Health inspection·March 17, 2025

F 0684 Review of Resident #1's progress note by LVN A dated 02/10/25 reflected, New order for itching to increase hydroxyzine to 20 mg q6hr prn. Level of Harm - Actual harm Residents Affected - Some Review of Resident #1 progress note by LVN A dated 02/19/25 reflected, Resident states that she is still itching and in pain. PRN tramadol given for the pain and hydroxyzine (used to treat itching caused by allergies) for the itching. hydroxyzine is not helping, PCP notified awaiting response. Review of Resident #1's MD note dated 02/25/25 revealed Resident #1 presented with generalized pruritus. She reported itching in various areas including her throat, tummy, and legs and mentioned having sores on her head which she describes as full of sores and so bad. Review of Resident #1's progress note by AN C dated 03/03/25 reflected, patient is requesting medication for itching, told her she had it ordered 4 times a day. She wanted something between that. Will ask MD in the morning (have AM nurse call MD). Review of Resident #1's progress notes from 3/04/25 through 3/15/25 revealed no progress notes concerning any contact made to the MD regarding additional medication for Resident #1's itching. Attempted to reach AN C on 03/17/25 at 1:16 pm regarding Resident #1's progress note made by AN C dated 03/03/25 by leaving a voice mail and sending a text message, no response was received from AN C. Observation and interview on 03/15/25 of Resident #1's pillowcase at 11:45 am revealed many areas of varying sizes of dried brown spots that appeared to be blood. Resident #1 revealed she said she itched all the time, and it was horrifying. She said she itched on her head, neck, and back and the doctor told her it was her kidneys that caused the itching issues, and he could not do anything else for her. She said she had sores on her head and neck. She said, oh yea, she had told the staff she was uncomfortable, but she did not remember the names of anyone she told. She revealed the dried brown spots on her pillow were from blood from her scratching her head. Interview on 03/16/25 with CNA B at 10:12 am revealed Resident #1 had asked to go to the hospital for itching and had sores from where she was scratching. CNA B revealed there were sores on Resident #1's shoulders and her head where Resident #1 had scratched. CNA B said the nurses were aware of the areas where Resident #1 had scratched. CNA B said Resident #1 was always complaining of itching and it worried CNA B that Resident #1 was always telling them she was, itching and itching and itching. CNA B said they have, done above and beyond for the itching. CNA B said Resident #1 was itching because she had kidney failure. Review of Resident #1's hospital records dated 03/16/25 reflected Resident #1's chief compliant was skin rash and itching. Records reflect that, it started several months and is still present. It is described as itchy. Not painful or burning and has been located on the right and left back. It has been located on the right and left shoulder and neck. No cause has been identified. Observation on 03/17/25 at 1:20 pm with LVN A present revealed Resident #1 left thigh had some red marks, total size about 2 inches in length ¾ inch width. A couple pin-point areas where skin was broken. No drainage or odor. Wound looked very new. Bilateral trapezius/shoulder area with multiple 0.5cm or less scabs. Surrounding skin not red/inflamed or otherwise irritated. Resident rolled on side, no other skin impairment to back side. Resident complained of whole head itching, no wound visible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675096 If continuation sheet Page 2 of 6 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 675096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645 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 0684 Observation and interview on 03/17/25 at 2:45 pm Resident #1 was scratching her head and neck. Resident #1 said she itched a lot all the time and they never put any medicated lotion on her. Level of Harm - Actual harm Residents Affected - Some Interview on 03/17/25 at 12:21 pm LVN A revealed she gave the prn triamcinolone lotion to Resident #1 3-4 times, but did not chart the medication administration and said my bad. Observation and interview on 03/17/25 at 12:30 pm LVN A checked Resident #1's nurse cart, treatment cart, and medication room for Resident #1's triamcinolone prescription. LVN A revealed she could not find Resident #1's prn triamcinolone prescription medication. Interview on 03/16/24 with the ADON at 1:43 pm revealed Resident #1's itching had been an ongoing thing and they have tried different creams, but they could not cure it. She said Resident #1 had a kidney problem and that was the cause of the itching. Resident #1 had complained a lot about the itching, and she scratched herself a lot. She had a scratching tool at one time. The ADON stated her pillowcase had blood on it from areas where she was scratching, and the blood might be from scratching her shoulders. When shown the pictures of Resident #1's pillowcase with the brown areas the ADON said, oh wow she would have to go down there to look and see where it was coming from. She said Resident #1 got little nicks from scratching and Resident #1 did scratch on her shoulders and neck a lot. The ADON said sometimes Resident #1 was smiling and sitting up eating and then sometimes she was itching. The itching had been a problem for a long time. She asked sometimes to go to the hospital because she wanted it to be cured so badly because it was miserable. Interview on 03/17/25 with the ADON at 4:45 pm stated when you are nurse you are going to give residents the ordered medication and then offer them anything prn. She said Resident #1's itching could not be cured but you wanted to give her some relief if possible. She said it does not meet her expectations that Resident #1's prn triamcinolone prescription medication could not be located and was not ever administered to Resident #1. She said it was not good practice that it had not ever been tried as a relief for Resident #1's itching. Interview on 03/17/25 with the DON at 3:12 pm revealed Resident #1 had a complaint of itching, and whether to administer a prn medication was based on the nurse's assessment at that time. She said that because the prn medication had been ordered by the MD on 12/16/24 the nurses should have been applying the prescribed prn triamcinolone acetonide topical medication. The DON said the negative effect of not trying the prn medication was, if you did not apply the medication, you did not know if it worked. The DON stated she did not know that Resident #1's triamcinolone acetonide topical medication could not be located by LVN A and that was a problem because the medication was not available to administer to Resident #1. Interview on 03/17/25 with the Administrator at 4:04 pm revealed Resident #1's itching had been a problem