Health inspection·July 15, 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 observations, interviews and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 1 of 8 residents (Resident #1) reviewed for accident hazards and supervision.The facility failed to supervise and put measures in place to keep Resident #1 from eloping on 6/13/25.The facility failed to complete Resident #1's quarterly elopement risk assessment due after 12/27/25. Resident #1's elopement risk assessment was not completed until 06/13/25, after she had eloped from the facility.The noncompliance was identified as PNC. The IJ began on 06/13/25 and ended on 06/17/25. The facility had corrected the noncompliance before the survey began. These failures could place the residents at risk for serious injury, serious harm, serious impairment, or death. Findings included:Record review of Resident #1's face sheet, undated, indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses including schizophrenia (is a serious mental health condition that affects how people think, feel and behave), bipolar disorder (is a mental health condition that causes extreme shifts in mood, energy, and activity levels, impacting a person's ability to carry out daily tasks), generalized anxiety disorder (is a mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday things), intermittent explosive disorder (is a mental health condition characterized by sudden, impulsive, and disproportionate outbursts of anger or violence), autistic disorder (is a condition related to brain development that affects how people see others and socialize with them), tremor, and right ear hearing loss. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was usually understood and usually had the ability to understand others. Resident #1 had adequate hearing, clear speech, and impaired vision with corrective lenses. Resident #1 had a BIMS score of 09 which indicated moderate cognitive impairment. Resident #1 did not display wandering behaviors. Resident #1 used a walker and wheelchair as mobility devices. Resident #1 required supervision to walk 10 feet and 50 feet with two turns. Resident #1 required substantial assistance to walk 150 feet. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was usually understood and usually had the ability to understand others. Resident #1 had adequate hearing, clear speech, and impaired vision with corrective lenses. Resident #1 had a BIMS score of 11 which indicated moderate cognitive impairment. Resident #1 displayed wandering behaviors 1 to 3 days during the assessment period. Resident #1 used a walker and wheelchair as mobility devices. Resident #1 required supervision to walk 10 feet and 50 feet with two turns. Resident #1 required partial assistance to walk 150 feet. Record review of Resident #1's care plan dated 10/20/24, edited on 06/29/25 indicated:*Resident #1 had intermittent explosive disorder, Schizophrenia, bipolar disorder and anxiety which could affect her mood. Interventions included encourage to report any concerns or needs, assess, monitor, and document mood, and reassure and listen to concerns. Page 1 of 8 455963 455963 07/15/2025 Avir at Carthage 701 S Market St Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few *Resident #1 had cognitive deficits and mental disability with childlike responses, poor cognition, delayed response, concentration and attention difficulties, Autism, and speech impediment. Resident #1 had hearing loss in her right ear. Resident #1 had risk for communication deficits. Interventions included allow time when speaking to process thoughts and speck directly to resident in a clear voice facing her. Record review of Resident #1's care plan dated 06/13/25, edited on 06/29/25 indicated:*Resident #1 was at risk for elopement as evidenced by attempt to leave the facility on 06/12/25. Interventions included frequent monitoring and checks throughout the night to ensure safety and roam bracelet will be always worn.