Health inspection·September 17, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete choking, he could not notify anyone and numerous of other things could happen that he may need to call for help for. During an interview on 9/11/2025 at 11:19 A.M., the ADM said Resident #34's call light should be on his bed. She said all staff were responsible to ensure that the resident's call lights were within reach. She said a negative effect of a resident not having a call light within reach they would not be able to call for help.Record review of facility's Answering the Call Light Policy, revised March 21, 2021, reflected The purpose of this procedure is to ensure timely responses to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Record review of the facility's Accommodation of Needs policy and procedure, revised March 2021, titled, reflected Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom or bathroom, as well the common areas in the facility. a. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity. Event ID: Facility ID: 455963 If continuation sheet Page 2 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 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 observation, interview and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 15 residents (Resident #40) reviewed for accuracy of assessments. The facility failed to accurately complete the MDS assessment to indicate Resident #40's wander alarm/ bracelet (wearable safety device that uses door sensors to send real time alerts to care givers when a resident with the bracelet leaves a designated area). This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings include: Record review of Resident #40's face sheet, dated 09/15/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #40 had diagnoses which included schizophrenia (a chronic complex mental health disorder that affects a person's ability to think, feel and behave) and autistic disorder (a complex developmental disability characterized by persistent challenges in social communication and interaction). Record review of Resident #40's care plan, initiated 06/13/25, indicated Resident #40 was at risk of elopement with interventions that included resident will wear a roam alert bracelet at all times and assess roam alert function daily and placement verified every shift. Record review of Resident #40's quarterly MDS assessment, dated 08/09/25, indicated Resident #40 was not marked for wander/ elopement alarm use during the assessment period. The assessment indicated Resident #40 had a BIMS score of 10 of 15, which indicated moderately impaired of cognition with diagnoses of schizophrenia and autistic disorder. Record review of Resident #40's MAR dated 09/16/25 indicated her wander bracelet was assessed every shift for placement and daily for function. During an interview and observation on 09/15/25 at 10:50 a.m., Resident #40 was sitting in her wheelchair with a wander bracelet on her left wrist, Resident #40 said she had a special bracelet she wore all the time, and the staff checked it every day. During an interview on 09/16/25 at 3:33 p.m., LVN C said she was providing care for Resident #40 today (09/16/25) and Resident #40 wore a wander bracelet that was checked daily by staff. She said the MDS Nurse was responsible for all MDSs in the facility and the nurses completed a form related to resident ADLS as needed. During an interview on 09/16/25 at 3:45 p.m., the MDS Nurse said she was responsible for all MDSs in the facility and the Regional Reimbursement Consultant was the back up and double checked random MDSs for accuracy with August 2025 being the most recent reeducation. She said she was educated on completion of MDSs and accuracy. The MDS Nurse said Resident #40 should have been marked for her wander bracelet on her most recent MDS and was not. She said it was overlooked. The MDS Nurse said she would mark it immediately and correct the MDS. She said there was no resident risk to Resident #40's MDS not marked for a wander bracelet. She said Resident #40's wander bracelet had an order, was monitoring every shift and was care planned. The MDS Nurse said it was just an inaccurate MDS. During an interview on 09/16/25 at 3:50 p.m., the Regional Reimbursement Coordinator, said the MDS Nurse was responsible for all MDSs in the facility. She said she was the backup that double checked random MDSs for accuracy. She said the MDS Nurse was in-served on completion and accuracy of MDS with August 2025 the most recent in-service. The Regional Reimbursement Coordinator said Resident #40's wander bracelet should have been marked on the 08/09/25 MDS and was not, she said it was overlooked. She said there was no resident risk of Resident #40's wander bracelet not marked on the MDS, she said there was an order, it was monitored and care planned, it was just human error. During an interview on 09/16/25 at 4:37 p.m., the DON said the MDS Nurse was responsible for all MDSs in the facility and the Regional Reimbursement Director was the back up to double check some MDS. She said the MDS Nurse was educated on completion and accuracy of MDS and attended a conference in the last month for updates. She said there was no resident risk Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 3 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of the wander bracelet not marked on the MDS, she said there was an order, and it was monitored every shift. The DON said it was just an inaccurate MDS. She said her expectation was all MDSs completed accurately and timely. During an interview on 09/16/25 at 4:45 p.m., the Administrator said the MDS Nurse was responsible for all MDSs in the facility and the Regional Reimbursement Director was the back up to double check some random MDSs. She said the MDS Nurse was educated on completion and accuracy of MDSs. The Administrator said there was no resident risk of the wander bracelet not marked on the MDS, she said it was monitored, and care planned, it was just an inaccurate MDS. She said her expectation was all MDSs completed accurately and timely. