Health inspection·March 25, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 3 of 12 residents (Residents #18, #3, and #22) reviewed for ADL care. Residents Affected - Some 1. The facility failed to ensure Resident #18 had clean and trimmed nails on 3/24/25 and 3/25/25. 2. The facility failed to ensure Resident #3 had clean and trimmed nails on 3/34/2025 and 3/25/2025. 3. The facility failed to shave Resident #22 and she had facial hair on her chin and lip on 3/24/2025. These failures could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Findings included: 1.Record review of a facility face sheet dated 3/24/25 for Resident #18 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of dementia. Record review of a quarterly MDS dated [DATE] for Resident #18 indicated that he had a BIMS score of 5 which indicated severely impaired cognition. He did not exhibit rejection of care. He required supervision for personal hygiene. Record review of a comprehensive care plan dated 1/29/25 for Resident #18 indicated that he required assistance of 1 staff member for hygiene and grooming and nail care was to be performed on shower days. The care plan indicated shower days were Monday, Wednesday, and Friday. Record review of Point Of Care History for bathing/showering dated 3/1/25 to 3/25/25 for Resident #18 indicated he received a shower on 3/24/25. During an observation and interview on 3/24/25 at 10:10 am revealed Resident #18 was observed lying Page 1 of 6 455565 455565 03/25/2025 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in bed and had long fingernails with a dark brown substance observed underneath them. He said it had been a while since anyone had cleaned or trimmed his nails. He said he would like for them to be cleaned and shorter, and that it would make him feel better. During an observation on 3/25/25 at 8:51 am revealed Resident #18 was observed lying in bed with head of bed elevated, eating breakfast. His fingernails were observed to still be long and dirty. During an observation and interview on 3/25/25 at 11:14 am CNA C said CNAs were responsible for nail care unless the resident was diabetic. She observed Resident #18's fingernails and said they needed to be cleaned and trimmed. She said she would be giving him a shower today and would clean his nails. She asked him if he would like a shower and nail care and he said yes. She said there could be a risk of bacteria and infection if nails were not kept clean and trimmed. She said she would not like to have long, dirty nails. 2. Record review of a Face Sheet for Resident #3 dated 3/25/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mix of symptoms that include seeing and hearing things and mood disorders such as depression), atherosclerotic heart disease (caused by plaque buildup that restricts blood flow to organs and parts of the body), and polyosteoarthritis (multiple areas of arthritis). Record review of a Quarterly MDS Assessment for Resident #3 dated 1/29/2025 indicated she did not have any impairment in thinking with a BIMS of 15. She required partial/moderate assistance with personal hygiene. Record review of a care plan for Resident #3 dated 1/29/2025 indicated she had an ADL functional status/rehabilitation potential with interventions to clean and trim finger and toenails on bath/shower days. Record review of a point of care history for Resident #3 dated 3/1/2025-3/25/2025 indicated her shower days were on Tuesday, Thursday, and Saturday. Tasks to clean and trim fingernails and toenails on bath/shower days were documented as being done from 3/1/2025-3/25/2025. During an observation and interview on 3/24/2025 at 9:53 AM, revealed Resident #3 was in her room sitting up in a wheelchair. She was alert to person, place, time, and situation. Her nails were about ½ inch to 1 inch in length and had a brown substance underneath them. She said they trimmed them sometimes and would get the goo out of them. She said she received her showers on Tuesday, Thursday, and Saturday. She said she would like her nails trimmed and cleaned. During an observation on 3/25/2025 at 9:49 AM, revealed Resident #3 was in bed awake, and her fingernails were still long with a brown substance underneath them. During a joint interview on 3/25/2025 at 10:20 AM, CNA A and CNA C were both present in the room of Resident #3. Both said the resident would refuse care at times and said her shower days were on Tuesday, Thursday, and Saturday and that was when the resident's nails were trimmed and cleaned but only if the resident was not diabetic and she was not. Both observed her nails and said they were long and dirty and should have been cleaned. Both said they would feel upset and gross if they did not have their nails cleaned and she used her hands to eat at times. During an interview on 3/25/2025 at 1:35 PM, LVN D said if a resident was diabetic, then the nurse 455565 Page 2 of 6 455565 03/25/2025 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0677 Level of Harm - Minimal harm or potential for actual harm was responsible for cleaning and trimming nails, but if they were not diabetic, then the nurse aides were responsible for trimming, filing, cleaning, and soaking nails and it should be done daily. She said she was aware that nail care was not done daily and had talked to the nurse aides about it. She said if a resident refused, they could not make them. She said Resident #3 had refused in the past