Inspection·June 5, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few verbalize satisfaction with person centered programming over the next 90 days. Approach/interventions included: He spends much of his time walking around the facility. Understand that behaviors result from changes in the brain and difficulty with communication. I am on an antidepressant due to depression, with the goal that the resident will experience limit episodes of depression over the next 90 days. Approach/interventions included: Encourage resident to attend activities of choice. Observation and interview with Resident #23 on 06/03/2025 at 10:18AM revealed Resident #23 walking down the hallway and into his room. Resident #23 discussed with the surveyor that he did not participate in therapy provided by the facility. He stated he did his own exercise therapy to stay strong. Resident #23 had a goal of walking 100 laps around the facility each day. Observation and interview with Resident #23 on 06/03/2025 at 10:51AM revealed Resident #23 walking a lap in the hallway. During the resident's walk, he showed the surveyor the 2 sets of weights velcro wrapped around his wrists. Resident #23 stated he used wrist weights as a part of his exercise activity to stay strong. The resident discussed wanting to be discharged to go to an assisted living facility. Observation and interview with Resident #23 on 06/03/2025 at 11:03AM revealed Resident #23 approached surveyor visibly upset, indicated by his facial expression. The resident said the gym (the occupational therapy and physical therapy room) took away the wrist weights he was wearing because state was here and pointed to the surveyor. To confirm what the resident communicated, the resident was asked if he normally wears the weights around his wrists while he walks his laps, but because state surveyors are in the facility, they took them away. The resident confirmed this by stating yes and shaking his head. Interview on 06/03/2025 at 1:47PM with PTA revealed she worked with Resident #23 when he was on the physical therapy caseload. The resident discharged himself from therapy because he did not think he needed it. The PTA stated Resident #23 took charge of his physical activity and he had been given permission to use the therapy gym's equipment. She further stated Resident #23 knew he was not supposed to take the (wrist) weights out of the gym and had to be reminded not to take gym equipment. The PTA stated she recently talked with the DOR about alternatives options for the resident to prevent him from taking wrist weights out of the gym. Interview on 06/03/2025 at 1:56PM with the DOR revealed Resident #23 had a medical condition (impairment) due to frontal lobe involvement and it was hard to regulate the resident's agitation. The resident was periodically on therapy's caseload; he would stick with therapy for a couple weeks and then discharge from the therapy plan. The DOR stated the resident liked to come into the therapy gym and it was always open for him to come in and work out if staff were present. The DOR stated Resident #23 liked to be as independent as much as possible, and in the past, the resident wanted to use equipment outside of the gym, but it had to be stopped. She further stated with or without survey, he would have been stopped; therapy did not want the resident to lose the wrist weights. The DOR stated she planned to look into having the resident purchase his own set of wrist weights. Other alternatives include having him participate in group activities. The DOR stated staff have to be very mindful of resident switching gear or having agitation (when interacting with resident and trying to redirect him). Observation and interview on 06/04/2025 at 11:52AM with Resident #23 revealed the resident walking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0561 Level of Harm - Minimal harm or potential for actual harm around the facility while not wearing the wrist weights. Resident appeared to still be upset about the wrist weights being taken away. He stated he had not used them since because state was in the facility. At this time, the resident approached LVN 2. The surveyor asked LVN 2 if Resident #23 normally wears wrist weights when walking laps in the facility, she stated he did. LVN 2 stated the resident using the wrist weights has never been a problem. Residents Affected - Few Interview on 06/05/2025 at 11:38 PM with LVN 3 revealed she provided care to Resident #23, and he was independent, unless he was not feeling well or asked staff for something. She explained the resident walked all day and sometimes took breaks, he walked to stay strong. LVN 3 recalled Resident #23 wearing weights on his wrist on 06/03/2025. She said she questioned the resident on why he was wearing the wrist weights and that he became mad. She said that he made many laps around the facility, and she asked him to take a break from the weights; the resident said no