Health inspection·June 23, 2023

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Record review of Resident #1's care plan did not specifically address maintaining a comfortable temperature. Record review of the Resident #1's nursing progress note dated 6/18/23 at 12:55 p.m., stated Noted when patient was in dining room, he was lethargic, pale, sweaty, not eating well, not drinking, even with encouragement the patient needed assistance to eat, taking bites. Patient was asked if he felt ok, he said no, I just don't feel good, I don't know why, when asked where he was he said (another city's name) BS (blood sugar) at 1125 (11:25 a.m.) was 208 and 4 units Novolog Sliding Scale. Notified (Resident's MD) we would transfer the patient to ER for evaluation. Left message on (family members) phone for return call. When the ambulance arrived the patient could not stand, he could answer their questions, but very slowly. Their first BP reading was 86/42. This note was written by LVN A. Record review of Resident #1's hospital History and Physical dated 6/18/23 at 4:50 p.m., stated his date of admission was 6/18/23 and his admission diagnoses included Heat exposure and Acute metabolic encephalopathy (metabolic encephalopathy is a disorder that affects brain function. It can be temporary or permanent, depending on the severity of the damage. This condition is mainly caused by other severe health concerns. These problems affect electrolytes and blood chemicals in the body, resulting in brain cell damage. It is a severe health condition that can cause structural brain damage if not treated well. Causes of metabolic encephalopathy include; exposure to toxic chemicals; certain medications; illicit drugs; organ failure; dehydration and malnutrition; Excessive alcohol consumption; thiamine deficiency; severe and constant fever) and acute cystitis (an infection of the bladder or lower urinary tract). The History and Physical stated, (Resident #1) was received from the EMS services with generalized weakness and fatigue. Per EMS (emergency medical services), nursing home staff called EMS due to patient being generally weak and lethargic. The nursing facility has not had power due to damage sustained in a storm 3 days ago, and patient has been exposed to increased heat since. EMS administered 1L (liter) IV (intravenous) fluids in route, and patient is his baseline mentation (mental activity) upon arrival in the ED (emergency department). Record review of the hospital lab results obtained on 6/18/23 showed Resident #1 had an elevated BUN of 28 mg/dl (Normal range is 9-20 mg/dl [blood urea nitrogen- Urea nitrogen is a waste product made when your liver breaks down protein. It's carried in your blood, filtered out by your kidneys, and removed from your body in your urine. An elevated BUN can mean the kidneys are not working well but also can be due to dehydration]). During an interview on 6/20/23 at 4:50 p.m. the hospital's Compliance Officer said Resident #1 was admitted to the hospital with signs and symptoms of dehydration and heat exposure. Record review of the facility floor plan updated 5/17/19, displayed the layout of the facility as a capital I. The back hall or top of the I was divided into 2 resident areas. The back left side of the hall - was labeled zone 11/5. The back right side of the hall was labeled zone 7/5. The center of the I was also a resident area and was labeled zone 5. There was a bump off to the right center of zone 5 labeled Zone 10 which was the dining area. The bottom of the I was divided into 2 areas; the far right of the hall was labeled zone 6 and was the secured resident unit of the building. The center and left of the bottom of the I was labeled zone 8. Record review of the facility census dated 6/15/23 indicated Resident #1 was roomed in room [ROOM NUMBER] on the center hall toward the back left (zone 5). Record review of the facility admit/discharge report indicated Resident #1 was roomed in room [ROOM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 2 of 18 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 06/23/2023 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many NUMBER] on the center hall toward the back left (zone 5) just before his discharge from the facility on 6/18/23. During an interview on 6/19/23 at 12:55 p.m., the Regional Administrator said that a representative from the power company was at the facility at approximately 8:00 p.m. on 6/18/23 and had informed him the facility was expected to be up and running (power restored) at some point today (6/19/23). The Regional Administrator added, the statement from the power company representative was not a promise. During an interview on 6/19/23 at 1:30 p.m., the Administrator said the facility lost power at approximately 1:00 a.m. on 6/16/23. The Administrator said the facility's back up generator had kicked on upon the outage. The administrator said he had chosen not to evacuate the building because additional resources were coming to keep the building cool and if the facility evacuated the residents, they would have had to evacuate to another city, as many of the sister facilities had also been affected by the outage. He said the facility had maintained temperatures in the building from 72-82 degrees Fahrenheit since the outage to his knowledge. The Administrator said the secure unit (zone 6) and the back hall (zone 5/11 and zone 5/7) were warmer, but Residents were being kept on the front lobby/activity area (zone 8) where the temperature had been between 72-82 degrees. The Administrator said some residents have refused to come to the cool area (zone 8). During an interview on 6/19/23 at 1:40 p.m., the Maintenance Director said he had not kept any temperature logs for the facility since the power outage, so he could not accurately report what the temperatures in the facility had been since the outage. During an interview on 6/20/23 at 12:10 p.m., the EMTFD (Emergency Management Task Force Director)-Region 4, said he came to the facility on 6/17/23. He said he offered evacuation on two occasions that day (6/17/23). The EMTFD said the first time he came to the facility on 6/17/23, one of the thermostats read 88 degrees Fahrenheit. The EMTFD said the Administrator declined the evacuation offer and reassured him the facility had additional generators and portable HVAC units to cool the building on the way. The EMTFD said the second time he came to the facility on 6/17/23, the Administrator