but was not aware of any refusals recently. She said if her nails were long and dirty it would make her feel cruddy (dirty). Residents Affected - Some During an interview on 03/25/25 at 01:47 PM, the DON said the nurse aides were responsible for doing nail care and documenting it. She said there would be a risk for infection and cross-contamination if nails were not cleaned and trimmed. She said she would not feel good if her nails were long and dirty. She said going forward she would check behind the CNAs and ensure nail care was properly done. During an interview on 03/25/25 at 02:08 PM, the Administrator said he and the DON/ADON were responsible for ensuring ADL care was being done on the residents. He said the licensed nurses and certified nurse aides should be providing the ADL care to the residents. He said he would do in-services to ensure staff knew they were responsible for ADL care. He also said he would have the DON/ADON go behind staff to ensure compliance. He said CNAs and nurses were responsible for nail care and it should be done as needed and also on shower days. He said nail care would be added to Angel Rounds for observation that nail care was being done. He said if proper nail care was not done residents could be at risk for germs and bacteria, and it could be a dignity issue. Record review of a facility policy titled Fingernails/Toenails, Care of revised February 2018 indicated, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections. General Guidelines: 1. Nail care included daily cleaning and regular trimming . 3. Record review of a facility face sheet dated 3/24/25 revealed Resident #22 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of senile degenerative brain disorder (brain deterioration from age and disease). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #22's BIMS was not completed. Further review revealed a staff assessment for mental status (SAMS) was completed and indicated severely impaired cognitive skills for daily decision-making and required maximal assist with personal hygiene. Record review of a comprehensive care plan dated 12/11/2024 revealed Resident #22 had an ADL self-care deficit and required dressing and grooming every shift. During an observation on 03/24/25 at 11:46 am revealed Resident # 22 was observed with facial hair to her chin and upper lip that was approximately 1 inch long. During an interview on 03/24/25 at 11:50 am CNA A said that Resident # 22 was seen Monday through Friday for personal care by the hospice aide. She said care that was not done by the hospice aide should be done by the facility aide. She said she had not noticed the facial hair and had not shaved Resident #22. She said by leaving hair on her face could cause her embarrassment. During an interview on 03/24/25 at 11:54 am LVN B said that Resident #22 would sometimes refuse care, but she had allowed staff to shave her in the past. She said she had not noticed the aides were not shaving her. She said she oversaw the ADL care and helped as needed and Resident #22 should be 455565 Page 3 of 6 455565 03/25/2025 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0677 shaved as needed to prevent embarrassment. Level of Harm - Minimal harm or potential for actual harm During an observation on 03/25/25 at 7:21 AM revealed Resident # 22 up in the dining room and the facial hair had been removed. Residents Affected - Some During an interview on 03/25/25 at 7:26 am the Hospice Aide said she had provided personal hygiene and care to Resident #22 on 3/24/25. She said that Resident #22 had on her hospice aide care plan to shave weekly, but she had not been shaving her because she would resist care. She said she told the nurse at the facility but that was several months ago. She said a female having facial hair could be embarrassing. Record review of a hospice aide care plan report dated 3/24/2025 revealed Resident #22 was to be shaved once per week. During an interview on 03/25/25 at 7:33 am LVN B said the staff shaved Resident #22 yesterday evening and she did well. She said Resident #22 would at times resist care, but the staff should give her time to calm down and reapproach her again. She said she would continue to monitor that ADL care was completed. During an interview on 03/25/25 at 11:34 am the DON said that the charge nurses, ADON and herself were responsible for oversight of resident care. She said if a resident could not perform ADL's themself the staff were to provide that care to them. She said the facility staff were responsible regardless of hospice care and the facility staff should have been ensuring care was being completed. She said not providing grooming and a female resident being left with facial hair could affect their dignity and self-esteem. She said she would monitor ADL care more closely on a weekly basis. During an interview on 03/25/25 at 2:10 pm the Administrator said that himself, the DON and ADON were responsible for ADL oversight and ADL's should be provided by the nurses and aides. He said the facility staff should be checking behind outside care aides to ensure care was provided. He said not providing ADL care could affect dignity. He said he expected all care be provided and would retrain all staff on ADL care. Record review of a facility policy titled Activities of Daily Living (ADLs), Supporting dated March 2018 revealed, 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 including hygiene, 4. if residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem, approach the resident in a different way or different time . 