Health inspection·July 11, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (Resident #2).On 5/30/2025 at approx. 12:00 p.m., CNA D had been providing incontinent care to Resident #2. While care was being provided, the resident rolled off the bed onto the floor, hitting his face on the nightstand. Resident #2 sustained swelling and redness to the right side of his face, redness to his right knee, and required admission to the hospital on 5/30/25, for further treatment. A review of the care plan dated 5/20/20 reflected that Resident #2 required one-person assistance for bed mobility and transfers. And two-person assistance for ADL care.The noncompliance was identified as PNC. The IJ began on 05/30/25 and ended on 05/31/25 due to the in-services and CNA D had been suspended. The facility had corrected the noncompliance before the survey began. This failure resulted in resident #2 sustaining a femur fracture and hematoma.Findings included:A record review of Resident #2's face sheet reflected that he was a [AGE] year-old male admitted to the facility on [DATE]. He had been admitted with diagnoses including acute neurologic cerebral infarction, sepsis of an unspecified organ, dysphagia, cerebrovascular disease, chronic obstructive pulmonary disease, bipolar disorder, major depressive disorder, generalized muscle weakness, lack of coordination, and enterocolitis due to Clostridium difficile.A review of the MDS quarterly assessment dated [DATE] reflected a BIMS score of 6, indicating severe cognitive impairment. Section GG, which reflects functional abilities, indicated that Resident #2 required dependent, two-person assistance for showers, toileting, hygiene, and bed transfers. The MDS reflected prior to the incident resident #2 did not require a 2 person assist. A care plan dated 5/20/2025 reflected that Resident #2 required one-person assistance for bed mobility and transfers and two-person assistance for ADLs. Resident #2's care plan was updated after the incident to reflect the changes made to D/C the mattress.A record review of medical records dated 5/30/2025 reflected that Resident #2 had been admitted to the hospital with complaints of pain to his right knee and right cheek. The report stated that Resident #2 sustained an acute fracture of the right femur and a hematoma to the head without facial fracture.The record of doctors' orders reflected the doctor had put in an order for a low air mattress on 4/16/2025 for the resident and the resident denied wanting his mattress to be changed out. The doctor finally talked the resident into using the new mattress because it will help his wound heal and relieve the pressure. The day of the fall, the DON contacted the doctor and advised him of the fall and that the resident requested the mattress be taken off his bed and his old mattress be put back on and the doctor agreed to and D/C the low air mattress.An interview conducted on 6/24/2025 with Resident #2 revealed that he was not able to recall the incident.An interview on 6/24/2025 at 12:30 p.m. with CNA D who stated that on 5/30/2025 she had been providing incontinent care to Resident #2. She stated that while providing care, Resident #2 rolled off the bed, hitting his face and knee on the floor. CNA D reported that she Page 1 of 6 455489 455489 07/11/2025 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few immediately called for help, the nurse assessed Resident #2, and he was sent to the hospital. CNA D stated she had been employed at the facility since October 2024 and was not aware that Resident #2 was a two-person assist. She explained that she had always provided care to him alone. CNA D said she was suspended for one day after her shift ended at 2:00 p.m. She also stated that the Director of Nursing (DON) later informed her that Resident #2 was a two-person assist.An interview with the DON on 6/24/25 at 2:57pm revealed that she had not known whether CNA D was aware of the two-person assist requirement because the care plan and MDS conflicted-one stated one-person assist, while the other stated two-person assist. The DON explained that CNAs were responsible for reviewing a resident's care plan before providing care. She stated she had not been aware when the incident occurred. After the incident, the DON said she completed a return demonstration with CNA D for peri care and bed mobility when CNA D returned to work. The DON was uncertain whether CNA D had completed her shift before being suspended. She also reported that Resident #2 told her he had fallen out of bed.Interview with the Administrator dated 6/25/25 at 09:38am, who stated that she became aware of the fall around shift change at on 5/20/25 around 2:00 p.m. Resident #2 had been assessed by a nurse and immediately transferred to the hospital. The Administrator stated that CNA D was suspended pending investigation and returned to work on 6/1/2025 after being suspended on 5/31/2025. She explained it was her expectation that charge nurses ensure