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, indicated . P0200: Alarms . Code 0, not used: if the device was not used during the 7-day look-back period. Code 1, used less than daily: if the device was used less than daily. Code 2, used daily: if the device was used on a daily basis during the look-back period. Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, cane) or other belongings. Bracelets or devices worn by or attached to the resident and/or their belongings that signal a door to lock when the resident approaches should be coded in P0200E Wander/elopement alarm, whether or not the device activates a sound or alerts the staff. Event ID: Facility ID: 455963 If continuation sheet Page 4 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 15 residents reviewed for ADLs. (Residents #2) The facility failed to trim and clean under Resident #2's fingernails.This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.Findings included:Record review of Resident #2's face sheet dated 9/16/25 indicated he was [AGE] years old, admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #2 had diagnoses which included heart failure, diabetes (high blood sugar), conduct disorders, lack of coordination, flaccid hemiplegia (unable to move) right dominant side, and cerebral infarction (stroke-disruption of blood flow to the brain causing tissue damage).Record review of Resident #2's quarterly MDS dated [DATE] indicated he usually understood others and was understood. Resident #2 had a BIMS with a score of 6, which indicated he had severe cognitive impairment. The MDS indicated Resident #2 did not have physical, verbal, or other behavioral symptoms and he did not reject care. Resident #2 had impairment of upper lower extremities on one side of his body. Resident #2 was dependent on staff for most ADLs including personal hygiene.Record review of Resident #2's undated care plan indicated the following tasks would be documented in POCareAssist . Nail Care . once a day on Tuesday, Thursday, and Saturday 2:00 PM -10:00 PM.Record review of Resident #2's Point of Care History dated 9/01/25-9/17/25 indicated CNA A documented she performed Nail Care on 9/16/25 at 6:59 AM and CNA B documented she performed Nail Care on 9/16/25 at 5:58 PM.During an observation and interview on 9/15/25 beginning at 11:35 AM, Resident #2 was observed during lunch dining service sitting at the dining table in a geriatric chair. Resident #2's right hand was contracted with hand closed. Resident #2's fingernails were long on both hands and there was a black substance under his fingernails of his left hand. Resident #2 fed himself with his left hand and said the food was good.During an interview on 9/15/25 at 3:00 PM, Resident #2's RP said her only concerns she could think of was his hygiene, clipping and cleaning his dirty nails, and bathing. Resident #2's RP said the facility said he refused at times, and they could not make him bath. During an observation on 9/16/25 at 11:15 AM, Resident #2 was observed sitting in the dining room. Resident #2's fingernails continued to be long on both hands and he had a black substance under his fingernails of his left hand. Resident #2s fingernails on his right contracted hand were very long and were pressing into the palm area of his hand but the skin was not broken.During an observation and interview on 9/17/25 at 7:55 AM, Resident #2 was sitting in his geriatric chair in the dining area waiting to go smoke. Resident #2's fingernails on both of his hands continued to be long and his left hand continued to have a black substance under his nails. Resident #2 said he did not mind his nails being long, but he did not know what was black under his nails. Resident #2 said staff did clean under his fingernails and trimmed them sometimes.On 9/17/25 at 9:56 AM and 11:13 AM, CNA B was called. The call went straight to voicemail, and a detailed voicemail was left. CNA B did not return the call prior to surveyor exiting the facility.During an interview on 9/17/25 at 10:09 AM, CNA A said she had worked at the facility for twenty years. CNA A said nail care consisted of cutting the nails, cleaning under the nails, and handwashing. CNA A said the CNAs were responsible for ensuring nail care was done and the nurses followed up. CNA A said if the nurses noticed the resident's nails were dirty, they would either clean them or notify the CNAs to clean them. CNA A said she did nail care on Resident #2 on 9/16/25 the best she could. CNA A said Resident #2 digs in his private areas and masturbates. CNA A said they could not stop him from doing those things and Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 5 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no telling what was under his nails. CNA A said Resident #2 did allow her to do nail care yesterday (9/16/25) on his left hand but not his right hand. CNA A said she did not cut Resident #2's nails and she let the nurse or someone else cut nails because she had cut someone before, so she did not cut nails anymore. CNA A said sometimes, Resident #2 would refuse to have his nails cut and cleaned. CNA A said a resident having long/dirty nails, was not good, and the resident's nails needed to be cleaned, because it was not sanitary. CNA A said Resident #2 fed himself with his left hand. CNA A said Resident #2 usually ate with his hands and did not use utensils. CNA A said anything that would be under Resident #2's nails could go into his mouth. CNA A said Resident #2 would even take the butter and spread on his face at times and he had a lot