*Resident #1 was at risk for wandering due to attempt to exit seek. Resident #1 wore a roam alert bracelet. Intervention included an elopement assessment done on admission, as needed, and with significant change of condition and staff will monitor and report change in exit seeking behaviors. Record review of Resident #1's assessment for risk of elopement dated 12/27/24, completed by LVN A, indicated Resident #1 was not at risk for elopement at this time. Record review of Resident #1's medical records did not reflect an assessment for risk for elopement due 90 days or quarterly from the 12/27/24 assessment for risk of elopement. Record review of Resident #1's assessment for risk of elopement dated 6/13/25, completed by ADON G, indicated Resident #1 was likely at risk for elopement due to resident being ambulatory yet cognitively impaired with poor decision-making skills. Resident #1 was at risk for elopement. Resident #1 had the following intervention implemented of Wander guard ( is bracelet with triggering alarms and locking monitored doors to prevent wander-prone residents from leaving unattended) with informed consent of responsible party and updated care plan on 6/13/25. Record review of Resident #1's Event Report dated 06/13/25 at 12:48 a.m., completed by ADON G, indicated Resident #1 attempted exit seeking approximately 12:18 a.m. Resident #1 was found sitting near a road in the ditch. Resident #1 head to toe assessment did not reveal any injuries. Resident #1 exhibited the following behaviors prior to elopement: resisting redirection from staff, verbalizing statements about leaving, and stated she wanted to go to a group home and social service was working on placement prior to incident. Resident #1 had exhibited a change in mental status of new onset of agitation, resistiveness, and restlessness. Resident #1 stated she could do what she wanted to do. Resident #1 had possible contributing diagnoses to the safety event. Resident #1 had experienced absence of personal contact with family/friends. Resident #1 exhibited depressed, sad or anxious mood but was easily altered. Resident #1 had falls and attention seeking behaviors. Resident #1 had a new medication added at night. Resident #1 had door alarm band applied. Record review of Resident #1's Progress Notes dated 6/13/25, completed by LVN D, indicated .patient [Resident #1] had walked outside down to road and sat down on side of road.a woman came and told us that a lady was sitting on side of road, there was a walker and she was concerned.this sn [LVN D] and CNA K went to get patient [Resident #1], she was agitated and refused to get up and said she would do what she wanted to do.she [Resident #1] finally agreed to get up if she could have her vape.patient [Resident #1] finally got up with minimal assistance and walked back in to n/h with walker and nurse [LVN D] and CNA [K] at side.she [Resident #1] return outside to vape on front porch with supervision.head to toe assessment completed, no apparent injuries. Record review of Resident #1's Progress Notes dated 06/13/25 at 1:03 a.m., revised at 1:22 p.m., completed by ADON G, indicated .Resident [#1] was found attempting to elope from the facility shortly after a reported fall.when approached, resident [Resident #1] states she was upset because she wanted to vape and proceeded to exit the building without staff permission.staff made multiple attempts to redirect resident [Resident #1] back inside approximately 10 minutes, during which time the resident was verbally resistant and refused to comply.after continued encouragement and redirection, the resident [Resident #1] agreed to sit on front 455963 Page 2 of 8 455963 07/15/2025 Avir at Carthage 701 S Market St Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few porch with CNA J sitting with her at this time.this nurse [ADON G] notified resident's responsible party regarding the incident.RP was in agreement for placement of a Wanderguard for safety and care plan updated to reflect elopement risk.Resident [#1] refused to allow wanderguard placement and stated that if I attempted to place it on her that she would rip it off and that I am not gonna put it on her.RP and MD O notified. Record review of CNA K's witness statement dated 6/13/25 indicated, .at approximately 12:15 a.m., a lady came to the facility and said a resident was walking by the stop sign and was worried about her.LVN D and I [CNA K] went out the door and saw [Resident #1] sitting on the ground at the corner.she [Resident #1] refused to get up and said she ‘was leaving' until the nurse agreed to give let her vape.once LVN D agreed, [Resident #1] got up and quickly walked back to the building and sat on the porch.[ ADON G] got here and after [LVN D] had smoked on her vape, she [Resident #1] agreed to come back in the building but stayed in the lobby the rest of the night.this is the first time I've seen [Resident #1] act like that. Record review of CNA J's witness statement dated 6/13/25 indicated, .about 11:00 p.m. [Resident #1] was going to her room to go to bed.at about 12, she [Resident #1] she had her call light on and I [CNA J] went to answer it and observed [Resident #1] on the floor.she [Resident #1] was crying complaining her hip was hurting.I [CNA J] got the nurse [LVN D] who assessed her [Resident #1], we got her up off the floor and we put her back in bed and she was complaining about the head of her bed being up and was being really pouty.a few minutes later she [Resident #1] came to the nurse's station and asked to vape. the nurse [LVN D] told her she couldn't vape right now, that she had just fallen and said she was hurt.the nurse [LVN D] told her that she needed to go back and lay down.