Health inspection·February 18, 2026

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure personal privacy for 1 of 6 residents (Resident #1) reviewed for privacy while receiving care. 1. The facility failed to ensure the privacy of Resident #1 by not closing the door or pulling the privacy curtain during perineal care. This failure could place residents at risk of loss of privacy and dignity.Findings included: Review of Resident #1's face sheet dated 02/18/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (characterized as experiencing significant paranoia and delusions), reduced mobility, abnormalities of gait and mobility, muscle weakness, major depressive disorder (persistent feelings of sadness)- recurrent-severe with psychotic symptoms, and edema (swelling caused by trapped fluid in body tissues). Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 06 indicating severe cognitive impairment. Section GG for functional abilities reflected Resident #1 was completely dependent on staff for toileting hygiene. Section H for bowel and bladder reflected Resident #1 was always incontinent of urinary and bowel continence. Review of Resident #1's care plan last revised 12/05/25 reflected a focus resident is incontinent of bowel and bladder with intervention incontinent: check [Resident #1] frequently and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. During an observation on 02/18/26 at 12:45 PM, while walking down the hall, Resident #1's door was observed opened. From the hallway CNA A was observed on the opposite side of the bed (window side) providing perineal care to Resident #1. Resident #1 could be seen from the hallway fully exposed from the lower body while perineal care was performed as the curtain was not drawn and the door was fully opened. Surveyor knocked on the door and CNA A shouted resident care. Surveyor stepped to the side of the door in the hall waiting for any action from CNA A, however, CNA A continued with incontinent care with no privacy provided. Surveyor once again knocked on the door a second time and CNA A once again only stated resident care and continued to finish perineal care without drawing the curtain or closing the door to the room. CNA A was then observed leaving the room after care was provided to throw out the trash and remove soiled items. During an interview on 02/18/26 at 12:48 PM with CNA A, she stated she was in Resident #1's room providing perineal care. She stated that it is the expectation and procedure to shut the door or ensure the curtain is used to provide privacy to a resident when assisting with incontinent care. CNA A alleged that she initially did close the door but it did not latch and opened back up on its own. CNA A stated a potential negative outcome of failing to provide privacy for residents who are getting perineal care and are exposed would make them feel uncomfortable. During an interview on 02/18/26 at 12:54 PM with Resident #1, she stated CNA A was just in the room providing incontinent care for her and changing her brief. She stated that typically when that is performed the door is closed for her and there is privacy. She stated the lack of privacy that had occurred during this incident did not make me feel good. During an interview on 02/18/26 at 01:13 PM with the Residents Affected - Few Page 1 of 2 675096 675096 02/18/2026 Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON, she stated it was her expectation that when doing incontinent care the procedure is, knock on the door before entering, ensure the door is shut and say patient care if someone knocks to enter while care is being performed. If there are two residents in the room draw the curtain. She stated that failure to provide privacy for a resident during perineal care is a breach of their dignity. It's a huge dignity issue that can affect them mentally and physically. During an interview on 02/18/26 at 02:28 PM with the ADM, she stated it was her expectation that during incontinent care staff were making sure the door was closed and the curtain was pulled to ensure privacy. She stated failing to ensure there was privacy can affect the residents emotionally and psychologically. She went on to say, it is a resident rights and privacy issue. I wouldn't want someone to see me in that way. It can result in a negative outcome from that experience such as decline in health; they can feel embarrassed and disrespected. Review of the facility Dignity policy last revised in February 2021 reflected: Each resident should be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Residents are treated with dignity and respect at all times.Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of the facility Resident Rights policy last revised in February 2021 reflected:Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right toA dignified existenceBe treated with respect, kindness, and dignityPrivacy and confidentiality. Review of the facility Perineal Care policy last revised in February 2018 reflected: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents skin condition. Steps in the procedure:Provide privacy as appropriate, such as closing doors/ curtains, drape the resident.Cover the resident with a sheet or blanket. Raise cover to expose the perineum 675096 Page 2 of 2