Health inspection·June 23, 2025

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 acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to administer from 1/03/2025-01/06/2025 Resident #1's anticoagulant medication Eliquis 5MG BID. LVN A and RN A did not administer Resident #1's anticoagulation medication from 01/03/2025-01/06/2025 as prescribed. This failure could place residents at risk for serious complications such as atrial fibrillation, blood clots, and/or stoke. The findings included: Record review of admission record dated 06/23/2025 revealed Resident #1 was an [AGE] year-old male, who was initially admitted on [DATE] and readmitted on [DATE]. Resident #1 was admitted with diagnoses of paroxysmal atrial fibrillation (irregular heartbeat), unspecified atherosclerosis of native arteries of extremities of right and left leg (plaque builds up in the arteries that can cause heart attacks, strokes), venous insufficiency (blood doesn't flow back properly to the heart, causing blood to pool in the veins in your legs), chronic/peripheral and unspecified systolic (congestive) heart failure. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 3 which indicated severe cognition impairment, while additionally was dependent of staff for ADLs. Resident #1 was also coded for having heart concerns such as heart failure, hypertension (high blood pressure), and orthostatic hypotension (low blood pressure when changing positions). Record review of Resident #1's Care Plan date initiated 12/09/2024 revealed [Resident #1] was on anticoagulant/antiplatelet therapy R/T Paroxysmal Atrial Fibrillation. Goal: [Resident #1] will be free from discomfort or adverse reactions related to anticoagulant/antiplatelet use through the review date. Interventions: Administer Anticoagulant/Antiplatelet medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Daily skin inspection. Report abnormalities to the nurse. Eliquis Tablet 5mg (Apixaban): Give one tablet by mouth two times a day. Monitor/document/report PRN adverse reactions of Anticoagulant/Antiplatelet therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in V/S. Page 1 of 4 455923 455923 06/23/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's Active Physician Orders, ordered on 04/28/2025 revealed anticoagulant medication - monitor for discolored urine, black tarry stools, sudden severe headache, N&V, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/ or V/S, SOB, nose bleeds. Record review of Resident #1's Physician Orders revealed Resident #1 was ordered on 1/11/2023 and discontinued on 02/03/2025 the medication Eliquis Tablet 5 MG (Apixaban). Directions: Give 5MG by mouth two times a day related to Paroxysmal Atrial Fibrillation monitor and report S/S unusual bleeding. Record review of Resident #1's Physician Orders revealed on 02/09/2025 a new medication order of Eliquis 5 MG Tablet was ordered. Directions: GIVE 5 MG by mouth two times a day related to Paroxysmal Atrial Fibrillation monitor and report S/S unusual bleeding. Record review of Resident #1's MAR for January 2025 revealed on 01/03/2025 at 1700 (5:00PM), 01/04/2025 at 0800 (8:00am) and 1700 (5:00PM), on 01/05/2025 at 1700 (5:00PM), on 01/06/2025 at 8:00AM and 5:00PM did not receive Resident #1's prescribed anticoagulant medication Eliquis 5mg. Record review of Resident #1's progress notes, vital signs (blood pressure, heart rate), provided no indication that there were adverse effects of the missed anticoagulant medication. There was no indication of shortness of breath or palpitations noted. Record review of provider investigation report dated 01/17/25 reflected Investigation Summary: [Federal Government Agent] made facility visit for this resident. It was found by the [Federal Government Agent] that this resident had missing doses of Eliquis from 1/3/25-1/6/25 d/t medication not available. The medication needed to be refilled. In total there were 6 missed doses. [Nurse manager], immediately conducted a head to toes assessment and neuro assessment on the resident. There were no negative findings. Resident is alert with baseline chronic confusion and in no distress. He has no s/s of embolism. No C/O of SOB, localized redness, swelling, pain to arms or legs, dizziness, or cold sweats. Medical director was notified at 1425 (2:25PM) and gave no new orders. PT/INR and CBC were ordered per [Federal Government Agent] request. [family member] was notified at 1426 (2:26PM) and had no concerns at the time, [family member] wanted to be informed of findings of head-to-toe assessment. Return phone call was made to [family member] by assessing nurse. [Family member] had no concerns or questions at this time. Resident continues with no display of adverse reactions or negative outcomes. He continues at his baseline. This incident was reported to HHS via TULIP. The facility started a cart audit for Eliquis and Xarelto. It was identified that all orders for the anticoagulants had sufficient supply on hand. Anticoagulants were pulled from drawer into the control locked box. Sign out sheet was added to the control log and anticoagulants will be counted off at shift change with the narcotics. In-service was started with licensed nurses and medication aides on How to order refills and when to order refills in PCC and Education was also provided for the effects of Eliquis and what may happen if medication is stopped. Resident was seen by our medical director in the facility with no significant findings and no concern for future reactions. Medical director also indicated that no hematological monitoring is warranted. To date, resident still has no adverse reactions from the missing doses. Post investigation: Facility will continue with educating and auditing staff's knowledge of how and when to order medications and what indicates on the blister pack that it is time to reorder the medication. Anticoagulants will remain in the narcotic lock box with sign out form so they can be counted along with the narcotics. During a phone interview on 06/23/2025 at 2:05PM, RN A stated she could not recall the definitive 455923 Page 2 of 4 455923 06/23/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some date of the medication discrepancy regarding Resident #1, however did recall being spoken to by the DON. RN A stated she recalled when she was going to administer Resident #1's anticoagulant medication, she recalled that there was no medication available within her cart or Resident #1's blister medication pack, and therefore documented that the medication was unavailable. RN A stated she did not recall notifying the DON or MD of the lack of anticoagulation medication for Resident #1. RN A gave no definitive answer as to why she did not notify her DON or MD. RN A stated Resident #1's anticoagulation medication Eliquis, was utilized to minimize blood clots. RN A stated blood clots could potentially have a detrimental effect on Resident #1 as blood clots could travel to vital organs, for instance, lungs, veins, heart, and brain, which could potentially cut off oxygenation to those organs and cause a stroke, breathing problems or worse, death. RN A stated she was educated by the facility that she should have initially notified the DON, MD, of the medication issue, but continued to state Resident #1 did not have any adverse effects due to the lack of medication administration of his anticoagulant medication. RN A gave no definitive answer as to why she did not attempt to advocate for Resident #1's anticoagulant medication, and stated she wanted to terminate the interview. During a phone interview on 06/23/2025 at 2:40PM LVN A stated she vaguely recalled the details to the medication discrepancy regarding Resident #1. LVN A stated she did recall notifying one of her colleagues about Resident #1 not having his anticoagulant medication, and to her recollection that unknown colleague stated she would take care of the medication follow up. LVN A stated she could not recall who she spoke to about Resident #1's unavailable anticoagulation medication and documented in Resident #1's electronic health record that the medication was unavailable. LVN A stated she did not recall notifying the DON or MD about the medication irregularity, and continued to state, the DON spoke to her and reeducated her on what to do if she were to notice medication unavailable. LVN A stated Eliquis was utilized to prevent clots as clots could potentially negatively affect Resident #1's wellbeing. LVN A stated clots could travel throughout Resident #1's body and could have cut-off oxygenation to his vital organs. LVN A stated then Resident #1's vital organs would not receive oxygen and could have led to a stroke, however, did not. LVN A stated she was educated that she should have notified the DON about Resident #1's unavailable anticoagulation medication and will if she were to be met with the same situation in the future. LVN A stated she was in-serviced on 01/17/2025 about when to order medication refills, and the side effects of Eliquis. LVN A reiterated Resident #1 did not have any adverse effects when the medication was unavailable. During an interview on 06/23/2025 at 3:00PM, the DON stated from 01/03/2025-01/06/2025, she was never notified by the clinical staff that Resident #1 ran out of his anticoagulant medication. The DON stated there were two clinical staff members who currently work as needed, who were noted to be working with Resident #1 from 01/03/2025- 01/06/2025. The DON stated she was made aware of the medication administration irregularity by a Federal Government Agent, on or around 01/17/2025, while he was reviewing Resident #1's electronic health record. The DON stated the Federal Government Agent notified her that from 01/03/2025-01/06/2025 Resident #1 did not receive his Eliquis 5MG BID medication. The DON stated once she was made aware of the medication irregularity, she commenced an investigation into the details surrounding the medication irregularity. The DON stated the normal procedure for medication refills, was when a resident was close to finishing their medication, there was a designated day on the blister pack that would trigger the clinical nurse to request medication refills from the pharmacy. The DON stated specifically for Resident #1, he had an indefinite order for Eliquis 5MG BID, and therefore the clinical nurses would just have to request medication refill from the pharmacy. The DON stated from 01/03/2025-01/06/2025 no clinical staff requested Eliquis 5MG refill for Resident #1 nor did the clinical 455923 Page 3 of 4 455923 06/23/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff notify her of the completion of his medication. The DON stated, had she been notified of the medication necessity for Resident #1, she would have directed the clinical staff to retrieve the medication from the facility's emergency medication kit that was available to all nurses. The DON stated the clinical nursing staff from 01/03/2025-01/06/2025 should have notified her that Resident #1's medication was unavailable and additionally should have notified the MD, however, did not, and could have potentially compromised Resident #1's well-being. The DON stated due to Resident #1's cardiac rhythmic irregularity, Resident #1 was at risk for blood clots, however there was no adverse effects due to the non-administration of his anticoagulation medication from 01/03/2025-01/06/2025. The DON stated potential side effects of blood clots could terminate oxygenation to vital organs which would compromise the integrity of the functionality of those organs, but reiterated, for this medication irregularity for Resident #1 there was no adverse effect. The DON stated once she was made aware of the medication irregularity, she conducted an impromptu in-service on 01/17/2025 regarding medication administration, when to reorder medication, as well as the side effects of Eliquis. Record review of the facility's 01/17/2025 in-service regarding Medication administration: what to do if medication is unavailable? When to reorder? Notification of medication not given. How to reorder medication? was reviewed. Record review of the facility's 01/17/2025 in-service regarding Eliquis: side effects, what it is used for, what happens if you stop taking it? Was reviewed. Record review of the facility's Administering Medications policy revised on April 2019 documented, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 455923 Page 4 of 4