and continued walking. LVN 3 explained that when the resident does something he wants to do, you cannot tell him no; he can get upset quickly, and walking helps with the resident's mood. LVN 3 stated the resident had used a wheelchair in the past, but once he was walking, he felt like he was gaining independence. Interview with the DOR on 06/05/25 at 12:18 PM revealed Resident #23 had used the wrist weights while on caseload for therapy exercises like bicep curls. The DOR explained that it was preferred if the resident came into the therapy gym when it was not busy so they can keep an eye on him. She said the PTA said the gym was busy at the time of when Resident #23 had taken the wrist weights on 6/3/2025. The DOR stated that on 6/3/2025, Resident #23 was seen with multiple (2) sets of wrist weights on his wrist and wanted to walk laps around the facility; the resident was asked to leave the weights in the gym. She said that if the resident was walking around and no one needs the weights, he can walk with them. She emphasized him coming back and utilizing the weights at another time, if the gym was busy. The DOR described Resident #23 as goal driven did not follow a specific schedule, but she will talk with the resident about making more of a schedule to avoid types of conversations that would upset him. The DOR stated therapy wanted to provide patient centered care 100%. It's important to give him tools (equipment) to utilize safely, because the equipment was important to him. Interview with the DON on 06/05/2025 at 2:58PM revealed therapy (staff) and the DOR have told the DON that Resident #23 had to be supervised when using the wrist weights and they are to be kept in the therapy gym, so they were not lost or stolen. She further stated she has not seen Resident #23 wearing the wrist weights. The DON stated she had no problem care planning the wrist weights and it had never been an issue before since the resident has not been upset before. It was never a concern to have to come up with an intervention. She stated that it was resident's right to have independence, and if that (using the wrist weights) was what makes him feel better. Interview with the ADM on 06/05/2025 at 4:08PM revealed that the ADM was told the reason therapy wanted Resident #23 to stay in the gym with the wrist weights was for safety; she understood it as he was being monitored. The ADM stated the resident's independence was at risk if he was not able to have access to his wrist weights; it could have an issue with the resident being able to go home, since he wanted to discharge from the facility, and (not allowing the resident to walk with weights) could keep him from improving (his mobility and strength, in which is essential for performing ADL tasks independently). The ADM explained that the resident had a goal in his mind and it was his right to walk laps around the building. The ADM stated interventions to meet Resident #23 needs include providing him with his own wrist weights, to care plan use of wrist weights, and his preference to use in his room or the facility. Record review of the facility's Resident Rights Policy Statement revised February 2021 reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0561 Level of Harm - Minimal harm or potential for actual harm Employees shall treat all residents with kindness, respect, and dignity . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . e. self-determination; . p. be informed of, and participate in, his or her care planning and treatment . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. 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 a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for 1 of 1 reviewed for resident council meeting. Residents Affected - Some The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns [NAME] to lack of privacy. Findings included: Interview on 06/03/2025 at 1:00 PM with Activity Director revealed monthly resident council meetings were held in the facility's dining room because of space needed to accommodate the residents. She stated meetings should be conducted in a private area to allow the residents to express their concerns freely and openly. Observation and interview on 06/04/2025 at 10:00 AM during a confidential resident group meeting with 13 residents revealed the meetings were held in the dining room. The dining room was an open space where staff members would come into the dining room during resident council to get ice. Residents voiced concern for privacy but felt noting was being done. During survey, resident council meeting was held in the facilities therapy gym however due to limited space all residents who wanted to attend were unable to attend. Record review of resident council minutes for 3/2025, 4/2025 and 5/2025 addressed concerns with call light response time and meal portions. No location of resident council meetings. 