since she has been admitted to the facility. The Administrator felt that someone should have tried to use the ordered prn triamcinolone acetonide topical medication to see if it could have given her some relief from the itching. She stated she did not know if the nurses educated Resident #1 about the prn medication and did not know how, because of Resident #1's itching issues, this medication was never offered to Resident #1. The Administrator said she did not know that the prn triamcinolone acetonide topical medication could not be located when the nurse surveyor asked to see the medication. The negative effect of them not offering her the prn medication was that if given the medication, Resident #1 might have had some relief from the itching. The Administrator stated that not offering medication that could have potentially provide relief from her itching is not good quality of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675096 If continuation sheet Page 3 of 6 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 675096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645 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 0684 Level of Harm - Actual harm Residents Affected - Some Interview on 03/17/25 with Resident #1's MD at 3:47 pm revealed it was ridiculous that Resident #1 was never given her prn prescription for triamcinolone. The MD said the medication had a steroid that helped decrease inflammation and it could have potentially given Resident #1 some relief from the itching. He said Resident #1 had the prescription for several months, it should be available and at the facility for use, and he would not have prescribed it if he did not think it could have given her some relief. Facility Medication Administration policy dated April 2019 reflected medications are to be administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include enhancing optimal therapeutic effect of the medication and honoring resident choices and preferences, consistent with his or her care plan. If a drug is refused, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. Topical medications used in treatments are recorded on the resident's treatment administration record. Facility Medication Labeling and Storage policy dated 2001 reflected medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications for several residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675096 If continuation sheet Page 4 of 6 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 675096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645 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 observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one (Resident #1) of four residents reviewed for accidents hazards, in that: The facility failed to ensure Resident #1 was transferred by mechanical device from her shower chair to her bed without receiving a cut and a bruise on her right toe. This failure could place residents at risk of pain, bruising, or skin tears. The findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life, diastolic (congestive heart failure - a condition where the heart muscle is unable to relax properly between heartbeats, leading to reduced filling of the heart chambers and decreased cardiac output),). Review of Resident #1's care plan reflected no goal, problem, or approach related to resident's ADLs or transfers. Review of Resident #1's quarterly MDS assessment, dated 03/05/25, reflected a BIMS score of 10 suggesting moderate cognitive impairment. Section GG - Functional Abilities of Resident #1's MDS reflected lower extremity (hip, knee, ankle, foot) impairment on both sides, Resident #1 used a wheelchair as a mobility device, Resident #1 was dependent with toileting hygiene, shower/bathing, lower body dressing, and putting on/taking off footwear. Resident #1 requires substantial/maximal assistance with sit to lying, lying to sitting on the side of bed, sit to stand, and chair/bed-to-chair transfer. Review of facility Event Report dated 03/15/25 reflected, Per [CNA B] spoke with [family member] about skin tear to the end of right great toe. The incident occurred when transferring from shower chair to bed via [mechanical lift]. She grabbed chair as they were raising her with [mechanical lift]and it came up and hit the end of her toe. Observation on 03/15/25 at 11:45 am of Resident #1's right toe revealed a closed dark purple colored cut approximately 1 inch in length surrounded by bruising on the top of Resident #1's right toe. Wound surrounded by dry skin and left open to the air. Interview on 03/15/25 with Resident #1 at 11:45 am revealed, that staff (Resident #1 did not know the names of the staff) were giving her a shower and they hit her into something when she was in the mechanical lifting device and she was, screaming blood murder. She said it happened when they took her off the chair and the chair fell over. Interview on 03/16/25 with CNA B at 10:12 am revealed on 03/12/25, between 2:00 pm and 4:00 pm, CNA B and CNA E were transferring Resident #1 from the shower chair to the bed using a mechanical lifting device. The shower chair did not stay on the ground when Resident #1 was being raised by the mechanical lift. The shower chair, which was snug against Resident #1's sides, came up with Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675096 If continuation sheet Page 5 of 6 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 675096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645 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 when she was lifted by the mechanical lifting device. Resident #1 grabbed the arms of the shower chair and the shower chair fell to the floor, bounced and a wheel on the shower chair hit Resident #1's right toe and made a cut to Resident #1's right toe. Resident said, my toe my toe. CNA B said Resident #1's toe was bleeding and CNA B put a wipe around the base of Resident #1's toe away from the tip of the toe which was bleeding to catch the blood. CNA B stated the remainder of the transfer of Resident #1 to her bed was uneventful. CNA B stated she notified AN D. Attempted to reach CNA E on 03/17/25 at 11:51 am no response was received from CNA E. Attempted to reach AN D on 03/17/25 at 9:36 am and 10:10 am no response was received from CNA E. Interview on 03/17/25 with the Administrator at 1:21 pm reflected she was aware of the shower chair incident with Resident #1 and said Resident #1 was injured and the facility needed to check out the chair and talk to the staff and find out if it was an isolated accident. Review of Safety and Supervision of Residents policy dated July 2017 reflected the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk and environments hazards are addressed in dedicated policies and procedures. These risk factors and environments hazards include the following: Safe lifting and movement of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675096 If continuation sheet Page 6 of 6