Health inspection·July 28, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/27/22 at 11:00 AM, Resident #35 said she could not get some staff to empty her colostomy bag, some aides would refuse and said it made her feel bad and she would have to wait to be changed, sometimes it pops and makes a mess. The resident stated it would be easier to empty the bag than clean diarrhea. During an interview on 07/28/2022 at 11:15 AM, LVN A said the aides generally did not empty the colostomy bag the CNAs went to her. LVN A said the aides might be trained but was not sure. LVN A stated the aides should not tell the resident it was not their job. She said depending on how busy she was it could take some time to get to empty the collection bag. During an interview on 07/28/22 at 11:30 AM, the DON said she did not have regular staff and didn't want to train agency staff and her goal was to train regular staff on how to empty colostomy bags. They should never say it was not their job or make the resident feel uncomfortable. The DON stated she planned to educate the CNAs as part of their responsibilities. The DON said most CNAs know how to empty the colostomy collection bag but there is really no formal training at this time. She said she is getting more staff hired to train them. She said some of the agency staff will empty the collection bags. During an interview on 07/28/2022 at 11:45 AM, the Administrator said she hoped it (staff telling Resident #35 emptying her collection bag was not their job ) was not a dignity issue. She said Resident #35 regularly visited her in her wheelchair and never mentioned any problems. The Administrator stated she was surprised she had not mentioned anything to her. The facility worked hard to get agency staff to do certain things and sometimes they did not like emptying colostomy bags. When the facility got staff, they would train them on changing or emptying bags. No one should say anything to make a resident feel bad. During an interview on 07/28/2022 at 12:10 PM with Administrator, she said she reviewed a conversation with Resident #35 and wrote down the following information (provided to surveyor): Received report that CNA (s) told Resident #35 they were not going to burp (deflate collection bag) or change her colostomy bag and refused to do it-which in turn could make Resident #35 feel bad. I spoke to Resident #35 and was able to identify two agency aides in question CNA F and CNA G. She said she explained to Resident #35 that this would not be tolerated and would be handled . Validated with Resident #35 that this was indeed the staff members who did not want to perform care. (CNA G and CNA F) Attempted interview on 07/28/2022 at 3:30 PM with agency CNA F and CNA G was unsuccessful due to unanswered telephone calls. During an interview on 07/28/22 at 2:22 PM, the ADON said Resident #35 face timed her sometime ago (not sure day or time) about the aides not wanting to empty her bag and she told the resident to tell the nurse. She said she was not aware it was an ongoing problem. She said knew the person in questions was an agency staff member and Resident could not identify them because she did not ask them their names or tell the staff nurse on the floor. Record review of the facility's policy and procedure titled Guidelines for Colostomy Care for Certified Nursing Aides dated 10/2022 revealed the following: How to care for patient or residents with an ostomy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 2 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 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 0550 Level of Harm - Minimal harm or potential for actual harm The CNA/Nurse aide should always check the skin around where the bag is attached and report anything unusual to the nurse. It is the facility's policy to allow the CNA/Nurse Aide to provide colostomy care of emptying the resident's colostomy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 3 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure assessments accurately reflected the resident's status for 9 of 9 residents (Resident #'s 18, 50,20, 17, 5, 28 35, 41, 47 ) reviewed for PASSR Evaluation. Residents Affected - Some 1. Resident #18's Significant Change MDS dated [DATE] section A1500 indicated no, resident has not had a PE (PASSR Evaluation Assessment) and determined to have a serious illness. However, her PE (PASSR Evaluation Assessment by the Local Mental Health Authority or Local Intellectual Disability Authority) was documented as confirmed 12/11/18. 2. Resident #20's Annual MDS dated [DATE] section A1500 indicated: no, resident has not been evaluated by Level 2 PASRR and determined to have a serious illness. However, his PE (PASSR Evaluation) was documented as confirmed 02/20/2020. 3.Resident #50's Significant Change in Status MDS dated [DATE], indicated in section A1500 indicated: no, resident has not been evaluated by Level 2 PASRR and determined to have a serious illness. However, his PE (PASSR Evaluation) was documented as confirmed 02/26/2022. 