CNAs are aware of residents' care needs.A review of the facility's Fall Prevention Program policy, revised in November 2024, indicated that Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The facility completed a Plan of Removal.Interviews with two CNAs on 6/24/25 at 1:13pm, revealed that they had been in-serviced on Abuse/Neglect and assistance with mobility. CNA A and CNA B both stated they were aware of where to locate a resident's care needs in the care plan, and they stated they would notify the nurse if there was conflicting information.An interview with the Charge nurse A on 6/24/25 at 1:04pm revealed she had been trained on Abuse/Neglect and mobility assistance. She stated that when conflicting information was present, the DON would be contacted for clarification.A record review of in-services titled Assisting Dependent Residents, Abuse and Neglect, dated 5/31/2025 and conducted by the DON showed all employees had signed the documentation.A record review of a Perineal Care/Incontinent Care Competency dated 5/31/25 reflected that the DON had observed CNA D. All observation points were marked as satisfactory.Observations of CNA E and CNA F conducted at the facility on 6/24/2025 of two-person transfers using a mechanical lift revealed no concerns-staff appeared trained in mechanical lift usage. Observations of two-person in-bed peri-care also showed no concerns, and staff followed appropriate steps to ensure care and resident safety. In an interview on 7/11/2025 with the MDS Coordinator at 2:35pm revealed, that once the IJ (immediate jeopardy) was called all MDS's and care plans were reviewed and updated to reflect correct and accurate information for each resident. A record review was completed of 7 residents' (Residents #3, #4, #6, #7, #8, #9, #10) MDS's and Care plans to ensure they were correct and identified the resident's level of care required they had all been updated and were correct for each resident's chart reviewed. An observation was completed on 7/11/2025 of CNA D and another staff at 2:05pm completing a transfer using the mechanical lift with a resident no concern was noted during this observation. In an interview with CNA D on 7/11/2025 at 1:31pm revealed she was not trained but she was given an in-service, but she was not trained. She stated she watched another staff member perform the use of the mechanical lift. She stated she worked at another facility and in total she has been using the mechanical lift for 2 years. She stated she has the DON personally showed her how to locate the residents plan of care (POC). She stated the resident was a 1 person assist and after the 455489 Page 2 of 6 455489 07/11/2025 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few fall he became a 2 person assist. She stated the resident could roll on his own from side to side. She stated she was not aware of them changing his mattress. She stated she position herself as she always does and when he tuned, he slid straight off the bed. CNA D stated she was trained by the DON where to find the POC (plan of care) and if she needed more training she would provide it to her. In an interview on 7/11/2025 with the Administrator at 12:20pm revealed, to ensure that the information reflected in a resident's plan of care was accurate they were going to meet with the IDT tea. The Administrator stated they would discuss the change in condition per resident and once the changes have been placed in the computer, they would notify the nurses, so everyone could be aware of what changes had been made to a resident's plan of care.The noncompliance was identified as PNC. The IJ began on 05/30/25 and ended on 05/31/25 due to the in-services and CNA D had been suspended. The facility had corrected the noncompliance before the survey began. 455489 Page 3 of 6 455489 07/11/2025 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

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 the interviews and record review the facility failed ensure residents were free of any significant medication errors for 1(resident # 1) of 6 reviewed for significant medication errors.The facility failed to ensure Resident #1 received his prescribed medications. According to residents' #1 MAR the missed medications are: Insulin glargine prescribed for diabetes, Lactulose prescribed for weakness, Allopurinol prescribed for hypertension, Clotrimazole prescribed for a disorder of the skin, Docusate sodium prescribed for obesity, fish oil prescribed for hyperlipidemia, Gabapentin prescribed for type 2 diabetes mellitus with foot ulcer, Rosuvastatin prescribed for hyperlipidemia, Tamsulosin prescribed for diabetes mellitus, and Valsartan prescribed for hypertension according to the physicians' orders on June 5, 2025 and June 6, 2025. Medication Technician #1 failed to ensure that resident #1 was free of a medication error.This deficit practice could place residents at risk of serious harm, up to and including death.Findings included:Based on the