Health inspection·October 25, 2023

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 accurately assess each resident's status for 1 of 4 Residents (Resident #36) reviewed for assessment accuracy in that: Residents Affected - Few Resident #36's admission MDS dated [DATE] did not have Section H (bowel and bladder) coded correctly. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records. Finding included: Record review of Resident #36's face sheet dated 08/25/2023 revealed she was [AGE] year-old female. She was admitted to the facility on [DATE] with a diagnosis of Cerebral infarction due to thrombosis of unspecified cerebral artery (disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #36's admission MDS dated [DATE] revealed the following: Section C (BIMS) revealed a score of 11 out 15, reveals that the resident had moderate cognitive impairment. Section H (bowel and bladder) revealed the resident did not have an indwelling catheter, did have an ostomy. Record review Resident #36's orders revealed that the resident had a Foley Catheter, start date of 08/07/2023. Record review of Resident #36 orders from 08/07/2023 to 08/25/2023 revealed that the resident did not have an Ostomy. Record review of Resident #36's care plan dated 08/25/2023 revealed that the resident did not have an ostomy and did have a catheter. During an observation and interview on 10/23/2023 beginning at 3:16 PM, Resident #36 was in her room lying in bed. Resident had a catheter bag hanging from bedside that was covered by a privacy bag. She revealed that she had a catheter before she was admitted into the facility. She revealed that she has never had an ostomy and was unsure what it even was. Observation revealed that the resident did not have an ostomy and did have a catheter. During an interview on 10/25/23 at 09:56 AM, the MDS Coordinator, revealed the admission MDS dated [DATE] was coded inaccurately under the bowel and bladder section. She revealed that Resident #36 has had a catheter since admission and has not had an ostomy since admission. She revealed that the failure could cause an inaccurate care plan and confusion with the floor staff in the care areas. The MDS coordinator revealed that they use the RAI manual for guidance, she was unsure of they had a policy covering it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 2 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr Weatherford, TX 76086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility's policy and procedures regarding resident assessments dated October 2010 revealed: The purpose of this assessment is to describe the resident's capabilities to perform daily life functions and to identify significant impairments in functional capacity derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. A copy of the facilities policy on Accuracy of Assessments was requested on 08/25/2023 and was not received at the time of exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 3 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop the comprehensive care plan with the participation of the resident and the IDT (Interdisciplinary Team) for 2 of 6 residents (Resident #36 and #37) reviewed for care plans. The facility's failure could affect residents by placing them at risk for individual needs not being identified and addressed in the IDT meeting and decreased feelings of self-determination and psychosocial well-being within their living environment. The findings included: Record review of Resident #36's face sheet dated 10/25/2023 revealed resident was a [AGE] year-old female. She was admitted to the facility on [DATE] with a diagnosis of Cerebral infarction due to thrombosis of unspecified cerebral artery (disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #36's admission MDS dated [DATE] revealed the following: Section C (BIMS) revealed a score of 11 out 15, reveals that the resident had moderate cognitive impairment. Record review in Resident #36's electronic record revealed there was a Care Conference completed on 08/10/2023, but it was before the admission MDS assessment containing Section V (CAAS) and the Care Plan was completed. The resident was not included or invited to the meeting. In an interview on 10/23/23 at 3:16 PM, Resident #36 revealed that she has not been included or attended a care plan conference or meeting. She revealed that she had some things she would like to discuss concerning her care. Record review of Resident #37's face sheet dated 10/25/2023 revealed resident was a [AGE] year-old male. He was admitted to the facility on [DATE] with a diagnosis of end stage renal disease (kidney failure), gangrene (tissue death), hypertension (high blood pressure) and symbolic dysfunctions (language deficit). Record review of Resident #37's admission MDS dated [DATE] revealed the following: Section C (BIMS) revealed a score of 15 out 15, reveals that the resident was cognitively intact. Record review in Resident #37's electronic record revealed there was a Care Conference completed on 09/26/2023, but it was before the admission MDS assessment containing Section V (CAAS) and the Care Plan was completed. A RN was not included in the IDT meeting. In an interview on 10/23/2023 at 3:13 PM, Resident #37 stated he had never been invited or attended a care plan conference meeting. In an interview on 10/25/2023 at 09:56 AM the MDS Coordinator revealed from electronic record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 4 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review that the IDT meeting was not conducted at all on Resident #36. She revealed that what was captured before the MDS was completed was a care conference that was requested by the family. She revealed that the care plan was not discussed, since it was not completed yet. She revealed for Resident #37, she did not have a RN or the full IDT present. She revealed that was not doing them correctly. She revealed that Resident #37 did not even have his CAAS completed or the care plan when they had a meeting on 09/26/2023. The MDS Coordinator revealed that she forgot to do it. The MDS Coordinator revealed that the care plan failure could cause the residents to receive improper care. She revealed that she uses the RAI for guidance and for their policy and procedure. Record review of the facility policy Care Plans, dated 02/2021, reflected the following [in part]: 1. Concerns and Problems a. Review CAA (Care Area Assessment) triggers on the MDS. If the interdisciplinary Team (IDCPT) decides to proceed with care planning, list the problem. 