met him on the front porch of the facility. The EMTFD said he was not invited into the building at that time. The EMTFD said he thoroughly explained to the Administrator that the evacuation services offered would be at no cost to the facility and that there was already space for the facility's residents at a local hospital. The EMTFD said he explained to the Administrator the facility would not lose any money while the residents were evacuees at the local hospital and would be able to continue to bill for services as the facility's staff would continue to provide care for the residents. The EMTFD said the Administrator insisted the residents were doing just fine and they had a cool area in the facility for the residents. During an interview on 6/20/23 at 2:05 p.m., LVN A said Resident #1 had a significant cognitive change on Sunday (6/18/23). LVN A said she had been to his room and taken his blood sugar at approximately 11:25 a.m. She said he was talking and seemed like his normal self. LVN A said he was not sweating profusely, nor did he have any complaints. LVN A said by 12:00 p.m. his whole demeanor had changed. LVN A said she saw him in the dining room, and he was sweating profusely and was not making any sense. During observations on 6/20/23 at 12:10 to 12:35 p.m., the facility temperatures on the Center Hall (zone 5) were 76 degrees F at the front of the hall and 85 degrees at the back of the hall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 3 of 18 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 06/23/2023 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many During observations on 6/20/23 at 12:35 to 12:40 p.m. facility temperatures on the back hall (zones: 5/11 and 5/7) were 85-86 degrees Fahrenheit. During observations on 6/20/23 at 12:50 p.m., in the front/ right hall (secured unit- zone 6) the facility temperature was 86 degrees Fahrenheit. During an interview on 6/20/23 at 12:55 p.m., the Maintenance Director said the facility's current 150 kw generator was not big enough to run additional AC units for the whole building. The Maintenance Director said the Power went out at 1:00 a.m. in the morning on Friday (6/16/23). He said the emergency generator came on immediately and fans were gathered and plugged in to keep areas cool. The Maintenance Director said portable HVAC units arrived early afternoon on Friday (6/16/23). He said window units arrived Saturday morning around 10:00 a.m. The Maintenance director said the large generator arrived Sunday (6/18/23) evening around 11:00 p.m. The maintenance director said without the larger generator the temperatures had been between 82- and 84-degrees Fahrenheit. During observations on 6/20/23 at 3:40 p.m. the front cool area (zone 8) temperatures were 78-79 degrees Fahrenheit. During observations on 6/20/23 at 3:40 to 3:41 p.m., facility temperatures on the Center Hall (zone 5) were 91-93 degrees Fahrenheit. During observations on 6/20/23 at 3:44-3:47 p.m., facility temperatures on the back hall (zones: 5/11 and 5/7) were 90- 93 degrees Fahrenheit. During observations on 6/20/23 at 3:45 pm the facility census 52 residents had all been moved to the front cool area of the building. During an interview on 6/20/23 at 3:47 pm the Administrator said all Residents were currently being kept in the front lobby. The Administrator reported all residents had been sleeping in their rooms since the outage. According to the website www.accuweather.com accessed on 6/20/23 the outside temperature on 6/20/23 at 4:16 p.m. was 99 degrees Fahrenheit with a heat index of 120 degrees. Record review of the face sheet for Resident #3 dated 6/20/23 indicated she was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including heart failure, muscle wasting and atrophy, heart disease, and high blood pressure. Record review of the MDS dated [DATE] indicated Resident #3 usually made herself understood and usually understood others. The MDS indicated she had severe cognitive deficit (BIMS of 4). The MDS indicated she required limited assistance with most ADLS (bed mobility, Transfers, dressing, toilet use, bathing and personal hygiene) but did require extensive assistance with locomotion in her wheelchair on the unit. During an interview and observation on 6/20/23 at 1:00 p.m., Resident #3 laid in her bed on the back hall (zone5/7) with a cold washcloth on her face. Resident # 3 said she was hot. Resident #3 said she had been in the front of the building and wanted to go back up there. Record review of Resident #4's face sheet indicated she was [AGE] years old admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 4 of 18 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 06/23/2023 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 0584 Level of Harm - Immediate jeopardy to resident health or safety facility on [DATE] with diagnoses including, history of hypertensive urgency muscle wasting and atrophy, muscle weakness, diabetes, high blood pressure, and history of stroke. The MDS indicated she required supervision only with ADLS except for bathing for which she required limited assistance. Record review of the MDS dated [DATE] indicated Resident #4 understood others and made herself understood. The MDS indicated she had no cognitive impairment (BIMS of 13). Residents Affected - Many During an interview and observation on 6/20/23 at 1:10 p.m., Resident #4 was sitting in a wheelchair in her room on the back hall (zone 5/11). Resident #4 said she was about to go back to the front of building because it was a little cooler up there. Resident #4 said she slept up there on the couch (in the front lobby area zone 8) last night because it was just too hot in her room and said she was dripping with sweat. Record review of Resident #6's face sheet dated 6/20/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including history of metabolic encephalopathy, back abscess (a swollen area within body tissue, containing an accumulation of pus.), history of GI hemorrhage (Gastrointestinal (GI) bleeding is any type of bleeding that starts in the GI tract, also called the digestive tract), high blood pressure, history of skull fracture, history of traumatic brain injury, Type II diabetes, and dysphasia after stroke. Record review of the MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated he had moderate cognitive impairment (BIMS of 11 ). The MDS indicated he required supervision only with most ADLS except for bathing for which he was