Health inspection·November 29, 2023

F 0580 encounter for open fracture. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/29/23 at 10:56 AM Resident #41's responsible party said the staff called her to notify of the incident, but it was after resident had made it to the emergency room. She said the staff never notified her that Resident #41 had a fractured right finger, but they were notified of the laceration. She said she never knew the fracture was there until her doctor visit on 10/09/23. Residents Affected - Some During an interview on 11/29/23 at 12:23 PM LVN E said she was the charge nurse on 09/30/23 and Resident #41 was sent out to the ER after an incident involving her fourth right finger. LVN E said when Resident #41 returned from the hospital she returned with the laceration with stitches and the finger was wrapped and had orders for treatments. She said she thought she saw the fracture diagnosis. LVN E said the responsible party was at the hospital, so she figured she knew Resident #41's diagnosis. She said she did not remember a conversation with the responsible party about the finger fracture. She said she notified resident's primary doctor or fracture and the laceration. LVN E said she should have notified the responsible party of the right finger fracture at the time she returned to the facility. LVN E said the failure placed a risk of the responsible party not knowing what was going on with the resident's care. During an interview on 11/29/23 at 12:50 PM the DON said she recalled the incident with Resident #41. She said she was sent to the emergency room, and she did not see the visit paperwork when Resident #41 returned. The DON said she knew she had a fracture but unsure if it was on the first emergency room visit. She said she expected the responsible party to be notified on the day the resident returned to the facility from the hospital. The DON said charge nurse on duty was responsible for notifying the responsible party. She said she did not realize the fracture was not mentioned or noted. The DON said the failure placed the resident and family at risk of not knowing residents diagnosis and it was their right to know the resident's diagnosis and treatments. During an interview on 11/29/23 at 1:35PM the Administrator at the time of the incident said he did not recall any incidents involving Resident #41 and he hated to say what he would expect or think since he did not work at the facility since 11/30/23. Review of training records provided by the facility revealed LVN A received training on Notification to NPs on 7/25/2023. The flyer attached to the sign-in sheet stated: Notify Nurse Practitioner of vital signs out of parameters or changes in condition every time. Review of LVN A's Clinical Skills evaluation dated 05/09/2023 revealed LVN A demonstrated competency in: 7. Resident Care Procedures f) Recognizes abnormalities; documentation; reporting. Record review of the Job Description for Licensed Vocational Nurse, revised 05/20/2021, provided by the facility, revealed: Essential Functions/Primary Duties: .communicate with residents, family members, other interdisciplinary team members and management regarding resident status. Record review of facility policy Change of Condition-Observing, Reporting and Recording dated 1-2023 indicated: Policy It is the policy of this home to informs the resident, the residents physician and if indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 2 of 15 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 11/29/2023 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 0580 residents responsible party of the following. Level of Harm - Minimal harm or potential for actual harm 1. Residents Affected - Some An incident involving the resident, which results in injury and has the potential requiring physician intervention; 2. A significant change in the resident's physical, [NAME], or phychosocial status, such as a deterioration in health, mental, or psychococial status, in life threatening conditions or clinical complications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 3 of 15 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 11/29/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 8 residents (Resident #31, Resident # 32, Resident #33, and Resident #41) reviewed for comprehensive person-centered care plans. 1. The facility failed to include Resident #31's behavior to take others food and drinks in her care plan after she was involved in a resident-to-resident altercation for taking another resident's milk on 06/26/2023. 2. The facility failed to care plan Resident #32's and Resident #33's risk for resident-to-resident altercations after an altercation that occurred between them on 07/19/2023. 3. The facility failed to care plan Resident #41's right finger fracture (diagnosed on [DATE]). These failures could place the residents at increased risk of not having their individual needs met, future resident-to-resident altercations, and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 11/29/23 indicated Resident #31 was a [AGE] year old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance (deterioration of memory, language, and other thinking abilities without behaviors) and anxiety and Alzheimer's disease with late onset (progressive disease that destroys memory and other important mental functions). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #31 was sometimes understood by others and usually understood others. The MDS assessment indicated Resident #31 was unable to complete the BIMS interview. The MDS assessment indicated Resident #31 had a short-term and long-term memory problem. The MDS assessment indicated Resident #31's ability to make decisions regarding tasks of daily life were severely impaired. The MDS assessment indicated Resident #31 displayed the behavior of inattention. The MDS assessment indicated Resident #31 displayed other behavioral symptoms not directed toward others (such as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS assessment indicated Resident #31 required setup or clean-up assistance for eating, substantial/maximal assistance for toileting hygiene, and was dependent for upper and lower body dressing and personal hygiene. Record review of the Provider Investigation Report dated 06/29/2023 indicated on 06/26/2023 Resident #31 took another resident's milk from his lunch tray and the resident slapped Resident #31 on her face. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 4 of 15 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 11/29/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the care plan last reviewed 11/01/2023 did not indicate Resident #31 took others food and drinks. During an interview on 11/28/2023 at 10:07 AM, RN D said Resident #31 tended to grab others drinks and food, and they tried to keep her seated away from others to prevent her from grabbing other residents' things and upsetting them. 2. Record review of a face sheet dated 11/29/2023 indicated Resident #32 was an [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included intermittent explosive disorder (behavioral disorder characterized by explosive outbursts of anger and violence in which one reacts out of proportion to the situation). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #32 was able to make himself understood and understood others. The MDS assessment indicated Resident #32's BIMS score was 13, which indicated his cognition was intact. The MDS assessment indicated Resident #32 did not experience physical or behavioral symptoms directed towards others. The MDS assessment indicated Resident #32 did not experience other behavioral symptoms not directed toward others. Record review of the Provider Investigation Report dated 07/24/2023 indicated on 07/19/2023 Resident #33 went to the dining room and accused Resident #32 of being in the wrong seat. Resident #32 refused to move, and Resident #33 attempted to push Resident #32 out of the way, and Resident #32 swung at Resident #33. Record review of the care plan last revised 11/09/2023, did not indicate resident experienced behaviors of aggression towards others or outbursts of anger or had a history of a resident-to-resident altercation. Record review of a face sheet dated 11/29/2023 indicated Resident #33 was an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included bipolar disorder, current episode depressed, severe, without psychotic features (a serious mental illness characterized by extreme mood swings). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #33 was understood by others and was able to make himself understood. The MDS assessment indicated Resident #33 had a BIMS score of 11, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #33 did not experience physical or behavioral symptoms directed towards others. The MDS assessment indicated Resident #33 did not experience other behavioral symptoms not directed toward others. Record review of the care plan dated 09/25/2023 did not indicate Resident #33 had a history of a resident-to-resident altercation. During an interview on 11/29/2023 at 10:59 AM, the DON said Resident #32 was sitting in Resident #33's regular sitting spot. The DON said there were no assigned seats in the dining room, but generally the residents sit in the same seats. The DON said Resident #33 got mad, there were some words exchanged, and Resident #32 and Resident #33 were separated by the staff. The DON said there were no injuries to either of the residents, and they were both referred to the behavioral unit per the doctor's order. The DON said these behaviors were abnormal for both Resident #32 and Resident #33, and they had not displayed any aggression towards others since returning from the behavioral unit. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 5 of 15 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 11/29/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said the staff tried to keep Resident #31 away from other residents that were eating because she liked to get other residents' food and drinks. During an interview on 11/29/2023 at 12:39 PM, the DON said behaviors would be care planned by whoever encountered the behaviors. The DON said any nurse manager was responsible for care planning behaviors. The DON said Resident #32 and Resident #33 were not care planned for the resident-to-resident altercation or for behaviors because it was an isolated incident. The DON said Resident #31's behavior of taking other residents food/drinks should be included in her care plan. The DON said it was important for behaviors and resident-to-resident altercations to be care planned so the staff were aware of the behaviors and could intervene appropriately. The DON said the MDS Coordinator reviewed the care plans during the care plan meetings. During an interview on 11/29/2023 at 1:47 PM, the MDS Coordinator said behaviors and resident-to-resident altercations should be included in the care plan. The MDS Coordinator said the social worker should have included Resident #31's, Resident #32's, and Resident #33's behaviors in their care plans. The MDS Coordinator said the social worker who should have done that was no longer employed at the facility. The MDS Coordinator said she was not responsible for reviewing the care plans. The MDS Coordinator said the care plans were reviewed as a team, and the staff should be changing the care plans when incidents occur. The MDS Coordinator said it was important for behaviors and resident-to-resident altercations to be care planned so that the staff knew how to address the behaviors, to prevent further altercations, find out what the issue is and make appropriate referrals. 