4. Resident #17's Quarterly MDS dated [DATE], indicated in Section P0100 C. Limb Restraint, indicated used less than daily. 5. Resident #5's admission MDS dated [DATE], Sections A1500 and A1510 revealed the following: A1500 Preadmission Screening and Resident Review was marked No and Section A1510 had none of the three boxes checked indicating Resident 5 had a serious mental illness 6. Resident #28's admission MDS dated [DATE] Sections A1500 and A1510 revealed the following: A1500 Preadmission Screening and Resident Review was marked No and Section A1510 had none of the three boxes checked indicating Resident 28 had a serious mental illness. 7. Resident #35's MDS (minimal data set), dated 05/27/22, Section A 1500 indicated Resident #35 did not have a mental illness and did not progress to Section A 1550 which she had a mental illness 8. Resident #41 admission MDS dated 2/12/ 22 section A1500 indicated: no, resident has not been evaluated by Level 2 PASRR and determined to have a serious illness. However, his PE (PASSR Evaluation) was documented as confirmed in the long-term care portal. 9. Resident #47 -. Resident #41 Annual MDS dated [DATE] section A1500 indicated: no, resident has not been evaluated by Level 2 PASRR and determined to have. However, her PE (PASSR Evaluation) was documented as confirmed in the long-term care portal. These deficient practices could place residents at risk of inadequate care and services based on inaccurate assessment and place residents at risk of inaccurate information being transmitted to CMS which uses the data to shape future regulations and improve the quality of life and care for residents who live in nursing facilities. The findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 4 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 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 0641 Resident #18 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #18's face sheet, dated 07/28/2022, revealed a [AGE] year-old female with an initial admission date of 04/24/2017 and the latest return date of 04/27/2022. The resident had diagnoses which included: Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, and unspecified Dementia without behavior disturbance. Residents Affected - Some Record Review of Resident #18's Significant Change in Status MDS dated [DATE] section A1500 indicated: No the resident had not been evaluated by PASSR and determined to have a serious mental illness and/or mental retardation or a related condition Record review of Resident #18's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), dated 12/11/2018, indicated Yes for Mental Illness. His PE was documented as confirmed 12/11/2018 Observation and interview of Resident #18 on 07/26/2022 revealed the resident was alert and oriented but. She was lying in her bed watching TV. She said she had not received any additional counselling services or PASARR services. Resident # 20 Record review of Resident #20's face sheet, dated 07/28/2022, revealed a [AGE] year-old male with an initial admission date of 03/24/2017 and the latest return date of 05/18/2018. The resident had diagnoses which included: Bipolar II Disorder. Record Review of Resident #20's Annual MDS dated [DATE], Section A1500 indicated No, the resident had not been evaluated by PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. Record review of Resident #20's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), dated 02/20/2020, indicated Yes for Mental Illness. His PE was documented as confirmed 02/20/2020. Resident #50 Record review of Resident #50's face sheet, dated 07/28/2022, revealed a [AGE] year-old male with an initial admission date of 08/18/2019 and the latest return date of 05/10/2022. The resident had diagnoses which included: Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. Record Review of Resident #50's Significate Change in Status MDS, dated [DATE], Section A1500 indicated: No, the resident had not been evaluated by PAS and determined to have a serious mental illness and/or mental retardation or a related condition. Record review of Resident #50's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), dated 2/21/2020, indicated Yes for Mental Illness. His PE was documented as confirmed 02/26/2020. Resident #17 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 5 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #17's face sheet, dated 07/28/2022, revealed an [AGE] year-old female with an initial admission date of 03/14/2020 and the latest return date of 04/16/2022. The resident had diagnoses which included: Unspecified dislocation of left hip, encounter for prophylactic measures, and unspecified dementia without behavioral disturbance. Resident #17's Quarterly Review MDS, dated [DATE], Section P0100 C. Limb Restraint, indicated used less than daily, the resident was being restrained. In an observation on 07/26/22 at 10:40 AM, Resident #17 refused to be interviewed