an [AGE] year-old female admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 03 (severe cognitive impairment); Section I-Active Diagnosis with following diagnosis of Alzheimer and dementia; Section K- Swallowing/Nutritional Status Resident # 25 had a mechanically altered diet. Record review of Resident # 25's Quarterly MDS dated [DATE] revealed an [AGE] year-old male admitted on [DATE]; Section C- Cognitive Patterns had a BIMS score of 0 (severe cognitive impairment); Section I-Active Diagnosis with following diagnosis of Alzheimer and dementia; Section K- Swallowing/Nutritional Status Resident # 25 had a mechanically altered diet. Record review of facility puree menu for lunch meal on 02/13/204 revealed: Puree Sour Cream Chicken Enchiladas, Puree Spanish rice, Pure Refried beans, Puree Churro bites. Record review of facility puree menu for lunch meal on 02/14/2024 revealed: Puree Meatball w/Spaghetti, spaghetti noodles, puree capri vegetables, puree herb butter roll, puree cheesecake. Record review of facility puree menu for lunch meal on 02/15/2024 revealed: puree frosted banana cake. During an observation and interview on 02/13/2024 between 11:00 AM to 12:30 PM of the kitchen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 9 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed the DM added 5 ladles of warm broth to the 5 servings of rice before he started to puree the rice. Once the DM started to puree the rice, he added some warm water, then added a hot dog bun, then a little more water and 3 scoops of thickener. The DM stated he had recipes, but he did not use them. He stated he knew what to do when pureeing food. The DM stated he was taught to add bread to the mixture but did not get the recipe to see what the recipe stated. The DM started to puree the charro beans he added warm broth, then added a hot dog bun and then added 2 scoops of the thickener. The DM did not look at the recipe to confirm what to add to the beans. The DM did not puree a dessert of mixed fruit and cream; puree residents were given yogurt. The DM did not have an explanation for not pureeing the fruit and cream. The DM stated they were supposed to have churros but he forgot to order them so that was why they were having fruit and cream. During an observation and interview on 02/14/2024 at 11:50 AM, the DM prepared the banana cake and did not follow the menu that stated it should have been iced banana cake. The puree meal was served with puree spaghetti and meatballs, puree vegetable mixture and a container of yogurt with fruit. The DM stated he did not have a reason for not icing the banana cake. The DM stated he did not puree a roll because the puree meal had noodles, and he forgot to puree the cake. The DM stated residents that received a puree diet should have received the same menu has regular diet. The DM did not give a reason as to why, except he forgot. The DM stated he did not think it would have affected the residents not receiving the same items or receiving the same dessert two days in a row. During an interview on 02/14/24 at 3:37 PM, the Dietician stated the residents that received puree diets should have received what the generated menu stated they should have received. The Dietician stated the DM should have followed the recipes when pureeing food. The DM stated if the recipe did not call for bread, he should not have added the bread. The Dietitian stated he should not have used water to thin the puree. The Dietitian stated that if the menu statedfrosted banana cake, then he should have iced the cake. The Dietitian stated her expectation was that the DM followed the menus and ordered what was on the menu. The Dietitian did not have an explanation for the DM not following the recipes or menu. The Dietician stated not icing the cake could have affected residents' satisfaction and the icing may have encouraged them to eat the cake. The Dietitian stated she did not think adding the bread would have affected the rice flavor and nutritional value minimally. The Dietitian stated staff should use Thickner(a white powder) to thicken puree items. During an interview on 2/15/2024 at 2:15 PM, the ADMN stated residents who received puree diets should have received the same meal as the residents on a regular diet. The ADMN stated the effect on residents could have been they received meals that might not be as flavorful, and they may not have received the appropriate nutritional value, especially if the menu or recipe was not followed. The ADMN stated what led to failure was the DM did what he wanted instead of following the menu and recipes. The ADMN stated the Dietitian and herself were responsible to monitor the DM. The ADMN stated she did not think they had a policy for puree diets. Record reveiew of facility recipe dated 02/23/2024 for Pur Spanish Rice revealed: Ingrediants: Puree [NAME] Instant; Base Chicken Paste, Tap Water, spice cumin ground, spice chili powder light, spice garlic powder, margarine vegetable solids, juice tomato. Instrucitons: Bring pepared chicken broth to boil. Whisk in pureed rice mix; contine whisking until lumps disapper. Whisk in tomatoe juice, all spices, and margarine until well blended. Reheat to an interal temerature of 165 held for 15 second, within 2 hours one time only. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 10 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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 0803 During exit conference on 02/15/2024 at 3:30 PM, the ADMN stated they did not have any relevant policies or recipes to provide. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 11 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure foods were labeled properly in refrigerators. The facility failed to ensure that food items were disposed of properly. The facility failed to ensure staff used proper hand hygiene. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 02/13/2024 between at 9:00 AM to 9:30 AM of the kitchen's refrigerator revealed: 1. One open container of tartar sauce with an open date of 12/10/2023 not labeled with a use by date. 2. One open container of coleslaw dressing with an open date of 1/12/2024 not labeled with a use by date. 3. One head of lettuce that was brown. During an observation and interview on 02/13/2024 between 11:00 AM to 12:30 PM of the kitchen revealed the hand washing sink was being used as a prep sink and a handwashing sink. The DM used the hand washing sink to fill a pitcher of water, he then poured some of the water into the pureed rice mixture. The DM laid the clean spatula and blade for the blender on counter next to the sink. The DM washed his hands in sink where he had placed the utensils needed for puree. While he washed his hands, soap and water was observed to drip on the clean utensils and splashed on the wall. The DM failed to wash hands after making a peanut butter and jelly sandwich and starting a new task. The DA lifted the trash can lid and then lifted the lid that was storing the residents' drinks without washing her hands. The DM failed to his wash hands after changing gloves on several occasions. The DM stated the sink next to the microwave was the handwashing sink and the sink on the other side of the kitchen was the prep sink. The DM stated he should not have used the handwashing sink as the prep sink. The DM stated items should be thrown out after a week. During an interview on 02/14/24 03:37 PM, the Dietician stated the coleslaw dressing and tartar sauce should have been discarded no more than a month after it had been opened. The Dietician stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 12 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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 the staff should have washed their hands each time they changed tasks and after changing gloves. The Dietitian stated the DM should not have used the handwashing sink as a prep sink. The Dietitian stated she had told the DM to make the sink next to the microwave his prep sink and the sink on the back wall of kitchen the hand washing sink. The Dietician stated the DM using the same sink for washing hands and to prep food could have caused cross contamination which could have led to residents getting sick. Residents Affected - Many During an interview on 2/15/2024 at 2:15 PM, the ADMN stated the Dietitian was responsible to monitor the DM. The ADMN stated food should have been thrown out after it had been open for more than a week. The ADMN stated vegetables that appeared to have spoiled should have been thrown out. The ADMN stated the DM and the DA should not have used the same sink to wash hands that he was prepping food. The ADMN stated this could have led to cross contamination. The ADMN stated what led to failure was the DM doing what he wanted instead of following the polices. The ADMN stated all residents ate out of the kitchen. Record review of facility's policy titled, Food Storage dated 2018 revealed: To ensure that all food served by the facility is a good quality and safer consumption of the store according to the state, federal and US food codes in HACCP guidelines . all containers must be labeled and dated . Date, label and tightly seal, all refrigerated food using clean, non-[NAME] cover containers that are approved for food storage During exit conference on 02/15/2024 at 3:30 PM the ADMN stated they did not have any other policies to provide. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 02/15/2024 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 13 of 14 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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 nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. Level of Harm - Minimal harm or potential for actual harm (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Residents Affected - Many Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. Review of the FDA (Food and Drug Administration) Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 02/15/24), FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; . (D) . after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; . (E) After handling soiled EQUIPMENT or UTENSILS; . (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 14 of 14