Inspection·June 20, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/20/2023 at 09:15 AM with Resident #1, said she was not given her medication correctly for clostridium difficile. She said the facility did not follow the physicians' orders and gave her the medication daily instead of every other day as it was ordered. Resident #1 said she told the facility how the physician wanted her to take it, but they would not listen to her. Record review of Resident #1's care plan conference dated 06/06/2023 revealed, Resident #1 and Resident #1's sister notified the Administrator, DON, MDS Nurse, and Ombudsman of the medication error during the care plan conference meeting. During an interview on 06/20/2023 at 09:59 AM, MA A said the charge nurse receives new orders from the physician and enters it into the computer system. She said the order is sent electronically to the pharmacy to be filled and is then delivered from the pharmacy on the next delivery. She said she administers medications that are on the resident's medication list. During an interview on 6/20/2023 at 10:15 AM, LVN B said she had worked at the facility for 2 years. She said the charge nurse or the administration nurses receives new orders from the physician and enters them into the computer system. She said once the order is entered into the computer it is electronically ordered from the pharmacy and is delivered on the next pharmacy delivery. She said she is not sure of the process used to ensure the accuracy of the orders that have been entered. She said once the physician order in entered into to the computer the MA can then administer the medication. During an interview on 06/20/2023 at 11:20 AM, LVN C said she had worked at the facility for 3 ½ years. She said the nurse, DON, or ADON enter new physician orders into the computer system. She said the orders are sent electronically to the pharmacy and the medication is delivered on the next pharmacy delivery. She said she thinks the DON and ADON check the orders to make sure they have been entered in the computer accurately but is unsure of that process. She said once the physician order in entered into to the computer the MA can then administer the medication. During an interview on 06/20/2023 at 03:00 PM, MA D said she had worked at the facility for 6 months. She said the nurse enters new physician orders into the computer. She said she is not sure of a system to check the accuracy of orders entered except for the DON and ADON to check the orders. During an interview on 06/20/2023 at 03:10 PM, the Regional Clinical Resource Nurse said the DON and ADON are not available for interview. She said the DON and ADON are to review all new orders received in the last 24 hours daily in the daily clinical meeting. She said on Mondays the DON and ADON review all new orders received in the 72 hours in the clinical daily meeting. She said she is not sure how the dificid medication for Resident #1 was entered incorrectly and not caught in the daily clinical meeting. During an interview on 06/20/2023 at 4:00 PM, the Administrator said she had worked at the facility for three weeks and was not employed at the facility at the time of the medication error and is not sure how it happened. She said the interdisciplinary team is to go over new medication orders in the clinical meeting every morning to ensure all orders have been transcribed correctly. She said the resident could have adverse effects if medication orders are not followed correctly. A record review of the facility's Medication Orders policy, dated November 2014, revealed, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders: 1. When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675011 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 675011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksonville 305 Bonita St Jacksonville, TX 75766 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of the facility's Medication Errors policy, dated April 2014, revealed, Policy Statement: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as medication errors. Adverse consequences shall be reported to the attending physician and pharmacist, and to federal agencies as appropriate. Policy interpretation and implementation: If a medication error is identified the resident will be assessed to ensure that any adverse consequences are identified . a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physicians' orders, manufacturers specifications, or accepted professional standards and principles of the professionals' providing services. examples of medication errors include: . wrong time, wrong dose . failure to follow manufacturer's instructions and or accepted professional standards . A record review of the National Library of Medicine, accessed 06/20/2023, Fidaxomicin (Dificid), a Novel Oral Macrocyclic Antibacterial Agent For the Treatment of Clostridium difficile-Associated Diarrhea in Adults - PMC (nih.gov) revealed: The recommended dosage of fidaxomicin for the treatment of adults with CDAD is 200 mg twice daily with or without food for 10 days. No dosage adjustment is required based on the patient's renal function, age, or sex.17 According to the drug's labeling, fidaxomicin should be used only for infections that are known or are strongly suspected to be caused by C. difficile to avoid the development of drug-resistant bacteria, which would lessen the effectiveness of fidaxomicin.17 To date, fidaxomicin and vancomycin are the only medications approved for the treatment of CDAD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675011 If continuation sheet Page 3 of 3