Health inspection·April 5, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 04/04/23 at 09:16 AM, Resident #12 had multiple, white facial hairs on her chin that were approximately 0.5 cm - 1 cm in length. Resident #12 said she felt the facial hair on her chin and did not like it because it did not look good for a woman. Resident #12 said staff normally helped her remove it by shaving when she showered, but sometimes they did not. Resident #12 said she preferred to have her facial hair removed because it did not make her feel good. Residents Affected - Few During an observation and interview on 04/05/23 at 10:34 AM, Resident #12 was in the dining room. Resident #12 continued to have chin hairs that were approximately 0.5 cm - 1 cm in length. She said she did not recall having a shower but did want the hair removed from her face because it did not look good. During an interview on 04/05/23 at 01:25 PM, CNA E said facial hair removal should have been performed during the resident showers for men and women. CNA E said she was unsure when Resident #12's scheduled showers were, but they provided showers according to the shower sheets. CNA E said facial hair for Resident #12 had not been removed because she did not notice the hair. CNA E said it was important to ensure facial hair was removed so Resident #12 felt comfortable with the way she looked. During an interview on 04/05/23 at 03:18 PM, the DON said the CNAs were responsible for removing Resident #12's chin hairs. She said the CNAs should have been shaving the men and women when they completed their showers. The DON said the failure of not keeping the resident shaved could have caused dignity issues or caused the resident to not feel good about herself. During an interview on 04/05/23 at 03:35 PM, the administrator said he expected the female residents with facial hairs to receive showers and have facial hair removed. The administrator said if any resident refused care, the staff should have returned or had another CNA attempt to ask the resident. The administrator said all CNAs should follow the shower schedule and remove residents' facial hair. He said he noticed Resident #12 had chin hairs on 04/04/23. The administrator said he was sure it did not make Resident #12 feel good having chin hairs, and it was considered an issue. During an interview on 04/05/23 at 03:45 PM, the ADON said the nurses and the CNAs were responsible for ensuring all residents received baths or showers, and their facial hair was removed. She said they had to use so much agency that they had not been able to keep up with things of that nature. The ADON said she was responsible for looking at the bath assignment sheets and ensuring the residents were bathed, showered, and shaved but had been so busy that shower sheet monitoring may had been missed. The ADON said women with chin hairs not being trimmed could have caused the resident to feel bad or be embarrassed. Record review of the facility's Activities of Daily Living Policy, dated 1-2023, indicated Policy It is the policy of this home to assure residents have their activities of daily living needs met FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 2 of 13 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 675812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the residents environment remained free of accident hazards for 1 of 2 resident (Resident #5) reviewed for transfers. The facility failed to ensure Resident #5 was transferred using a gait belt. This failure could place residents at risk for injuries and falls. Findings include: Record review of Resident #5's face sheet, dated 04/04/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia with behavioral disturbance (memory loss with behaviors), essential hypertension (high blood pressure), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting left non-dominant side (stroke affecting left side), and diabetes (a chronic condition that affects the way the body process blood sugar). Record review of Resident #5's comprehensive care plan, dated 07/08/22, indicated he had a self-care deficit related to impaired cognition and impaired mobility. The care plan interventions included staff to assist Resident #5 with transfers as needed and required extensive assistance. Record review of Resident #5's quarterly MDS assessment, dated 02/23/23, indicated Resident #5 was usually understood and usually understood others. Resident #5 had a BIMS score of 6, which indicated he had severe cognitive impairment. Resident #5 required extensive assistance with 2-person physical assist for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Resident #5 was totally dependent with bathing. The MDS's definition of extensive assistance indicated resident involved in activity, staff provide weight-bearing support. During an observation on 04/03/23 at 09:40 a.m., CNA A and CNA B assisted Resident #5 to a sitting position on the right side of the bed. CNA A placed Resident #5's wheelchair on the right side of the bed. CNA A and CNA B held Resident #5 underneath each arm