[Resident #1] said, ‘I'm not hurt, I'm a grown woman and I want to vape.' LVN D told her again that she needed to go back to her room.Resident #1 said, ‘Do you want me to come get my vape myself?' and the nurse [LVN D] said no, you need to go back and lay down.[Resident #1] said, ‘I'm leaving' and went outside to sit on the porch.Resident #1 had mentioned earlier in the week that she was moving to a group home so that's what I [CNA J] thought she was talking about when she said, ‘I'm leaving.'.[Resident #1] never tried to leave the building and likes to sit outside on the front porch.approximately 15 minutes later a lady came and said a resident was in the road with her walker.[CNA K] and [LVN D] went outside to see who it was.I [CNA J] stayed in the facility with the other residents, and they came back with [Resident #1] about 5-10 minutes later.I [CNA J] then went outside on the porch with {Resident #1] so she could vape.[ADON G] came after that and got [Resident #1] to come inside and sit in the lobby.I've never seen [Resident #1] act like this before. Record review of ADON G, undated statement indicated, .this nurse [ADON G] received a call around 1218 ish from charge nurse [LVN D] that a lady came to facility and reported a lady was sitting in ditch with walker at roadside and almost hit her and was concerned.she [LVN D] and [CNA K] were at roadside attempting to get resident [Resident #1] to come inside facility and was refusing.this nurse [ ADON G] spoke with resident [Resident #1] and she stated that she did not want to go inside and she did not have to.this nurse [ADON G] discussed with the resident [Resident #1] of the safety issues and concerns and told her that I was on my way to the facility.[LVN D] reported back that resident [Resident #1] agreed to go back if she could vape.stated that she [Resident #1] got up without difficulties, took her walker and walked quickly to facility.upon arriving to facility at 1241am the resident [Resident #1] was sitting on front porch with CNA K vaping.she [Resident #1] was agitated and stated that she wanted to go [local city] to group home. Record review of PIR started on 6/13/25, completed on 6/19/25 by the ADM, indicated a missing resident/individual incident occurred on 6/13/25 at 12:30 a.m. The incident occurred in front of the building and involved Resident #1. Resident #1 was noted to be outside on the corner of two local streets with her walker. Resident #1 455963 Page 3 of 8 455963 07/15/2025 Avir at Carthage 701 S Market St Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few had no injuries noted. The investigation summary indicated, .Resident #1 reported fall in room at approximately 11:45 p.m. on 6/12/25.no injuries noted at time nut Resident #1 complained of pain.staff encourage resident [Resident #1] to rest in bed.Resident #1 came to nurses station approximately 5 minutes later wanting to vape and became upset when she was advised she could not vape per the smoking schedule, no one available to monitor her and staff concerned due to recent fall.staff encouraged resident [Resident #1] to rest and monitor condition, however, Resident #1 stated she was leaving and proceeded to exit the building to sit on the front porch, which is a permitted area.approximately 5-10 minutes later, a passerby observed Resident #1 walking with her walker near the end of the building on the corner.passerby alerted staff who directed Resident #1 back to facility.Resident #1 had been verbalizing her plans to move to a group home so when she said she was leaving, they thought she was talking about moving to the group home.staff noted she had been sitting on the front porch 5-10 minutes which was typical behavior for her and other residents and had never attempted to wander off.Resident #1 did not have wanderguard at the time based on her elopement assessment and no history of elopement or wandering behavior.unconfirmed. During an observation on 7/14/25 at 9:15 a.m., the facility's front door was locked. Two residents were outside on the porch and instructed the surveyor to ring a bell. A doorbell was located on the wall and a keypad was also noted. The surveyor was admitted entrance by staff at the front desk. Two keypads were noted on the inside of building near the