Health inspection·January 21, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm HCl capsule, extended release; 240 mg; amt: 1 cap; oral; once a day 08:00 AM with a start date of 11/08/24. Lisinopril tablet; 10 mg; amt: 1; oral. Once a day 08:00 AM with a start date of 10/09/24. Omeprazole capsule, delayed release; 20 mg; amt: 1; oral. Once a day 08:00 AM with a start date of 08:00 AM. Prednisone tablet; 5 mg; amt: 1; oral. Once a day 08:00 AM with a start date of 10/09/24. Xarelto (rivaroxaban) tablet; 20 mg; amt: 1 tab; oral. Once a day 08:00 AM. Residents Affected - Few During a phone interview on 01/21/25 at 4:47 PM, LVN A stated she worked weekends at the facility. She stated she was at work on 01/18/25 and was scheduled to work from 06:00 AM to 06:00 PM that day. LVN A stated she was passing medications on hall 3 between approximately 07:30 AM and 08:30 AM and she parked the medication cart outside Resident #1's room. She stated she dispensed Resident #1's morning medications into a medication cup and took the medications in to Resident #1. She stated Resident #1 did not like to be rushed and preferred to take her medications one at a time while she visited with staff. LVN A stated, while in Resident #1's room, another resident across the hall called for assistance. She stated Resident #1 had not taken any of her medications yet and she left the cup of medications on Resident #1's bedside table, left the door open and walked across the hall to check on the resident who called for assistance. LVN A stated she thought she would be gone from Resident #1's room briefly but the interaction with the other resident took longer than she expected. She stated she was gone from Resident #1's room for approximately five to ten minutes. She stated she re-entered Resident #1's room and observed Resident #1 holding the cup of medications. She stated she observed Resident#1 take each medication in the cup one-by-one. She stated she then made sure the resident was comfortable and exited the room. LVN A stated she should not have left the cup of medications unattended in the room, even briefly. She stated she should have taken the cup of medications with her and locked them in the medication cart when she left the room to check on another resident. During a follow-up phone interview on 01/21/25 at 05:14 PM, LVN A stated she had been trained to witness a resident take all dispensed medications prior to leaving the room and signing the MAR. LVN A stated she had been trained on proper medication storage and administration through quarterly in services and through medication pass observations conducted by the ADON. She stated a potential negative outcome for leaving medications unsupervised and unsecured would be that the resident may drop a medication, which would result in not receiving medications as ordered by the physician. During an interview on 01/21/25 at 05:47 PM, the DON stated he was not aware that medications had been left unsupervised by LVN A on 01/18/25. He stated LVN A should not have left medications unsupervised in a resident room. He stated she should have put the medications back in the cart and locked the cart. He stated all staff had been trained not to leave a resident unattended with medications. The DON stated staff were trained on proper medication storage and administration through annual skills checks and quarterly medication administration observations conducted by the pharmacy consultant. He stated a potential negative outcome for failure to properly secure medications would be the resident could miss a dose or another resident could take medication that was not ordered for them. Record review of a facility training document titled Licensed Nurse Proficiency Audit, dated 05/03/24, revealed LVN A's name and satisfactory was checked for the skill administers medication properly. Record review of the facility-provided policy titled Medication Administration - Orals, dated 2007 revealed: Policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 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 675014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Haskell 1504 North First St Haskell, TX 79521 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 To administer oral medications in an organized, accurate and safe manner. Level of Harm - Minimal harm or potential for actual harm Procedures . Residents Affected - Few 10. administer medication and remain with resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675014 If continuation sheet Page 3 of 3