Health inspection·August 12, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure its residents were free of any significant medication errors for 2 (Resident #1 and Resident #2) of 10 residents reviewed for medications. The facility failed to hold Losartan per parameters stated in physicians' orders for a total of 8 doses in July 2025 for Resident #1. The facility failed to hold Metoprolol per parameters stated in physicians' orders for 4 doses and Clonidine per parameters stated in physicians' orders for a total of 9 doses in July 2025 for Resident # 2. These failures placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications.Findings Included: 1. Record review of Resident #1's face sheet indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Alzheimer's disease (progressive disease that destroys memory and other important mental functions), severe protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and malignant neoplasm of overlapping sites of bronchus and lung (a cancerous tumor which is located in the lungs and in the two main airways of the body that join the windpipe to each lung). Resident #1 discharged on 07/28/2025 to an acute care hospital. Record review of Resident #1's significant change in status MDS assessment dated [DATE], indicated she was severely impaired cognitively with a BIMS score of 01. She required maximal assistance with self-care and mobility. Record review of Resident #1's Comprehensive Care Plan last revised 02/15/2024, indicated she had hypertension with interventions to give antihypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness and report to MD as necessary. Record review of Resident #1's physicians' orders indicated: Losartan Potassium Oral Tablet 25 mg give 1 tablet by mouth at bedtime for high blood pressure hold for SBP 110 & below & DBP 60 & below order dated 05/26/2025. Record review of Resident #1's MAR for July 2025 Blood Pressure monitoring indicated: 07/07/2025 at 7:00 p.m. BP 102/61, 07/08/2025 at 7:00 pm. BP 110/60, 07/09/2025 at 7:00 p.m. BP 110/62, 07/10/2025 at 7:00 p.m. BP 104/61, 07/17/2025 at 7:00 p.m. BP 99/67, 07/19/2025 at 7:00 p.m. BP 104/72, 07/20/2025 at 7:00 p.m. BP 105/61 and 07/25/2025 at 7:00 p.m. BP 126/58. Record review of Resident #1's MAR for July 2025 indicated Losartan was not held on: 07/07/2025 at 7:00 p.m. BP 102/61 by RN D, 07/08/2025 at 7:00 pm. BP 110/60 by LVN C, 07/09/2025 at 7:00 p.m. BP 110/62 by RN D, 07/10/2025 at 7:00 p.m. BP 104/61 by RN D, 07/17/2025 at 7:00 p.m. BP 99/67 by RN D, 07/19/2025 at 7:00 p.m. BP 104/72 by RN D, 07/20/2025 at 7:00 p.m. BP 105/61 by RN D and 07/25/2025 at 7:00 p.m. BP 126/58 by RN D. Unable to interview Resident #1, no longer resided at the nursing facility and has been admitted to an inpatient hospice facility. 2. Record review of Resident #2's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] and Residents Affected - Some Page 1 of 6 455001 455001 08/12/2025 Avir at Beaumont 4195 Milam St Beaumont, TX 77707

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some readmitted on [DATE] with diagnoses to include: high blood pressure, cognitive communication deficit, anxiety and depression. Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated she had active diagnoses in the last 7 days of hypertension (condition in which the force of the blood against the artery walls is too high) and she was moderately impaired cognitively with a BIMS score of 10. She used a manual wheelchair for mobility but was totally dependent on staff for mobility and assistance with transfer to and from a bed to wheelchair. Record review of Resident #2's Comprehensive Care Plan last revised 12/13/2024, indicated she had hypertension with interventions to give antihypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness and report to MD as necessary. Record review of Resident #2's physician's orders indicated: Clonidine HCl Tablet 0.1 mg give 1 tablet by mouth three times a day related to hypertension HOLD IF BP < 110/60 OR PULSE <60; order dated 02/06/2022. Record review of Resident #2's physician's orders indicated: Metoprolol Tartrate Oral Tablet give 25 mg by mouth two times a day for hypertension HOLD FOR BP < 110/60. Record review of Resident #2's MAR for July 2025 Blood Pressure monitoring indicated: 07/04/2025 at 1:00 p.m. BP 100/65, 07/07/2025 at 1:00 p.m. BP 92/68, 07/08/2025 at 7:00 a.m. BP 101/60, 07/08/2025 at 1:00 pm. BP 101/60, 07/14/2025 at 7:00 a.m. BP 109/70, 07/14/2025 at 1:00 p.m. BP 109/70, 07/22/2025 at 8:00 p.m. BP 107/60, 07/27/2025 at 1:00 p.m. BP 110/54, and 07/29/2025 at 8:00 p.m. BP 106/72. Record review of Resident #2's MAR for July 2025 indicated Clonidine was not held on: 07/04/2025 at 1:00 p.m. BP 100/65 by LVN A, 07/07/2025 at 1:00 p.m. BP 92/68 by LVN F, 07/08/2025 at 7:00 a.m. BP 101/60 by LVN A, 07/08/2025 at 1:00 pm. BP 101/60 by LVN A, 07/14/2025 at 7:00 a.m. BP 109/70 by LVN A, 07/14/2025 at 1:00 p.m. BP 109/70 by LVN A, 07/22/2025 at 8:00 p.m. BP 107/60 by LVN B, and 07/29/2025 at 8:00 p.m. BP 106/72 by LVN E. Record review of Resident #2's MAR for July 2025 indicated Metoprolol was not held on: 07/08/2025 at 7:00 a.m. BP 101/60 by LVN A, 07/14/2025 at 7:00 a.m. BP 109/70 by LVN A, 07/22/2025 at 8:00 p.m. BP 107/60 by LVN B, and 