but was observed lying in bed. The resident was not restrained nor was there any indications or devices that would be used to restrain the resident. In an interview with the ADON on 07/27/22 at 2:35 PM, she said the facility is a non-restraint facility. She said the Resident #17 has never been restrained. Resident #17 did have an order for an abductor pillow that was used between her legs when her hip was fractured, and it must have been miscoded in the MDS as a restraint instead of an assistive device. In an interview with the DON on 07/28/22 at 2:22 PM, she said the facility is a non-restraint facility and Resident #17 had never been restrained. The MDS Coordinator no longer works at this facility who would have entered in that information. Resident #5 07/27/2022 Record review of Resident #5's electronic medical record revealed the following; Resident# 5 is a [AGE] year old female admitted on [DATE] with the following diagnoses; Unspecified dementia without behavioral disturbance (Primary, Admission), Schizophrenia, unspecified, Unspecified mood [affective] disorder, 07/27/2022 Record review of Resident #5's admission MDS dated [DATE], Sections A1500 and A1510 revealed the following: A1500 Preadmission Screening and Resident Review was marked No and Section A1510 had none of the three boxes checked indicating Resident 5 had a serious mental illness. Resident #28 07/27/2022 Record review of Resident #28's electronic medical record revealed the following; Urinary tract infection, site not specified (Primary), Unspecified dementia without behavioral disturbance (admission Anxiety disorder, Major depressive disorder, 07/27/2022 Record review of Resident #28's admission MDS dated [DATE] Sections A1500 and A1510 revealed the following: A1500 Preadmission Screening and Resident Review was marked No and Section A1510 had none of the three boxes checked indicating Resident 28 had a serious mental illness. 07/27/2022 Record review of Resident #28's Annual MDS dated [DATE] revealed the following: A1500 Preadmission Screening and Resident Review was marked No and Section A1510 had none of the three boxes checked indicating Resident 28 had a serious mental illness. Resident #35 Record review of Resident #35's updated Face sheet revealed she was a [AGE] year-old-female (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 6 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 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 0641 Level of Harm - Minimal harm or potential for actual harm admitted on [DATE] with the diagnosis of urinary tract infection, metabolic encephalopathy (Metabolic encephalopathy-a problem in the brain caused by a chemical imbalance in the blood) dysarthria-anarthria ( Dysarthria a motor speech disorder that occurs when someone can't coordinate or control the muscles used for speaking- anarthria a severe form of dysarthria) type II diabetes(disease that occurs when blood glucose, also called blood sugar, is too high) and unspecific psychosis. Residents Affected - Some Review of Resident #35's initial PASRR (Pre-admission Screening and Resident Review) Dated 05/22/18 revealed Resident had a mental illness. Record review of Resident #35's MDS (minimal data set), dated 05/27/22, revealed a Brief Interview of Mental Status score of 13 (A score of 13 to 15 suggests the patient is cognitively intact), Section A 1500 indicated Resident #35 did not have a mental illness and did not progress to Section A 1550 which she had a mental illness Resident # 47 Record review of Resident #47's face sheet in the EMR, revealed a [AGE] year-old female with an initial admission date of 12/01/2018 and a readmission date of 06/24/20 with the following diagnoses: post-traumatic stress disorder, Anxiety disorder, psychosis, major depressive disorder, and Schizoaffective disorder Record Review of Resident #47's Annual MDS dated [DATE], Section A1500 indicated No, the resident had not been evaluated by PASRR and determined to have a serious mental illness and/or mental retardation or a related condition Record reviews of Resident #47 's EMR and the long-term care portal documentation on 07/28/2022, revealed the resident's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), dated 12/07/2018, indicated yes for mental illness. Her PE section for mental Illness was documented as completed on 12/10/18. Section C documented the resident had the following Mental Illness Diagnoses: mood Disorder bipolar, major depression or other mood disorder, psychotic disorder, and schizoaffective disorder (all are classified as mental illness diagnoses by the Diagnostical and Statistical Manual of Mental Disorders 5th Edition - DSM-5). Observation and interview of Resident #47 on 07/27/2022 revealed the resident was alert and oriented. She stated did not remember how long she had been at the facility. Resident #41 Record review of Resident #41's face sheet in the EMR, revealed an [AGE] year-old female with an initial admission date of 10/27/2021 