Health inspection·November 14, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few consent was not in the facility. She stated the SW was responsible for following up with consents, uploading them into the medical records, as well as placing the DNR status on the hard copy chart. The DON stated the negative affect on the resident was, if the resident was not truly a DNR they could expire with CPR not being performed and ultimately passing away. She stated the failure occurred with the family having not returned the consent form in a timely manner. She stated the consent form should have been back in the facility before the two weeks if it was truly what they had wanted. The DON stated her expectations was the DNR consent form should have been signed in a timely manner if those were their wishes. She stated it was not okay to have a verbal of family wishes without the consent. The DON stated she and her nursing staff would have gone first by the Face sheet and second look at the red DNR sign on the hard copy for guidance on what to do if a resident was to code. During an interview on [DATE] at 4:51 PM the ADMN stated the nursing staff can follow the physician order if there were a code while awaiting the DNR consent or if in transit. She stated the consent was really for EMT's. During an interview on [DATE] at 5:16 PM with, LVN-B stated if there happened to be a code on a resident, she would first look at the resident Face sheet under their picture as that would have been the quickest way to locate resident DNR status. She stated residents' charts (hard copies) also have the red DNR page as soon as you open their charts. During an interview on [DATE] at 5:21 PM, LVN C stated she would have looked first for residents DNR in their chart or the computer, but the most reliable would be their hard copy chart. LVN-C stated she staff should have looked in the front to see the red paper with red DNR signage, then she would have flipped it over to see there if there was a signed DNR. She stated the resident would not be considered a DNR status until the consent was in your hand. During an interview on [DATE] at 5:20 PM, RN-D stated when a patient was found unresponsive, she would have first checked resident electronic chart or the resident hard copy chart for resident's code status. She demonstrated that this information could be found in the resident's chart by pointing to the first red colored page in the chart that revealed Do Not Resuscitate (DNR). RN-D then flipped the colored folder over to display a signed DNR order and stated the DNR order would have directed her as to whether to perform resuscitation on the resident or not. She stated if there were no signed DNR present, she stated she would have Immediately started CPR. During an interview on [DATE] at 5:25 PM, RN-E stated when a resident was found unresponsive, she first thing she would have done would grab the crash cart and call for assistance. When asked how she would know if resident was to have been resuscitated, she states, I know my hospice patients. When asked for more information regarding how it was determined if other residents were to be resuscitated, she stated she would have checked their chart and if DNR, the first page would have displayed a red sign that revealed Do Not Resuscitate. RN-E identified where the DNR was at in the chart. When asked how she would have responded if a DNR was not present, she stated she would have checked the resident's chart for the small red icon DNR under the resident's picture in their electronic chart. She stated if she observed the printed red page Do Not Resuscitate and the small red icon in the resident electronic chart, it would have indicated in two areas that resident was a DNR status and would have been then she would have known not to provide CPR. Record Review on [DATE] of a blank Out of Hospital Do Not Resuscitate (OOH-DNR) Order Tx Dept. of State Health Services consent form, page 1, reads in part: This document becomes effective immediately on the date of execution for health care professionals acting in out of hospital settings. It (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 2 of 24 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 11/14/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few remains in effect until the person is pronounced dead by an authorized medical or legal authority or the document is revoked. Resuscitation measures include cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, Defibrillation, advanced airway management, artificial ventilation. Comfort care will be given with a Representative and physician signature and License # in the electronic charting or admission paperwork. The Physician Statement section and the final section instructs and reads in part, All persons who have signed above must sign, acknowledging the document has been properly completed. Record Review of page 2 of the Texas Out of Hospital Do Not Resuscitate form, Publication No EF01-11421 revised [DATE], by the Texas Department of State Health Services titled Instructions for Issuing an OOH-DNR Order reads in part: IMPLEMENTATION: A competent adult person .or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section A-If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. Section B-If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, a guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating in section B. Section D if the person is incompetent and his/her attending physician has seen evidence of the person previously issued proper directive to physicians or observe the person competently issue and OH DNR order or a nonwritten manner, the physician may execute the order on behalf of the person signing and dating it in section D. In addition, the OOH-DNR order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either section B, C, or E, and if applicable have witnessed a competent adult person making an OOH-DNR order by nonwritten communication to the attending physician, who must sign in section D and also the physicians statement section. Record Review of the facility policy Advanced Directives Policy and Records, revised [DATE] revealed: Policy: It is the facility's policy to recognize and implement the resident's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives. Decisions Concerning Medical care and Valid Advance Directives: Facility agrees to honor: a. Decisions concerning medical care, including the right to accept and refuse treatment, when made in accordance with state law. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 3 of 24 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 11/14/2024 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 0578 b. Level of Harm - Minimal harm or potential for actual harm Valid Advance Directives made in accordance with state law. Residents Affected - Few The making of Advance Directives by the resident is not a precondition to admission; nor does the facility otherwise discriminate against a resident based on whether or not Advance Directives have been made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 4 of 24 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 11/14/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs for 2 of 5 residents (Resident #'s 61 and 76) whose records were reviewed for psychotropic drugs, in that: 1. Resident #61 received an order for the antianxiety medication Valium PRN (as needed), and the order did not include an end date after 14 days. Valium was administered on 11/1/24, 11/2/24, 11/3/24, 11/4/24, 11/6/24, 11/8/24, 11/11/24, 11/12/24, 11/13/24, and 11/14/24 PRN. 2. Resident #76 had an order for the antipsychotic medication Seroquel was administered at bedtime11/1/24 thru 11/13/24 for a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety which was not an appropriate indication for use. This failure placed residents at risk for being over medicated or experiencing undesirable side effects and could cause a physical or psychosocial decline in health status. The findings included: Review of Resident # 61's Face Sheet (not dated) revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: - amyotrophic lateral sclerosis ( - dysphagia (difficulty swallowing) - major depressive disorder, recurrent - anxiety disorder. Review of Resident # 61's current physician orders, dated 11/14/24, revealed the following: -Diazepam gel 10 mg/ml Apply 1 ml topically to inner wrist and rub in well for anxiety Every 4 Hours - PRN (start date 5/9/24, order was last renewed on 10/28/24) there was not an end date. Review of Resident # 61's Medication Administration Records, dated 11/1/24 through 11/30/24, revealed Valium 10 mg topically every 4 hours prn was administered on 11/1/24, 11/2/24, 11/3/24, 11/4/24, 11/6/24, 11/8/24, 11/11/24, 11/12/24, 11/13/24, and 11/14/24 PRN. Review of Resident #61's Quarterly MDS Assessment, dated 8/21/24 revealed the resident had anxiety disorder, major depressive disorder, recurrent; and antianxiety medications were given during the 7-day review period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 5 of 24 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 11/14/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Review of Resident #61's comprehensive care plan, last revised on 8/19/24, revealed she was PASRR positive and was administered antianxiety and antidepressant medications. Review of the Pharmacy recommendations for the month of October of 2024 revealed the following recommendation to the physician by the pharmacy consultant: Residents Affected - Some PRN psychotropic medications require a 14 day stop date. At that time physician will need to re-evaluate the need for the following Valium prn, duration greater than 14 days will need a physician rationale. The physician had signed the recommendation on 10/28/24 and written 14 days with no rationale. In an interview on 11/14/24 at 1:00 PM the ADON stated a prn psychotropic medication should not be ordered longer than 14 days without a stop date, or a rationale why the medication should be continued beyond the 14 days. Review of Resident # 76's Face Sheet (not dated) revealed an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: - Unspecified dementia, with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. - chronic kidney disease - unspecified dementia with psychotic disturbance, -delirium Review of Resident # 76's current physician orders, dated 11/14/24, revealed the following: -Seroquel 200 mg po at hs for unspecified dementia, with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. Review of Resident # 76's Medication Administration Records, dated 11/1/24, thru 11/30/24 revealed Resident # 76 received Seroquel 200 mg at hs 11/1/24 thru /11/13/24. Review of Resident #76's admission MDS Assessment, dated 10/22/24 documented the resident did not meet the level 2 PASRR definition of mental illness, had no behavioral symptoms such as hallucinations or delusions or indicators of psychosis, she had no verbal or physical behavioral symptoms , had unspecified dementia without behavioral disturbances, and resident was currently taking an antipsychotic. Review of Resident # 76's comprehensive care plan, last revised in 10/20/24, revealed the following: - Problem: The resident requires psychotropic drugs for the treatment of depression, mood disorder, Behavior management. - Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 6 of 24 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 11/14/2024 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 0758 impairment through review date. The resident will reduce the use of psychoactive medication through the review date. Level of Harm - Minimal harm or potential for actual harm -Interventions: Residents Affected - Some Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Consultant pharmacist to review medication regime monthly. Discuss with MD, family re ongoing need for use of medication. Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms. In an interview with the ADON on 11/14/24 at 1:10 PM she stated that Seroquel 200 mg at hs ordered for resident #71 did not have a diagnosis which would indicate the appropriate use of an antipsychotic. She stated that the diagnoses of unspecified dementia, with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety was not an indication for the use of an Antipsychotic. She stated that she and the DON were responsible for monitoring to ensure that residents had an appropriate diagnosis for the psychotropic medications they were prescribed. She stated a negative outcome of the use of antipsychotics and psychotropic medications in the elderly resident could be increased falls, confusion, and adverse events. In an interview on 11/14/24 at 1:35 PM the DON stated Resident #71 was admitted to the facility from another nursing facility and was on the Seroquel when she was admitted and the diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety was not an appropriate indication for use. She stated that an appropriate diagnosis would be schizophrenia, Huntington, or Tourette. She stated the facility could not request a diagnosis change, unless they could find out what the resident's past mental health history was. She stated she and the ADON do monitor new admissions before they come into the facility for their diagnosis and medication history. Review of the facility's policy and procedure for Medication Monitoring and Medication Management, dated 2007, revealed the following [in part]: It is the policy of this home to use antipsychotic medications per CMS guidelines and to perform dose reductions and monitoring as required by regulation, to promote the highest level of resident care and safety. DEFINITIONS 1. A gradual dose reduction is a tapering of the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 7 of 24 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 11/14/2024 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 0758 2. Level of Harm - Minimal harm or potential for actual harm Behavioral interventions mean modification of the resident's behavior and/or the resident's environment, including staff approaches to care, to the largest degree possible to accommodate the resident's behavioral symptoms. Residents Affected - Some 3. Clinically contraindicated means that a resident with an appropriate diagnosis for use who has had a history of recurrence of psychotic symptoms, which have been stabilized, with a maintenance dose of an antipsychotic drug without incurring significant side effects should not receive gradual dose reductions. In residents with organic mental syndromes, it means that a gradual dose reduction has been attempted twice in one year and that attempt resulted in the return of symptoms for which the drug was prescribed to a degree that a cessation in the gradual dose reduction, or a return to previous dose levels was necessary. 4. Specific Conditions for which antipsychotic drugs may be used: o Schizophrenia o Schizo-affective disorder o Delusional Disorder o Psychotic mood disorders (including mania and depression with psychotic features) o Acute psychotic episodes o Brief reactive psychosis o Schizophreniform disorder o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 8 of 24 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 11/14/2024 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 0758 Atypical psychosis Level of Harm - Minimal harm or potential for actual harm o Tourette's disorder Residents Affected - Some o Huntington's disease o Organic mental syndromes (including dementia and delirium) with associated psychotic and/or agitated behaviors: which have been quantitatively (number of episodes) and objectively (biting, kicking, scratching) documented which are not caused by preventable reasons which are causing the resident to: 1) Present a danger to her/himself or to others 2) Continuously scream, yell, or pace if these specific behaviors cause an impairment in functional capacity. 3) Experience psychotic symptoms (hallucinations, paranoia, delusions) not exhibited as dangerous behaviors or as crying, screaming, yelling, or pacing but which cause the resident distress or impairment in functional capacity 5. Conditions for Which Antipsychotic Drugs Should NOT Be Used (as an only indication): o Wandering o Poor self-care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 9 of 24 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 11/14/2024 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 0758 o Level of Harm - Minimal harm or potential for actual harm Restlessness o Residents Affected - Some Impaired memory o Anxiety o Depression (without psychotic features) o Insomnia o Unsociability o Indifference to surroundings o Fidgeting o Nervousness o Uncooperativeness o Agitated behaviors which do not represent danger to the resident or others. 