door. During an observation on 7/14/25 starting at 11:22 a.m., Hall 100-600 doors and side door near the kitchen area had red box alarm lights noted on the keypads. All the doors red box alarms were in the on position. A resident with a wanderguard was near the front door and the alarm sounded. Staff responded to the alarm and redirected the resident. During an observation and interview on 7/14/25 at 1:32 p.m., Resident #1 was sitting in a wheelchair with a wanderguard on her left wrist. Resident #1 had a speech impediment but was understood. Resident #1 was hesitant and appeared nervous when asked about the elopement on 6/13/25. She said she did not remember getting out of the facility last month (June 2025). She said she did not know why she had the bracelet on her wrist. She said the ADM put the bracelet on her wrist. She said the ADM did not want her to go by the front door alone. She said someone was coming on the 27th of July to help her get in a group home. On 7/14/25 at 2:06 p.m., attempted to contact LVN D by phone. Contact was unsuccessful and a message left with callback phone number. On 7/14/25 at 2:11 p.m., attempted to contact CNA J by phone. Contact was unsuccessful and a message left with callback phone number. On 7/14/25 at 2:12 p.m., attempted to contact CNA K by phone. Contact was unsuccessful and a message left with callback phone number. During an interview on 7/14/25 at 2:16 p.m., ADON G said it was reported to her that Resident #1 had a fall then wanted to vape. She said LVN D asked Resident #1 to wait to vape and to stay to be assessed from the earlier fall. She said she did not know if Resident #1 had smoked at the last smoke break at 10 pm. She said the front door was not locked on 6/13/25. She said about a week prior to the elopement, Resident #1 had mentioned leaving. She said when Resident #1 was talking about leaving, it was to a group home in [nearby city]. She said the DON was on vacation and unavailable for an interview. During an interview on 7/14/25 at 2:57 p.m., CNA K said prior to the incident, the residents that vaped could smoke anytime. She said the residents could vape even at 12am and 1am. She said she was in the breakroom on 6/13/25 but overheard the conversation between LVN D and Resident #1. She said Resident #1 wanted to vape but LVN D told her to wait because she just had a fall. She said LVN D told Resident #1 to go to her room and put her feet up. She said Resident #1 refused to lay down. She said the front door was locked so she did not know how Resident #1 got out. She said she did not hear any alarms go off when she was in the breakroom. She said 10-15 minutes later, she heard someone 455963 Page 4 of 8 455963 07/15/2025 Avir at Carthage 701 S Market St Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few knocking on the facility's front door. She said when she got to the door, a lady said she had almost hit someone. She said when they found Resident #1, she was at the [nearest two streets], in the ditch. She said Resident #1 had refused to get up. She said Resident #1 would only get up after they agreed to let her vape. She said Resident #1 got up by herself. She said she had heard from other employees that Resident #1 had threatened to leave, prior to getting out. She said Resident #1 had never told her she wanted to leave the facility. She said Resident #1 had never misbehaved before the incident on 6/13/25. She said after the incident on 6/13/25, she knew not to take the statements of leaving as a joke. She said if a resident mentioned leaving, she needed to report it to the charge nurse and act. She said if it was not taken seriously, then a resident could get out. During an interview on 7/14/25 at 3:56 p.m., CNA J said she took the smokers to their smoke break at 10 p.m. She said Resident #1 was one of the residents. She said Resident #1 had smoked a cigarette not vaped. She said during the smoke break, Resident #1 said, I'm leaving, She said she replied, Oh, really. Where are you going? She said Resident #1 said, I'm going to [a nearby city]. She said she did not think much of it and brought the residents back in from the smoke break. She said not too long after coming in from the smoke break, she heard Resident #1 ask LVN D for her vape. She said LVN D told Resident #1 she needed to rest her feet. She said LVN D told Resident #1 someone would take her later. She said Resident #1 was not happy and told LVN D, That's why I'm leaving this place!' She said Resident #1 did not go back to her room but went to the lobby in front of the nurses' station and sat down. She said she started answering call lights after that. She said when