of behaviors. During an interview on 9/17/25 at 10:23 AM, the DON said the CNAs should be doing the nail care and the nurses follow up to ensure that it was completed. The DON said the nurses looked at the POC (where the CNAs document tasks) to ensure tasks were completed. The DON said the CNAs should be letting the nurse know when a resident refused care. The DON said she put out a list of residents that needed to be looked at to ensure nails, facial hair, and assessed for any needs on Sundays. The DON provided a copy of her list from 9/14/2025 and it included Resident #2. The DON said nail care should consist of staff asking the resident if it was okay to trim their nails, cleaning under the nails, and trimming to an appropriate length. The DON said dirty/long nails could hold bacteria and placed the resident at risk for infection. The DON said the nurses were supposed to supervise the CNAs to ensure the nail task had been completed. The DON said Resident #2 would sometimes refuse care and the refusal should be documented.During an interview on 9/17/25 at 11:00 AM, the ADM said she would expect staff to be ensuring the resident's fingernails were trimmed and cleaned if the resident allowed. The ADM said dirty/long fingernails could be an infection control issue, especially if the resident was feeding themselves. The ADM said the DON and ADONs would be responsible for ensuring nail care was being performed, but ultimately, she (ADM) would be responsible.Record review of the facility's policy titled Activities of Daily Living (ADLs) dated 7/01/25, indicated . The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable . care and services will be provided for the following activities of daily living . 1. Bathing, dressing, grooming, and oral care . Policy Explanation and Compliance Guidelines . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . The facility will maintain individual objectives of the care plan and periodic review and evaluation .Record review of the facility's policy titled Nail Care dated 7/2025, indicated . The purpose of this procedure was to provide guidelines for the provision of care to a resident's nails for good grooming and health . Policy Explanation and Compliance Guidelines . 3. Routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis . 4. Routine nail care, to include trimming and filing, would be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care would be provided between scheduled occasions as the need arises . 5. The resident's plan of care would identify . a. the frequency of nail care to be provided b. The type of nail care provided c. The person(s) responsible for providing nail care (licensed nurse, nurse aide, podiatrist, activity professional) . 6. Principles of nail care . a. Nails should be kept smooth to avoid skin injury b. Only licensed nurses shall trim or file fingernails of residents with diabetes . 7. Procedure . b. fill wash basin with warm water . soak hands/feet in wash basin for 10-20 minutes, unless resident had diabetes or circulation problems c. Gently clean underneath nails with orange stick d. If trimming was allowed, clip nails using nail clippers straight across and even (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 6 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 with the tops of the fingers/toes e. Shape nails straight across using nail file, emery board, or the like . i. Document completion of task, any complications, or if the resident refused . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 7 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident received adequate supervision using a mechanical lift (assistive device) to prevent accidents for 1 of 18 residents reviewed for accidents (Resident #2). The facility failed to ensure Resident #2 was safely transferred using a mechanical lift with 2-person transfer on 9/16/2025 at 7:55 AM. This failure could place residents at risk for injury or harm. Findings included:Record review of Resident #2's face sheet dated 9/16/2025 indicated he was [AGE] year-old male readmitted to the facility on [DATE]. Some of his diagnoses included chronic diastolic heart failure (a condition in which your heart's main pumping chamber (left ventricle) becomes stiff and does not relax properly between heartbeats), Cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage), Flaccid hemiplegia affecting right dominant side (a condition characterized by flaccid paralysis on one side of the body), hyperlipidemia (a condition that causes high levels of lipids, or fats, in blood), type II diabetes (a chronic condition characterized by high blood sugar levels due to insulin resistance and relative lack of insulin production),schizophrenia(a serious mental health condition that affects the way a person thinks, acts and feels), and morbid obesity (a condition that is characterized by an extremely high body weight that can lead to serious health complications and mobility changes). Record review of Resident #2's MDS dated [DATE] indicated a BIMS score of 6 (severely cognitively impaired). The MDS indicated Resident #2 required a wheelchair in the lookback period of 7 days and was dependent with toileting hygiene, showering/bathing, dressing upper and lower body and personal hygiene. The MDS indicated Resident #2 was dependent with transfers. Record review of Resident #2's care plan dated 5/30/2025 indicated resident had impaired physical mobility related to paralysis and contractures to right extremities. The MDS indicated Resident #2 required a mechanical lift to transfer from chair to bed which puts resident at risk for injury. The MDS goal indicated the resident would not have any injuries due to the mechanical lift over the next 90 day. Interventions included ensure there were no objects in the way during the use of the