with the following diagnoses: schizophrenia, unspecified, delusional disorders, bipolar disorder, current episode mixed unspecified, severe without psychotic features, anxiety disorder and unspecified dementia with behavioral disturbances. Record reviews of Resident #41 's EMR and the long-term care portal documentation on 07/28/2022, revealed the resident's PL 1 (initial screening to identify an individual as having a mental illness or intellectual disability), dated 10/26/2021, indicated yes for mental illness. Her PE section C for mental Illness was documented as completed on 10/30/2021. Section C documented the resident had the following mental illness diagnoses: schizophrenia and mood disorder. (all are classified as mental illness diagnoses by the Diagnostical and Statistical Manual of Mental Disorders 5th Edition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 7 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 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 0641 DSM-5). Level of Harm - Minimal harm or potential for actual harm Resident #41 admission MDS dated 2/12/ 22 section A1500 indicated: no, resident has not been evaluated by Level 2 PASRR and determined to have a serious illness. However, his PE (PASSR Evaluation) was documented as confirmed in the long-term care porta Residents Affected - Some During an interview with MDS Regional Consultant on 07/28/22 at 11:07 AM she stated she had been covering the MDS position for approximately two weeks. She stated the previous MDS nurse had resigned. Resident 41's admission MDS dated 2//12/22, section A1500 and A1510 were marked no for Mental illness and this would be an inaccuracy. MDS nurse agreed that this was an MDS inaccuracy the resident did have diagnoses of Schizophrenia, Mood disorder. In an interview on 03/24/2022 at 10:30 AM, the Administrator stated she was not aware there was a problem with the accuracy of the MDS's. She stated the MDS nurse was responsible for the accuracy of those documents and she should have filled them out correctly. She did not state how the residents could be affected by these inaccuracies. The MDS Regional Consultant and the Administrator were asked for a Policy on Resident Assessment. They provided a policy titled Care Plan-Resident. A policy on MDS assessments was not provided. During an interview with the Regional MDS Consultant on 7/28/2, She stated she followed the RAI (Resident Assessment Instrument Manual Manual) for information on completion of the MDS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 8 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 9 residents (Resident #57) reviewed for PASRR assessments. 1. The facility failed submit a complete and accurate request for NFSS for Speech Therapy, Physical Therapy, Occupational Therapy, LTC Online Portal within 20 business days after the date of Resident #57's IDT meeting. 2. The facility failed to submit a NFSS form or request a Service Planning Team meeting with the resident's LIDDA by the noted due date to document changes or remove or update the services in the portal on the patient Care service plan form. These failures could place residents at risk of not receiving specialized services that would enhance the highest level of functioning. Findings included: Record review of Resident #57's face sheet (not dated) revealed she was a 51 -year-old female admitted to the facility on [DATE] with the following diagnoses: severe intellectual disability, lack of coordination, muscle wasting and atrophy, muscle weakness and anxiety disorder. Record review of Resident 57's PASRR Level 1 screening dated 02/10/2 section C, revealed Resident #57 did not have a mental illness, or a developmental disability but did have an intellectual disability Record review of Resident 57's PASRR Evaluation dated 02/17/2022, revealed she had the following diagnoses: Severe intellectual disabilities, unspecified convulsions, polyneuropathy, morbid obesity Record Review of the care conference Reports dated 02/21/2022 revealed the following: admission PASRR and care plan meeting. Resident has no skin DOR (director of rehab services) will be doing evaluations on resident to decide if resident is able to participate in PT and OT services. Resident was asked if she would like someone to come visit with her once a month to do crafts and reading. Resident stated no. The resident, her brother, local intellectual disability authority and nursing staff were present. Record review of Resident #57's Care Conference dated 3/30/2022 documented the following: CALL TO POA FROM MULTIPLE NUMBERS, NO ANSWER. MEETING AND AGREEING TO REMOVE PT/OT ASSESSMENTS AND SERVICES FROM PCSP. RESIDENT admitted FROM DIFFERENT COUNTY. MCO IS NEEDING TO BE CHANGED TO AMERIGROUP OR [NAME] FROM SUPERIOR. ADMISSIONS HAS SPOKE WITH POA ABOUT WEEK AND HALF AGO. WAS INFORMED MCD NEEDING CHANGED OVER. MEDICAID STILL SHOWS TO BE SUPERIOR AND CANNOT MOVE FORWARD WITH SUBMITTING NFSS FORMS. ADMISSIONS TO SPEAK