totally dependent on staff. During an interview on 6/20/23 at 3:00 p.m. Resident #6 was sitting in his wheelchair in the front lobby area (zone 8). He said the temperature up here was not terrible and was much better than it was over the weekend. Resident #6 said he did not know what the actual temperature was over the weekend but said it was real hot. Resident #6 said he had not been able to sleep much because it was just too hot in his room on the back hall (zone 5/11). Record review of Resident #5's face sheet dated 6/20/23 indicated he was [AGE] years old readmitted to the facility on [DATE] with diagnoses including COPD, Schizoaffective disorder, bradycardia, muscle wasting and atrophy, history of left knee replacement, and chest pain. Record review of the MDS dated [DATE] indicated Resident #5 understood others and made himself understood. The MDS indicated he had moderate cognitive impairment (BIMS of 11). The MDS indicated he required supervision with ADLS except for bathing for which he was totally dependent on staff. During an interview on 6/20/23 at 4:16 p.m., Resident #5 was sitting in the front lobby area (zone 8). Resident #5 said he has had increased trouble breathing with the heat and has not been able to sleep since the outage. He said it was just too hot to get any sleep. Resident #5 said it helped to sit up here (in the front [zone 8]) but at night, he said residents go back to the rooms to sleep and it's just too dang hot to sleep on the back hall (Zone 5/7). During an interview on 6/20/23 at 11:56 a.m., CNA B said she worked at the facility Friday (6/16/23) morning from 6am to 2pm. She said the power had gone out sometime before her shift started but was not sure what time. CNA B said it was very hot in the building. CNA B said it was hotter in the back of the building than it was in the front of the building. CNA B said she could not say what the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 5 of 18 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 06/23/2023 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many thermostats read on the resident halls during her shift. CNA B said she remembered looking at the thermostat in the dining room when the residents were eating lunch and it said 93 or 94 degrees Fahrenheit. She said it was very hot and the facility was gathering fans at that time. CNA B said there were no portable HVAC units in the building at the time (6/16/23 from 6am to 2pm). During an interview on 6/20/23 at 12:09 pm MA C said she worked Friday (6/16/23) and it was awful. MA C said it was awful because it was so hot in the building. MA C said she did not recall what the thermostats said in the building. During an interview on 6/20/23 at 12:12 p.m., CNA D said she worked in the facility on Saturday (6/17/23) and Sunday (6/18/23). CNA D said it was very hot in the building all weekend. CNA D said she did have some residents compliant to her about the heat but could not recall their names. CNA D explained she worked for a staffing agency and was not extremely familiar with the residents. CNA D said she was told an additional generator was coming to help cool the building. CNA D said she heard the nurses saying that a big generator was coming to help cool the building, so that was what she told residents. CNA D said the big generator did not come until Sunday night. CNA D said she heard there was some delay with getting the generator started on Sunday night due to some of the cords needed had not arrived. CNA D said she was not sure what time the big generator was up and running Sunday night. CNA D said the front of the building (zone 8) was just as hot as the rest of the building Saturday (6/17/23) and Sunday (6/18/23). CNA D said the thermostat to the immediate left when entering the back hall (zone 5) on Saturday between 4:00 p.m. and 5:00 p.m. read 92 degrees Fahrenheit. On Sunday (6/18/23) CNA D said the same thermostat read between 80-85 degrees Fahrenheit during her 2:00 p.m.-10:00 p.m. shift. During an interview on 6/20/23 at 12:20 pm the ADON said she came home early from her vacation on Saturday (6/17/23) to help out at the facility. The ADON said she worked as the medication aide that day. The ADON said it was hot in the building but not unbearable. The ADON said there were fans up and running throughout the building but said she could not say if there were any portable HVAC systems in the building at that time. The ADON said she also came in Sunday to help out. The ADON said no residents complained to her about the heat. The ADON said she knew the idea of evacuation was mentioned but never heard any actual plan. The ADON said the DON was on vacation herself and could not be reached. The facility Emergency preparedness plan reviewed on 7/22/21, Emergency Preparedness Plan Loss of Power Heat and Water , stated . (2) Loss of Comfort Heating/Cooling .(b) If loss is in the entire home due to interruption of public utilities (electrical /natural gas) and residents become uncomfortable, they will be placed in the beds and protected by an adequate supply of linen, or they will be moved to a central location that can be heated/cooled. (c) If loss is for extended period of time and the residents can no longer be protected in a comfortable manner, the residents will be evacuated to another location . The Administrator was notified on 6/20/23 at 5:33 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 6/20/23 at 5:37 p.m. The facility's Plan of Removal was accepted on 6/21/23 at 2:20 p.m., and included: Immediate Action Taken (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 6 of 18 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 06/23/2023 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 0584 Resident Specific Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Many All residents assessed on 6/20/23 at 1830 [6:30 p.m.]by licensed nurses (MDS Coordinator and ADON) for signs or symptoms of heat exhaustion and dehydration. Findings documented on the Resident Monitoring Form, and reviewed by RN (Regional Nurse.) No residents in the facility currently display any signs or symptoms of heat exhaustion and dehydration. o All residents were moved to the front lobby area of the facility, on 6/20/2023. As of 1340 on 6/20/2023, no residents remained in their rooms. The temperature of the front lobby area remained at 78-79 degrees. Residents returned to their rooms 6/20/2023 by 2330, once the temperature in the facility was