she last saw Resident #1 in the lobby, LVN D was at the nurses' station. She said she then heard someone beating on the front door. She said a lady told them she was driving by and almost hit Resident #1. She said no one knew when or how Resident #1 got out of the facility. She said the facility's front door was not locked at that time. She said Resident #1 said she left because she wanted to vape. She said she knew not to assume what a resident meant when they said, I'm leaving. She said she knew to report what the resident said to the charge nurse. She said she knew to monitor the resident and not let them leave the building. She said the resident could get hurt if they left the building. During an interview on 7/14/25 at 4:10 p.m., the ADM said before the incident on 6/13/25, the front door only alarmed when the resident with a wanderguard got too close to the door. She said the front door was not locked before the incident on 6/13/25. She said sometimes the staff locked the door after 10pm to the outside but not the inside. She said Resident #1 could have easily got out on 6/13/25 because she did not have on a wanderguard. She said Resident #1 had mentioned going to a group home earlier in the week. She said Resident #1 had made false abuse allegation on a male resident (6/9/25). She said Resident #1 reported she lied because she wanted to go to a group home. She said the facility informed Resident #1's PASRR representative of her request the next day (6/10/25). She said the facility's last smoke break was at 10 pm. She said before the incident, the night shift staff were letting the few residents that vaped, go out anytime. She said that was why Resident #1 felt like she could ask to vape at 12am. She said the resident's elopement assessment were done quarterly and with a change of condition. She said she expected the nursing staff to do the scheduled risk assessments. She said she wished the staff had taken Resident #1's leaving' statements seriously. She said she wished the staff had not let Resident #1 go outside to sit on the porch. She said a staff member had reported seeing Resident #1 sitting on the porch for 10 minutes on 6/13/25. She said Resident #1 was known to sit on the front porch unsupervised prior to the incident. She said a resident sitting on the front porch, unsupervised at 12 am was not a safe idea. Record review of a facility's Wandering and Elopements policy revised 4/22/2025 reflected, .the facility will ensure that residents who exhibit wandering behaviors 455963 Page 5 of 8 455963 07/15/2025 Avir at Carthage 701 S Market St Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care.residents will be assessed by the IDT for risk of elopement and unsafe wandering on admission, readmission, quarterly, and/or with a change of condition (e.g., increased agitation, changes in mobility, wandering). Record review of a facility's Change in a Resident's Condition or Status policy revised 4/20/23 and reviewed 6/2025 reflected, .our facility promptly notifies the resident, his or her attending physician, healthcare provider and the resident representative of changes in the resident's medical/mental condition and/or status. Record review of a facility conducted in-service, Wandering and Elopement dated 6/13/25 reflected provider and non-provider staff members were provided education on the topic. Record review of a facility conducted in-service, Emergency Procedure-Missing Residents dated 6/13/25 reflected provider and non-provider staff members were provided education on the topic. Record review of a facility conducted in-service, Abuse, Neglect and Exploitation dated 6/13/25 reflected provider and non-provider staff members were provided education on the topic. Record review of facility conducted in-service, Smoking Policy dated 6/13/25 reflected all smoking residents were provided education on the topic. Record review of a facility conducted in-service, Resident Change in Condition dated 6/17/25 reflected provider and non-provider staff members were provided education on the topic. Record review of a facility's smoking policy dated August 2019 indicated .this facility shall establish and maintain safe resident smoking practices .for the purpose of the policy, smoking and smoking materials included but not limited to; cigarettes, cigars, pipes, chewing tobacco, electronic cigarettes and vaporizers .all residents shall have the direct supervision of a staff member while smoking . The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy on (6/17/25) by:- Conducted observation on 7/14/25 at 9:15 a.m., of door lock project completed on 6/17/25. The facility's front door was locked. A doorbell was located on the wall and a keypad was also noted. Two keypads were noted on the inside of building near the door. - Conducted observation on 7/14/25 starting at 11:22 a.m., of all the facility's Halls (100-600 and side door) door alarms were armed. - Conducted observation on 7/14/25 at 1:32 p.m., of Resident #1 with wanderguard on left wrist.