and transferred him to his wheelchair without a gait belt. During an interview on 04/03/23 at 09:46 a.m., CNA A said they had never used a gait belt before to transfer Resident #5. CNA A said they just assisted him since Resident #5 could stand on his strong leg. CNA A said by not using a gait belt Resident #5's leg could have slip and he could have fallen . CNA A said she should have used a gait belt to transfer Resident #5. During an interview on 04/03/23 at 09:52 a.m., CNA B said Resident #5 did not require a gait belt to be used because he would usually help stand up. CNA B said she did not pull-on Resident #5 during the transfer. During an interview on 04/05/23 at 10:08 a.m., CNA B said they should of have used a gait belt to transfer Resident #5 from the bed to the wheelchair on 04/03/23. CNA B said Resident #5 required extensive assistance with two-person assist for transfers. CNA B said she was responsible for ensuring gait belts were used during transfers for patient safety . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 3 of 13 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 675812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 04/05/23 at 10:35 a.m., CNA A said she assisted Resident #5 by holding his arm during the transfer on 04/03/23. CNA A said Resident #5 had days where he required more assistance. CNA A said Resident #5 required extensive assistance with two-person assist for transfers. During an interview on 04/05/23 at 10:49 a.m., LVN C said the amount of assistance Resident #5 required depended on his mood that day. LVN C said she had seen the aides use the back of Resident #5's pants to transfer him. LVN C said using a gait belt would be safer to transfer Resident #5 to prevent falls. During an interview on 04/05/23 at 03:11 p.m., the ADON said she expected gait belts to be used on residents that required extensive assistance. The ADON said by not using a gait belt with transfers could place the resident at risk for falls or accidents. The ADON said the nursing staff had transfer competencies completed upon hire and as needed. The ADON said the DON and herself checked off the staff by return demonstration. During an interview on 04/05/23 at 03:18 p.m., the administrator said he expected transfers to be done properly and with the use of a gait belt if required. The administrator said by not using the gait belt the resident was at risk for falling. The administrator said the staff were checked off upon hire by return demonstration. During an interview on 04/05/23 at 03:35 p.m., the DON said she expected a gait belt to be used with transfers for residents who required extensive assistance. The DON said the resident's safety was a priority and by not using a gait belt it placed the resident at risk for falls or accidents. The ADON said the administrative staff were responsible for ensuring staff used appropriate measures to transfer the residents safely. Record review of the CNA A's CNA Proficiency, dated 12/21/22, indicated skill for transfers was satisfactory. Record review of the CNA B's CNA Proficiency, dated 03/28/23, indicated skill for transfers was satisfactory. Record review of the facility's policy Gait Belt- Correct use of, dated 01/2023, indicated . when a gait belt is used with a resident, the correct procedure will be followed to promote safety for the resident and employee . 4. Apply the gait belt: always use the gait belt when the resident requires ' hands on' assistance to ambulate or transfer . Stroke/paralyzed residents- must use strong side to assist weak side and aid as necessary with gait belt FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 4 of 13 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 675812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that medication error rates of 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 2 errors out of 28 opportunities, which involved 1 of 7 residents (Resident #23) reviewed for medication administration . Residents Affected - Few The facility failed to ensure Resident #23 received aspirin (non-steroidal anti-inflammatory) and magnesium oxide (supplement) at the correct dosage. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Record review of Resident #23's face sheet indicated an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses which included Alzheimer's disease (memory loss), and atrioventricular block (heart beats more slowly). Record review of Resident #23's consolidated physician's orders, dated 03/04/2023, indicated she was prescribed aspirin delayed release 325 milligrams by mouth daily for a slow heartbeat with a start date of 03/04/2023, and magnesium oxide 500 milligrams by mouth for osteoporosis (brittle bones) with a start date of 03/04/2023. Record review of Resident #23's Annual MDS, dated [DATE], indicated she usually understood and was usually understood. Resident #23's BIMS score indicated she had a severe cognitive deficit. Record review of Resident #23's comprehensive care plan, dated 03/23/2023, indicated she had a diagnosis of osteoporosis (brittle