below 80 degrees. o Residents are being provided cool beverages, meals and snacks as desired. Fluids are being offered every 2 hours and being documented on the Resident Monitoring Form. Residents unable to make their own decisions are automatically given fluids. This practice will increase in frequency to every 30 minutes, if the facility experiences loss of power during an extreme heat advisory. o MD notified of the IJ on 6/20/2023 at 1815 by Regional Nurse, no new orders received . System Changes o Licensed nurses assessing residents every 2 hours for signs and symptoms of heat exhaustion or dehydration, and documenting on the Resident Monitoring Form. Family and MD will be notified of any signs of symptoms of heat exhaustion or dehydration. Residents are currently in an area where temperatures do not exceed 79 degrees This practice will increase in frequency to every 30 minutes, if the facility experiences loss of power during an extreme heat advisory. o Licensed nurses checking vital signs and offering fluids every 2 hours and documenting on the Resident Monitoring Form. Residents are currently in an area where temperatures do not exceed 79 degrees. This practice will increase in frequency to every 30 minutes, if the facility experiences loss of power during an extreme heat advisory. o Temperature Log initiated for each occupied resident room. Maintenance Director or Licensed Nurse to use hand held thermometer and document temperature of each occupied resident room on a census each hour. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 7 of 18 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 06/23/2023 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 0584 o Level of Harm - Immediate jeopardy to resident health or safety Obtained 6 porta-coolers on 6/17/2023 at 1300. These are stationed throughout the facility. Residents Affected - Many 6 porta-coolers - Secured unit, 2 dining room, 2 private hall, long hall o o Obtained 5 portable generators and 4 commercial fans on 6/18/2023 between 0100 and 1200. These were used to power 6 window unit air conditioners through out the facility. o 5 portable generators - secured unit dining room, 3 in main dining room, day room in the rear of the building o 6 window units - secured unit dining room, 4 in main dining room, day room in the rear of the building o 4 commercial fans - 2 in the lobby, long hall, middle hall o Obtained an industrial 120kw generator on 6/18/2023 at 1930. This supplied air conditioning to middle hallway and lobby area. o Obtained a 60kw generator on 6/20/2023 at 1700. This supplied air conditioning to the dining room and the secured unit hallway. o Facility purchased 21 personal battery operated fans for resident use on 6/20/23 at 1400. o Facility in process of obtaining 8 additional porta-coolers. These items currently en route to the facility, expected by 2100 on 6/20/2023. o Facility now has an additional industrial 300kw generator at the facility, as of 2015 on 6/20/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 8 of 18 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 06/23/2023 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 0584 This generator now providing electricity to the entire facility, including the HVAC systems. Level of Harm - Immediate jeopardy to resident health or safety Education Residents Affected - Many Regional Nurse providing education to all staff regarding signs and symptoms of heat exhaustion. All staff present in the facility were educated on 6/20/2023, at 1830. Staff not present for the education will receive the education prior to their next shift. o o Regional Nurse providing education to all staff regarding signs and symptoms of dehydration. All staff present in the facility were educated on 6/20/2023, at 1830. Staff not present for the education will receive the education prior to their next shift. o Regional Nurse providing education to licensed nurses regarding Resident Monitoring Form, and the frequency to complete. This is the form that resident vitals, signs and symptoms of heat exhaustion or dehydration, offering fluids will be documented on. All licensed nurses in the facility were educated on 6/20/23 at 1830. Licensed nurses not present for the education will receive the education prior to their next shift. Regional Nurse providing re-education to licensed nurses regarding Resident Monitoring Form, and the frequency to complete. The frequency is currently every 2 hours. The frequency will increase to every 30 minutes, if the facility experiences loss of power during an extreme heat advisory. The frequency information is included in this education. This is the form that resident vitals, signs and symptoms of heat exhaustion or dehydration, offering fluids will be documented on. All licensed nurses in the facility are currently being educated as of 6/21/2023 at 12:15pm. Licensed nurses not present for the education will receive the education prior to their next shift. o Regional Nurse providing education to Maintenance Director and Licensed Nurses on hourly temperature logs for each occupied resident room. Maintenance Director and licensed nurses on duty educated on 6/20/23 at 2110. All licensed nurses not present for the education will receive the education prior to their next shift. o Regional Director of Operations educated Administrator on emergency procedures and reporting changes and displaced residents on 6/20/23 at 2110. o Facility Disaster/Emergency Plan reviewed and updated on 6/21/2023 at 0830, to include Should building be unable to maintain temperatures between 71 - 81 degrees, the evacuation plan will be initiated. Corporate will ensure HHSC, local emergency management systems, families and Medical Director are notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 9 of 18 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 06/23/2023 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 0584 Monitoring Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Many Administrator/designee to review Temperature Logs 3 times per day until power is restored and facility temperatures are at 80 degrees or below. Findings are to be reported to Regional Director of Operations. Should temperatures exceed 80 degrees, HHSC will be notified. DON/designee to review the Resident Monitoring Form with Vitals 2 times per day until power is restored, and facility temperatures are at 80 degrees or below. If any resident assessed has any indication