- Reviewed completed facility self-reported incident to HHSC for Resident #1 dated 6/13/25. - Reviewed Resident #1's care plan on 7/14/25 which reflected updated care area of elopement risk and incident on 6/13/25.- Reviewed Resident #1's medical record on 7/14/25 which reflected an elopement risk assessment was completed on 6/13/25. Resident #1 was at risk for elopement with intervention in place. - Reviewed resident roster dated 6/13/25 at 1:00 a.m. with validated head count after incident, completed by ADON G. All residents were accounted for.- Reviewed incident reported dated 6/13/25 reflected Resident #1 did not have injuries noted, MD O and Resident #1's RP were notified of the incident. - Reviewed all (7) residents with wanderguards, progress notes dated 6/13/25 which reflected a function test was completed and wander guard functioning properly. Staff members noted location of wanderguards placement.- Reviewed of a facility's Missing Resident Drill-AM shift in-service and sign-in sheet dated 6/13/25 reflected 23 staff members attended the drill. - Reviewed of a facility's Missing Resident Drill-PM shift in-service and sign-in sheet dated 6/13/25 reflected 7 staff members attended the drill. - Record review of a Record of Drills dated 6/13/25 at 12:15 p.m., for 6am-2pm shift reflected adequate response of personnel for missing residents. All departments responded appropriately. Drill conducted by ADM. - Record review of a Record of Drills dated 6/13/25 at 3:38 p.m., for 2pm-10pm shift reflected adequate response of personnel for missing residents. All departments responded appropriately. Drill conducted by DON. - Record review of a Record of Drills dated 6/13/25 at 10:30 p.m., for 10pm-6am shift reflected adequate response of personnel for missing residents. All departments responded 455963 Page 6 of 8 455963 07/15/2025 Avir at Carthage 701 S Market St Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few appropriately. Drill conducted by DON. - Record review of an Ad Hoc QAPI- Elopement meeting dated 6/13/25 reflected the MD O attended by phone, ADM, DON, ADON P, and ADON G were in attendance. Record review of a safe survey on resident who sat on the front porch unsupervised dated 6/16/25-6/17/25 reflected 13 residents understood to never leave the facility grounds. - Reviewed in-service and sign in sheet on Wandering and Elopement for all staff which indicated the following:*dated 6/13/25 reflected 51 employees were provided education on the topic. - Reviewed in-service and sign in sheet on Emergency Procedure-Missing Residents for all staff which indicated the following: *dated 6/13/25 reflected 51 employees were provided education on the topic.- Reviewed in-service and sign in sheet on Abuse, Neglect, and Exploitation for all staff which indicated the following:*dated 6/13/25 reflected 51 employees were provided education on the topic.- Reviewed in-service and sign in sheet on Smoking Policy for all smoking residents which indicated the following:*dated 6/13/25 reflected 13 residents were provided education on the topic.- Reviewed in-service and sign in sheet on Resident Change in Condition for all staff which indicated the following:*dated 6/17/25 reflected 46 employees were provided education on the topic.Reviewed the facility's Change in a Resident's Condition or Status policy was reviewed on 6/2025. Reviewed all current residents with wander guards and a random sample of other residents' elopement risk assessments on 7/15/25. All residents reviewed had elopement risk assessments completed on 6/13/25.Reviewed Elopement Binder for accuracy on 7/15/25. All (8) resident's pictures were current with consents noted. - Reviewed logbook documentation for Door, Locks, Gates, and Alarms dated 6/11/25 and 7/9/25 reflected pass for Hall 1-6 exit doors, dining room exit door, entrance door, and service door exit. Reviewed of a Record of Drills dated 7/10/25 were completed for all three shifts by ADON G. No issue noted.During an interview conducted on 7/14/25 starting at 11:36 a.m., Resident #2, Resident #3, and Resident #4 verbalized understanding of not leaving the facility property without supervision or authorization. On 7/15/25 at 9:59 a.m., attempted to contact Resident #1' RP by phone. Contact was unsuccessful