1. Documenting the appropriate specific conditions for antipsychotic medication use: a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 10 of 24 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 11/14/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm For resident's already receiving an antipsychotic medication that does not have an approved diagnosis listed in their medical record, the nursing staff and/or the consultant pharmacist will request a specific diagnosis for its use. b. Residents Affected - Some For resident's who receive a new order for an antipsychotic medication, the nurse will request a specific diagnosis at the time the medication is ordered. c. The specific behavior(s) exhibited by the resident will be documented on the appropriate Clinical Software Monitoring Flow Sheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 11 of 24 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 11/14/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 1 of 1 Treatment Cart observed for medication storage. The facility did not ensure the Treatment Cart was locked and secured on 11/13/24 on 300 hallway with resident present and no nurse present. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: Observation on 11/13/24 at 11:31 AM revealed the treatment cart was parked in the 300 hallway with a resident within 6 feet of the opened, unsecured cart. No nurse was in sight of the cart. Present in cart were medicated dressings, antiseptic ointment, triple antibiotic ointment, chlorhexidine gluconate solution antiseptic, Iodine swab sticks, adhesive remover, and wound cleanser. In an interview on 11/13/2024 at 11:37 AM the Treatment Nurse stated that she could not see treatment cart because she had walked 3 rooms down and into a resident room to speak with them. She stated that she normally locked her cart but failed to do so that time. She also stated that the expectation was to lock the cart and that she or any other nurse using the cart was responsible for locking it. She also stated that lack of locking cart would allow access for residents to get into the cart and gain access to the contents. She stated lots of things in this cart could harm the residents if ingested. There are creams, cleaners, and those orange sticks. There are also clippers and scissors that could hurt them. In an interview on 11/14/24 at 4:01 ADON stated that treatment cart should be locked when not in sight of nurse or in use. She also stated that anybody that had access with keys to the cart was responsible for ensuring that the cart was locked. She further stated that lack of locking the cart could result in A resident could get ahold of something that is not good for them. In an interview on 11/14/24 at 4:05 PM the DON stated that her expectation was for treatment cart to be locked when not in use or in sight by nurse responsible for cart. The DON stated that the nurse in charge of cart was responsible for locking cart. The DON stated that she and the ADON were ultimately responsible for monitoring cart security. She further stated that lack of locking treatment cart would allow resident access to cart contents and ability to ingest contents, put contents on skin, possibly be allergic to contents. Record review of policy Medication Storage- in the Home dated 12/2018 revealed the following [in-part]: POLICY: It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure, or misuse. PROCEDURE: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 12 of 24 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 11/14/2024 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 0761 2. Level of Harm - Minimal harm or potential for actual harm Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (i.e., medication aides, etc.) are allowed access to medications. Medication rooms, carts, and medications supplies are locked or attended by persons with authorized access. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 13 of 24 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 11/14/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 each resident received food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, and appearance: Residents Affected - Many The facility failed to provide palatable food served at an appetizing temperature as evidenced by a sample tray tested on [DATE]. This failure could affect the residents who ate food from the facility's kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served. The findings included: During an interview on 11/12/2024 at 10:16 AM, Resident #45 stated the food was not good and was cold. He stated the dietary offered a substitute, but it was not good. During an interview on 11/12/2024 at 10:49 AM, Resident #46 stated the facility had a new cook and nothing tasted good. He stated he was on a mechanical diet being ground up and nothing tasted right. During an observation on 11/12/2024 at 1:10 PM the test tray was on the hall cart, at 1:15 PM, the test tray was in the conference room with DM to temp and test for palatability. The temperatures of test tube revealed: 1. Chicken [NAME] 126 degrees 2. Green Beans 118 degrees 3. Hot Apple dessert 82.9 During an interview on 11/12/2024 at 1:20 PM, the DM stated the temperatures were not warm enough to sustain the palatability. She stated the dining room trays were most likely cold as well since they were served last. She stated the failure could have been due to the [NAME] not stirring the food and getting from the top of the pan, and not the bottom. She stated the vegetables should have been served in a bowl to retain the heat as well as the juice of the beans made the roll soggy. The DM stated the apples were not served hot with the low temperature playing the major part as not being palatable. She stated she felt the cook had not seasoned the sauce after being advised to do so. The DM stated could have affected the residents with them not eating which could have causes them not to