bones) and was at risk for fractures. The care plan indicated the goal was Resident #23 would remain free of any injuries. The intervention was to administer medications as ordered. During an observation on 04/03/2023 at 10:45 a.m., the ADON administered aspirin 81 milligrams, and magnesium oxide 400 milligrams by mouth to Resident #23. During an interview on 04/05/2023 at 10:40 a.m., the ADON said she should have administered aspirin 325 milligrams, and magnesium oxide 500 milligrams . The ADON said by not administering the ordered doses of these medications Resident #23 was not receiving the desired therapeutic effects. The ADON said the usual dose of magnesium oxide was 400 milligrams not realizing she misread the dosage. During an interview on 04/05/2023 at 3:30 p.m., the administrator said medications should be administered by the right medication, right dose, the right person, and the right time. The administrator said the resident would not receive the same results with the inaccurate dosing. The administrator said the pharmacy consultant evaluated medication pass. The administrator said he expected the residents to receive the medications the physician ordered to have the therapeutic results. During an interview on 04/05/2023 at 3:38 p.m., the DON said she expected the medications to be administered as prescribed. The DON said not receiving the prescribed medications in the correct doses could provide less of the desired effect. The DON said she and the ADON were responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 5 of 13 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 675812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 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 0759 ensuring medications were administered according to the 6 rights of medication administration. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled, Medication-Administration, dated 01/2023 indicated, .It was the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations.13. Prior to administration, the medication and dosage schedule on the resident's medication administration record is compared with the medication label. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 6 of 13 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 675812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 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, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 6 medication carts (main street medication cart) reviewed for medication storage. The facility failed to ensure the main street hall medication cart was locked when the ADON left the floor and left the cart unattended. This failure could place residents at risk of taking medications not intended for them with adverse outcomes; risk of loss/interruption in receiving medications. Findings included: During an observation on 04/03/23 from 11:46 a.m. to 11:57 a.m., the main street hall medication cart was left on the main street hall unlocked and unattended while nurse had left it to go to the dining room. During an observation and interview on 04/03/23 at 11:57 AM, the Corporate Clinical Nurse walked up to the cart and tried to hide her hand while she locked the medication cart. The Corporate Clinical Nurse said anything could happen with the cart being unlocked. The Corporate Clinical Nurse said anyone could have accessed the cart and ingested the medications. She said the nurse was responsible to ensure the carts were locked. During an interview on 04/03/23 at 12:07 PM, the ADON said she was responsible for the medication cart and had forgotten to lock the cart. The ADON said with the cart being unlocked any resident, staff, or visitor could have opened the cart and took the medications out of the cart. The ADON said she was busy and did not lock the cart prior to her leaving the cart. The ADON said the facility performed proficiency checkoffs to ensure the nurses and medication aides were aware of the need to lock the medication carts on the hallways when the carts were not in use. She said the DON was responsible for completing proficiency checkoffs. During an interview on 04/05/23 at 03:21 PM, the DON said the medication carts should always be locked if the nurse or aide was not working out of the cart. The failure to lock the medication cart could place a staff or visitor, who was unauthorized to access the medications, capability of getting in the cart. The DON said any resident in the facility could get into the cart and take the medications. The policy and procedures upon hire instructed all nurses or med aides to always keep the cart locked. She said it was a part off the skills checkoff During an interview on 04/05/23 at 03:38 PM, the administrator said if the medication carts were not being used, they should be closed and locked. He said the failure to lock the medication carts provided risks of residents taking medications that they did not need, as well as other staff and visitors. The administrator said the nursing staff were responsible for ensuring the carts were locked. Record review of the policy for Medication Storage, dated 1-2023, indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 7 of 13 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 675812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 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 Policy Level of Harm - Minimal harm or potential for actual harm It is the policy of this home that the medications will be stored appropriately as to be secure from tampering, exposure, or misuse. Residents Affected - Few Procedure 1. The provider pharmacy dispenses medications . 