3/2025 meeting minutes revealed 9 residents attended; 04/2025 meeting minutes revealed 9 residents attended; 05/2025 meeting minutes revealed 10 residents attended. Review of policy titled Resident Council revised February 2021 reflected, The resident council group is provided with space, privacy and support to conduct meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide a clean and functional environment for 3 of 14 rooms (Residents #5, Resident #36, Resident #1, and Resident #14) reviewed for a sanitary, functional, and homelike environment, as evidenced by: 1. Resident #5's room had an unrepaired wall and noticeably hanging loose paint particles by the head of his bed. 2. The facility failed to ensure Resident #36, Resident #1 and Resident #14's restroom flooring and tiles were repaired, and faucets had both hot and cold running water in the sink. 3. The facility failed to ensure Resident #1 and Resident #14's room did not have a strong urine odor. These failures could place residents at risk for a decreased quality of life. 1. Resident #5 Record review of Resident #5 face sheet dated 06/05/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting the left side (Partial paralysis of left side due to stroke), major depressive disorder a mental health disorder characterized by persistently depressed mood and loss of interest in activities), wheezing (high pitch sound when breathing caused by inflammation of airways in lungs), dermatitis (itchy inflamed skin), and speech and language problem, and generalized anxiety disorder (this is a mental condition characterized by feeling worried, anxiety, or fear that is strong enough to interfere with one's daily activities. Record review of Resident #5's quarterly MDS assessment, dated 05/24/25, revealed a BIMS score of 9 which indicated moderative impairment. Resident #5 has a range of motion impairment on the left side of her upper and lower extremities and uses a wheelchair for mobility. Resident #5 required substantial/maximum assistance of staff for all ADLs and was always incontinent of bladder and bowel. Observation and interview on 06/03/25 at 11:26 AM revealed the bed for Resident #5 had been moved from the wall a few inches and revealed wall paint that had peeled off and some paint was hanging off the wall and uneven, bumpy texture of wall behind Resident #5's headboard. Resident #5 stated that because the damaged wall was hidden from his viewpoint, it did not bother him. In an interview with Housekeeper H on 06/04/25 at 1:02 PM, she stated she was not aware of the condition of Resident #5's wall prior to observing it today. She said it appeared as if someone had been pushing the bed too close to the wall and the up and down movement of the head of the bed had peeled the pain off the wall. She said that housekeeping would clean the area if it was dirty. She stated everyone was responsible for reporting an item that was broken, including walls that needed fixing. Housekeeper H stated she would report Resident #5's wall to her manager immediately. She said maintenance was responsible for monitoring the conditions of the building, however it was everyone's responsibility to report any maintenance issues. She said the risk to the resident was that the loose and hanging paint could fall on his food or it could fall in his eyes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0584 Level of Harm - Minimal harm or potential for actual harm In an interview with LVN E on 06/05/25 at 1:43 PM, it was revealed she had verbally reported Resident #5's wall condition to the previous maintenance several times. She said they had a lot of maintenance turnover and that could be why it was not fixed. She said the risk to the resident was that it was not a homelike environment. Residents Affected - Some 2. Resident #36 Record review of Resident #36's face sheet, dated 06/05/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] with an original admission date of 03/05/2021. Resident #36's primary diagnosis was cerebral infarction (stroke). Record review of Resident #36's Quarterly MDS, dated [DATE], revealed a BIMS score of 12, indicating moderate cognitive impairment. Observation on 06/03/2025 at 10:10 am revealed Resident #36's bathroom entry had approximately 5 floor tiles missing, and the faucet had no water when the cold handle was turned. 3. Resident #1 Record review of Resident #1's face sheet, dated 06/05/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1's primary diagnosis was epileptic seizures (a brain condition that causes recurring seizures) related to external causes. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate cognitive impairment. Resident #14 Record review of Resident #14's face sheet, dated 06/05/2025, revealed a [AGE] year-old man who admitted to the facility on [DATE]. Resident #14's primary diagnosis was dysthymic disorder (a form of depression). Record review of Resident #14's Quarterly MDS, dated [DATE], revealed a BIMS score of 8, indicating moderate cognitive impairment. Observation on 06/03/2025 at 10:07 am revealed Resident #1 and Resident #14 were not in the room. The room smelled like urine and the bathroom had approximately 2 missing floor panels underneath the sink. Observation on 06/03/2025 at 1:29 pm revealed Resident #1 and Resident #14's room had a strong urine odor. Observation on 06/04/2025 at 1:21 pm revealed Resident #1 and Resident #14 room had a strong urine odor. The bathroom sink had no running water when the hot handle was turned on. Interview on 06/05/2025 at 10:37 am, Housekeeper G stated she did notice an odor in Resident #1 and #14's room. She stated she mopped the floor with disinfectant and wringed out the mop. She stated there was not much they could use for the smell. She stated when she noticed something that needed to be repaired in a resident room she would tell her boss, the Maintenance Man or front office. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated it was important for rooms to be clean and functioning for the residents' sake because it was their home. Interview on 06/05/2025 at 10:47 am, The Housekeeping Supervisor stated Resident #1 and #14's room was pretty hard to clean. She stated they did the best they could and mopped the floor 3-4 times a day. She stated they used the chemicals provided and sometimes the resident would urinate on the floor. Interview on 06/05/2025 at 11:01 am, CNA A stated Resident #1 urinates on his pants, removes his clothes, and puts them in the closet. CNA A stated Resident #1 does not wear briefs and was independent. She stated she noticed an odor in his room in the morning, but after staff picked up the clothes and housekeeping cleaned the room there was no odor. CNA A said she did not notice the bathroom flooring missing or that there was no hot water on in the sink. She stated if something needed repairs she would tell maintenance. CNA A stated it was important for residents to have a clean and functioning environment for their health and comfort. Interview on 06/05/2025 at 11:32 AM, LVN 3 stated she could not deny there was an odor in Residents #1and #14's room. She stated if she noticed a strong urine odor, she would let the doctor know in case the resident had an infection and let housekeeping know to clean the room. LVN 3 stated she did not notice the missing flooring or no hot water in the bathroom. She said if something was not working, she was supposed to let Maintenance know. She stated it was important to make sure residents had a clean environment to prevent infection and because it was their home. Interview on 06/05/2025 at 3:00 pm, the DON stated she was aware of the odor in Resident #1's room. She said staff worked on it nonstop to make sure Resident #1 was clean and dry, linens were clean and dry, and to make sure nothing on the floor was clean. The DON stated Housekeeping was responsible for cleaning the room and nursing was responsible for changing clothing. The DON stated she was not aware of any water issues in Resident #1, #14 and # 36's rooms. The DON stated water was a basic need and residents needed to be able to wash their hands or wash up and staff needed to be able to wash their hands. She stated she expected staff to report any issues to maintenance through TELS, and to tell him verbally if it was urgent. She stated they monitor the environment by making rounds Monday through Friday, and anything noticed they would bring to the morning meeting and notify Maintenance or Housekeeping. Observation and interview on 06/05/2025 at 3:46 pm, the Maintenance Director stated he put a brand new faucet in Resident #1 and #14's room today. The hot and cold water was observed to be working. He stated he did not notice the flooring in that room. Surveyor and Maintenance Director went to Resident #36's room and the Maintenance Director stated there was tile missing on the floor and there was no hot water when he turned on the faucet. He stated he was not aware of the water or missing tiles. He said staff were supposed to call or text him if something needed to be fixed. He stated he had access to TELS work order system on his phone. He said it would not be a homelike, safe, or clean environment resident rooms were not working or needed to be repaired. He stated it was important to have working faucets so residents could wash themselves and for staff to wash their hands. Interview on 06/05/2025 at 4:18 pm, the Administrator stated staff were supposed to put in a work order to let Maintenance know, as well as go tell him if something needed to be repaired. She stated if they could not find him, they were to let someone in management know. She stated Resident #1 would sometimes go to the restroom, but it was hit and miss. She stated the risks would be UTI, dignity, comfort, and depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0584 Level of Harm - Minimal harm or potential for actual harm Record review of facility work orders, dated 03/01/2025 through 05/31/2025, revealed no work orders for rooms of Residents #5, #36, #1 or #14. Review of the facility policy Homelike Environment, revised February 2021, reflected: Homelike Environment Residents Affected - Some Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment ( .) Policy Interpretation and Implementation: 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; ( .) c. inviting colors and décor; d. personalized furniture and room arrangements; e. clean bed and bath linens that are in good condition; f. pleasant, neutral scents; ( .) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 - Some 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, interview and record review, the facility failed to ensure that one of one resident (#31) removed oxygen tubing and tank before entering smoking area and smokers extinguish cigarette in designated areas. Staff failed to ensure smoking residents extinguished cigarettes in a safe manner. Staff failed to remove Resident #31's oxygen tubing and tank before entering smoking area. This failure could affect residents by placing them at risk for burns and injuries. Findings included: 1.Review of current, undated admission Record for Resident #31 revealed she was a [AGE] year-old female, re-admitted on [DATE] with diagnosis including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, encounter for adjustment and management of vascular access device, acute bronchitis and nicotine dependence, cigarettes. Review of Resident #31's Care Plan dated 04/15/2025 revealed the following focus areas: *Problem; Non-compliant with smoking policy r/t hiding leftover cigarette and hides in room. Approach: instructed resident cigarettes must be disposed of appropriately during smoke break and cannot be kept, cannot be saved. Smoking policy has been provided to resident and resident has signed and agreed to policy. *Problem: Resident has oxygen saturation disturbance symptoms related to emphysema/COPD. Approach: administer oxygen as ordered. Observe oxygen precautions. *Problem: I am a smoker, and I must be supervised when smoking. Patient may go to smoke with no oxygen in use in smoking area. Review of Resident #31's Minimum Data Set Interim Payment Assessment Item Set dated 05/28/2025 revealed; BIMs score 11 (moderate impairment). Review of Resident #31's active orders reveal; nasal cannula 9continuous): O2 @ 4l/Min every shift. Review of Resident #31's Safe Smoking Evaluation dated 06/03/2025 revealed, Supervised smoker. Additional comments: Resident removes her oxygen before smoking. Observation on 06/04/2025 at 10:35 AM revealed, Resident # 31 sitting in her wheelchair outside (Nurse station one) exit door smoking a cigarette accompanied by male staff. Observation of resident flicking her ashes onto the ground. Interview on 06/04/2025 at 10:39 am with resident #31 revealed she that was the only place she can smoke, outside the door because she cannot be around people that smoke per her doctor's orders. She stated staff will push her outside and she will take a few puffs from her cigarette and come back inside because she cannot be off her oxygen for too long. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 - Some Observation and interview on 06/04/2025 at 1:58 pm revealed; CNA I with resident 31 outside in the courtyard. CNA I was observed with O2 tubing in her hand wrapping it up. She then removed the Oxygen tank from the back of the resident's wheelchair. Resident was observed with a cigarette that was not lit. Resident smoked the cigarette and extinguished it on the bottom of her shoe. Resident #31 revealed she told CNA I to take off the tank when they were inside. She stated they (staff) always take it off, but she did not normally take me out. Interview on 06/04/2025 at 2:00 pm with CNA I revealed she takes resident #31 out to smoke at 9, 11, 2pm. She stated she does not know why the resident smoked outside the door she thought she went to an appointment one time, and they told her not to be around others. She stated she knew to take the oxygen tank off the back of the wheelchair before the resident goes outside but the resident was calling her stupid and saying she did not need to take it off. She stated the resident wanted to go outside and get it over with. She said the resident continued to call her stupid. She stated the risk of not removing the oxygen could cause the resident to burn herself. She stated she should have taken the resident back to her room and told the nurse. Interview on 06/05/2025 at 1:43 pm with LVN E revealed; staff know they are supposed to take Resident #31 to smoke, but the tank should not go outside the door. Leave the tank and tubing inside (right inside the door). They know the risk with oxygen you can blow up; it can blow all of us up. LVN E stated she had them take her out more because the resident takes two or three puffs because she cannot breathe. The oxygen tank was right there (by the door) because when she comes back in, she needs the oxygen. Interview on 06/05/2025 at 3:00 pm with DON revealed; staff are educated often to remove oxygen tank before they go outside. We in-service them at least weekly about the risk. The risk was it could catch on fire. She stated she was not aware that the area where Resident # 31 was smoking did not have an ashtray to extinguish the cigarette safely. 