get receiving proper nutrition which could have caused weight loss or depression. She stated the [NAME] was responsible as well as her as the DM since she monitored her in the taking of temperatures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 14 of 24 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 11/14/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The DM stated she monitored 2-3 times a week. She stated her expectations were for meals to be prepared according to the recipe as well as residents be provided their choices. The DM stated the failure was a combination of staff needing more education, with 3 of her staff having trained and not performed what they learned. During an interview on 11/14/2024 at 2:15 PM the ADMN stated she could not answer how unpalatable food could have affected the residents. She stated, the cold food should be cold, and the hot food should be hot. The ADMN stated the DM monitored the temperatures and palatability of the food, with herself as the ADMN monitored the DM. She stated she usually monitored daily. The ADMN stated the last time she had entered into the kitchen was a week ago having done a quick look around due to a morning meeting. She stated her expectations was that the food have the correct seasonings, with the temperatures being correct. The ADMN stated the plate warmer may had not been working correctly possibly could have been where the failure occurred, but she wasn't there or observe and could not say. Record review of facility policy Test Trays, dated 2018 revealed the following [in-part]: Policy: The facility recognizes the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable and served at the correct temperatures. Record review of facility policy Food and Holding Service dated 2018 revealed the following [in-part]: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP guidelines. Procedure: 1. Serve all hot foods at a temperature of 135°F or greater and all cold food at 41°F or less. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 15 of 24 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 11/14/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: Residents Affected - Many The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. The facility failed to ensure kitchen staff followed proper hand hygiene during meal preparations. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: During an observation on 11/12/2024 at 9:46 AM of the pantry was; 1 gallon of blended oil, unable to read the received date with no opened date. 1 16 oz. opened clear zip lock bag of marshmallows with no opened date. 1 5 lb. opened bag of potato chips with no opened date. 1 26 oz. opened bag of Dried Classic Mashed Potatoes in a clear zip lock bag with no opened date. 1 8 lb. opened container of Creole Seasoning with no opened date. 1 opened bag of hamburger buns with no opened date. 1 20 oz. opened loaf of bread with no opened date. 1 17 oz. opened container with the opened date unreadable. Expired food 1 6 lb. opened box container with a received date of 02/04/2023 and no opened date. 1 8.1 oz can of Baking Powder with an expiration dated 08/06/2019. Refrigerator #1 1 clear container labeled tapia fruit with no use by date. 1 container labeled gravy dated 11/12 with no use by date. 1 clear zip lock bag labeled carrots with no use by date. 1 clear zip lock bag labeled taco meat and dated 4/9 with no use by date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 16 of 24 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 11/14/2024 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 0812 1 clear zip lock bag labeled eggs, dated 11/12/24 with no use by date. Level of Harm - Minimal harm or potential for actual harm 1 clear zip lock bag labeled sausage, dated 11/12/24 with no use by date. 1 10 lb. opened and unsealed box of Sausage Patties with no opened date. Residents Affected - Many 1 clear zip lock bag labeled Pork Chops, dated 11/12/24 with no use by date. 1 original clear bag labeled Sausage dated 11/9 with no use by date. Refrigerator #2 1 clear zip lock bag dated 10/23 with a head of (browning) lettuce. 1 clear zip lock bag dated 10/10 with (browning) shredded lettuce. 1 clear zip lock bag labeled cheddar cheese dated 11/7 and no use by date. 1 head of lettuce in original bag undated. 1 opened box and unsealed bag of Parsley dated 10/10 and appeared to be wilted. Freezer #1 1 clear zip lock bag unlabeled of what appeared to be French toast dated 11/11. 1 opened box with an unsealed bag of Turkey Sausage dated 10/30/24. 1 15 lb. opened box with an unsealed bag of Swai Fillet fish, undated. 2 sealed and unlabeled clear bags of what appeared to be frozen chicken, unlabeled and undated. During an observation on 11/12/2024 at 11:06 AM the Dish Washer and [NAME] had not used proper hand hygiene when washing their hands, not using soap and scrubbing hands in the time required for proper sanitizing. During an interview on 11/14/2024 at 2:40 PM the ADMN stated she expected her staff to wash their hands thoroughly and to know how long to not transmit any bacteria or cross contamination to the residents. She stated some residents had low immune systems therefore easier for them to get sick. The ADMN stated it was the DM's job to monitor. She stated her expectations were for the kitchen to be maintained. The ADMN stated the failure occurred with the DM and new staff, as they needed to be monitored as well as have an increased list of in-services for new staff. She stated all products that came into the kitchen should have been labeled and dated, which included, the received date and opened date prior to being placed on the shelves. The ADMN stated her