2. 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 medication supplies are locked or attended by persons with authorized access FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 8 of 13 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 675812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Record review of Resident #12's face sheet indicated an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses which included Alzheimer's disease (memory loss), and atrioventricular block (heart beats more slowly) and dry eye syndrome (little moisture in the eye). Residents Affected - Few Record review of Resident #12's consolidated physician's orders, dated 03/04/2023 - 04/04/2024, indicated she was prescribed Restasis (dry eye medication) one drop to each eye twice daily for dry eye syndrome. During an observation on 04/03/2023 at 10:45 a.m., the ADON provided Resident #12 with a tissue, and she wiped her nose. The ADON held Resident #12's right eye lid open with an ungloved hand and administered the Restasis eye medication in the resident's right eye. The ADON did not sanitize or perform hand hygiene before or after administering the eye drop with ungloved hands . The ADON held Resident #12's left eye open with an ungloved hand and administered the Restasis eye medication in the resident's left eye. The ADON used the same tissue Resident #12 used to clean her nose to dab around each of Resident #12's eyes with ungloved hands. During an interview on 04/05/2023 at 3:14 p.m., the ADON said she should have used gloves during the administration of eye medications. The ADON said she was the infection preventionist. The ADON said touching Resident #12's eye lids barehanded could spread infection . The ADON said she should have sanitized her hands before applying gloves, and after removing gloves. During an interview on 04/05/2023 at 3:30 p.m., the administrator said he expected eye drops to be administered with gloves to prevent any type of infection. Record review of the facility's nursing policy and procedure Medication Administration, dated 01/2023, indicated the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. Eye Drops Procedure .3. Cleanse hands 4. Prevent tip of the eyedropper from touching the resident 6. While holding the bottle or tube in a vertical position and slightly to the side of the eye and about one-half inches above the eye, instill the ordered number of drops into the conjunctiva sac, or a ribbon of ointment along the lower conjunctiva from the inner to outer canthus. 7. Wipe excess medications from around the eye with tissue if needed. Record review of the facility's policy Hand Washing, dated 01/2023, indicated . hand hygiene is the primary means to prevent the spread of infection . Employees must wash their hands for at least 20 seconds using antimicrobial or nonmicrobial soap and water under the following conditions .before and after assisting a resident with personal care after removing gloves . Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 16 residents (Residents #5 and #23) reviewed for infection control practices. 1. CNA A failed to wash or sanitize her hands before, in between glove changes, and after performing peri care to Resident #5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 9 of 13 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 675812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm 2. The facility failed to ensure the ADON used gloves when she administered Resident #23's eye medication. 3. The facility failed to ensure the ADON did not dry Resident #23's eyes with the same tissue used to clean Resident #23's nose. Residents Affected - Few These failures could place residents at risk for infections. Findings included: 1. Record review of Resident #5's face sheet, dated 04/04/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia with behavioral disturbance (memory loss with behaviors), essential hypertension (high blood pressure), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting left non-dominant side (stroke affecting left side), and diabetes (a chronic condition that affects the way the body process blood sugar). Record review of Resident #5's comprehensive care plan, dated 07/08/22, indicated Resident #5 was occasionally incontinent of bowel and bladder. The care plan interventions included incontinent checks to be performed approximately every 2-3 hours and perineal care to be given as needed. Record review of Resident #5's quarterly MDS assessment, dated 