Health inspection·August 6, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of senile degeneration of the brain (age-related cognitive decline), Chronic Kidney Disease, and Metabolic encephalopathy (altered cognition related to metabolic imbalances). Record review of a significant change MDS dated [DATE] indicated Resident #3 had a BIMS score of 3 which indicated severe cognitive impairment. She required total assistance with toileting hygiene and showering/bathing; she required maximum assistance with lower body dressing and taking off/putting on footwear; she required moderate assistance with upper body dressing; she required supervision with oral hygiene and personal hygiene; she required setup/cleanup assistance with eating. She was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 2/27/24 indicated Resident #3 had an ADL functional deficit related to unsteady gait and confusion. Appropriate interventions were in place including assistance with dressing, grooming, bathing, and bed mobility.During an interview on 8/4/25 at 10:40 a.m., Resident #1's RP said she had concerns about slow call light response times. She said she put a camera in Resident #1's room and saw her on several occasions, dates unknown, banging on the wall to get staff attention because no one was answering her call light. She said she thought the new ADM would resolve the issues.During an observation on 8/4/25 at 10:45 a.m. of a photograph taken from the camera in Resident #1's room Resident #1 appeared to be banging on the wall. The photograph was dated 4/30/25 at 7:43 a.m.During an interview on 8/4/25 at 11:10 a.m., Resident #1 said call lights were always answered slowly. She said she usually did not use her call light because staff never answered it. She said she had to bang on the walls and yell for help on multiple occasions, dates unknown. She said staff responded quickly when she banged on the walls and hollered for help.During an observation and interview on 8/4/2025 at 11:34 a.m., Resident #2 was sitting in her wheelchair in her room beside her bed. She appeared to be clean and well-groomed with no offensive odors. There were no visible marks, skin tears, or bruises. Her call light cord was sticking out from under the fitted sheet on her mattress. She said a CNA came in and made her bed in a rush. Resident #2 said it typically took an estimated 20 to 30 minutes for staff to respond to call lights. Resident #2 said both she and her roommate have had to yell for staff assistance (dates unknown) due to slow staff response times to call lights. She said staff responded faster when she yelled out for assistance.During an observation and interview on 8/4/25 at 11:45 a.m., Resident #4 , who was Resident #2's roommate, was lying in her bed in her room. She appeared clean and well-groomed with no offensive odors. She had no visible skin tears, marks, or bruising. She was receiving supplemental oxygen via nasal canula at 2L . Resident #4 said she frequently used her call light for assistance and staff response time was an estimated average 15-20 minutes. Resident #4 said she has had to yell for assistance once before, unknown date, due to slow staff response. She said staff came quickly when she yelled for help.During an interview on 8/4/25 at 12:24 p.m., CNA D said she did not always have time to complete all resident care timely when she was the only CNA assigned to work on the memory care unit.During an interview on 8/4/25 at 2:05 p.m., LVN B said CNAs were expected to round on residents at least every 2 hours and part of that rounding was to include making sure the resident's call lights were left within reach and accessible. She said CNAs were expected to answer call lights timely to address resident needs. LVN B said she monitored for staff compliance with policies and care planned interventions by rounding frequently.During an anonymous interview on., Anonymous said the facility was short staffed. Anonymous said they did not have enough time in the day to perform all their duties and frequently had to stay late to ensure adequate resident care.During an interview on 8/6/25 at 9:20 a.m., the DON said she was aware of the staffing concerns at the facility. The DON said she was trying to hire additional CNAs by posting on a job board with a starting pay of $15.00 per hour and sign-on bonus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 2 of 4 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many of $2,000.00. The DON said applicants were not showing up for interviews or were working one shift and then quitting. The DON said the facility had been in talks with corporate who had informally agreed to conduct a wage analysis to increase pay to attract and retain staff. During an interview on 8/6/25 at 9:30 a.m., the ADON said she was aware of the staffing concerns at the facility and had been in discussions with corporate regarding a wage analysis to increase pay. During an interview on 8/6/25 at 9:40 a.m. Resident #3's RP said she visited Resident #3 every day and recorded staff interaction in a notebook. The RP said on 7/29/25 at approximately 7:30 a.m. Resident #3 had an incontinent episode, and no staff responded to the call light to change her until approximately 9:00 a.m. The RP said on 8/1/25 staff checked on Resident #3 at approximately 2:00 p.m. and did not come back to check on her again until approximately 6:00 p.m.An observation of a hand-written note on 8/6/25 at 9:45 p.m. written by Resident #3's RP indicated .7/29 [Resident #3] needs changing no help it's 7:30 in the morning.8:30 no one has come yet to change [Resident #3]. Over an hr.9:00 [CNA] came to change [Resident #3].8/1 [Resident #3] last changed at 2:00 it is now 6:00 no one has come to check her. 4 hrs??? .During an observation and attempted interview on 8/6/25 at 9:50 a.m., Resident #3 was observed in her