of heat exhaustion or dehydration the physician/DON/designee will be notified On 6/21/23 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: The arrival of the large 300 kw generator at the facility was observed by the surveyors on 6/20/23 at approximately 8:30 p.m. The system was up and running and providing electricity to the entire facility, including the HVAC systems throughout the building. Resident rooms were spot checked for cool air coming out of the vents and falling temperatures were verified by surveyors before exiting the building on 6/20/23 at approximately 10:45 pm. Record review of Facility Temperature logs dated 6/20/23 at 11:00 p.m. confirmed Resident room temperatures in all zones were below 80 degrees Fahrenheit. (73.2 to 79). Record review of the Facility Temperature Logs dated 6/21/23 revealed all occupied resident rooms had a temperature check hourly starting at 12:00 a.m. All room temperatures were below 80 degrees. Record review of the untitled Facility log indicated residents were assessed for signs and symptoms of heat exhaustion and dehydration, vitals obtained, and fluids offered (with the exception of those residents asleep during sleep hours) every two hours starting on 6/20/23 at 6:30 p.m. During an interview on 6/21/23 at 8:34 a.m., Resident # 6 said he slept so much better last night. During an interview on 6/21/23 at 11:02 a.m. Resident #5 reported he slept good last night and was breathing better. During Observations from 11:40 a.m. to 3:47 p.m., surveyors continued to monitor temperatures in the facility. Initially, elevated temperatures were obtained in the facility dining area/ Kitchen of 81 degrees (in the dining room) and 91 degrees (in the kitchen). The facility responded by obtaining additional portable HVAC units for those areas. After the HVAC units were placed temperatures in the dining room and kitchen were 78 degrees (in the dining room) and 78-81 degrees (in the kitchen). All resident occupied areas and rooms checked were found to be between 71-79 degrees Fahrenheit. In-service sign in sheets over Checking the temperature of Resident Rooms hourly, Resident Monitoring Form to be completed every 2 hours, signs and symptoms of dehydration and signs and symptoms of heat exhaustion were reviewed. The In-service sign in sheet for the Administrators direct in-service over Emergency preparedness was reviewed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 10 of 18 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 06/23/2023 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 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the updated Facility Disaster/Emergency Plan stated Should building be unable to maintain temperatures between 71 - 81 degrees, the evacuation plan will be initiated. Corporate will ensure HHSC, local emergency management systems, families and Medical Director are notified. During staff interviews on 6/21/23 from 2:11p.m. to 3:13 pm the following clinical staff were interviewed (MA C, RN E, CNA F, LVN G, CNA H, LVN I, CNA K, LVN L, LVN M, CNA O, LVN P, MA Q, LVN R, RN S, CNA T, and the ADON [On the 6:00 a.m. to 2:00 p.m. shift 2 nurses, the ADON, 2 MAs and 2 CNAs; on the 2:00 p.m. to 10:00 p.m. shift 3 nurses, 7 CNAs and 1 MA; and on the 10:00 p.m. to 6:00 a.m. shift 3 nurses and 1 CNA]. During these interviews CNAs and MAs said they had been in-serviced over Checking the temperature of Resident Rooms hourly , Resident Monitoring Form to be completed every 2 hours, signs and symptoms of dehydration (feeling thirsty, Lightheaded, tiredness, dry mouth, dark colored or strong smelling urine, decreased urination) signs and symptoms of heat exhaustion elevated body temperature, hot, red, dry or damp skin, headache, dizziness, nausea, confusion, heavy sweating, cold pale or clammy skin, elevated heart rate, muscle cramps). They indicated if any resident displayed s/s of heat exhaustion or dehydration during rounds they would immediately report it to the nurse. During these interviews nurses said they had been in-serviced over Checking the temperature of Resident Rooms hourly, Resident Monitoring Form to be completed every 2 hours, signs and symptoms of dehydration (feeling thirsty, Lightheaded, tiredness, dry mouth, dark colored or strong smelling urine, decreased urination) signs and symptoms of heat exhaustion (elevated body temperature, hot, Event ID: Facility ID: 675812 If continuation sheet Page 11 of 18 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 06/23/2023 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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 be administered in a manner that enables it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 5 residents( Resident #3, #4, #6, and #5) reviewed comfortable and safe temperatures and 5 of 6 zones (Zone 6, Zone 5, Zone 5/11, Zone 5/7 and Zone 10) reviewed for comfortable and safe temperatures. Residents Affected - Many The Facility Administrator failed to ensure temperatures in the building were adequately monitored after a power outage on 6/16/23. The facility Administrator failed to accurately monitor the effectiveness of his action plans as additional equipment continued to fail to sustain appropriate temperatures. These failures could place residents at risk of heat exposure and dehydration. Findings included: During an interview on 6/19/23 at 1:30 p.m., the Administrator said the facility lost power at approximately 1:00 a.m. on 6/16/23. The Administrator said the facility's backup generator had kicked on upon the outage. The administrator said he had chosen not to evacuate the building because additional resources were coming to keep the building cool and if the facility evacuated the residents, they would have had to evacuate to another city, as many of the sister facilities had also been affected by the outage. He said the facility had maintained temperatures in the building from 72-82 degrees Fahrenheit since the outage to his knowledge. The Administrator said the secure unit (zone 6) and the back hall (zone 5/11 and zone 5/7) were warmer, but Residents were being kept on the front lobby/activity area (zone 8) where the temperature had been between 72-82 degrees. The Administrator said some residents had refused to come to the cool area (zone 8). During an interview on 6/19/23 at 1:40 p.m., the Maintenance Director said he had not kept any temperature logs for the facility since the power outage, so he could not accurately