3. Record review of Resident #41's face sheet dated 11/29/23 indicated she was a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with the diagnoses atrial flutter (a common abnormal heartbeat), Pneumonia (lung inflammation caused by bacterial or viral infection in which lungs become filled with fluid), and muscle weakness. Record review of Resident #41's annual MDS dated [DATE] indicated she had a BIMS score of 11 which indicated she had moderately impaired cognition. The MDS also indicated Resident #41 required Supervision assist stance from staff for bed mobility, transfers, toileting, and eating, and required total assistance from staff for bathing. Record review of Resident #41's care plan last revised 11/28/23 did not indicate that she had a right finger fracture. During an interview on 11/29/23 at 2:15 PM the DON said LVN E was responsible for ensuring the care plan was in place. She said any nurse manager could have input the care plan. The DON said the risk to the Resident #42 not having the finger fracture care planned placed a risk for improper care and improper healing. During an interview on 11/29/2023 at 2:00 PM, the Administrator said his first day employed at the facility was Monday )11/27/2023, and he was not aware of who was responsible for ensuring the care plans were individualized and included all the residents' needs. The Administrator said he expected for the care plans to include the residents needs including behaviors, resident-to-resident altercations, and fractures. The Administrator said it was important for the care plan to include these, so everyone understood what behaviors the residents had and how to respond to them. Record review of the facility's policy titled, Care Plan-Resident, with an effective date of 1-2023, indicated, Policy It is the policy of this home that staff must develop a comprehensive care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 6 of 15 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 11/29/2023 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 0656 to meet the needs of the resident .b. Level of Harm - Minimal harm or potential for actual harm Sources are, but are not limited to: 1. Problems relating to diagnoses. 2. Residents Affected - Some Problems relating to physician's orders. correspond to a diagnosis.) . 7. Behavior control problems . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 7 of 15 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 11/29/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 4 of 4 residents (Residents #34, Resident #35, Resident #36, and Resident #37) reviewed for pharmacy services. 1. The facility failed to ensure MA C (no longer employed) documented on Resident #36's narcotic record the time of administration for 1 dose of hydrocodone-acetaminophen (a narcotic medication used for pain) given on 06/16/2023. 2. The facility failed to ensure MA B documented on Resident #37's narcotic record the time of administration for 1 dose of hydrocodone-acetaminophen given on 10/17/2023. 3. The facility failed to ensure MA B documented on Resident #35's narcotic record the time of administration for 1 dose of hydrocodone-acetaminophen given on 11/23/2023. 4. The facility failed to ensure MA A documented on Resident #34's narcotic record the time of administration for 2 doses of hydrocodone-acetaminophen given on 11/28/2023. These failures could place the residents at risk of not having medications available for use, medication errors, and drug diversion. Findings included: 1. Record review of a face sheet dated 11/30/23 indicated Resident #36 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic pain. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #36 was sometimes able to make himself understood and sometimes understood others. The MDS assessment indicated Resident #36 had a BIMS score of 13, which indicated his cognition was intact. The MDS assessment indicated Resident #36 had not received pain medication in the 5-day look back period, and he did not have any pain. Record review of the Physician Order Report dated 10/30/2023-11/20/2023 indicated Resident #36 had an order for hydrocodone-acetaminophen 10-325 mg 1 tablet every 6 hours as needed with a start date of 03/23/2021. Record review of the care plan last reviewed on 09/13/2023 indicated Resident #36 required pain management related to recent left knee replacement to administer medications as ordered. Record review of Resident #36's Individual Patient's Narcotic Record for hydrocodone-acetaminophen 10-325 mg dates ranged from 04/01/2023-11/28/2023 indicated on 06/16/2023 MA C administered 1 tablet of hydrocodone-acetaminophen but there was no time documented. Record review of Resident #36's MAR dated from 06/05/2023-06/30/2023 did not indicate the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 8 of 15 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 11/29/2023 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 0755 hydrocodone-acetaminophen 10-325 mg was administered on 06/16/2023. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #37's face sheet dated 11/28/2023 indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included chronic demyelinating polyneuritis (rare disorder that damages the protective layer of nerve fibers, causing weakness, numbness, and pain in the limbs) and low back pain. Residents Affected - Some Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #37 was able to make herself understood and understood others. The MDS assessment indicated Resident #37 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #37 had received pain medication in the 5-day look back period. The MDS assessment indicated Resident #37 occasionally had pain. Record review of the Physician Order Report dated 10/01/2023-11/28/2023 indicated Resident #37 had an order for hydrocodone-acetaminophen 10-325 mg 1 tablet every 6 hours as needed with a start date of 08/31/2023. Record review of Resident #37's care plan last revised 11/17/2023 indicated Resident #37 required pain management and monitoring for diagnosis of neuritis (inflammation of a peripheral nerve or nerves, usually causing pain and loss of function) to administer medications as ordered. Record review of Resident #37's Individual Patient's Narcotic Record for hydrocodone-acetaminophen 10-325 mg dates ranged from 09/13/2023-10/18/2023 indicated on 10/17/2023 MA B administered 1 tablet of hydrocodone-acetaminophen but there was no time documented. Record review of Resident #37's MAR dated from 10/01/2023-10/31/2023 indicated hydrocodone-acetaminophen 10-325 mg was administered on 10/17/2023 at 9:00 PM by MA B. 3. Record review of a face sheet dated 11/30/2023 indicated Resident #35 was a [AGE] year-old female initially admitted to the facility on [DATE] and discharged on 11/25/2023 with diagnoses which included type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugars that caused nerve damage resulting in numbness, tingling, pain, or weakness in the hands or feet). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #35 was usually understood and usually understood others. The MDS assessment indicated Resident #35 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #35 had not received pain medication in the 5-day look back period. The MDS assessment indicated Resident #35 did not have pain. Record review of the Physician Order Report dated 10/30/2023-11/30/2023 indicated Resident #35 had an order for hydrocodone-acetaminophen 5-325 mg every 6 hours as needed with a start date of 10/09/2023. Record review of Resident #35's electronic health record indicated the comprehensive care plan had not been completed. Record review of Resident #35's Individual Resident Narcotic Record for hydrocodone-acetaminophen 5-325 mg dates ranged from 11/13/2023-11/23/2023 indicated on 11/23/2023 MA B administered 1 tablet of hydrocodone-acetaminophen but there was no time documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 9 of 15 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 11/29/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #35's MAR dated from 11/10/2023-11/25/2023 did not indicate hydrocodone-acetaminophen 5-325 mg was administered on 11/23/2023. 4. Record review of a face sheet dated 11/30/2023 indicated Resident #34 was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included secondary osteoarthritis (a form of arthritis where joint cartilage breaks down and may cause pain, stiffness, and limited range of motion). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #34 was usually understood and usually understood others. The MDS assessment indicated Resident #34 had a BIMS score of 1, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #34 received a scheduled pain medication regimen. The MDS assessment indicated Resident #34 had pain. Record review of the Physician Order Report dated 10/20/2023-11/20/2023 indicated Resident #34 had an order for hydrocodone-acetaminophen 10-325 mg three times a day with a start date of 02/23/2023. Record review of the care plan last revised 11/16/2023 indicated Resident #34 required pain management related to a diagnosis of osteoarthritis to administer medications as ordered. Record review of Resident #34's Individual Resident Narcotic Record for hydrocodone-acetaminophen 10-325 mg dates ranged from 11/27/2023-11/28/2023 indicated two separate entries on 11/28/2023 documented by MA A with one table of hydrocodone-acetaminophen administered each time. Both entries dated 11/28/2023 did not have a documented time the medication was administered. Record review of Resident #34's MAR dated from 11/01/2023-11/30/2023 indicated hydrocodone-acetaminophen 10-325 mg was administered on 11/28/2023 at 9:00 AM and 2:00 PM by MA A. During an interview on 11/29/2023 at 9:33 AM, MA A said when administering a narcotic medication, the narcotic drug record should be filled out with the date and time administered, initials, quantity given and the quantity remaining. MA A said for the Norco given on 11/28/2023 she must have forgotten to put the time because she was rushed. MA A said the person administering the medication should be making sure the log was filled out correctly. MA A said it was important to fill out the narcotic drug record as required to keep track of the medications and to ensure the residents received the right amount and the right dose at the right time. During an interview on 11/28/2023 at 3:57 PM, MA B said when she administered a narcotic medication, she would look at the order in the computer then pop the medication out of the medication card, log it on the narcotic drug record, and sign it off as administered on the MAR. MA B said on the narcotic drug record she would fill out the date, time, name, the quantity given and the quantity remaining. MA B said every time a narcotic medication was administered this was supposed to be done. MA B said she had not put the time on the narcotic drug record and not signed the medication as administered on the MAR because she was rushed and distracted. MA B said sometimes the residents were asking her for things and this made her feel rushed and distracted. MA B said it was important to document medications when administered so the times would be accurate. MA B said not putting the time administered on the narcotic drug record could result in the narcotic medications being mishandled, given at the inappropriate times, or unaccounted for. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 10 of 15 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 11/29/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 11/29/2023 at 9:14 AM, the ADON said when administering a narcotic medication, the medication should be signed out on the narcotic medication record, the pill popped from the medication card, signed off in the computer, all at the same time, so the computer matches the narcotic medication record. The ADON said the narcotic medication record should have the date, time, initials, how many pills were given and how many were remaining. The ADON said the person giving the medication was responsible for ensuring the narcotic medication record was filled out properly. The ADON said when the medication aides and nurses were reconciliating the narcotic medications they were supposed to be checking to ensure the narcotic medication records were filled out properly. The ADON said no one was monitoring the narcotic medication records to ensure they were being filled out properly. The ADON said it was important for the narcotic medication records to be filled out properly to ensure the staff were not giving too many pills and medications were administered at the correct time. The ADON said MA C had retired and was no longer employed at the facility. During an interview on 11/29/2023 at 10:59 AM, the DON said when the staff administered a narcotic medication, they were supposed to fill out the narcotic medication record with the time it was given, their signature, date, how many were given, and how many were remaining. The DON said the ADON and herself were responsible for ensuring the narcotic medication records were filled out properly. The DON said she was reviewing the narcotic medications records randomly twice a week. The DON said she had noticed they were not being properly filled out mostly by the nighttime staff, and she had provided an in-service to them. The DON said she had not noticed Resident #34's, Resident #35's, Resident #36's, and Resident #37's narcotic medication records were not filled out properly. The DON said it was important for the narcotic medication records to be filled out properly, so the staff knew exactly when a medication was given. The DON said not filling out the narcotic medication record properly could result in overdose and medication errors. During an interview on 11/29/2023 at 1:59 PM, the Administrator said he expected the nurses and medication aides to fill out the narcotic medication record properly when administering narcotic medications. The Administrator said the DON was responsible for ensuring the nurses and medication aides filled out the narcotic medication records properly. The Administrator said it was important for the staff to fill out the narcotic medication records properly to ensure it was all being done timely, the narcotic medications were monitored properly, and for the quality of care of the residents. Record review of the facility's policy titled, Medication-Controlled Substances, effective date 1/2023, indicated, .5. Proof-of-use records in the form of a declining inventory record are to be maintained for all Schedule II, III and IV drugs. The following information will be recorded for each such controlled substance: a. Name of the resident. b. Physician's name. c. Prescription number. d. Name and strength of the drug. e. Date received by the home. f. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 11 of 15 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 11/29/2023 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 0755 Original amount dispensed. g. Level of Harm - Minimal harm or potential for actual harm Date and time administered. h. Dose administered. i. Residents Affected - Some Signature of the person administering the dose . 8. As soon as possible after each dose is administered, the individual administering the drug is to enter the required information on the proof-of-use record, but no later than the end of the shift in which the administration occurred . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 12 of 15 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 11/29/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain clinical records on each resident that were complete and accurately documented for 1 of 15 residents (Resident #42) reviewed for clinical records. The facility failed to ensure Resident #42's electronic record reflected the residents accurate skin conditions during her respite stay from 10/04/23-10/08/23. This failure could place residents at risk of worsening skin integrity and decline in comfort level. The findings included: Record review of Resident #42's face sheet dated 11/29/23 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] and discharged on 10/08/23. Resident #42 had diagnoses which included heart disease( a heart condition that includes diseased blood vessels, structural problems, and blood clots), chronic kidney disease stage 4(disease in which the kidneys do not function as they should to filter waste from the body), chronic diastolic congestive heart failure(a disease in which the left side of the heart does not function well and causes decreased blood flow), diabetes mellitus with hyperglycemia( disease in which the body does not produce or respond to the hormone insulin and causes blood sugars to elevate), anxiety, and high blood pressure. Record