expectations were to label, date, and rotate all products. During an interview on 11/14/2024 at 9:23 AM, the DM stated all products were to be labeled with a received date and when opened. She stated when the product is opened and placed in another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 17 of 24 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 11/14/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many container, staff needed to label and place all dates needed on the product. The DM stated if the food product was a leftover in the refrigerator, there should have been a use by date of 3 days. She stated when the products were opened in the freezers, staff should have sealed the bag completely before closing the box. The DM stated the failure was with her staff getting in a hurry. She stated in not doing so, it could have affected the resident with the possibility of cross contamination which could have led to a food borne illness. The DM stated DM oversaw the kitchen and dining, but not often enough. She stated her expectations were to have all products labeled, dated and with the use by date when needed, as well as rotate products when needed. The DM stated the failure was with her and her staff having not followed regulations. The DM stated all staff also has been in-serviced as to how to wash their hands. She stated in not doing so, could have caused residents to become sick. She stated the DM monitored staff with in-services and observations. The DM stated, the failure was that staff were not following protocols and regulations of their in-services. Record Review of facility policy, Food Storage dated 2018, revealed: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry Storage rooms d. to ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated f. Where possible, leave items in the original cartons placed with the date visible. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that older items are used first. 2. Refrigerators .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 3. Freezers . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record Review of facility policy, Food Preparation and Handling dated 2018, revealed: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state, federal and US Food Codes and HACCP guidelines. 1. General Guidelines . b. Wash hands properly before beginning food preparation. C. Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly. Record Review of facility policy, General Kitchen Sanitation dated 2018, revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 18 of 24 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 11/14/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: Residents Affected - Many 12. Make sure hand-washing facilities are easily accessible and supplied with soap and paper towels. Record Review of facility policy, Hand Washing dated 2018, revealed: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents All Nutrition & Food service employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness. Procedure: 1. Hand-washing stations . a. Make sure hand washing stations are located in food preparation areas to encourage employees to wash their hands frequently. b. Make sure there are hand washing stations in all areas that employees' hands may become contaminated, including food preparation areas, service areas, dishwashing areas and rest-rooms. c. Make sure all hand washing stations are equipped with the following i. Hot and cold running water. Ii. Hand cleaning liquid, powder, or bar soap. Iii. Individual, disposable towels, a continuous towel system that supplies the user with a clean towel or a heated-air hand-drying device. Iv. A receptacle for disposable towels. v. A sign that indicates employees must wash hands before returning to work. d. Sinks used for food preparation or washing utensils or a service sink or curbed cleaning facility used to dispose of mop water or similar wastes cannot be used as a hand-washing station. 2. Hands should be washed after the following occurrences: a. using the restroom b. Handling raw food (before and after) c. Touching the hair, face, or body d. sneezing or coughing e. smoking f. eating or drinking g. Handling chemicals h. taking out the garbage i. Clearing tables j. Touching clothing or aprons k. Touching unsanitized equipment, work surfaces, or wash cloths l. Assisting residents 3. Hand-washing steps . a. Wet hands and exposed arms with hot water at least 100* F. b. Apply soap c. scrub hands, exposed arms and fingernails for a minimum of 20 seconds being sure to apply a vigorous friction d. Rinse hands and exposed arms thoroughly under hot running water e. Dry hands and arms with a paper towel f. Turn off the faucet with the paper towel to avoid contaminating hands and discard towel. Review on 11/14/2024 of the FDA Food Code 2022: Full Document accessed on 10/16/2024 in annex 7 page 37, 38 revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 19 of 24 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 11/14/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Applicable Code Sections: 3-501.16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done. Event ID: Facility ID: 455574 If continuation sheet Page 20 of 24 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 11/14/2024 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 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 observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 (Resident #'s 7, 33, and 61) of 4 residents reviewed for infection control , in that: Residents Affected - Some Agency LVN failed to intervene and practice EBP (enhanced barrier precautions) to protect resident's from MDRO'S by not donning