Inspection·August 27, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 08/26/23 at 12:43 PM, Resident #1 had a bottle of Tussin DM sitting in a plastic container on the floor in her room next to her bed. Resident #2 said she had the bottle of Tussin DM since she admitted to the facility. Resident #2 said she had taken some cough medicine a little while ago due to her cough and phlegm as that helped it. Record review of Resident #1's EMR on 08/26/23 at 4:31 PM, did not indicate a self-administration assessment had been completed. 2. Record review of Resident #2's face sheet indicated a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's diagnoses included seasonal allergic rhinitis (inflammation and irritation of mucous membrane of the nose), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs, heart failure (the heart muscle doesn't pump blood as well as it should), and essential hypertension (high blood pressure). Record review of Resident #2's annual MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS indicated Resident #2 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS indicated Resident #2 required extensive assistance with bed mobility, dressing, and personal hygiene. Resident #2 required extensive assistance of 2 person assist with toileting and bathing. Record review of Resident #2's comprehensive care plan last revised on 07/02/23, indicated Resident #2 had a diagnosis of seasonal allergic rhinitis and was taking loratadine (allergy medication) with interventions to monitor and report side effects. The care plan did not indicate Resident #2 was taking Sinux nasal spray. Record Review of Resident #2's physician order report dated 07/27/23-08/27/23, did not indicated Resident #2 had an order for Sinux nasal spray. During an observation and interview on 08/26/23 at 11:41 AM, Resident #2 had a bottle of [NAME] Nasal Spray inside a jar on the night stand next to his bed. Resident #2 said he had the [NAME] Nasal Spray because he had severe allergies and that was what he used for relief of his nasal congestion. Record review of Resident #2's EMR on 08/26/23 at 4:33 PM, did not indicate a self-administration assessment had been completed. During an interview on 08/26/23 at 4:54 PM, MA A said she had not seen any over the counter medications in the resident's room. During an interview on 08/27/23 at 11:16 AM, LVN B said residents could not have over the counter medications at bedside. LVN B said residents have bought medications before when they went shopping to Walmart. LVN B said the facility staff told the residents, previously, not to buy over the counter medications. LVN B said the risks of residents having medications at bedside was that they would not know what the resident took and could cause them to have a reaction. LVN B said the facility staff needed to be aware of what the resident were taking as it could be contraindicated with other medications given. LVN B said everyone was responsible for ensuring residents did not have over the counter medications in their room. During an interview on 08/27/23 at 11:34 AM, ADON C said over the counter medications were stored in the medication cart. ADON C said there were only two residents in the facility that could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Carthage 701 S Market St Carthage, TX 75633 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few self-administer their own medications, but Resident #1 and Resident #2 were not either of them. ADON C said the risk of having over the counter medications at bedside was that the wrong person could get it, or the wrong dose could be given. ADON said they have tried to make sure the family does not bring the residents any medications. During an interview on 08/27/23 at 12:14 PM, the DON said over the counter medications were not allowed to be kept at bedside, unless the resident could self-administer their own medications. The DON said over the counter medications were kept in the medication cart. The DON said residents who had over the counter medications, that staff was not aware they had, could cause the resident to have an interaction with something the facility was administering. The DON said residents brought over the counter medications, but they obtained them, wrote the residents' name on them and then they were placed in the medication room. The DON said everyone was responsible for ensuring residents did not have medications at bedside. The DON said if a CNA was to see a medication in a resident's room, she was to bring the medication to the nurse and the nurse should note it was found in the resident's room. During an interview on 08/27/23 at 12:33 PM, the Administrator said residents should not have medications at bedside unless they had a physician's order. The Administrator said she found Resident #1's Tussin DM bottle and Resident #2's [NAME] Nasal Spray bottle on 08/26/23, and she took them to the nurse's station. The Administrator said the risks of residents having medications at bedside were that it could cause interactions with prescribed medications, or the resident could be over medicated. The Administrator said it was everyone's responsibility to ensure medications were not kept at beside. The Administrator said most of the time, it was the family that brought the over-the-counter medication to the resident. Record review of the facility's policy Storage of Medications revised in November 2020, indicated .The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . Record review of the facility's policy Self-Administer of Medications revised February in 2021, indicated . 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455963 If continuation sheet Page 3 of 3