room lying in bed. Resident was covered up by a blanket and only her head was visible. There were no visible marks, skin tears, or bruising and no offensive-odors were detected. Resident #3 did not respond to interview questions.During an interview on 8/6/25 at 9:55 a.m., the AD said she was regularly placed on the schedule as a CNA and was expected to perform all duties as an AD in addition to working on the floor as a CNA. The AD said there was not enough time in the day to perform all CNA duties adequately.During an attempted interview on 8/6/25 at 9:58 a.m., the DON said ADM was out sick today. ADM was not interviewed as part of this investigation.Review of a facility policy titled Answering the Call Light dated 9/21/22 indicated .Answer the resident's call light as soon as possible.2. During an observation on 8/4/25 at 10:00 a.m., a Daily Assignment Sheet dated 8/4/25 indicated there was no support nurse scheduled to work that day. During an interview on 8/4/25 at 12:24 p.m., CNA D said if she needed the charge nurse, she would have to leave the secured memory care unit and look for them or ask another staff member to. CNA D said the charge nurse was usually in a resident room and not at the nurse's station.During an interview on 8/4/25 at 2:05 p.m., LVN B said she worked 6:00 a.m. to 6:00 p.m. as the charge nurse and was expected to cover all 6 resident halls. LVN B said she was supposed to have the help of a support nurse during the daytime, but usually didn't. LVN B said the ADON and DON provided some support during daytime hours but there was no support on other shifts. During an interview on 8/6/25 at 9:20 a.m., the DON said she was aware of the staffing concerns at the facility. The DON said corporate only allowed for one charge nurse position to cover 6 resident halls. The DON said one charge nurse for 6 halls was not an adequate staffing ratio, but corporate would not allow for a second nurse unless the facility census was 56 or more residents, and the current census was 54. The DON said the ADON lived three minutes from the facility and came in on-call to assist the charge nurse when needed during nights and weekends. The DON said the charge nurse who worked 6:00 a.m. to 6:00 p.m. received assistance from a support nurse which was usually herself or the ADON. The DON said there was no support nurse for evening hours after 5:00 p.m. or overnight from 6:00 p.m. to 6:00 a.m. The DON said she was trying to hire another LVN for the support nurse position and advertising on a job board with a sign-on bonus of $3,000.00. The DON said applicants were not showing up for interviews or not accepting the position so she and the ADON were serving as support nurse in addition to their administrative duties.During an interview on 8/6/25 at 9:30 a.m., the ADON said she was aware of the staffing concerns at the facility and had been in discussions with corporate regarding only allowing for a second charge nurse. The ADON said during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675217 If continuation sheet Page 3 of 4 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 675217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Elkhart 214 Jones Rd Elkhart, TX 75839 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete the day administrative nurses supported the charge nurse, but in the evening and overnight, there was no additional support. The ADON said on 7/20/25 a resident had a fall with injury during the evening and the charge nurse on duty had to spend approximately 45 minutes assessing the resident and dressing wounds. The ADON said she had to come into the facility on-call because the charge nurse was unable to provide care to the other residents while completing post-fall protocols.During an interview on 8/6/25 at 9:55 a.m., the AD said the facility only staffed one charge nurse for all 6 resident hallways. The AD said she did not feel this was an adequate staffing ratio because nurses were often busy with one resident for up to 45 minutes at a time leaving other resident needs unattended in a timely manner. During an anonymous interview, Anonymous #2 said the facility's expectation was for one nurse to cover all 6 resident hallways. Anonymous #2 said the charge nurse who worked from 6:00 a.m. through 6:00 p.m. was supposed to have help from a support nurse, but they usually did not. Anonymous #2 said the administrative nurses assisted, but typically came in after 8:00 a.m. and left by 4:00 p.m. which did not cover the busiest times of the day which was around shift change. Anonymous #2 said they felt the nurses had to sacrifice quality of care to accomplish all their responsibilities. Review of staffing assignment sheets indicated no support nurse worked on 8/4/25, 8/5/25, or 8/6/25.Review of a facility assessment tool dated 5/28/25 indicated if the DON had other responsibilities another RN must be added as an ADON.Review of employee timesheets indicated the ADON worked the following hours: 8/4/25 from 10:09 a.m. to 3:37 p.m., and 8/5/25 from 8:11 a.m. to 3:47 p.m., (there was no time sheet data available for 8/6/25), leaving no additional support nurse for the remainder of the 6:00 a.m. to 6:00 p.m. shifts and no ADON to allow for the DON to take on additional responsibilities of a support nurse per the facility assessment.In an email from the ADM received on 8/7/25 at 12:45 p.m., the ADM said the support nurse position was to be an extra LVN who acted as a second nurse due to the facility's growth in census and to assist with wound treatments. The ADM said there was no specific policy associated with this position as tasks required would fall under LVN job description other duties as assigned.Review of an LVN job description indicated .ESSENTIAL JOB FUNCTIONS:.Other duties as assigned. Event ID: Facility ID: 675217 If continuation sheet Page 4 of 4