report what the temperatures in the facility had been since the outage. During an interview on 6/20/23 at 12:10 p.m., the EMTFD (Emergency Management Task Force Director)-Region 4, said he came to the facility on 6/17/23. He said he offered evacuation on two occasions that day (6/17/23) because he was concerned about the well being of the residents. The EMTFD said the first time he came to the facility on 6/17/23, one of the thermostats read 88 degrees Fahrenheit. The EMTFD said the Administrator declined the evacuation offer and reassured him the facility had additional generators and portable HVAC units to cool the building on the way. The EMTFD said the second time he came to the facility on 6/17/23, the Administrator met him on the front porch of the facility. The EMTFD said he was not invited into the building at that time. The EMTFD said he thoroughly explained to the Administrator that the evacuation services offered would be at no cost to the facility and that there was already space for the facility's residents at a local hospital. The EMTFD said he explained to the Administrator the facility would not lose any money while the residents were evacuees at the local hospital and would be able to continue to bill for services as the facility's staff would continue to provide care for the residents. The EMTFD said the Administrator insisted the residents were doing just fine and they had a cool area in the facility for the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 12 of 18 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 06/23/2023 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 0835 Level of Harm - Minimal harm or potential for actual harm During observations on 6/20/23 at 12:10 to 12:35 p.m., the facility temperatures on the Center Hall (zone 5) were 76 degrees F at the front of the hall and 85 degrees at the back of the hall. During observations on 6/20/23 at 12:35 to 12:40 p.m. facility temperatures on the back hall (zones: 5/11 and 5/7) were 85-86 degrees Fahrenheit. Residents Affected - Many During observations on 6/20/23 at 12:50 p.m., in the front/ right hall (secured unit- zone 6) the facility temperature was 86 degrees Fahrenheit. During an interview on 6/20/23 at 12:55 p.m., the Maintenance Director said the facility's current 150 kw generator was not big enough to run additional AC units for the whole building. The Maintenance Director said the Power went out at 1:00 a.m. in the morning on Friday (6/16/23). He said the emergency generator came on immediately and fans were gathered and plugged in to keep areas cool. The Maintenance Director said portable HVAC units arrived early afternoon on Friday (6/16/23). He said window units arrived Saturday morning around 10:00 a.m. The Maintenance director said the large generator arrived Sunday (6/18/23) evening around 11:00 p.m. The maintenance director said without the larger generator the temperatures had been between 82- and 84-degrees Fahrenheit. Record review of the face sheet for Resident #3 dated 6/20/23 indicated she was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including heart failure, muscle wasting and atrophy, heart disease, and high blood pressure. Record review of the MDS dated [DATE] indicated Resident #3 usually made herself understood and usually understood others. The MDS indicated she had severe cognitive deficit (BIMS of 4). The MDS indicated she required limited assistance with most ADLS (bed mobility, Transfers, dressing, toilet use, bathing and personal hygiene) but did require extensive assistance with locomotion in her wheelchair on the unit. During an interview and observation on 6/20/23 at 1:00 p.m., Resident #3 laid in her bed on the back hall (zone5/7) with a cold washcloth on her face. Resident # 3 said she was hot. Resident #3 said she had been in the front of the building and wanted to go back up there. Record review of Resident #4's face sheet indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including, history of hypertensive urgency muscle wasting and atrophy, muscle weakness, diabetes, high blood pressure, and history of stroke. The MDS indicated she required supervision only with ADLS except for bathing for which she required limited assistance. Record review of the MDS dated [DATE] indicated Resident #4 understood others and made herself understood. The MDS indicated she had no cognitive impairment (BIMS of 13). During an interview and observation on 6/20/23 at 1:10 p.m., Resident #4 was sitting in a wheelchair in her room on the back hall (zone 5/11). Resident #4 said she was about to go back to the front of building because it was a little cooler up there. Resident #4 said she slept up there on the couch (in the front lobby area zone 8) last night because it was just too hot in her room and said she was dripping with sweat. Record review of Resident #6's face sheet dated 6/20/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including history of metabolic encephalopathy, back abscess (a swollen area within body tissue, containing an accumulation of pus.), history of GI hemorrhage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 13 of 18 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 06/23/2023 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (Gastrointestinal (GI) bleeding is any type of bleeding that starts in the GI tract, also called the digestive tract), high blood pressure, history of skull fracture, history of traumatic brain injury, Type II diabetes, and dysphasia after stroke. Record review of the MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated he had moderate cognitive impairment (BIMS of 11 ). The MDS indicated he required supervision only with most ADLS except for bathing for which he was totally dependent on staff. During an interview on 6/20/23 at 3:00 p.m. Resident #6 was sitting in his wheelchair in the front lobby area (zone 8). He said the temperature up here was not terrible and was much better than it was over the weekend. Resident #6 said he did not know what the actual temperature was over the weekend but said it was real hot. Resident #6 said he had not been able to sleep much because it was just too hot in his room on the back hall (zone 5/11). Record review of Resident #5's face sheet dated 6/20/23 indicated he was [AGE] years old readmitted to the facility on [DATE] with diagnoses including COPD, Schizoaffective disorder, bradycardia, muscle wasting and atrophy, history of left knee