2.Observation on 06/03/2025 at 1:04 PM revealed at least 100 cigarette butts scattered around the courtyard's grassy area outside less than 2 feet from kitchen zone 3 exit door and at least 100 cigarette butts and a metal chair located outside the door of nurse station one to the courtyard. No ashtrays were observed by each exit doors. Observation of No Smoking signs posted on each door. Interview on 06/03/2025 at 1:15 PM with Activity Director revealed, residents are not supposed to smoke by the doors only under the covered patio area and extinguish their cigarettes in ashtrays. She stated staff members are assigned to monitor residents during smoke breaks. Interview on 06/03/2025 at 1:25 PM with Maintenance Director revealed, his duties include maintaining the facility grounds. He stated he did not notice the cigarette butts on the ground. Interview on 06/05/2025 at 4:17 pm with Administrator revealed; oxygen should come off the resident before exiting the door. If the resident did not allow the removal of the tank and tubing, then the CNA I should have alerted the nurse. The risk was a fire hazard. She stated there was a designated smoking area for residents to smoke. She stated maintenance was responsible for cleaning the smoking area. Policy review of Resident Smoking Policy dated 2024 revealed; 1. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area Sign will be prominently posted. 4. No smoking signs will be maintained on doors or gates where oxygen is used or stored. 15. All smoking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 material will be maintained by nursing staff and at no time are to be kept on stored in a resident's room. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident The designated interdisciplinary team member is responsible for the following: ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians for two (resident #22 and Resident #44) of four residents reviewed for hospice services. 1.The facility did not designate a member of the facility to obtain Resident #22's current hospice recertification, most current hospice orders, and most recent plan of care since hospice benefits expired on [DATE]. 2.The facility did not have the same physician determination of terminal illness as hospice company did. The facility had a COPD as the primary hospice admission diagnosis while in the hospice binder, the primary hospice admission was Metabolic Encephalopathy (this is a fluid disorder that causes brain alteration and brain function) and vascular dementia (this is a brain condition that progressively destroys memory and other important mental functions) for Resident #22 3.The facility did not designate a member of the facility to obtain Resident #44's current recertification records from hospice, most recent hospice plan of care, most recent hospice physician orders, and most current hospice nursing documentation since benefit period ended on [DATE]. 4.The facility did not designate a member of the facility to verify signing in for hospice RN for Resident #44 since [DATE]. These failures could affect residents by placing them at risk for services and treatments not being coordinated for end-of-life care. Findings included: Resident #22 Record review of Resident #22 admission record dated [DATE], revealed an [AGE] year-old female who was readmitted to the facility on [DATE] with an initial admission of [DATE]. Her primary diagnosis was metabolic encephalopathy (this is a fluid disorder that causes brain alteration and brain function). Her secondary diagnoses included chronic obstructive pulmonary diseases (a lung disease that blocks airflow and makes it difficult to breathe), hypo-osmolality and hyponatremia (low levels of sodium due to fluid imbalance), wheezing (high pitch sound when breathing caused by inflammation of airways in lungs), coughing and plural effusion (this is a buildup of excessive fluid in the spaces between the lungs and chest walls). Resident was her own RP, and she was on hospice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0849 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #22's quarterly MDS assessment, dated [DATE] reflected a BIMS score of 8 which indicated moderative impairment. Resident #22 required substantial/maximum assistance of staff for all ADLs and was always incontinent of bladder and bowel. Resident #22 received hospice services while in the facility, she did not have a left expectancy of less than six months. Further review of MDS did not reflect active diagnoses of dementia. Residents Affected - Few