WITH BOM AND WILL AWAIT NEXT STEPS. Review of the printout of the LTC portal provided by the MDS Nurse revealed Resident #57's initial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 9 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few IDT Meeting was held on 02/21/2022. The resident, local authority from a local agency, MDS nurse, RN, Therapy, POA, social worker, were present. Goals of specialized PT, OT were discussed to be provided. Observations of Resident #57 on 07/28/2022 at 10;00 PM revealed that she was alert and cheerful. She was neat and well groomed. She resided in the locked memory care unit. Her speech was not clear, and she required extra time for communication but was able to make herself understood. She greeted the surveyor in an engaging, cheerful manner. Interview and Record Review with the Regional MDS Nurse on 7/28/2022 at 8:30 AM of the Long-Term Care Portal and a printout of the NFSS Activity form (not dated) for Resident #57 provided by the MDS nurse revealed the following information: There were NFSS requests completed for OT and PT that were over 29 days old and would not be accepted. They stated the PT and OT requests could not be processed because the person does not have ae a Medicaid care service authorization for the submitted provider date. It stated the OT and PT assessment dates should be corrected or the necessary paperwork should be submitted to establish the appropriate service authorization before the form is resubmitted. A notice in the portal indicated an NFSS form was not accurately completed within 30 calendar days of the IDT meeting. She stated There was no documentation of an IDT meeting held to remove services from Resident #57's comprehensive care plan documented in the portal. She stated the IDT meeting would need to be completed and entered in the long-term care portal if the Individuals Medicaid is not active or if the PASRR specialized services are no longer needed. In an interview on 7/28/2022 at 12:14 PM, the Regional MDS Nurse stated she had not checked the LTC Portal daily. She said that she was not aware the facility had received a notice regarding resident #57's PASRR services. Attempted to interview the PASRR Unit Program Specialist in [NAME], but she was unavailable, a message was left on her answering machine and she did not return a call to the number provided by the surveyor. Record review of a letters from the PASSR unit in [NAME] revealed the facility was contacted in an email 06/21/2022 by the PASRR unit Program Specialist containing the following verbiage: Sent: Tuesday, June 21, 2022 4:21 PM . This email is to summarize our phone conversation regarding your facility's Follow up to compliance phone call- PASRR information VENDOR ID non-compliance with the requirements outlined in the Texas Administrative Code, Chapter 19, Subchapter BB, section §19.2704(I)(7)(A), which states your facility must initiate nursing facility specialized services within 20 business days after the date that the services are agreed to in the IDT meeting for the resident we spoke about. As discussed on the phone, you will need to submit a NFSS request form for PASRR Specialized Services (Therapies and Assessments OT and PT) by 6/24/22 through the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Portal found at: [email address] **If your facility uses a third-party vendor, you will need to contact the vendor for assistance** Providers must complete a Nursing Facility Specialized Services (NFSS) form to request PASRR nursing facility specialized services . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 10 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a spreadsheet provided by The PASSR Unit titled Out of Compliance revealed the following information in part for the facility and Resident ID #57: PCSP (PASRR Comprehensive Service Plan) created date 02/21/22 IDT meeting held 02/21/2022, IDT date plus 30 days is 03/23/2022. Specialized Assessment Occupational Therapy (OT) - Needs service, Specialized Assessment Physical Therapy (PT) Needs service, Specialized Occupational Therapy - needs service, and Specialized Physical Therapy needs service. In an interview on 7/28/2022 at 2:15 PM the Administrator stated that her expectation was for the facility to follow state and federal guidelines regarding the PASRR process. She stated that she had not read the email of notification by the PASSR Unit of any late submissions or pending denials of PASSR services. She stated she had passed any communication to the prior MDS Nurse and expected her to take care of the problem. She stated she assumed that the fact that the services were not covered by Medicaid and the facility was actively trying to assist with getting the Resident's Medicaid approved so that she was able to receive PASRR services was sufficient. She stated she understood now the facility should have documented the information that they were unable to provide the services until the Resident's Medicaid was