07/29/2025 at 8:00 p.m. BP 106/72 by LVN E. During an interview on 08/11/2025 at 9:00 a.m., Resident #2 said she received her medications as prescribed, and they monitored her BP routinely. Resident #2 denied any signs and symptoms of low BP (dizziness, light headedness, fainting, blurred vision, and/or increased fatigue) and said if she did have any, she would notify the nursing staff. Resident #2 said staff checked her BP prior to administering her BP meds and would hold med if the blood pressure was low. During an interview on 08/11/2025 at 3:00 p.m., LVN E said she checked the BP and then reviewed the resident's MAR to determine if the blood pressure medication was to be administered. She said some residents had parameters to hold the blood pressure medication if the BP was low. She said if the resident's BP was low, she held the medication and documented on the MAR. LVN E said that Resident #2 does have parameters with her evening BP medications and during July MAR review was unable to provide explanation of why she administered Resident #2 her evening BP medication when her BP was out of parameters but said it must have been an error. She said if BP medication administered when BP was low, residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury. She said she received training about administering BP medication back in May 2025. During an interview on 08/11/2025 at 3:15 p.m., LVN G said the residents' blood pressure should be checked each time the blood pressure medication was due. She said the blood pressure protocol ordered by the physician should be followed. She said if residents' blood pressure was low and they were still given a blood pressure medication, it could get too low or if blood pressure was low and medications were not given to increase it, that could cause hypotension symptoms. She said residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury. During an interview on 08/11/2025 at 5:00 p.m., 455001 Page 2 of 6 455001 08/12/2025 Avir at Beaumont 4195 Milam St Beaumont, TX 77707

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LVN C said the residents' blood pressure should be checked by the nurse each time the blood pressure medication was due. She said the blood pressure protocol ordered by the physician should be followed. She said if Resident #1's blood pressure was low and was still given a blood pressure medication, it could get too low. She said residents was at risk for passing out or dizziness resulting in a fall or injury. During an interview on 08/11/2025 at 5:30 p.m., LVN H said the residents' blood pressure should be checked by the nurse each time the blood pressure medication was due. She said the blood pressure protocol ordered by the physician should be followed. She said if the residents' blood pressure was low and was still given a blood pressure medication, it could get too low. She said residents were at risk for being lightheaded, passing out or dizziness resulting in a possible fall or injury. She said she would contact the physician if she was unsure of the parameters or dosing, or if BP medication was repeatedly being held or missed. During an interview on 08/12/2025 at 11:40 a.m., LVN A said she checked residents' BP prior to administering BP medications. She said she checked the BP and then reviewed the resident's MAR to determine if the blood pressure medication was to be administered. She said some residents had parameters to hold the blood pressure medication if the BP was low and medications to administer if BP was low. She said she checked the BP, reviewed and administered the medication if within acceptable parameters. She said if residents' blood pressure was low and they were still given a blood pressure medication, it could get too low or if blood pressure was low and medications were not given to increase it, it could cause hypotension symptoms. She said residents were at risk for hypotension including passing out or dizziness which could result in a fall or injury. During an interview on 08/12/2025 at 11:28 a.m., RN D, said he administered Resident #1's BP medications during the evening shift. He said prior to administer BP medication he checked the MAR for parameters and then checked the resident's BP if it was out of parameters, he would hold the BP medication and document on the MAR. He said that he recalls Resident #1's BP being low during her evening BP med dosing and the medication would be held. He said he would contact the physician if he was unsure of the parameters or dosing, or if BP medication was repeatedly being held or missed. RN D said if it showed he administered a BP medication when the BP was out of parameters it must have been documentation error because he held Resident #1's BP medication if it was out of parameter. RN D said if the blood pressure dropped too low Resident #1 could have dizziness, unresponsiveness, or even possibly death. RN D said he was recently terminated so he was unable to review the residents' MAR for clarification. During an interview on 08/12/2025 at 1:30 p.m., the DON said she expected her nurses to follow physicians' orders. She stated she expected them to read the MAR and follow parameters. The DON said if cardiovascular medication was ordered with parameters, parameters