02/23/23, indicated Resident #5 was usually understood and usually understood others. Resident #5 had a BIMS score of 6, which indicated he had severe cognitive impairment. Resident #5 required extensive assistance with two-person physical assist for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Resident #5 was totally dependent with bathing. Resident #5 was always incontinent of urine and frequently incontinent of bowel. During an observation on 04/03/23 at 09:26 a.m. revealed CNA A entered Resident #5's room to provide incontinent care. CNA A put on gloves and did not wash her hands prior to the start of care. CNA A obtained a package of disposable wipes, removed multiple wipes from the package, and placed them directly on the linen of Resident #5's bed. CNA A removed the soiled brief from Resident #5, removed her gloves and put on a new pair of gloves. CNA A failed to perform hand hygiene prior to putting on clean gloves. CNA A removed multiple wipes from the package and placed them directly on Resident #5's bed linen. CNA A continued to provide incontinent care to Resident #5. CNA A placed a clean brief on Resident #5 with same gloves. CNA A removed her gloves and put on clean gloves. CNA A did not perform hand hygiene in between glove changes and did not perform hand hygiene after the completion of care. During an interview on 04/03/23 at 09:46 a.m., CNA A said she should have had performed hand hygiene before and after incontinent care and in between glove changes. CNA A said failure to perform hand hygiene could place Resident #5 at risk for infections. CNA A said she was responsible for performing hand hygiene. CNA A said she had been checked off on incontinent care and hand hygiene by the DON by return demonstration . During an interview on 04/05/23 at 1:40 p.m., LVN C said she expected hand hygiene to be performed before and after care, before meals, after removing gloves and in between glove changes. LVN C said failure to perform hand hygiene placed residents at risk for infection. LVN C said everyone was responsible for ensuring hand hygiene was performed. LVN C said staff had hand hygiene and incontinent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 10 of 13 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 675812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 care competencies completed upon hire and yearly. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/05/23 at 3:11 p.m., the ADON said she expected staff to perform hand hygiene before, after, in between care, and after changing gloves. The ADON said failure to perform hand hygiene placed the residents at risk for infection. Residents Affected - Few During an interview on 04/05/23 at 3:18 p.m., the administrator said he expected the staff to wash their hands before, after, and in between care. The administrator said he expected the staff to perform hand hygiene in between glove changes. The administrator said failure to perform hand hygiene between glove changes could place residents at risk for infection. During an interview on 04/05/23 at 3:35 p.m., the DON said staff should wash their hands between soiled and clean tasks, and before and after completion of incontinent care. The DON said not performing hand hygiene could cause a break in infection control. The DON said everyone was responsible for ensuring hand hygiene was performed. Record review of the CNA A's CNA Proficiency, dated 12/21/22, indicated skill for male perineal care was satisfactory. Record review of the facility's policy Incontinent care/Perineal care with or without a catheter, dated 01/2023, indicated . It is the policy of this home to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination .Beginning steps a. wash hands .Discard soiled gloves along with the soiled brief and/or wipes . wash hands with soap and water .sanitize hands and put on gloves .Re-glove prior to touching clean linens/adult brief .If gloved, remove and discard gloves following home guideline at the appropriate time to avoid environmental contamination. Sanitize hands FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 11 of 13 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 675812 B. Wing (X3) DATE SURVEY COMPLETED A. Building 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, and interviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 3 of 3 showers (Whispering Lane shower, Park Place shower, and Texas Boulevard shower), and 1 of 3 public restrooms (nursing station area public restroom) observed. 1. The facility failed to ensure the three common shower rooms were free of black and green substances growing in the grout, towels lying on the floor, and a pink slimy substance growing on the undersurface of the shower chairs. 