approved. She stated she was not aware that the services needed to be initiated within 20 days. The administrator stated the facility did not have a policy on PASRR other than following the federal and state guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 11 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that it is not possible or resident preferences indicated otherwise for 1 of 13 Residents (Resident #46) reviewed for weight loss. Residents Affected - Some The facility failed to ensure Resident #46 did not have unplanned weight loss of -13.9% in six months. This failure could place residents at risk of not maintaining their nutritional needs. The findings include: Record review of Resident #46's electronic face sheet revealed a 47 -year-old female with an original admission date of 04/27/2016 and the latest return date of 02/03/2022. She had diagnoses which included: multiple sclerosis, muscle wasting and atrophy, multiple sites, chronic obstructive pulmonary disease ( a chronic lung condition), lack of coordination, difficulty walking and dysrhythmic disorder ( an irregular rhythm of the heart) Record review of Resident # 46's Quarterly Minimum Data Set (MDS), section C, dated 05/20/2022, revealed a BIMS (Brief Interview for Mental Status) score of 11, which indicated moderate cognitive impairment. Review of section G revealed the resident required extensive assistance with dressing, and personal hygiene, total dependence of 2 with toileting, and supervision, oversight or cueing with eating. Section K indicated the resident had a 5% wt. loss in one month. or 10% or more in 6 months and was not on a prescribed weight loss program. Record review of Resident 46's electronic medical record revealed on 01/24/2022, Resident #46 weighed 213.3 pounds and on 07/19/ 22 the resident weighed 183.3 pounds which was a -13.9% Loss. The electronic record also revealed the following: 07/19/2022 15:39 Weight: 183.3 lbs. / Routine BMI: 30.5 06/05/2022 16:29 On 12/01/2021, the resident weighed 206 pounds. On 07/28/2022, the resident weighed 180 pounds which is a -12.62 % Loss. Weight: 188.8 lbs. / Routine BMI: 31.41 05/19/2022 13:46 Weight: 185.1 pounds. / Routine BMI: 30.8 05/05/2022 10:06 Weight: 186 pounds. / Routine BMI: 30.95 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 12 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 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 0692 04/05/2022 10:03 Level of Harm - Minimal harm or potential for actual harm Weight: 190 pounds / Routine BMI: 31.61 03/17/2022 08:21 Residents Affected - Some Weight: 186.5 pounds / Routine BMI: 31.03 03/05/2022 13:26 Weight: 186.6 pounds / Routine BMI: 31.0 02/05/2022 17:22 Weight: 213 pounds. / Routine BMI: 35. 01/24/2022 12:182 13.3 pounds BMI:35.49 Record review of Resident #46's orders, dated 07/28/2022, revealed the resident was on Lasix 20 mg daily (a diuretic) Record review of the EMR for Resident # 46 revealed the following nursing progress note documentation: 07/26/2022 1:24 PM During lunch today resident requested that the call light be attached to her side rail. Upon entering the room resident had food from on her person and tray table, tray replaced and assisted with set up. Record review of the dietary progress notes revealed the following: 07/22/2022 11:13 AM RD f/u note: Current weight 183.3 pounds, indicating weight loss -2.9%x 30 days , -3.5%x90d, and -14%x180 days ( Receiving Lasix - fluid shifts may affect weight trend. Other ax includes: miralax, KCl (potassium chloride) , senna, synthroid, Vitamin D, Zofran. No new labs available. Receiving Regular/Thin liquids diet with high calorie snack BID. Intake noted 50-100%. RN reports resident has good appetite, and requires limited assist at meals, but mostly feeds self. Overall intake likely adequate to meet nutrition needs. Continue with current diet order, honor food preferences as able, and offer snacks between meals. Goal to maintain weight +/-5%. RD to monitor and f/u prn. 06/03/2022 3:31 PM RD note: Resident re-weight follow-up. Current weight 185 pounds indicating stable weight x90days. Current intake adequately meeting nutrition needs. RD to continue to monitor and f/u prn. 05/19/2022 2:59 PM RD follow up note: Current weight 112 [sic] pounds indicating weight loss -2% x 30d, -12.7% x 90d (sig), and -12%180d (sig). Receiving lasix -fluid shifts may affect weight trend. Other medications includes: KCl (Potassium chloride), miralax, senna, synthroid, Vitamin D, zofran. ADON has requested a re-weigh, and resident on weekly weights to monitor. Report's resident has good appetite/intake and eats snacks between meals. Receiving Reg/Reg/Thin diet with high calorie snacks BID. No new labs available. Intake likely meeting nutrition needs adequately. Will monitor weekly weight trend. Continue w/ current diet order, honor food preferences as able, and send snacks BID between meals. Goal to maintain weight +/-5%. RD to monitor and follow up as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 