were to be checked prior to administration the medication and to be held if out of the ordered parameters. She said it was the nurse's responsibility to check vitals prior to administering any cardiac medications with parameters. She said if BP medication administered and BP is low (out of parameters) the resident could experience symptoms of hypotension including syncope (fainting or passing out), confusion, and even death. During an interview on 08/12/2025 at 1:45 p.m., the Administrator said she expected her staff to follow physicians' orders and to check parameters prior to administering cardiac medications if ordered and if BP or pulse is out of parameters not to administer and document on MAR and/or progress note. Record review of a facility's Administering Medications policy revised April 2019, indicated Policy: Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders including any required time frame. 11. The following information is checked/verified for each resident prior to administering medications: a. allergies to medication; and b. vital signs if necessary . 455001 Page 3 of 6 455001 08/12/2025 Avir at Beaumont 4195 Milam St Beaumont, TX 77707

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 6 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure Resident #1's Comprehensive Metabolic Panel, also known as CMP (a blood test that checks for a wide range of substances in your blood, including proteins, enzymes, electrolytes, and minerals), Complete Blood Count also known as CBC (a blood test that measures amounts and sizes of your red blood cells, hemoglobin, white blood cells and platelets), carcinoembryonic antigen also known as CEA (blood test measures the level of a specific protein in the blood, primarily used to monitor certain types of cancer), Thyroid-Stimulating Hormone also known as TSH (blood test to assess level of thyroid stimulating hormone and thyroid function and metabolism) and Thyroxine test also known as T4 (blood test that helps diagnosis thyroid conditions) was drawn every 14 days as ordered. This failure could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level.Finding included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Alzheimer's disease (progressive disease that destroys memory and other important mental functions), severe protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and malignant neoplasm of overlapping sites of bronchus and lung (a cancerous tumor which is located in the lungs and in the two main airways of the body that join the windpipe to each lung). Resident #1 discharged on 07/28/2025 to an acute care hospital. Record review of Resident #1's significant change in status MDS assessment dated [DATE], indicated she was severely impaired cognitively with a BIMS score of 01. She required maximal assistance with self-care and mobility. Record review of Resident #1's comprehensive care plan last revised 04/23/2025, indicated she had potential nutritional problem related to low body weight, cancer, and protein calorie malnutrition with interventions of health shakes with meals, magic cup, house supplement, liquid protein and obtain and monitor lab/diagnostic work as ordered, and report results to MD and follow up as indicated. Record review of Resident #1's physician's orders indicated: Obtain CBC w/diff, CEA, CMP, T4, and TSH every 14 day(s) for 6 occurrences start order dated 05/30/2025 and end date 08/08/2025. Record review of Resident #1's electronic health record lab results indicated that her CBC w/diff, CEA, CMP, T4, and TSH was due on 05/30/2025, 06/13/2025, 06/27/2025, 07/11/2025, 07/25/2025 and 08/08/2025. Her CBC w/ diff was obtained on 05/30/2025, 06/12/2025, 07/01/2025, and 07/25/2025. No indication that CBC w/ diff was obtained on 06/27/2025, and 07/11/2025 as ordered by physician. Her CEA was obtained on 05/30/2025 and 06/12/2025. No indication CEA was obtained on 06/27/2025, 07/11/2025, and 07/25/2025 as ordered by physician. Her CMP was obtained on 05/30/2025, 06/12/2025, 06/26/2025, 07/21/2025, and 07/25/2025. No indication CMP was obtained on 07/11/2025 as ordered by physician. Her TSH and T4 was obtained on 05/30/2025, 06/12/2025, 07/01/2025, and 07/25/2025. No indication TSH and T4 was obtained on 06/27/2025 and 07/11/2025 as ordered by physician. During an interview on 08/11/2025 at 3:05 p.m. and 3:20 p.m., LVN E and LVN G said when the nurses received an order for a lab, they would enter it in their electronic medical record system as a lab order and into a lab request electronic system. She said the two systems communicated and the request would generate a lab results entry into the medical records identifying that the labs were ordered and when obtained the results uploaded into the medical records. She said it was the responsibility of the nurse to go into the electronic Residents Affected - Few 455001 Page 4 of 6 455001 08/12/2025 Avir at Beaumont 4195 Milam St Beaumont, TX 77707