lift, have 2 people to safely transfer resident from bed to chair using the mechanical lift. During an observation on 9/16/2025 at 7:55 AM, CNA A wheeled the mechanical lift to Resident #2's room. CNA A secured the sling under Resident #2 prior to being placed on the mechanical lift. CNA A used the electronic remote to lift the resident up and CNA G was across the room holding the Geri-chair (a type of clinical recliner to provide comfortable seating and mobility assistance for residents with limited mobility) in place. CNA A spread the legs of the mechanical lift and lowered Resident #2 into the Geri-chair. During an interview on 9/16/2025 at 8:43 AM, CNA G said she had worked at the facility for 15 years. She said Resident #2 was a 2-person transfer with the mechanical lift. CNA G said the second person was supposed to stand behind the resident once he was secured in the lift. She said she was not standing behind him as he was being transferred. She said she should have been right with CNA A and the resident. CNA G said there should always be 2-person. CNA G said she should have been standing right behind him as CNA A was moving the mechanical lift across the room to the Geri-chair (a type of clinical recliner to provide comfortable seating and mobility assistance for residents with limited mobility). CNA G said she was standing behind the Geri chair. She said the resident could have fallen out of the sling (a fabric support used with a mechanical lift to safely transfer individuals with limited mobility from one surface to another). She said there was no excuse. She said she was caught off guard when asked for her to come assist with the transfer. CNA G said both CNAs were responsible for the resident during a mechanical lift transfer. During an interview on 9/17/2025 at 10:03 AM, CNA A said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 8 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the transfer went well until I talked to CNA G, the other CNA. We have not been doing it that way. CNA A said she had been trained on a mechanical lift. She said the facility wanted to make sure the sling is secure with the straps, and no one was doing the transfer by themselves. CNA A said the facility policy should require 2 persons during the transfers to ensure the straps do not break or someone falls. CNA A thought it was done properly. CNA A said she walked over to the chair, and she should have remained with the resident until he was moved across the room into his Geri chair. CNA A said the strap could have broken or he could have fell. CNA A said she could have assisted if there was an issue. During an interview on 9/17/2025 at 10:13 AM, LVN H said a resident who was non-weight bearing would require a mechanical lift. Resident #2 requires a mechanical lift due to being unable to transfer. The facility policy requires 2 persons for transfer with a mechanical lift. LVN H said the staff should check equipment prior to use. LVN H said the other person should aid and not walk away from the resident. LVN H said for safety there would need to be someone next to the resident. She said the resident would be swinging away if the second person was not there to guide and assist with the transfer. LVN H said the resident could swing and hit head on bar or hit their feet. LVN H said if there was too much weight, the mechanical lift could tip over and a resident could break something or could cause death. LVN H said the nurse or CNAs working the mechanical lift were responsible. During an interview on 9/17/2025 at 10:53 AM, the DON said the second person should remain with resident during the full transfer. She said the resident could fall causing injury by hitting head, it could also result in death. The DON said she expected the staff to have 2-person transfer. Having another person who is trained with a mechanical lift. The DON Said the 2 CNAs have been trained. The charge nurse who is over the floor is responsible for ensuring residents were transferred safely. The DON said she expected the staff to always have a 2 person transfer through the entire process. During an interview on 9/17/2025 at 11:05 AM, the ADM said she expected the 2 persons transfer to be next to the resident during the transfer. If there was an issue with the lift, the resident could fall if the lift and if the second person were not next to the resident to assist. The ADM said the administrative staff was responsible for ensuring the resident were transferred safely. The ADM said the CNAs and nursing staff would also be responsible for transferring the resident safely. The ADM said the resident could have a major injury. Record review of facility's policy dated 7-2025 titled Safe Resident Handling/Transfers indicated Policy.It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance guidelines.3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident needs.6. The staff will inspect the equipment prior to use.10. Two staff members must be utilized when transferring residents with a mechanical lift.11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises.13. Staff members are expected to maintain compliance with safe handling/transfer practices. Event ID: Facility ID: 455963 If continuation sheet Page 9 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 8 residents reviewed for respiratory care. (Resident #47)The facility failed to ensure Resident #47 received continuous oxygen as ordered by the physician when his oxygen tank was empty on 9/16/25. This failure could place residents at risk of respiratory complications. Findings included:Record review of Resident #47's face sheet dated 9/16/25 indicated he was [AGE] years old and admitted to the facility on [DATE] and re-admitted [DATE]. Resident #47 had diagnoses which included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), weakness, and