1. The specific problem as well as the underlying cause should be listed. 2. If the home is using nursing diagnoses for problem statements, the underlying condition must be identified. This may be done by following the nursing diagnoses with a statement beginning Due to . or Related to . b. Sources are, but are not limited to: 1. Problems relating to diagnoses. 2. Problems relating to physician's orders. (Remember, all orders for care should correspond to a diagnosis.) 3. Dietary problems - including the need for feeding assistance. 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 5 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 0657 Psychosocial problems. Level of Harm - Minimal harm or potential for actual harm 5. Activity problems. Residents Affected - Few 6. Rehabilitation problems. 7. Behavior control problems. 8. Problems related to preventive care. 9. Problems related to provision of safety. 10. All problems identified on all assessments. 11. Specialized services related to PASRR and RT 2. Resident Goals (Short-Term Goals) a. List a measurable, reasonable goal for each problem identified. Goals should be stated in terms of what the resident will or will not accomplish. b. It may be difficult for the staff to think in these terms for gravely ill residents. However, specific goals such as, Skin intact, No weight loss, No further contractures, etc. are measurable. However, the IDCPT must be sure to state a reasonable goal. c. Although each discipline may have a unique goal to accomplish for each problem, all disciplines should work as a team and coordinate efforts to accomplish care plan goals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 6 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 0657 3. Level of Harm - Minimal harm or potential for actual harm Approach / Plan a. Residents Affected - Few List care to be provided for the problem listed. The care must be NECESSARY AND APPROPRIATE to accomplish the goal stated. b. Coordinate care to be provided to the resident for the most effective, efficient utilization of resources. c. Individualize care to ensure the care plan is person centered for the unique needs of the resident. d. Communicate vital information to staff providing direct resident care. e. List infection control measures. f. List safety measures. g. Each discipline should list approaches for the care it will provide. Coordinating care by all disciplines, working toward a common or similar goal, will improve efficiency. 4. Involved Service or Responsible Discipline a. The following persons are to be involved in the development of the care plan: Licensed nurses (LVN/RN) Registered Nurse (RN) Nursing assistants (C N A responsible for resident). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 7 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 0657 Restorative nursing assistant (RNA). Level of Harm - Minimal harm or potential for actual harm Dietary supervisor (FSS). Social Service Designee (SSD). Residents Affected - Few Activity Director (AD). Therapists (RPT, ST, OT, RRT). Attending Physician Any other professional needed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 8 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 2 (Resident #31 & Resident #36) residents reviewed for individual activities. Residents Affected - Some The facility failed to provide one-on-one visits to Resident #31 & Resident #36 as care planned. This failure could result in residents having a diminished quality of life. Findings included: Record review of Resident #31's face sheet dated 10/24/2023 revealed an [AGE] year-old female who was admitted on [DATE] (initial) and 09/10/2023 (most recent) with diagnoses of adult failure to thrive (state of decline), cognitive communication deficit (difficulty with thinking and how someone uses language), weakness, dysphagia following nontraumatic subarachnoid hemorrhage (difficulty swallowing after brain bleed not caused by trauma), reduced mobility, and hemiplegia (inability to move one side of the body). Record review of Resident #31's quarterly MDS dated [DATE] revealed BIMS of 15 meaning cognitively intact. Resident #31 needs extensive one person assistance with bed mobility, self-performance, and toilet use. Resident #31 was not observed to transfer or walk at the time of the assessment. Resident #31 needed supervision / setup with eating at the time of the assessment. Received medications for anxiety, depression, fluid retention, and infection. Record review of Resident #31's care plan revealed problem start date: 04/12/2023 category: activities . is a one on one in room. She likes to have her nails done and reminisce. Her Husband visits her every day. She likes to read and watch television. She is a bed bound resident. But enjoys our visits. Intervention: Resident will have one on one room visits 3 times per week through the review date. The resident will maintain involvement in cognitive stimulation, social activities as desired through review date. During an interview on 10/24/2023 at 12:07 p.m., Resident #31 stated there was a man that comes to visit her some but doesn't know when he was here. She stated that she thought he was a chaplain. She stated that she had care plan meetings in her room since she did not like to get out of bed. She stated that the activities director did not come into room three times a week. Resident #31 stated that she was not lonely as she had Jesus. Record review of Resident #36's face sheet dated 10/24/2023 revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses of pain, open-angle glaucoma (disease that affects vision), cerebral infarction due to thrombosis of infarction (stroke caused by blood clot), aphasia (difficulty swallowing), hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side (inability to move or weakness of left side that is not dominant as person is right handed), cognitive communication deficit (difficulty with thinking and how someone uses language), weakness, and depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 9 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #36's comprehensive MDS dated [DATE] revealed BIMS of 11 meaning moderately impaired cognition. Resident is dependent on staff to perform oral hygiene (clean teeth), toileting, bathing, dressing, putting on and taking off footwear, and transferring from bed to chair. Record review of Resident #36's care plan revealed problem start date: 10/01/2023 category: activities . needs one on one in room social interactions AD visits 2x a week for stimulating conversations about news and tv shows the weather current events in the work. Sometimes refuses visits do to pain or family visitors. During an interview on 10/24/2023 at 10:23 a.m., Resident #36 stated she did not get to participate in activities much. She stated she uses a hoyer lift (machine that allows staff to transfer someone that cannot assist with transfer). During an interview on 10/25/2023 at 9:50 a.m., AD stated that she had been doing activities. She will provide print out of documentation for the residents' one on one activities. She revealed she had not been good with documenting activities in facility's electronic system. Record review of the facility's one on one documentation dated 08/25/2023 provided revealed that both Resident #31 and Resident #36 had two 1:1 observation in the month of October. During an interview on 10/25/2023 at 1:30 p.m., AD stated that the observations were the only documented. She stated that she has 7 days to document activities. During an interview on 10/25/2023 at 1:48 p.m., ADMN stated that documentation should occur within 24 hours of activity being performed. She stated that staff members should not be documenting anything on a note pad, it should be completed in electronic documentation. She stated that all staff had been trained on documentation. Record review of the policy titled ONE-ON-ONE PROGRAM dated 01/01/2023 revealed Policy One-on-one wellness visits will be provided for those residents whose physical or intellectual impairments prohibit their active involvement in group programs and/or those residents wo prefer not to attend group programs and/or for identified short term rehab patients. Procedure Wellness staff will utilize the One-on-One Tracking form to maintain an up to date list of residents identified for one-on-one programming each month. When visits are completed the date of intervention is noted and the appropriate documentation information is completed in the wellness activity participation documentation (form or EMR depending on facility) .The resident's individual care plan must include identified need and interventions as well as the number of visits he/she is to receive per week. The wellness staff are responsible for documenting each one-on-one session according to the facility documentation process (see Home Office Forms for paper log and refer to EMR as identified) and should include: Date, Duration of visit, Intervention(s), Response(s). If a one-on-one intervention is offered but the resident refuses, it must also be documented with reason for refusal. Based on interview, and record review the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 2 (Resident #31 & Resident #36) residents reviewed for individual activities. The facility failed to provide one-on-one visits to Resident #31 & Resident #36 as care planned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 10 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 0679 This failure could result in residents having a diminished quality of life. Level of Harm - Minimal harm or potential for actual harm Findings included: Residents Affected - Some Record review of Resident #31's face sheet dated 10/24/2023 revealed an [AGE] year-old female who was admitted on [DATE] (initial) and 09/10/2023 (most recent) with diagnoses of adult failure to thrive (state of decline), cognitive communication deficit (difficulty with thinking and how someone uses language), weakness, dysphagia following nontraumatic subarachnoid hemorrhage (difficulty swallowing after brain bleed not caused by trauma), reduced mobility, and hemiplegia (inability to move one side of the body). Record review of Resident #31's quarterly MDS dated [DATE] revealed BIMS of 15 meaning cognitively intact. Resident #31 needs extensive one person assistance with bed mobility, self-performance, and toilet use. Resident #31 was not observed to transfer or walk at the time of the assessment. Resident #31 needed supervision / setup with eating at the time of the assessment. Received medications for anxiety, depression, fluid retention, and infection. Record review of Resident #31's care plan revealed problem start date: 04/12/2023 category: activities . is a one on one in room. She likes to have her nails done and reminisce. Her Husband visits her every day. She likes to read and watch television. She is a bed bound resident. But enjoys our visits. Intervention: Resident will have one on one room visits 3 times per week through the review date. The resident will maintain involvement in cognitive stimulation, social activities as desired through review date. During an interview on 10/24/2023 at 12:07 p.m., Resident #31 stated there was a man that comes to visit her some but doesn't know when he was here. She stated that she thought he was a chaplain. She stated that she had care plan meetings in her room since she did not like to get out of bed. She stated that the activities director did not come into room three times a week. Resident #31 stated that she was not lonely as she had Jesus. Record review of Resident #36's face sheet dated 10/24/2023 revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses of pain, open-angle glaucoma (disease that affects vision), cerebral infarction due to thrombosis of infarction (stroke caused by blood clot), aphasia (difficulty swallowing), hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side (inability to move or weakness of left side that is not dominant as person is right handed), cognitive communication deficit (difficulty with thinking and how someone uses language), weakness, and depression. Record review of Resident #36's comprehensive MDS dated [DATE] revealed BIMS of 11 meaning moderately impaired cognition. Resident is