2. The facility failed to ensure the bathtub in the public restroom was free of a black substance . These failures could place residents at risk of infections and a loss of dignity. Findings included: During an observation on 04/04/2023 at 11:50 a.m., clean and folded towels and wash cloths were sitting exposed on the half wall petition in the communal shower room on Park Place Hall; used and un-labeled toothpaste was on the sink; and the dirty linen and trash barrels were stored in the shower. During an observation and interview on 04/04/2023 at 12:10 p.m., the communal shower on Whisper Lane Hall (secured unit) had a black substance in the grout; the shower wall had missing tiles; the windowsill had dirt like material on it; the white window blind was covered in a dirt like material; the toilet had brown stains inside; and a bottle of degreaser and bathroom cleaner was sitting on top of the locked cabinet. CNA B said the housekeeper cleaned the shower every morning. During an observation on 04/04/2023 at 12:20 p.m., the shower on Texas Boulevard Hall had a pink slimy substance on the undersurface of the shower chair. The grout in the shower stall had black in areas on the wall and green in areas around the space where the walls and floor met. The shower stall had a rusted and broken over the bed table with a stack of clean, folded towels, and wash cloths lying on top and sitting next to the towels was a spray bottle labeled bathroom cleaner. There was a gallon of liquid bath soap, two cans of shaving cream, a bottle of hair shampoo, conditioner, a handheld mirror, and a large pump bottle of lotion on the table. The shower stall had towels lying on the floor. The unlocked cabinet had Calmoseptine ointment, razors, and a bottle half full of mouth wash. During an observation and interview on 04/04/2023 at 12:55 p.m., RN D said the shower on Texas Boulevard Hall and was not clean for residents to use. RN D said it was her responsibility to ensure the showers were clean. RN D said a resident could get an infection from an unclean shower. RN D said the showers were cleaned daily by housekeeping. RN D was unsure why the shower was not cleaned. During an observation and interview on 04/04/2023 at 12:58 p.m., the DON and administrator, after viewing the showers, said the showers should be clean for the residents' use. The DON and administrator said the unsecured chemicals in the shower could be an accident especially sitting next to the bath linen. The DON said the showers should be cleaned daily by housekeeping . During and observation and interview on 04/05/2023 at 1:30 p.m., the bathtub in the public restroom (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 12 of 13 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 675812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Winnsboro 910 S Beech St Winnsboro, TX 75494 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 0921 Level of Harm - Minimal harm or potential for actual harm had a black substance growing. The DON said the black substance in the bathtub in the public bathroom should be cleaned daily by housekeeping . During a confidential resident group meeting, 1 of 11 residents said they hated to shower in the resident communal showers because they were so filthy. Residents Affected - Some During an interview on 04/05/2023 at 1:16 p.m., the Housekeeping Supervisor said she was responsible for ensuring the communal showers and public restrooms were clean for use. The housekeeping supervisor said she had three open positions, and this played a role in some cleaning lapses . During an interview on 04/05/2023 at 3:15 p.m., the ADON said the showers should be cleaned at least daily. The ADON said the CNAs were responsible for cleaning up after a communal shower was used. The ADON said a resident could acquire an infection from a dirty shower. During an interview on 04/05/2023 at 3:30 p.m., the administrator said he was responsible for the oversight of the communal shower rooms and public restroom's cleanliness with the help of the Housekeeping Supervisor. The administrator said the Housekeeping Supervisor did not have a cleaning schedule at this time. The administrator said the showers and the public restroom should be cleaned daily by housekeeping. During an interview on 04/05/2023 at 3:41 p.m., the DON said she believed the communal showers were being overlooked for cleaning. The DON said the nurse managers made morning rounds but had not implemented afternoon rounds to ensure rooms and showers were cleaned. The DON said no one would want to be bathed in an area that was not clean. The DON said a resident could get an infection from being bathed in an unclean area. Record review of the facility's nursing policy and procedure, Infection Control-Environmental Rounds, dated 01/2023, indicated the policy of this home was that the administrator or other appropriate designee completes environmental rounds on a regular basis. Environmental rounds will be an integral part of the daily routine and will be performed regularly throughout the entire home, with detailed reporting to all units and departments as needed. (It is suggested that a selection of individual units as well as the dietary, laundry, and housekeeping departments be specifically identified for closer scrutiny each month.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 13 of 13