anxiety (mental health condition characterized by excessive worry, fear, nervousness).Record review of Resident #47's quarterly MDS assessment dated [DATE], indicated he had a BIMS score of 8, which indicated he had moderate cognitive impairment. The MDS did not indicate Resident #47 was receiving oxygen therapy.Record review of Resident #47's Care Plan with a problem date of 9/12/25 indicated he had COPD and was at risk of hypoxemic (low oxygen in the blood) hypercarbic (high carbon dioxide in the blood) respiratory failure due to impaired gas exchange, chronic lung disease, and increased oxygen needs. The interventions included monitoring oxygen saturation, maintaining prescribed oxygen therapy. The Care Plan indicated Resident #47 required oxygen at 4 LPM via nasal cannula related to COPD.Record review of Resident #47's Resident Orders dated 9/18/25 revealed an order for nasal cannula continuous oxygen at 4 LPM with a start date of 9/15/25. Record review of Resident #47's Medication Administration Record dated 9/01/25-9/16/25 indicated he received oxygen at 4 LPM by nasal cannula continuously. During an observation and interview on 9/16/25 beginning at 11:18 AM, Resident #47 was sitting up in his wheelchair at a table in the dining room wearing a nasal cannula with the nasal cannula tubing attached to an oxygen tank hanging on the back of his wheelchair set at 4 LPM. The oxygen tank regulator dial showed the arrow was at the bottom of the red area of the dial which indicated the tank was empty. Resident #47 said the staff took good care of him and were real nice. The ADM then brought Resident #47 his lunch and set it up for him, she did not check his oxygen tank.During an observation on 9/16/25 beginning at 1:00 PM, Resident #47 was sitting in his wheelchair in front of the nurse's station and Resident #47 asked this surveyor to fix his oxygen. Resident #47's nasal cannula was in between his hip and chair, and the oxygen tank was set on 4 LPM, however, the oxygen tank regulator dial showed the arrow was at the bottom of the red area of the dial which indicated the tank remained empty. LVN C was sitting behind the desk at the nurse's station and this surveyor asked LVN C if she could look at Resident #47's oxygen. LVN C then took Resident #47 outside of a closet in the hallway and changed out his oxygen tank and tried several different oxygen regulators (attach to oxygen tank to control the rate of delivery) and said they were not working. After multiple failed attempts to set up a full oxygen tank, LVN D told LVN C to take Resident #47 to his room and place him on his oxygen concentrator (medical device that delivered oxygen to resident from drawing oxygen from the air) until they were able to fix Resident #47's oxygen tank.During an interview on 9/16/25 at 2:11 PM, LVN D said she had worked at the facility for one and a half years. LVN D said she was Resident #47's nurse. LVN D said she was responsible for ensuring the oxygen tanks had oxygen in them and the resident was receiving their oxygen as ordered by the physician. LVN D said she had checked Resident #47's oxygen saturation (measurement of oxygen in the blood) level at 12:30 PM and it was 93% (within normal limits). LVN D said Resident #47 was lying in his bed and using his oxygen concentrator and not the oxygen tank at that time. LVN D said she did not check the oxygen tank to ensure it had oxygen at that time, because Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 10 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #47 was not using it at that time. LVN D said at some point between her checking Resident #47's oxygen level and when everyone was gathered around Resident #47 in front of the nurse's station, he must had transferred his self and went up there (nurse's station). LVN D said she normally checked her oxygen tanks every 2-3 hours to ensure the resident did not run out of oxygen, but Resident #47 had just recently returned from the hospital and was new to requiring oxygen continuously. LVN D said at 4 LPM continuously, it appeared to be running out sooner and she was having to figure it out when she needed to check it. LVN D said Resident #47's oxygen tank was empty when he was in front of the nurse's station, and they were having trouble getting the regulator to work on the new oxygen tank and eventually had to take Resident #47 to his room to put him back on his oxygen concentrator. LVN D said if a resident that required continuous oxygen ran out of oxygen, the resident could become hypoxic (not enough oxygen to in the tissues to sustain bodily functions) and get really bad and they could have increased anxiety. LVN D said she was not aware Resident #47's oxygen tank was empty in the dining room before lunch. During an interview on 9/16/25 at 3:30PM, LVN C said she had worked at the facility for about one and half years. LVN C said when this surveyor notified her to look at Resident #47's oxygen, his oxygen tank was empty. LVN C said they replaced Resident #47's empty tank with a new one but did have issues with getting the regulator to work. LVN C said LVN D ended up taking Resident #47 to his room to put him on the oxygen concentrator until they were able to get his oxygen tank fixed. LVN C said if a resident who required continuous oxygen had an empty oxygen tank, the resident could become short of breath, have increased confusion, pass out, or even die if it got bad enough. During an interview on 9/17/25 at 10:23 AM, the DON said the nurses would be responsible for ensuring the oxygen tank was on, was not empty, and their oxygen saturation was staying up. The DON said if the oxygen tank was empty and the oxygen dependent resident was not receiving the ordered amount of oxygen, it could lead to respiratory failure and cause harm to the resident. The DON said the nurse should check the oxygen tank frequently at least every two hours, if the resident was up and using the oxygen tank. During an interview on 9/17/25 at 11:00 AM, the ADM said she would expect the nursing staff to ensure the oxygen dependent residents' oxygen tanks had oxygen in them. The ADM said if the oxygen dependent resident was not receiving their ordered amount of oxygen, then it could cause the resident to have confusion and shortness of breath. Review of the facility's policy titled Oxygen Administration dated February 2025, indicated . Oxygen was administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . Policy Explanation and Compliance Guidelines . 