dependent on staff to perform oral hygiene (clean teeth), toileting, bathing, dressing, putting on and taking off footwear, and transferring from bed to chair. Record review of Resident #36's care plan revealed problem start date: 10/01/2023 category: activities . needs one on one in room social interactions AD visits 2x a week for stimulating conversations about news and tv shows the weather current events in the work. Sometimes refuses visits do to pain or family visitors. During an interview on 10/24/2023 at 10:23 a.m., Resident #36 stated she did not get to participate in activities much. She stated she uses a hoyer lift (machine that allows staff to transfer someone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 11 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 0679 that cannot assist with transfer). Level of Harm - Minimal harm or potential for actual harm During an interview on 10/25/2023 at 9:50 a.m., AD stated that she had been doing activities. She will provide print out of documentation for the residents' one on one activities. She revealed she had not been good with documenting activities in facility's electronic system. Residents Affected - Some Record review of the facility's one on one documentation provided on 10/25/2023 revealed that both Resident #31 and Resident #36 had two 1:1 observation in the month of October of 2023. During an interview on 10/25/2023 at 1:30 p.m., AD stated that the observations were the only documented. She stated that she has 7 days to document activities. During an interview on 10/25/2023 at 1:48 p.m., ADMN stated that documentation should occur within 24 hours of activity being performed. She stated that staff members should not be documenting anything on a note pad, it should be completed in electronic documentation. She stated that all staff had been trained on documentation. During an interview on 10/25/2023 at 1:48 p.m., AD stated she had not documented activities. She stated that she was unsure of how many times each resident required one on one. Record review of the policy titled ONE-ON-ONE PROGRAM dated 01/01/2023 revealed Policy One-on-one wellness visits will be provided for those residents whose physical or intellectual impairments prohibit their active involvement in group programs and/or those residents wo prefer not to attend group programs and/or for identified short term rehab patients. Procedure Wellness staff will utilize the One-on-One Tracking form to maintain an up to date list of residents identified for one-on-one programming each month. When visits are completed the date of intervention is noted and the appropriate documentation information is completed in the wellness activity participation documentation (form or EMR depending on facility) .The resident's individual care plan must include identified need and interventions as well as the number of visits he/she is to receive per week. The wellness staff are responsible for documenting each one-on-one session according to the facility documentation process (see Home Office Forms for paper log and refer to EMR as identified) and should include: Date, Duration of visit, Intervention(s), Response(s). If a one-on-one intervention is offered but the resident refuses, it must also be documented with reason for refusal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 12 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift in a place readily accessible to residents and visitors, in that: Residents Affected - Many 1. The facility failed to update and post the daily nurse staffing information on 10/25/2023. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. The findings included: Observation on 10/25/2023 at 2:30 PM revealed the daily nurse staffing pattern was not posted on the wall in the location designated for it. In an interview on 10/25/2023 at 2:35 PM, ADON stated, I'm sorry I failed to change the staffing today because I've been working ever since last night. In an interview on 10/25/23 at 2:40 PM DON stated, We post the staffing daily today it was just an oversight on our part, and she said failure to post the daily staffing would give the public inaccurate information regarding the facility staffing, and census. In an interview on 10/25/23 at 2:53 PM Administrator stated, we don't have a policy on nurse staff posting but the staff posting is posted daily by the ADON and I check it on a daily basis but with everything that's going on I failed to check it today. She said not posting the information would give the public inaccurate information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 13 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Keeneland 700 S Bowie Dr 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 medications were secured on 1 of 2 medication carts reviewed for pharmacy services. The facility did not ensure medications carts were secured and locked. This failure could place the residents who resided in the facility at risk of a drug diversion. Findings included: During an observation on 10/24/2023 at 4:36 PM, LVN A left a medication cart unlocked and unattended. She did not have visual of the medication cart. There were 3 residents that were in close range to the medication cart. The medication cart contained medications that were perscribed to the residents. During an interview on 10/25/2023 at 9:32 AM with LVN A, she revealed that she walked away after she found out she was going to have to work a different area than she normally does. She stated she stepped away and wasn't paying attention to the cart and if she locked it. She revealed the failure could cause the resident to gain access to medications that would be bad for them. She revealed she has received training on locking the medication carts. She revealed that it was a one-time failure, and she has since been in-serviced on it. During an interview on 10/25/2023 at 10:00 AM with the DON, revealed that her expectations are for the medication carts to be locked anytime a nurse walks away from it. She revealed that she has provided training to LVN A. A policy and procedure titled: Medication storage dated 02/2021 was received on 10/25/2023 at 10:03 AM, revealed the following: 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675708 If continuation sheet Page 14 of 14