and a message left with callback phone number. No return call received prior or after exit. During interviews conducted on 7/15/25 starting at 11:33 a.m., CNA N (6a-2p), CNA H (6a-2p & 2p-10p), CNA M (6a-2p), LVN A (6a-6p), LVN E (6a-6p), LVN C (6p-6a), CNA L (10pm-6am), CNA K (10pm-6am), HSK/Laundry Manager, Maintenance Supervisor, CNA F (2p-10p), MA B (6a-2p & 2p-10p), LVN D (6p-6a), ADON G, and CNA J (10p-6a) were provided in-service education on abuse, neglect, and exploitation, emergency procedure-missing resident, wandering and elopement, resident's change in condition, and smoking policy. The staff also participated in missing resident drills. The staff were able to give examples of the different types of abuse to include neglect, identify the abuse coordinator, and verbalize abuse or neglect should be reported immediately. The staff were able to verbalize policy and procedure for elopement and identified residents at risk. The staff were able to verbalize interventions that could be used to prevent elopement for residents at risk. The staff verbalize the front door was to be always locked. The staff verbalize understanding of identifying a resident's change in behavior that could place them at risk for elopement. The staff verbalize the smoking policy rules which included adequate supervision and following the smoking schedule. The staff verbalized honoring the resident's rights as much as while keeping them safe. During an interview on 7/15/25 at 12:36 p.m., LVN A said if a resident started talking about leaving the facility, they needed to be monitored. She said if the resident continued talking about it then a consent for a wander guard needed to be obtained. She said it was important to take what the resident said seriously. She said when a resident became agitated, the staff should try to redirect them. She said if the agitation and exit seeking behavior was new, then it needed to be reported immediately. She said when a resident was not taken seriously, they could exit and harm 455963 Page 7 of 8 455963 07/15/2025 Avir at Carthage 701 S Market St Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few themselves and others. She said elopement was when a resident left the facility unsupervised or without staff knowledge. She said the elopement risk assessments were done on admission, quarterly, and with a change of condition. She said the nurses were responsible for the assessments. She said the assessments should be done on schedule to keep everything updated. She said the resident's condition changed frequently. She said when the elopement risk assessments were not done, a resident could get out without supervision. She said the resident could hurt themselves and others. During an interview on 7/15/25 at 2:07 p.m., LVN E said an elopement was when a resident left the facility unsupervised or without staff knowledge. She said the elopement risk assessments were done on admission, quarterly, and with a change of condition. She said the nurses were responsible for completing the assessments. She said the assessment needed to be done to identify who was most likely to elope. She said when the assessments were not done it increased the risk of a resident slipping through the cracks and missing who was a wander risk. During an interview on 7/15/25 at 3:45 p.m., MA B said an elopement was when a resident left the facility unsupervised or without staff knowledge. She said if a resident started displaying exit seeking behaviors, she would report it to the charge nurse immediately. She said if a resident started making statements of leaving or wanting to go somewhere, she would also report it. She said the statements may or may not be serious. She said the resident needed to be monitored until it was determined how serious the resident was. She said if the resident was not taken seriously, it could be considered neglect and the resident could elope. She said if the resident eloped, they could get hurt. She said when Resident #1 eloped, Resident #1 said she was going to [a nearby city] to get a vape. During an interview on 7/15/25 at 4:09 p.m., LVN D said Resident #1 had a fall late on 6/12/25. She said the staff had to pick Resident #1 off the floor and she was complaining of pain. She said 10-15 minutes after the fall, Resident #1 walked to the nurses' station wanting to vape. She said she told Resident #1 to lay down and rest awhile since she just had a fall. She said Resident #1 got upset and went to the lobby near the nurses' station. She said she did not know when Resident #1 exited the facility. She said she was going back and forth from the nurses 455963 Page 8 of 8