1. Oxygen was administered under orders of a physician . staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy . 11. Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them . Event ID: Facility ID: 455963 If continuation sheet Page 11 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 18 residents (Resident #14) reviewed for drug storage. The facility failed to securely store a white powder substance in a medication cup for Resident #14 located on bedside table. This failure could place residents at risk for access to medications/biologicals not approved for their health condition. Findings included:Record review of the face sheet dated 9/17/2025 indicated Resident #14 was [AGE] year-old female who was admitted on [DATE] with diagnoses including Chronic inflammatory demyelinating polyneuritis (s a rare neurological condition that causes worsening (progressive) muscle weakness, numbness and other symptoms.), muscle weakness, ataxia (lack of coordination of voluntary muscle movements) and mild intermittent asthma (mild persistent asthma which causes airways to narrow and swell, making it difficult to breath). Record review of the quarterly MDS dated [DATE] indicated Resident #14 was usually understood and usually understood others. The MDS indicated a BIMS score of 10 indicating Resident #14 was moderately cognitively impaired. Record review of a care plan revised on 9/15/2025 indicated Resident #14 had redness under breast related to yeast rash with interventions to avoid positioning resident on a rash, keep clean and dry as possible, minimize skin exposure to moisture, apply nystatin per MD order and monitor effectiveness and report adverse effects to MD.Record review of MAR dated 9/1/2025-9/17/2025 indicated Resident #14 was prescribed Nystatin powder 100,000 Units/gram amount to administer moderate amount topically. The MAR indicated LVN D administered the medication between the scheduled times of 6 AM-10 AM.During an observation and interview on 9/15/2025 at 10:02 AM, Resident # 14 said she could never find her call light. Resident #14 was observed to have 1 medication cup on her bedside with a white powdery substance in the cup. Resident #14 said it was medication that the staff had used to place on her breast for a rash she had developed.During an interview on 9/17/2025 at 10:13 AM, LVN H said medications should be stored on the medication cart or medication room. She said powders are normally stored on the nurse's medication cart. LVN H said a resident should not have nystatin on their bedside table. LVN H said if a nurse took the medication in the room, the nurse should be the one to apply the medication and the medication should be discarded once the nurse leaves the room. She said a medication or powder could be toxic and another person could have a reaction. She said a child could consume it and cause a reaction or death if not used properly. LVN H said the nurse and medication aides were responsible for ensuring the medications were properly stored.During an interview on 9/17/2025 at 10:22 AM, CNA A said the nurses were responsible for ensuring medication was properly stored. CNA A said if she had observed a white powder in a medication cup at the resident's bedside, she would go get a nurse. CNA A said if a resident or visitor took the medication, it could cause them to get sick. During an interview on 9/17/2025 at 10:53 AM, the DON said residents should not have medication on their bedside table. She said she does have some residents who are able to self-administer medication, but Resident #14 was not one of them. The DON said she expected the nurse or staff to dispose of medications in a resident's room. She said another resident could wander in the room and take the medication. She said it may not mix with medication other medications a resident was on. The DON said the charge nurse and the medication aide were responsible for making sure medications were taken and disposed of medication cup. During an interview on 9/17/2025 at 11:05 AM, the Administrator said a resident can have medication at bedside if there was an order, care plan and assessed to see if they can have the medication at bedside or self-administer. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 12 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Administrator said the medication would need to be out of sight. She said it could cause harm if a visitor, a resident with dementia wandered in the room. The Administrator said the medication aide, nursing staff, and nursing administration was responsible for ensuring medications were properly stored. Review of a Medication Storage policy titled Medication Storage in the Facility dated 6/1/2022 indicated 1. Storage of medication. Policy.Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. Procedure.a. The provider pharmacy dispenses medications.b. Only licensed nurses, the consultant pharmacist and those authorized to administer medications. c. All medications dispensed by the pharmacy are store in the container with pharmacy label.d. orally administered medications are kept separate from externally used medication and treatments such as suppositories, ointments, creams, vaginal products, etc.I. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. Event ID: Facility ID: 455963 If continuation sheet Page 13 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 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 review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1of 3 residents reviewed for infection control practices (Resident #3). The facility failed to ensure CNA G and CNA M donned a gown when they performed peri care on Resident #3. Resident #3 was on enhancement barrier precautions. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.Findings included: Record review of Resident #3's face sheet, dated 9/16/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included klebsiella pneumoniae (a type of bacteria normally found in human stool (feces) that can cause health-associated infections), personal history of other infectious and parasitic diseases, carrier or suspected carrier of methicillin resistant staphylococcus aureus (a type of staph bacteria that become resistant to many common antibiotics), contact with and (suspected) exposure to other viral communicable diseases. Record review of Resident #3's quarterly MDS assessment, dated 8/1/25, indicated she was usually able to make herself understood and usually understood others. Resident #3's BIMS score was 10, which indicated moderate cognitive impairment. Resident #3 required dependent assistance with ADL's. Resident #3 was always incontinent of bladder and bowel. Record review of Resident #3's care plan dated 7/31/25 indicated resident required enhancement barrier precautions (an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multidrug-resistant organisms) due to following: I am colonized or infected with multi-drug organism and contact precautions do not apply, feeding tube, and wound. Resident #3's interventions required staff will wear PPE during high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing, device care or use (central line, urinary catheter, feeding tube, trach care, colostomy care, etc., dated 5/29/25. Other interventions included for Resident #3 was post a sign on my door that says enhanced barrier precautions dated 5/29/25 and PPE will be available (including gowns/ gloves/ face shield or goggles) will be available right outside my room, in the shower room, dated 5/29/25. Record review of Resident #3's order summary report dated 9/16/25 indicated resident required Enhanced Barrier Precautions in place due to a diagnosis of klebsiella pneumoniae as the cause of diseases classified elsewhere. During observation on 9/16/2025 at 11:36 A.M., CNA G and CNA M provided peri care for Resident #3 and did not apply gowns before providing peri care; the resident was on enhanced barrier precautions. During an interview on 9/16/25 at 1:37 P.M., the ADON said Resident #3 was on enhanced barrier precautions for venous ulcer wound; she should not be on enhanced barrier precautions now, but she would clarify it. During an interview on 9/16/25 at 1:39 P.M., the DON stated Resident #3 should be on enhanced barrier precautions. She said the facility could choose to keep a resident on enhanced barrier precautions. She said Resident #3 had a history of klebsiella pneumoniae (a type of bacteria normally found in human stool (feces) that can cause health-associated infections). She said if staff were doing peri care on Resident #3, they should wear their gowns, because the bacteria could lay dormient in the resident and arrive again. She said the order was still in the computer for Resident #3 to be on enhanced barrier precautions, and the staff should be following the MD orders. She said if the resident was no longer on enhanced barrier precautions, she would have removed the EBP sign outside the resident's door and discontinued the order in the computer for EBP for Resident #3. She said if staff are not wearing the appropriate PPE for residents on EBP they could spread a Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 14 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete multi-drug resistant organisms (MDRO) to the next resident. During an interview on 9/16/25 at 1:50 P.M., CNA G said she did not know Resident #3 was supposed to be on EBP. She said there were no boxes in her room or PPE set up outside her door. She said a negative effect of not wearing the appropriate PPE for a resident on EBP was transferring infections to other residents. She said the nurse was not even aware that Resident #3 was still on EBP. During an interview on 9/16/25 at 1:57 P.M., LVN C said she did not know Resident #3 was still EBP, because the boxes to discard used PPE were not in her room and the PPE was not outside her door. She said a negative effect of giving peri care without a gown when a resident was on EBP precautions was staff could give an infection to another resident. During an interview on 9/16/2025 at 2:06 P.M., CNA M said she was not aware Resident #3 was on EBP, because she would have applied her PPE if knew that. She said she knew back in the past she was EBP, and she thought Resident #3 was cleared of everything. She said it was a lack of communication on her still being on EBP with staff. She said a negative effect of not wearing the appropriate PPE was staff could get an infection or staff could transfer the infection to other residents. During an interview on 9/17/25 at 11:10 A.M., the DON stated the staff should know who the residents are that were on EBP by the signs on the resident's door, an orange sticker by the resident's name at the door and the resident should have PPE placed at the door. The DON stated the Infection Preventionist was responsible for ensuring the correct PPE was placed at the resident's door, but she checked to make sure measures were in place. She said those were the 3 indicators for residents on EBP. She said she absolutely expected her staff to follow EBP to prevent infections of the other residents. During an interview on 9/17/25 at 11:19 A.M., the ADM stated there was a list at the nurses' station and it was marked on the resident's door if they were on EBP. She said she expected her staff to follow EBP. She said a negative effect of staff not following EBP was an infection control issue. Record review of the facility's policy, Enhanced Barrier Precautions, revised March 1, 2024, stated: Enhanced barrier precautions (EBPs) are to implement for the prevention of transmission of multidrug organisms.Enhanced barrier precautions (EBPs) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following.ii. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply.3. Implementation of Enhanced Barrier Precautions. a. Make gown and gloves immediately near or outside of the resident's room.b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.4. High-contact resident care activities include: d. Providing hygiene. f. Changing briefs or assisting with toileting. Record review of the facility's policy, Infection Prevention and Control Program, dated June 2025, stated: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted CDC national standards and guidelines.2. All staff are responsible for following all policies and procedures related to the program.5. Isolation Protocol (Transmission-Based Precautions): .a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.d. When a resident on transmission-based precautions must leave the resident care unit/area, the charge nurse on that unit/area shall communicate to all involved departments the nature of the isolation and shall prepare the resident for transport in accordance with current transmission-based precaution guidelines. Event ID: Facility ID: 455963 If continuation sheet Page 15 of 16 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 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove in the kitchen was in a safe operating condition when on 09/19/25 three of ten burners did not light when turned on and on 09/16/25 two of ten burners did not light. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.Findings included: During an observation and interview on 09/15/25 at 9:44 a.m., [NAME] E turned on the gas stove burners with 3 of 10 burners not lighting. The left front burner did not light but no gas was smelled. The back stove second burner to the left and far right did not light with no gas smell noted. She said she was responsible and had been educated to notify the DM and Maintenance Director if the stove burners did not light. She said the burners lit this morning. [NAME] E said the resident risk of a stove burner not lighting was a resident could smell gas. During an observation and interview on 09/16/25 at 11:37 a.m., the DM turned on the gas stove burners with 2 of 10 burners not lighting. The left front burner did not light but no gas was smelled and the back middle burner (3rd from the left) did not light with no gas smell noted. She said the cooks were responsible for notifying her and the Maintenance Director if the burners did not light and she was responsible for notifying the Maintenance Director if the stove burners did not light. The DM said sometimes the stove burners took a long time to light a minute or so. She said the burners lit this morning. The DM said the resident risk of a stove burner not lighting was that a resident could smell gas. During an interview on 09/16/25 at 3:15 p.m., the Maintenance Director said the dietary staff were responsible for notifying him if the stove burners did not light and he would try to fix the stove if he was unable to fix it a technician would be called to come out and fix the stove. He said the dietary staff did not notify him the burners on the stove did not light, but he would go check on it now. The Maintenance Director said the resident risk of a stove burner not lighting was a resident may smell gas but he said no residents are allowed to go in the kitchen so that would not happen. During an interview on 09/16/25 at 3:23 p.m., the Administrator said the cooks or the Dietary Manager was responsible for notifying the Maintenance Director if the stove burners did not light and the Maintenance Director was responsible for notifying her if he was unable to repair it and she would have a technician come out and repair the stove. She said she was ultimately responsible for ensuring the stove and all equipment in the kitchen was in working order. She said a technician was in the facility and had tried to repair the stove but needed to order a part and it would be repaired as soon as the part came in. The Administrator said the cooks would turn the burner off if it did not light immediately until repaired. She said the dietary staff were educated to notify the Maintenance Director and Administrator with all equipment not functioning properly in the kitchen and the Maintenance Director was educated to repair or notify her if he was unable to repair any equipment in the facility. The Administrator said the resident risk of a stove burner not lighting was a resident could possibly get a headache. She said her expectation was all equipment function properly in the kitchen. Record Review of an undated facility policy titled, Maintenance Policies & Procedures indicated, . Ensuring that all equipment, building, spaces, and fixtures are kept in operable condition. The center shall properly maintain the building, its fixtures, systems, and equipment in good working order to ensure that the entire center is clean, free of environmental pollutants, and in good repair at all times. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 16 of 16