13 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident's care plan, revised on 07/27/2022, revealed the following problems and interventions. Problem: Resident is at nutritional risk of weight loss. Interventions included: Dietician referral as needed, monitor and report to physician significant weight loss, offer substitute if less than 50 % of diet is consumed, offer tray set up, assist with verbal cueing/feeding as needed. Resident prefers to eat independently, Approach Start Date: 02/07/2020 Encourage fluid intake, offer fluids the resident likes as much as possible, Monitor weight monthly and prn - report greater than 5% loss to MD and responsible party. Problem Falls: Intervention keep call light in reach. Problem Start Date: revised 07/27/2022 Category: Nutritional Status resident has a significant unplanned/unexpected weight loss r/t Acute illness, diuretic use, and decline in intake Edited: 07/27/2022 Goal Target Date: 10/26/2022 Resident will consume 75-100% two of three meals/day through the review date. Resident will experience no further weight loss this review period. Created: 07/27/2022 Approach Start Date: 07/27/2022 Dental Consult as needed Created: 07/27/2022 Nursing, Social Services Approach Start Date: 07/27/2022 Encourage food related activities Created: 07/27/2022 Activities, Nursing Approach Start Date: 07/27/2022 Give the resident supplements as ordered. Alert nurse if not consuming on a routine basis Created: 07/27/2022 Dietary, Nursing Approach Start Date: 07/27/2022 Labs as ordered. Report results to physician Created: 07/27/2022 Nursing Approach Start Date: 07/27/2022 Monitor and record food intake at each meal Created: 07/27/2022 Nursing Approach Start Date: 07/27/2022 Notify the dietician of the weight loss upon their next visit Created: 07/27/2022 Observation on 07/26/2021 at 12:23 PM revealed Resident #46 alone in her room, sitting up in bed at a 90-degree angle with her bedside table in the high position and her food out of her reach. She leaned with her right upper body against her right ¼ side rail. Her call light was attached to her left ¼ bed rail and tied to the rail in a knot and hung over the outer side of the rail. The resident was unable to reach the call light or pull it by the cord to call for assistance. She said she would like some help to be able to reach her food. The state surveyor rang the call bell to get her assistance. In an interview and observation on 7/26/2022 at 12:23 PM Resident #46 stated she had a pillow somewhere to help support her so she would not lean. She stated she did not know why they didn't use it. In an observation and interview with CNA C at 12:30 PM, CNA C stated she served Resident #46 her meal tray. She stated she was in a hurry and did not notice the tray was raised too high for the resident to easily reach her food. She stated the resident was in an upright position when she left the room and told her she did not want her wedge pillow. CNA C with the assistance of Agency CNA D retrieved a wedge pillow laying on Resident #46's bed side table and positioned her in an upright position. The resident had eaten only approximately 25 % of her meal at this time. CNA D stated she would know to use a positioning device on a resident by just looking at them. CNA C stated she would know by looking in the resident's EMR (electronic medical record). During interview on 07/26/22 at 1:30 PM with LVN E, she stated residents who were served their meals in their rooms should be assisted to reach their food. She stated the CNA's monitored the meal intake for the residents and recorded the amount eaten in the electronic medical record. She stated call lights should be in reach of residents. She stated Resident #46 did lean to the side at times and her wedge should be used to help keep her up right. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 14 of 15 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 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 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 0692 Level of Harm - Minimal harm or potential for actual harm Record review of the policy intitled Meal Service - Nursing responsibilities, with an effective date of October 2020, revealed: It is the policy of this home that Nursing Services will work with the Dietary Services Department to ensure that each resident is served per regulations. Residents Affected - Some Assist in preparing food after the meal has been delivered to the resident. Open all condiment packages and uncover all wrapped/covered items. Offer to cut up the meat, put butter on the bread, and season food when desired by resident. Explain location of food items on the plate if resident is sight impaired. Offer meal alternates of equal nutritive value to a resident if the resident refuses a menu item, eats less than 50% of meal or if the resident requests it and is allowed by diet order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 15 of 15