a gown when caring for and administering medications to Resident #7 on 11/12/24 via his gastrostomy (an opening into the stomach through the abdominal wall to provide medication and nourishment) tube. The facility failed to intervene and practice EBP when caring for Resident # 33 who had a pressure area on her coccyx. The facility failed to intervene and practice EBP when caring for Resident # 61 a who had a foley catheter . These failures could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #7's electronic face sheet not dated reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: dysphagia (difficulty swallowing) hemiplegia (paralysis on one side of the body) cerebral infarct (stroke) diarrhea, and hypertension(high blood pressure). Record review of Resident # 7's Annual MDS, dated [DATE], reflected he had a BIMS of 15 (cognitively intact), received gastrostomy tube feedings, and that he was occasionally incontinent of bowel and bladder. Record review of Resident #7's comprehensive person-centered care plan reflected a last care conference date of 6/18/2024 reflected Problem: Feeding tube There was no Problem or intervention for enhanced barrier precautions. During an observation and interview on 11/12/2024 at 1:43 PM of Resident # 7's room revealed he did not have had a sign on his door or in his room which indicated he was on EBP. He stated the staff did not wear a gown when they provided care or administered his medications through his gastrostomy tube. During an observation on 11/13/24 at 3:20PM, Agency LVN entered Resident #7's room to administer his 3 PM medications which he received via gastrostomy tube (a tube placed through the abdominal wall and into the stomach). She wore gloves but did not put a gown on to administer the medication through the indwelling gastrostomy tube. After obtaining vital signs, the nurse prepared all medications as ordered to be given via the gastric tube route, she completed hand hygiene, and applied gloves. She paused the feeding pump, unscrewed the pump line from the gastric tube, placed the pump line hanging from the top of the IV pole, attached the appropriate syringe to patients' gastric tube and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 21 of 24 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 11/14/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some checked for residual fluid in the stomach. She then removed the plunger from the syringe and began administering medications via gravity feed one medication at a time mixed with 5ml water, followed by 15ml water flush between each medication. She re-attached the tube feed line to the gastric tube and restarted the tube feed pump. During an interview on 11/13/2024 at 03:25 PM with the Agency LVN, she stated she did not think about wearing a gown when she administered medication through the gastric tube for Resident #7, she stated cross contamination could result from improper use of PPE. She stated she was trained on the new EBP guidelines which included to wear a gown when working with a resident who had a wound or indwelling medical device. She stated she did not know if anyone was on EBP on the 100 hall on which she was assigned. She stated it was usually posted on the door of the resident's room at other facilities but at this facility she was informed in report of the resident's that require enhanced barrier precautions. She stated she did not receive any information on any of her residents requiring EBP. She stated a negative impact for residents that could occur if enhanced barrier precautions were not used on a resident that required their use, would be infection. She stated she had not had an in-service on EBP recently. Record review of Resident #33's electronic face sheet not dated reflected she was a [AGE] year-old female with a readmission date of 5/29/24. Her diagnoses included: dysphagia (difficulty swallowing) cerebral palsy (a congenital condition affecting the developing brain of an infant while in the womb. Damage affects the region of the brain in charge of motor skills. Movement and balance which can result in paralysis), contractures, and dysfunction of bladder. Record review of Resident # 33's Annual MDS, dated [DATE], reflected she had a had a long term and short-term memory problem and her cognitive skills for decision making were severely impaired, she had a stage 4 pressure ulcer ( open area involving muscle and bone) and was incontinent of bowel and bladder. Record review of Resident #33's comprehensive person-centered care plan reflected a problem start date of 11/14/24. Resident requires EBP (Enhanced Barrier Precautions) during contact care r/t(ex: chronic wounds, indwelling catheter, central lines, Infection). POA, refuses continued use of EBP while providing personal care. POA feels that staff using PPE upsets Resident # 33 and she wishes for it to be discontinued at this time. Risks and benefits of EBP explained and understanding voiced. Created: 11/14/2024 Approach: Staff is not required to use Enhanced Barrier Precautions; Staff to communicate refusal for EBP via POC/staff reports. Created: 11/14/24 During an observation on11/12/24 at12:30 PM it was noted that there was no enhanced barrier precautions sign noted outside or inside of Resident #33's room and no PPE other than a box of gloves available inside or outside the room. CNA C was observed performing Peri-care and she did not wear any PPE other than gloves to provide care to the resident. During an interview on 11/13/24 at 4:14 PM CNA C stated that she was not sure what EBP meant but does know that if a resident has their name on a blue tab outside the door she should wear gloves, gown, and mask if providing