replacement, and chest pain. Record review of the MDS dated [DATE] indicated Resident #5 understood others and made himself understood. The MDS indicated he had moderate cognitive impairment (BIMS of 11). The MDS indicated he required supervision with ADLS except for bathing for which he was totally dependent on staff. During an interview on 6/20/23 at 4:16 p.m., Resident #5 was sitting in the front lobby area (zone 8). Resident #5 said he has had increased trouble breathing with the heat and has not been able to sleep since the outage. He said it was just too hot to get any sleep. Resident #5 said it helped to sit up here (in the front [zone 8]) but at night, he said residents go back to the rooms to sleep and it's just too dang hot to sleep on the back hall (Zone 5/7). During an interview on 6/20/23 at 11:56 a.m., CNA B said she worked at the facility Friday (6/16/23) morning from 6am to 2pm. She said the power had gone out sometime before her shift started but was not sure what time. CNA B said it was very hot in the building. CNA B said it was hotter in the back of the building than it was in the front of the building. CNA B said she could not say what the thermostats read on the resident halls during her shift. CNA B said she remembered looking at the thermostat in the dining room when the residents were eating lunch and it said 93 or 94 degrees Fahrenheit. She said it was very hot and the facility was gathering fans at that time. CNA B said there were no portable HVAC units in the building at the time (6/16/23 from 6am to 2pm). During an interview on 6/20/23 at 12:09 pm MA C said she worked Friday (6/16/23) and it was awful. MA C said it was awful because it was so hot in the building. MA C said she did not recall what the thermostats said in the building. During an interview on 6/20/23 at 12:12 p.m., CNA D said she worked in the facility on Saturday (6/17/23) and Sunday (6/18/23). CNA D said it was very hot in the building all weekend. CNA D said she did have some residents compliant to her about the heat but could not recall their names. CNA D explained she worked for a staffing agency and was not extremely familiar with the residents. CNA D said she was told an additional generator was coming to help cool the building. CNA D said she heard the nurses saying that a big generator was coming to help cool the building, so that was what she told residents. CNA D said the big generator did not come until Sunday night. CNA D said she heard there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 14 of 18 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 06/23/2023 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many was some delay with getting the generator started on Sunday night due to some of the cords needed had not arrived. CNA D said she was not sure what time the big generator was up and running Sunday night. CNA D said the front of the building (zone 8) was just as hot as the rest of the building Saturday (6/17/23) and Sunday (6/18/23). CNA D said the thermostat to the immediate left when entering the back hall (zone 5) on Saturday between 4:00 p.m. and 5:00 p.m. read 92 degrees Fahrenheit. On Sunday (6/18/23) CNA D said the same thermostat read between 80-85 degrees Fahrenheit during her 2:00 p.m.-10:00 p.m. shift. During an interview on 6/20/23 at 12:20 pm the ADON said she came home early from her vacation on Saturday (6/17/23) to help out at the facility. The ADON said she worked as the medication aide that day. The ADON said it was hot in the building but not unbearable. The ADON said there were fans up and running throughout the building but said she could not say if there were any portable HVAC systems in the building at that time. The ADON said she also came in Sunday to help out. The ADON said no residents complained to her about the heat. The ADON said she knew the idea of evacuation was mentioned but never heard any actual plan. The ADON said the DON was on vacation herself and could not be reached. During observations on 6/20/23 at 3:40 p.m. the front cool area (zone 8) temperatures were 78-79 degrees Fahrenheit. During observations on 6/20/23 at 3:40 to 3:41 p.m., facility temperatures on the Center Hall (zone 5) were 91-93 degrees Fahrenheit. During observations on 6/20/23 at 3:44-3:47 p.m., facility temperatures on the back hall (zones: 5/11 and 5/7) were 90- 93 degrees Fahrenheit. During observations on 6/20/23 at 3:45 pm the facility census 52 residents had all been moved to the front cool area of the building. During an interview on 6/20/23 at 3:47 pm the Administrator said all Residents were currently being kept in the front lobby. The Administrator reported all residents had been sleeping in their rooms since the outage. According to the website www.accuweather.com accessed on 6/20/23 the outside temperature on 6/20/23 at 4:16 p.m. was 99 degrees Fahrenheit with a heat index of 120 degrees. During an interview on 6/23/23 at 10:50 a.m., the Administrator said hindsight being 20/20 he might have evacuated the Residents. He continued, but we just really thought when the first big generator got here Sunday night (6/18/23) it was going to fix our problems. The facility Emergency preparedness plan reviewed on 7/22/21, Emergency Preparedness Plan Loss of Power Heat and Water, stated . (2) Loss of Comfort Heating/Cooling .(b) If loss is in the entire home due to interruption of public utilities (electrical /natural gas) and residents become uncomfortable, they will be placed in the beds and protected by an adequate supply of linen, or they will be moved to a central location that can be heated/cooled. (c) If loss is for extended period of time and the residents can no longer be protected in a comfortable manner, the residents will be evacuated to another location . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 15 of 18 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 06/23/2023 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 4 of 4 residents ( Resident #1, #7, #4, and #3) reviewed for RP notification. The facility did not notify Resident representatives of the facility's power outage that occurred 6/16/23, in compliance with its Emergency Preparedness Plan. This failure could place residents at risk of decreased quality of services and unmet needs. Findings included: 1.Record review of Resident #1's face sheet indicated he was [AGE] years old, re-admitted to the facility on [DATE] with diagnoses including history of heart attack, high blood pressure, history of urinary retention, muscle weakness, history of urinary tract infections, BPH (Benign prostatic hyperplasia is also called an enlarged prostate which can impede urine flow) Type II diabetes, and Alzheimer's disease. Record review of Resident #1's MDS dated [DATE] indicated he understood others and made himself understood. The MDS indicated he had severe cognitive impairment (BIMS of 5). The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressing, eating, toilet use and personal hygiene. The MDS indicated he was totally dependent on staff for bathing. The MDS indicated he had an indwelling catheter and was frequently incontinent of bowel. Record review of Resident #1's progress notes from 6/16/23 to 6/18/23 did not indicate his responsible party had been notified of the power outage at the facility. During an interview on 6/22/23 at 10:12 a.m., Resident #1's responsible party said she was not notified by the facility in regard to the power outage. Resident #1's responsible party said she was not aware of the outage until after Resident #1 was in the hospital (admitted to the hospital on [DATE]) and said she had heard it through the grapevine. 2.Record review of Resident # 7's face sheet dated 6/20/23 indicated he was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty speaking) after stroke, hypothyroidism, high blood pressure, high cholesterol, History of stroke and Atrial fibrillation (an irregular and often very rapid heart rhythm). Record review of the MDS dated [DATE] indicated Resident #7 sometimes made himself understood and understood others. The MDS indicated he had moderate cognitive impairment (BIMS of 11 ). The MDS indicated he required Supervision with bed mobility, transfers, locomotion in his wheelchair, eating, toilet use and personal hygiene. The MDS indicated he required limited assistance with dressing. The MDS indicated he was totally dependent on staff for bathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 16 of 18 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 06/23/2023 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of Resident #7's progress notes from 6/16/23 to 6/19/23 (on 6/19/23 Resident #7 went out on pass with his family) did not indicate his responsible party had been notified of the power outage at the facility. During an interview on 6/22/23 at 10:15 a.m., Resident #7's responsible party said she had not been notified of the facility's power outage. Resident #7's responsible party said she had heard about the outage from her family member who went to visit Resident #7 days after the outage. Resident #7' responsible party said he was taken out of the facility on pass on 6/19/23. 3. Record review of Resident #4's face sheet indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including, history of hypertensive urgency muscle wasting and atrophy, muscle weakness, diabetes, high blood pressure, and history of stroke. Record review of the MDS dated [DATE] indicated Resident #4 understood other and made herself understood. The MDS indicated she had no cognitive impairment (BIMS of 13). The MDS indicated she required supervision only with ADLS except for bathing for which she required limited assistance Record review of Resident #4's progress note dated 6/20/23 at 6:14 p.m., stated Resident RP notified of power outage and current situation. No concerns at this time. This note was written by the Social Worker. During an interview on 6/22/23 at 10:27 a.m. Resident #4's responsible party said the facility did not notify her of the power outage. Resident #4's responsible party said she had called up to the facility herself on Tuesday (6/20/23) and spoke with the Social Worker. Resident #4's responsible party said the Social Worker notified her at that time because she (Resident #4's representative) asked about the outage. Resident #4's responsible party said no one at the facility had any communication with her or attempted to call her before 6/20/23. 4.Record review of the face sheet for Resident #3 dated 6/20/23 indicated she was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including heart failure, muscle wasting and atrophy, heart disease, and high blood pressure. Record review of the MDS dated [DATE] indicated Resident #3 usually made herself understood and usually understood others. The MDS indicated she had severe cognitive deficit (BIMS of 4). The MDS indicated she required limited assistance with most ADLS (bed mobility, Transfers, dressing, toilet use, bathing and personal hygiene) but did require extensive assistance with locomotion in her wheelchair on the unit. Record review of the Resident # 3's progress note dated 6/20/23 at 6:02 p.m., stated Resident RP notified of power outage and current situation. No concerns at this time. This note was written by the Social Worker. During an interview on 6/22/23 at 10:28 a.m., Resident #3's responsible party said the facility did not notify her of the outage at the facility. Resident #3's responsible party said she did not know the facility was without power until late Saturday (6/17/23) when she went to the facility herself. During an interview on 6/22/23 at 11:25 a.m., the Social Worker said she had not notified any families of the power outage before Tuesday 6/20/23 . The Social Worker said she had not notified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 17 of 18 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 06/23/2023 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 0836 families because no one had told her to until Tuesday 6/20/23 (4 days after the outage). Level of Harm - Minimal harm or potential for actual harm During an interview on 6/22/23 at 11:32 a.m., the Administrator said it was the responsibility of the social worker to ensure that families / responsible parties were notified about the power outage at the facility. The Administrator said RPs and families should have been notified prior to 6/20/23. He said he was looking into putting in place an alert system that would notify families all at once via email or text. Residents Affected - Many The facility Emergency preparedness plan reviewed on 7/22/21, Amendment to Emergency Procedures for (Facility) Sheltering in Place, stated .Resident Family members will be notified by facility staff and may come to facility to be with residents for the duration of the emergency if they choose . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 18 of 18