interviews and record review the facility failed ensure residents were free of any significant medication errors for 1(resident # 1) of 6 reviewed for significant medication errors. The facility failed to ensure Resident #1 received his prescribed medications. According to residents' #1 MAR the missed medications are: Insulin glargine prescribed for diabetes, Lactulose prescribed for weakness, Allopurinol prescribed for hypertension, Clotrimazole prescribed for a disorder of the skin, Docusate sodium prescribed for obesity, fish oil prescribed for hyperlipidemia, Gabapentin prescribed for type 2 diabetes mellitus with foot ulcer, Rosuvastatin prescribed for hyperlipidemia, Tamsulosin prescribed for diabetes mellitus, and Valsartan prescribed for hypertension according to the physicians' orders on June 5, 2025 and June 6, 2025. Medication Technician #1 failed to ensure that resident #1 was free of a medication error. This deficit practice could place residents at risk of serious harm, up to and including death.Findings included:A record review of Resident #1's face sheet dated on 6/24/25 reflected that a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had a medical history of acute osteomyelitis (a rapidly developing inflammation and infection of the bone, often caused by bacteria, that can lead to bone damage if not treated promptly), Diabetes mellitus due to underlying condition with other diabetic kidney complication (kidney disease (diabetic nephropathy) that develops as a consequence of diabetes caused by another underlying condition, and is characterized by specific kidney issues), Acute pain due to trauma (a sudden, intense pain that arises from an injury or physical damage, like a fall, car accident, or bone fracture), Essential hypertension (a condition characterized by persistently elevated blood pressure where no specific underlying medical cause can be identified), non-pressure chronic ulcer of part of right foot with necrosis of bone (a persistent open sore on the foot, specifically on the right foot, that is not caused by pressure, and involves the death of bone tissue (necrosis)), Disorder of the skin and subcutaneous tissue, unspecified (a skin or subcutaneous tissue disorder where the specific nature of the condition), Type 2 diabetes mellitus with foot ulcer (a situation where a person with type 2 diabetes develops a wound on their foot that doesn't heal properly), Hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), unspecified Sepsis in right foot, unspecified organism (Unspecified sepsis in the right foot with an unspecified organism means that the patient has a serious condition where their body's response to an infection is causing damage to its own tissues and organs, and the source of that infection is located in their right foot), Streptococcus (a type of bacteria that can cause skin, soft tissue and respiratory tract infections), Obesity (a chronic condition characterized by excessive accumulation of body fat that poses a risk to health). On 6/7/25, Resident #1 was discharged voluntarily due to him feeling that the facility had failed him by not providing Residents Affected - Few 455489 Page 4 of 6 455489 07/11/2025 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few prescribed medications. A record review for Resident's #1 care plan, was not able to be reviewed. Resident #1 was at the facility for two days; a care plan was not yet in place. A record review of Residents #1 MAR dated 6/7/2025, reflected that Insulin glargine, Lactulose, Allopurinol, Clotrimazole, Docusate sodium, fish oil, Gabapentin, Rosuvastatin, Tamsulosin, and Valsartan, where missed June 5th and June 6th, 2025. Next to the medications, the medication Technician noted that the medications were not in the facility. A record review of Residents #1 progress report dated 6/6/25 10:30pm reflected that resident c/o pain, tramadol had not come in. Hydrocodone 5/325 mg was delivered earlier 06/5/25, by the pharmacy. This medication was prescribed from Doctor #A. According to the progress note entered by Charge nurse A, notified the DON, the DON gave an okay to give Hydrocodone for pain, until the Tramadol could be delivered to the facility. Hydrocodone would be dc' d when Tramadol was delivered. On 6/6/25 at 8:03pm a progress note entered by Charge nurse A stated that Lantus, prescribed for diabetes, was given. A record review of Resident #1 notes dated 6/7/25 3:36pm entered by CNA A, reflected that Resident #1 had been yelling for 911 to be called, it stated that his right leg was hurting, and he didn't want to be at the facility any longer. Charge nurse A, talked to him several times, but he continued to state that he wanted to go to the hospital. The facility Called 911 for non-emergency. When EMS arrived, Resident #1 stated that no one had been in his room since June 6/6/26. Resident #1 was transferred out as requested. A record review of Resident's #1 orders as well as medical discharge summary, on 6/24/25, at 