care including emptying catheter or changing residents. She stated that on 300 hall only Resident # 49 and Resident # 47 have blue names. CNA C stated I don't know what it could cause if don't wear PPE, I just know I am supposed to wear it when they have a blue tab. She then stated that Resident # 33 only requires gloves when providing care because her name is on a white (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 22 of 24 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 11/14/2024 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 0880 tab outside door. Level of Harm - Minimal harm or potential for actual harm 11/13/24 06:26 PM Interview with CNA B regarding EBP. She stated that she did not know what exactly that means. She stated that some residents with catheters have a blue name tag outside their door which meant staff should wear PPE such as gown, gloves, and mask to care for the resident. She stated that failure to do so could cause cross contamination to staff or others. Residents Affected - Some During an interview on 11/14/24 at 3:11 PM the ADON stated Resident # 33's responsible party does not want her on EBP. She stated the RP works in LTC and just doesn't want it done. Review of Resident # 61's Face Sheet (not dated) revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function), dysphagia (difficulty swallowing, major depressive disorder, recurrent, and anxiety disorder. Record review of Resident # 61's Quarterly MDS, dated [DATE], reflected she had a BIMS of 15 (cognitively intact), had an indwelling catheter, and was incontinent of bowels at times. Record review of Resident #61's comprehensive person-centered care plan reflected a problem start created date 11/14/24 Resident requires EBP(Enhanced Barrier Precautions) during contact care r/t(ex: indwelling catheter) EBP discussed with resident and her mother. Res states she no longer wishes for staff to use PPE while providing care and states it makes her feel uncomfortable and she doesn't feel like it's necessary. Risks of infection re: long term indwelling catheter explained as well as benefits of EBP. Approach: Staff is not required to use Enhanced Barrier Precautions; Staff to communicate refusal for EBP via POC/staff reports. Created: 11/14/24 During an interview on11/13/24 04:15 PM Resident # 61 stated staff does not wear gowns when caring for her because she doesn't want them to wear gowns. She also stated that it was a waste of time for them and her to get (PPE)on and take PPE off In an interview on 11/14/24 at 2:50 PM the DON stated that the following residents were on Enhanced Barrier Precautions: Resident #'s 7, 49 and 47. The DON stated that it was her expectation that EBP should be followed during medication administration via tube for resident # 7. They should wash hands, gown and glove when administering meds for Resident 7. She stated, If he had a MDRO staff could transfer infection to someone else. The DON stated the staff knew what precautions to take and on which residents by use of in-services and the blue label. The DON said agency staff was also educated in the same way on EBP. She further added that she determines if EBP will be used by the following means: We ask the resident if they want the use of EBP and they can decline it. We talk to the family, their RP. DON Stated that the resident or RP both have the right to decline it. The DON stated she had started an inservice for staff on 11/13/24 with CMS Provider letter QSO 24-08-NH regarding the use of EBP. Record review of facility policy and procedure titled Infection Control, Precautions, Categories and Notices, dated revised March 2024, reflected in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 23 of 24 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 11/14/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some enhanced barrier precautions should be used in the following situations: when a resident is infected or colonized with CDC-targeted MDRO without a wound, indwelling medical device or secretions or excretions that are unable to be covered or contained; Has a wound or indwelling medical device without secretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO; and at the discretion of the facility when a resident is infected or colonized with a non-CDC targeted MDRO without a wound, indwelling medical device, or secretions, or excretions that are unable to be covered or contained; If they do not meet the criteria for contact precautions and have a wound or indwelling medical device, and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the boy that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen. Considerations 1. For residents for whom EBP are indicated, EBP is employed when performing the following high contact activities: 2. Dressing, bathing showering, transferring providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use (central line, urinary catheter, feeding tube tracheostomy tube/ventilator, wound care, and any skin opening that has a dressing. 3. Ensure PPE and alcohol-based hand rub or readily accessible to staff. Review of website https://www.cdc.gov/preventmdro on 11/13/24, revealed the following: Enhanced Barrier Protection Multi drug resistant organism transmission is common in skilled nursing facilities, contributing to substantial resident, morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident activities. EBP may be indicated when contact precautions do not apply for residents with any of the following: wounds or indwelling medical devices regardless of multidrug resistant organism colonization status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455574 If continuation sheet Page 24 of 24