Record review of Resident #22's active physician orders for [DATE] reflected, Resident #22 admitted to hospice on [DATE] with a primary diagnosis of COPD. Her level of hospice care: routine in-patient. Record review of Resident #22's care plan, revision date [DATE] , revealed Resident #22 was admitted to hospice with a primary diagnosis of COPD. Her goal was comfort and dignity to be provided while on hospice through the next review date. Her interventions were to follow hospice orders as written, to inform hospice if any significant changes in residents' status including signs and symptoms of discomfort and will be addressed accordingly. Record review of Resident #22's hospice binder on [DATE] revealed a hospice initial plan of care and physician orders for benefit period [DATE] to [DATE]. Resident #22's terminal hospice admission diagnosis was revealed as ICD-10-CM code G93.41- Metabolic Encephalopathy (this code is used to classify a transient or permanent impairment of brain function resulting from abnormal metabolic process) and vascular dementia. Record review and interview with Resident #22 on [DATE] at 09:44 AM, revealed she was not interviewable. She was her own RP and no other family on her chart. In a phone interview with the hospice RN B on [DATE] at 10:16 AM, revealed he was Resident #22 hospice nurse, and he evaluated her, monitored her paperwork, and assessed her needs weekly. He said Resident #22 also had a hospice aide that came to perform personal hygiene and assist with ADLs, 5 days a week, and as needed. RN B said that he made sure that he communicated with the facility nurses for any changes, and he inquired with the facility nurses for a change in condition and if they needed any new orders or supplies. RN B stated he was sure that Resident #22 had a current and updated hospice care plan and orders because the hospice IDT team just met to do the recertification for Resident #22. He said the IDT was made up of RN's, Social workers, chaplain, and physician. He said he would fax to the facility the current benefit period, hospice plan of care, and orders. He said it was his responsibility to make sure that all hospice documentation in the hospice binder was current as these forms were pertinent to ensuring coordination of care. He stated not having accurate documentation would cause the resident not to have Continuity of care. He said not having accurate diagnoses for services causes a risk of being unable to verify that residents received scheduled care. During an interview with LVN E on [DATE] at 1:43 PM, LVN E said she worked the morning shift Monday to Friday and hospice RN B always verbally communicated with her when he came to see Resident #22 and she would sign his tablet to verify that he came to see the resident. She said she expected the hospice providers to keep resident hospice records current. LVN E said it was especially important to ensure coordination of care with medications and comfort and that the facility had corresponding orders, diagnoses, and plans of care as the hospice for continuation of care. She said it was important for the facility to have current orders for coordination of care. She said she did not know who was assigned by the facility for monitoring the hospice binders and documentation. LVN E said she uses the hospice binder to verify orders and to see if the aide came in to provide care if she did not see her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0849 Resident #44 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #44 face sheet dated [DATE], revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with an initial admission on [DATE]. Her diagnosis includes acute on chronic systolic congestive heart failure (this is a sudden worsening of symptoms in a person with pre-existing heart failure), malignant neoplasm of unspecifies site of left female breast (breast cancer), breast cancer surgery, high blood pressure, and chronic pain. Resident#44 was on hospice. Residents Affected - Few Record review of Resident #44's quarterly MDS assessment, dated [DATE], reflected a BIMS of 13 which indicated Resident #44 was cognitively intact. Resident #44 was occasionally incontinent, and she completed all ADL's independently with no assistance. Resident #44 received hospice services while in the facility; she did not have a left expectancy of less than six months. Record review of Resident #44's active physician orders for [DATE], reflected Resident # 44 was readmitted to hospice on [DATE] with diagnosis of Metastatic breast cancer (cancer that has spread). Her hospice level of hospice care: routine in-patient. Record review of Resident #44's care plan, revised [DATE], revealed Resident #44 was admitted to hospice with a primary diagnosis of Metastatic breast cancer. Her goal was to have an optimal quality of life. The intervention was to notify the hospice of a change in condition. A record review of Resident #44's hospice