455565 Page 4 of 6 455565 03/25/2025 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 8 resident's (Resident #5) personal refrigerators reviewed for food and nutrition services. Residents Affected - Few The facility failed to ensure a personal refrigerator on 3/24/2025 and 3/25/2025 for Resident #5 did not have a plastic bag of sliced cheese dated 9/24/2024. These failures could place residents at risk for food borne illnesses. Findings include: Record review of a face sheet for Resident #5 dated 3/25/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral palsy (a birth defect that caused damage to the brain), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), and GERD (reflux disease). Record review of an Annual MDS Assessment for Resident #5 dated 3/15/2025 indicated he did not have any impairment in thinking with a BIMS score of 14. He required supervision or touching assistance with eating. Record review of a MAR for Resident #5 dated 3/1/2025-3/25/2025 indicated an order for the resident's refrigerator daily at bedtime: check for cleanliness and expiration of foods. Everything should be labeled and disposed of within 5 days . Record review of a care plan for Resident #5 dated 1/29/2025 indicated he had ADL functional status/rehabilitation potential with interventions that included the resident required x 1 assistance with eating. During an observation on 3/24/2025 at 9:45 AM, revealed Resident #5 was not in his room, and he had a personal refrigerator present that had a plastic bag with sliced cheese dated 9/24/24. The cheese was not in the original package. During an observation and interview on 3/25/2025 at 9:20 AM, revealed Resident #5 was in the dining room and said he ate foods from his personal refrigerator and his best friend would get things out for him. He said the sliced cheese was purchased one day last week and his best friend made him a sandwich using the cheese yesterday, 3/24/2025. During an observation and interview on 3/25/2025 at 9:25 AM, the Best Friend of Resident #5 said she did not prepare a sandwich for Resident #5 yesterday, 3/24/2025 and he ate a sandwich that was prepared in the kitchen. She looked in the refrigerator and said the cheese had been in the refrigerator for a long time. She said she was not sure who was supposed to check his refrigerator for expired foods. During an observation and interview on 3/25/2025 at 10:08 AM, HSK E said she started at the facility in December 2024 and the housekeeping staff were responsible for checking the personal refrigerators for cleanliness, temperatures, and defrosted them as needed. She said they checked the 455565 Page 5 of 6 455565 03/25/2025 Avir at Town Creek 1816 Tile Factory Rd Palestine, TX 75801

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few refrigerators about every 2 weeks or so. She said she never checked the foods in the refrigerators because they belonged to the residents. She said she was not sure who was supposed to check the foods. During an interview on 3/25/2025 at 10:52 AM, the HSK Supervisor said the nurses were supposed to check the personal refrigerators for expired foods. She said the housekeeping staff were to only clean and check the temperatures. She said if she saw something that was expired, she would tell the resident and then throw it away. She said if a resident ate something that was expired, it could make them sick. During an observation and interview on 3/25/2025 at 1:35 PM, LVN D said housekeeping were responsible for checking the refrigerators in the residents' rooms for expired foods. She said Resident #5 had been known to refuse to allow staff to remove foods from his refrigerators in the past but was not aware of any recent refusals. She observed his personal refrigerator and a plastic bag of sliced cheese dated 9/24/24 was removed by her and said she would throw it away. She said residents could get sick if they ate foods that were expired. During an interview on 3/25/2025 at 1:55 PM, the DON said she had been employed as the DON for 4 weeks. She said housekeeping was responsible for checking the personal refrigerators to make sure they were clean; temperatures were good and did not have any expired or outdated foods. She said they were to check them weekly and was not aware that Resident #5 had any foods that were expired in his refrigerator. She said if a resident ate foods that were expired it could make them sick. During an interview on 3/25/2025 at 2:04 PM, the Administrator said he was ultimately responsible, but the nursing staff were supposed to check the personal refrigerators daily. He said he was not aware that Resident #5 had any foods that were expired in his refrigerator. He said he planned to make sure everyone was aware who was responsible for checking the personal refrigerators and they could be checked during morning rounds. He said there could be a risk for residents to get food borne illnesses if they ate foods that were beyond the expired date. Record review of a facility policy titled Personal Resident Refrigerators revised 9/11/2023 indicated, .This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. 3. Housekeeping and/or nursing staff as assigned shall clean the refrigerator weekly and discard any foods that are out of compliance . 455565 Page 6 of 6