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical record system periodically throughout the shift to check for lab and x-ray results, review results and report to the NP/MD if applicable. During an interview on 08/11/2025 at 5:05 p.m. and 5:35 p.m., LVN C and LVN H said when receiving orders from a physician via phone, fax or paper, the order was entered into the electronic medical record. They said if a lab was included on the order, the order must be entered into the electronic lab request system to notify the lab of the request. They said the lab system has a place to include date due and if reoccurring event, so one time ordered labs would have the specific date identified but if reoccurring labs would identify dates and that it was a reoccurring event. They said labs due were discussed during shift change and they print a copy of the lab request and place it at the nurses' station to identify any labs coming due and/or results pending. They said it was their responsibility to go into electronic medical records system several times during the shift to check for lab results, review and report to NP/MD if applicable. They said if the results were for upcoming appointments that the labs were also sent in the transfer packet. They said when residents were transferred out of facility to appointments or ER visits, they sent a copy of the resident's face sheet, list of medications and any recent labs with them to the appointment/ER visit. During an interview on 08/11/25 at 4:45 p.m., the ADON said she expected labs to be drawn per the physician's order. The ADON said she was unaware that Resident #1's was missing her labs until questioned by the state surveyor and provided the surveyor a copy of all Resident #1's labs in the electronic lab system for review. The ADON said she reviewed the labs routinely for completion. The ADON explained the process of entering the lab request into the electronic lab system for collection and how it communicated with the facility electronic medical records. The ADON was not able to provide why Resident #1's labs were not obtained as ordered. The ADON said that Resident #1 was transferred from Unit 3 to Unit 1 at the end of June 2025 and new management company made some changes with the electronic lab system. The ADON said she was made aware by the DON some labs had been missed on Resident #1 found during a discharge chart audit and concerns made by surveyor on 08/09/2025. The ADON said that the facility had initiated a new lab tracking form since identifying the issue. During an interview on 08/12/2025 at 1:30 p.m., the DON said she had identified missed labs on Resident #1 during surveyor intervention on 08/09/2025 and Resident #1 discharge chart review. She said she had initiated a new lab tracking form and was going to add lab collection per physician orders and obtaining results to the QAPI. The DON was not able to provide why Resident #1's labs were not obtained as ordered. The DON said she recalled all ordered labs were not completed on June 26, 2025, for Resident #1, and lab was contacted on 07/01/2025 to collect missed labs stat. The DON said that Resident #1 was transferred from Unit 3 to Unit 1 at the end of June 2025 and new management company made some changes with the electronic lab system which could have interfered with the reoccurring order for Resident #1's lab. The DON said it was important to ensure labs were drawn per the physician's order to ensure their health had been monitored per those lab values. The DON said Resident #1 did not miss any cancer center appointments or treatments due to the missed labs. During an interview on 08/11/2025 at 2:45 p.m., CM M with cancer center said that Resident #1 did not miss any scheduled appointment due to missing lab results, she said they ordered the labs every 14 days to verify that they would have a set of labs to review at least monthly for the required treatment provided. She said they expected labs to be drawn as ordered but unfortunately that does not always happen. She said that the missed labs did not alter Resident #1 cancer treatment plan. During an interview on 08/12/2025 at 1:45 p.m., the Administrator said she expected labs to be drawn as ordered. She said the DON/ADON oversaw the labs. She said the DON had already let her know they had identified missed labs on Resident #1 during surveyor intervention on 08/09/2025 and Resident #1 discharge chart 455001 Page 5 of 6 455001 08/12/2025 Avir at Beaumont 4195 Milam St Beaumont, TX 77707

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review. The Administrator said it was important that labs were drawn per the physician's orders to ensure the residents were getting the highest quality of care for their health. Record review of the facility's policy titled Test Results revised April 2007 indicated . the resident's attending physician will be notified of the results of diagnostic test. 1. Results of laboratory, radiological, and diagnostic test shall be reported to the resident's attending physician or to the facility. 2. Should the test results be provided to the facility, the attending physician shall be promptly notified of the results. 3. The director of nursing services, or charge nurse receiving the test results, shall be responsible for notifying the physician of such test results. Signed and dated/electronic signature as applicable of all diagnostic services shall be made a part of the residence medical records. Requested a policy regarding laboratory services with no policy provided by the exit conference. 455001 Page 6 of 6