Health inspection·January 29, 2024

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 01/29/2024 at 3:33 PM the DON said she received a call 7/15/2023 from LVN B notifying her that MA A had given the wrong medication to Resident #7. The DON said that they notified the physician and received an order to start a neurological evaluation and to monitor respirations and oxygen saturation. She said MA A received a written disciplinary action and was suspended pending investigation. The DON said she in serviced staff on administering medications. The DON said Resident #7 had no adverse side effects from the medication error. The DON said she expects her staff to follow the facility policy of administering medications. The DON said that not following the facility policy could have a potential negative outcome for residents including significant clinical changes in condition. During an interview on 01/29/2024 at 4:38 PM MA A said she had worked at the facility for about a year. She said Resident #7 and another resident were sitting in the dining room. She said she gave another resident her medication and Resident #7 grabbed the medication and took it. She said she sat the medication down in front of the other resident and turned her head and when she turned back around the other resident hollered out, she took my medication. MA A said she could have gotten the medications mixed up but is not sure what happened when she had her head turned. Said she had just become a certified medication aide and she could have made the medication error. MA A said the DON came to the facility to investigate the medication error and she was suspended pending investigation and received written disciplinary action. She said when she returned to the facility, she was in serviced on the facility policy of following the rights of administering medications, and she was observed during medication administration to ensure the rights of medication administration were being followed. MA A said she was observed during medication administration once a week for four weeks. During an interview on 01/29/2024 at 4:55 PM the Administrator said she expected her staff to follow the policies and procedures of the facility. She said that not following the medication administration policy places residents at risk of significant clinical changes in condition related to medication errors. Record review of a statement dated 07/15/2023 written by MA A revealed: While I was preparing their evening medication I went ahead and pulled them together because both residents were in the dining room and sit together during meal times. When I handed Resident #7 her meds she took them and when I handed the other resident her cup she realized they were not hers and upon inspection I found that Resident #7 had taken the other residents meds and I reported it to the nurse immediately. I am aware that I should not have prepared the 2 meds at the same time due to risk of med error and the risk of serious injury that I could have caused. Record review of a statement undated written by Resident #7 revealed: MA A handed me a cup of pills, I cannot see that well so I took them and the lady at the table with me told MA A those were not her pills, she determined that I had took the other residents pills and not mine. Record review of facility policy titled Administering Medications dated April 2019 revealed: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 10. The individual administering the medication check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of employee inservice titled Med Pass Error dated 7/15/2023 revealed: CMA A was educated on medication pass error. (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 01/29/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Employee Memorandum dated 7/15/2023 revealed: MA A had a medication error due to her preparing 2 residents' medications at the same time. CMA A was suspended on 07/15/2023. Record review of QAPI notes dated 08/23/23 indicated that the meeting was attended by the following members: Administrator, DON, ADON, MDS nurse, Dietary Manager, Director of Rehab, and Medical Director. The interventions and plan for correction included: 1. Inservice over administering medication policy and procedure. In-services dated 07/16/23. 2. Random check performed on nursing/CMA staff to ensure the medication administration policy was being followed. 3. Random checks performed to ensure no staff should be pre-setting up residents' medication that could lead to medication errors. 4. MA A to be observed weekly for four weeks to ensure medication administration policy was being followed. Record review of sign in sheets for all in-services dated 07/16/2023 indicated that 13 staff members had signed the sign in sheet for the in-services on Medication. During interviews on 01/29/2024 between 3:20PM and 5:00 PM MA A, LVN B, RN C, DON, LVN D, and LVN E were able to appropriately verbalize understanding of the facility medication administration policy and procedures. The staff were able to verbalize and demonstrate when administering the medication check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. On 01/29/2024 at 5:30 pm, the Administrator, DON and Corporate staff were notified the non-compliance was identified as past non-compliance. The facility had corrected the noncompliance before the investigation began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675011 If continuation sheet Page 3 of 3