binder on [DATE] revealed a comprehensive hospice assessment and plan of care updated report that ended on [DATE]. The frequency of skilled nursing visits was once a week. The hospice binder had no evidence of an updated hospice comprehensive assessment and plan of care report to reflect current recertification period, most recent hospice plan of care, and most recent hospice physician orders since [DATE]. The hospice binder also had no evidence to reflect current RN hospice nursing progress notes documentation since [DATE]. Further review of the hospice binder revealed RN last sign in was dated [DATE]. In an interview with Resident #44 on [DATE] at 08:58 AM, she said she was on hospice for breast cancer. She said she had been in hospice since 2023. She said that she did not have an aide in her plan of care as she did not need one. She said that her hospice nurse came weekly to see her, and the hospice case worker came to see her too although she could not recall which date. Resident #44 said she had no concerns with her hospice care. During a phone interview with hospice RN C on [DATE] at 11:04 AM, he said he forgot the updated documentation for Resident #44 when he was in the facility last week. He said he does not look at the hospice book because all documentation, evaluations and medication orders are on his tablet. He said he was responsible for monitoring and updating hospice B's documents so that they were current for all residents admitted to his hospice company. He said the risk of not having current hospice documentation lacked continuation of care between the facility and hospice. In an interview on [DATE] at 11:46 AM with LVN D, it revealed RN C came weekly, and RN C asked for his signature on his tablet for verification of visit. LVN D said he never looked at the hospice binder except when he handed it to the hospice providers. He said the hospice providers always communicate with him if there are changes. He said hospice RNC was especially good because he always asked if they needed to reorder any medications for Resident #44. He said it was important to have a current plan of care because when it was care planned, it was expected to be done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on [DATE] at 10:58 AM with SW, it was revealed that her responsibility with hospice was to give residents and family information for the different hospice companies that the facility had contracts with. She said after the family chooses the hospice of their choice then she reached out to nursing for the face sheets, diagnosis, and order and sends it to the hospice company. SW said she was not the designated coordinator to make sure that all hospice documentation was the same as the facilities. She said she expected the hospice providers to keep resident hospice records current to ensure coordination of care. During an interview on [DATE] at 03:01 PM, with DON, she said the hospice provider should supply all the admission paperwork when the resident admitted to hospice. DON said the facility had its own orders, and their own plan of care. DON said no one had been assigned as a hospice designated coordinator. She said moving forward they will meet and assign someone who will be responsible for ensuring and monitoring the hospice provider updated the clinical records of each hospice resident. She said not having current and accurate documentation prevents continuity of care. During an interview on the Administrator [DATE] at 4:28 PM, it was revealed she expected the hospice to provide all the required documents at the time of admission to ensure an accurate hand off care ensuring the coordination of care. The Administrator said the nurse completing the admission was responsible for ensuring the documentation was available. The Administrator said the process will be reviewed in the daily meetings to review the admissions, and then again in the weekly standards of care meetings. Review of Hospice A and Hospice B updated documents sent via fax on [DATE] at 12:22 PM for Resident #22 and Resident #44 revealed updated care plans, orders, and current recertification periods. Review of the facility's policy titled, Hospice Program, revised [DATE], did not reflect a designated coordinator. It reflected as follows: .12. Our facility has designated [blank/no name] to coordinate care provided to the resident by our facility staff and the hospice staff. He or she is responsible for the following: b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the terminal illness .; d. Obtaining the following information from hospice: .(2) Hospice election form, (3) Physician certification and recertification of the terminal illness specific to each resident .; e. Ensure that our facility staff provide orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements to hospice staff furnishing care to the residents. 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 If continuation sheet Page 16 of 16