Health inspection·November 18, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents with loss of bladder control receive treatment or services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents reviewed for incontinent care. (Resident #1) The facility failed to provide Resident #1 assistance with timely incontinence care from 09:30 a.m. until 01:45 p.m. on 10/06/2025. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.Findings included: Record review of Resident #1's face sheet, dated 10/06/2025, indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS assessment, dated 08/19/2025, indicated Resident #1 had severe impairment of cognition abilities with a BIMS score of 05. Resident #1 was noted to be dependent on staff for toileting, showering, and lower body dressing. Resident #1 required substantial/max assistance with eating and oral hygiene. Resident #1 was always incontinent of urinary and bowel. During observations of Resident #1 on 10/06/2025 from 09:30 a.m. through 2:00 p.m., the following was noted: 09:30 a.m. - Resident #1 was watching TV while sitting in a wheelchair. No urine or body odor noted. 10:38 a.m. - A Priest visited facility and Resident #1 received communion; 10:47 a.m. - Resident #1 received one cup of water from the staff; 11:32 a.m. - Resident #1 transported via wheelchair to dining room for the noon meal; 11:36 a.m. Resident #1 transported via wheelchair to outside smoking area for smoke time; 11:48 a.m. - Resident #1 returned to dining room for noon meal; 12:33 p.m. - Resident #1 remains in dining room eating meal; 12:54 p.m. - Resident #1 transported to common area Unit 100 and sat in wheelchair in front of the TV; 1:20 p.m. Resident #1 remained sitting in front of the TV with his head down and was seen occasionally dozing off and on. No urine or body odor noted; and 1:45 - 2:00 p.m. Resident #1 was finally provided incontinent care after 4.5 hours of observations. Resident #1 was transported to his room by CNA A. Resident #1 was transferred to bed by CNA A and CNA B. Resident #1's brief was removed, and he had recently had bowel movement. Resident #1's brief was wet but not soaked. No open areas noted to buttocks. Incontinent care was provided, and CNA A applied a barrier ointment to Resident #1's buttocks as a preventative. Resident #1 tolerated well. During a joint interview on 10/07/2025 at 11:05 a.m., CNA B said they checked on residents as they passed by them or if they called out to them. She said they were supposed to do every 2-hour checks on residents, to assess whether they had been incontinent and the staff were constantly all over the area. She added it was important to check residents at least every 2 hours for incontinence due to potential skin breakdown from sitting in wet briefs. CNA B said they performed spot checks on residents to see if they need any care performed. CNA A said Resident #1 was not a heavy wetter and she should stop and check on Resident #1 and the others more frequently. CNA A said Resident #1 had no skin breakdown currently. She said she applied a barrier ointment to the buttocks with each incontinent episode as a Page 1 of 2 455001 455001 11/18/2025 Avir at Beaumont 4195 Milam St Beaumont, TX 77707

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few preventative. During an interview on 10/07/2025 at 12:45 p.m., the Administrator said her expectations were for staff to check residents on rounds at least every 2 hours and throughout their shift when residents were in common areas. She added the staff should be offering fluids, snacks, and generally conversing with residents. During an interview on 10/08/2025 at 10:00 a.m., the DON said she expected the CNAs and the Nurses to work together to complete incontinent care as needed. The DON stated CNAs were responsible for doing rounds every 2 hours on residents to ensure they were clean and dry. The DON stated nurses were also responsible for checking on their residents to ensure they were doing okay. The DON stated leaving Resident #1 wet with urine or stool placed him at risk of skin breakdown, infection, and pressure sores. The DON said there was no facility policy on perineal care or incontinent care of residents. Record review of the facility's Activities of Daily Living policy, dated February 2025, indicated the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a) hygiene and c) elimination. 455001 Page 2 of 2