review of Resident #42's weekly skin assessment dated [DATE] indicated she had MASD to coccyx that measured 1cm X0.5cm. Record review of the facility skin report dated 10/06/23 indicated Resident #42 did not have a wound. Record Review of Resident #42's EMR (electronic medical record) on 11/28/23 at indicated resident did not have a comprehensive MDS completed. Record review of Resident #42's physician order report dated 10/29/23-11/29/23 indicated she had an order to Clean wound to coccyx with wound cleanser or NS (normal saline) pat dry using gauze apply Medi honey (a medicated dressing used for pressure ulcers/sores with partial a or full thickness) and cover with boarder foam dressing once a day with a start date of 10/04/23. Record review of Resident #42's treatment administration history dated 10/03/23-10/10/23 indicated she received treatment to wound to coccyx on 10/5/23, 10/06/23, 10/07/23, and 10/08/23 as ordered. The treat administration history indicated she did not receive treatment on 10/04/23 because the treatment had already been completed. Record review of Resident #42's hospice visit note report dated 10/07/23 completed by RN F indicated she had a stage II pressure ulcer to her coccyx with no measurements taken, and the wound contained 75-<100% epithelialized tissue (the tissue that covers a wound when healing). The visit note report also indicated the skilled nurse was to perform/teach wound care to the pressure ulcer stage II (wound with partial thickness loss of skin that presents as an open ulcer with pink or red wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 13 of 15 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 11/29/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bed) to coccyx. Wound was to be cleansed with NS, pat dry, apply Medi honey to wound bed, cover with foam dressing. Dressing was to be completed daily. During an interview on 11/28/23 at 2:46 PM RN G said Resident #42 had had a pressure area to her coccyx the entire time she was on the hospice services. She said she saw wound on the day Resident #42 discharged , 10/8/23 and it looked good with no decline. RN G said she would guess it was about 2cm X 2cm and like a stage 2 pressure ulcer in appearance with 0.1 in depth, but it was a healing stage 4 ulcer that Resident #42 began with. During an interview on 1/28/2023 at 3:50PM LVN E said she did not look at her wound on the first day. She said it was MASD (moisture associated skin damage). She said resident had a wound and the area was small and just a little bit open with no drainage, so she did not feel it was a pressure ulcer. LVN E said she did not add Resident #42 to the skin report because MASD would not be placed on the skin reports. During an interview on 11/28/2023 at 4:00PM the ADON said she never looked at Resident #42's wound to know what it looked like. She said residents with respite care were treated the same as a resident who admits for long term care and an accurate assessment should have been in her medical records. The ADON said she understood Resident #42 to have had a stage 4 at one time but was unsure of what it looked like as of the day she discharged on 10/08/23. During an interview on11/29/2023 at 9:10 AM the DON said she never looked at Resident #42's coccyx wound or MASD. During an interview on 11/29/23 at 12:15 PM LVN E said she would not have documented any differently had she known Resident #42 had a healing stage 4 pressure injury. She said she did question the hospice nurse about using barrier cream, but the hospice nurse said they would continue the use of medi-honey. The measurement was for the MASD. She said the depth of the open area was superficial and it looked as though it was MASD. LVN E said the DON normally would look at the wounds upon admission. She said had she known it was a previous wound she would have had the DON look at it to stage it. LVN E said she knew that you cannot down stage a wound. She said the failure placed the resident at risk of not having all the protocols and nutrition put in place for her benefit and healing. During an interview on 11/29/23 at12:55 PM the DON said LVN E documented what she thought it was and she did not have the documentation in place to know any different. She said it was a mistake in charting. The DON said if Resident #42 had significant wounds she would have gone behind the treatment nurse and assessed to ensure it was documented and staged correctly. The DON said LVN E was responsible for assessing and accurately documenting all skin. She said she should have notified the DON for staging wounds. The DON said the risk to the resident was a charge nurse not truly knowing what or how to care for the resident. During an interview on 11/29/23 at 1:35PM the previous Administrator resident was in the facility said he did not recall anything about Resident #42, or an incident and he hated to say what he would think or expect since he did not work there anymore. During an interview on 11/29/2023 at 2:05 PM the Administrator said he expected the labeling and staging for the wound to have been placed correctly and the correct plan of care followed. He said the DON was responsible for ensuring the correct documentation was in place, and the risk to the resident was that she would not be cared for properly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 14 of 15 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 11/29/2023 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 0842 During an interview on 11/29/23 at 2:10 PM the DON said the facility did not have a policy for accurate documentation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675812 If continuation sheet Page 15 of 15