1:34pm, reflected that [NAME] #B prescribed Allopurinol, Aspirin, Docusate Sodium, Lovenox, Gabapentin, Insulin Glargine, Insulin, Lactulose, Rosuvastatin, Tamsulosin, and Valsartan. During an interview via phone on 06/24/25 at 9:35am hospital Social Worker A stated that she was not present when Resident #1 came into the hospital, however she was able to read a report written by Social Worker B, both social workers work at the local hospital. Social Worker B stated that the report from the nursing facility reflected Resident #1 came into the ER with pain in his right foot from sepsis. She stated that Residents #1's foot was amputated a week prior to his admission the facility. Social Worker A stated that the report read that Resident #1 reported that the facility had not given him his Antibiotics, Sepsis medication or his insulin shots. According to Social Worker B, Social Worker #A wrote that she was sent medical records from the nursing facility. The medical records indicated that medications had been missed. According to the report read by Social Worker #B, missing the medications would have no lasting or harmful impact. An interview with the DON on 6/25/25 at 9:15am, who stated that the medications were in the facility. She said that all medical technicians are aware of this fact. DON also stated that there are over the counter medications in the medication room. She said that the Insulin glargine was given however, due to Medication Technician #A not being able to get into the MAR she was unable to see this. DON acknowledged that Resident #1 was supposed to receive his insulin shot twice, however he received it only once on 6/6/25. A second interview with the DON on 6/25/25 at 12:13pm reflected that there was an error with central intake. Central intake is a data base that send/hold residents' information. DON said that when Resident #1 was admitted to the nursing facility, he arrived with the incorrect social security number. DON said that Resident #1 arrived with the social security number of a different Resident from another facility with the same name. She said that once Central intake fixed the issue, Resident #1 received his medication at the end of the day 6/5/25. DON reported again that Resident #1, had still missed medication on 6/5/25 and 6/6/25. During an interview with the Medication Technician A on 6/25/25 at 10:30am, she stated that she takes her own notes of when she gives residents medication. She keeps these notes in a personal notebook that she keeps on her person during medication pass. Medical Technician A said that she does not include names when taking these notes. She said 455489 Page 5 of 6 455489 07/11/2025 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that Resident #1 has been aggressive since he arrived on 6/5/25. She stated that Resident #1 missed his morning medication of 6/5/25 due to entering the facility after medication pass had already been completed. Medication Technician #1 stated Resident #1 refused his medication on 6/6/25. Medication Technician A stated that she notated in the MAR that the medication was not in the building because she was unsure how to document that Resident #1 refused. During an interview with 3 CNA's on 6/25/25 at 11:14am, they stated that no resident has never reported not receiving medication to them. They said they were in-serviced on 6/24/25 about how and what to document if a resident refuses medication. CNA A stated that if she is unsure if a medication was given, she would ask a charge nurse. CNA B and CNA C said that they would ask their DON about it if the charge nurse was unavailable. During an interview with Resident #3 and Resident #4 (who reside at the nursing facility), on 6/25/25 at 12:23pm, Resident #3 stated that he enjoys being at the facility. He said that he feels safe, and that staff treat him with respect. Resident #2 stated he has never missed any medication since he has been present at the nursing facility. Resident #3 stated that he was new to the facility, however he feels comfortable, and he has received all his medications at the prescribed times. He stated that when he has asked for his pain medication, he has had no problem with receiving it.A Record review of Medication Unavailable in-service dated on 6/24/25 was completed and signed by Medication Technician A LVN's and CNA's. A record review of Employee Corrective Action Form completed on 6/24/25 signed by Medication Technician 1 indicated that she would follow policy moving forward and the MAR. During a record of undated policy When a Medication in NOT on Cart Unavailable Medication Policy it reads When a medication is unavailable on the med cart get medication from EKIT if not in EKIT notify Charge nurse. During a record review of undated policy When a Med is not Available policy it read Charge nurse will notify physician for a substitute or an order to hold until available from pharmacy. The communication should be documented in nurse notes. 455489 Page 6 of 6