Health inspection·January 21, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide residents a safe, clean, comfortable and homelike environment for 1 of 5 showers (Shower A) and 1 of 5 residents (Resident #1) reviewed for environment. The facility failed to ensure when a torn shower curtain and broken shower head holders were observed in a shared facility shower.This failure could place all residents at risk of diminished quality of life.Findings included: Review of an admission Record dated 1/21/26, for Resident #1 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Parkinson's Disease (neurological disorder that affects movement), Type 2 Diabetes Mellitus, and muscle wasting and atrophy (weakness). Record review of a quarterly MDS, dated [DATE], indicated Resident #1 had moderately impaired cognition with a BIMS of 11. Record review of a comprehensive care plan, dated 3/19/23, indicated Resident #1 required supervision to set-up assistance for all ADLs. Care planned appropriate interventions were in place including allow extra time to complete ADLs, monitor for pain/intolerance during self-care, and provide supervision to set-up assistance for all ADLs. During an interview on 1/20/26 at 8:50 a.m., Resident #1 said she did not like taking showers in the shared showers because they were always dirty. Resident #1 said the showers were not cleaned regularly between residents. Resident #1 said she complained about the showers for four months, but nothing was corrected. Resident #1 said the shower head holders were broken and she had to hang the shower head on the grab bars in the shower. Resident #1 said the shower head often slipped from the grab bars to the floor. Resident #1 said the showers were unsanitary. During an observation on 1/20/26 at 2:15 p.m., Shower A, a shared shower room for Halls 1 and 2, was noted to have a ripped/torn shower curtain, missing or broken shower head holders, and disposable gloves on the floor. During an interview on 1/20/26 at 4:00 p.m., Resident #1 said the shower curtain was ripped and the shower head holders were broken for over a month. Resident #1 said a CNA always stayed to provide shower assistance, if needed, but she never saw them clean or sanitize the shower between residents. During an interview on 1/21/25 at 9:12 a.m., the Maintenance Supervisor said the staff reported to him verbally, by phone, or through a computerized maintenance system for facility maintenance needs. The Maintenance Supervisor said he recently replaced the shower head holders in Shower A, approximately 1.5 weeks ago. The Maintenance Supervisor said there was no work order for the repair because he was informed verbally by staff. The Maintenance Supervisor said there was no invoice for parts available because parts used in repair were on hand. The Maintenance Supervisor said he was unaware of the shower curtain being torn. During an interview on 1/21/26 at 9:20 a.m., LVN A said CNAs were expected to clean and sanitize the showers between residents. LVN A said housekeeping also cleaned the showers daily, but not between each resident. LVN A said she ensured CNAs were cleaning the showers by going into the showers with them to perform visual inspections and reminded CNAs to take out dirty linens. During an interview on 1/21/26 at 10:00 Page 1 of 2 675217 675217 01/21/2026 Avir at Elkhart 214 Jones Rd Elkhart, TX 75839

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a.m., LVN B said it was the CNAs responsibility to clean showers between residents use. LVN B said housekeeping was responsible for daily cleaning. LVN B said she ensured CNAs were performing their job duties by good communication and following behind CNAs to ensure tasks were completed. During an interview on 1/21/26 at 10:30 a.m., CNA C said CNAs were expected to clean the showers after residents use, but not to sanitize them. CNA C said cleaning included picking up dirty linens and clothing. CNA C said the shower head holders were broken for several months. CNA C said the hole in the shower curtain was there for a few weeks. CNA C said she was unable to report the issues to maintenance because she didn't know how to use the electronic reporting system. CNA C said she could have reported the issues to maintenance verbally. During an interview on 1/21/26 at 10:45 a.m., CNA D said CNAs were responsible for cleaning and sanitizing showers between users. CNA D said CNAs were expected to clean the shower and pick up dirty linens and place them in the linen barrel. CNA D said she reported the broken shower heads and the torn shower curtain to maintenance verbally two weeks ago. During an interview on 1/21/26 at 11:00 a.m., CNA E said it was housekeeping's job to clean and sanitize the shower between residents use. CNA E said CNAs were only responsible for collecting dirty clothes and linens. During an interview on 1/21/26 at 11:10 a.m., the Floor Tech said housekeeping was responsible for cleaning the showers once per shift. The Floor Tech said to his knowledge housekeeping was not responsible for cleaning the shower after every resident. Floor Tech said it was the CNAs responsibility for cleaning/sanitizing the shower after every resident. During an interview on 1/21/26 at 11:30 a.m., the DON said CNAs were responsible for cleaning and disinfecting showers between residents so it would be safe for the next resident. The DON said housekeeping cleaned the showers once in the morning and once in the evening. The DON said she planned to in-service staff regarding cleaning/sanitizing showers between residents. During an interview on 1/21/26 at 1:15 p.m., the ADM said she was responsible for oversight of the nursing department. The ADM said CNAs were expected to clean and sanitize the shower between residents. The ADM said housekeeping cleaned daily but not between every resident. The ADM said risks to residents from improperly cleaned showers could include skin infections or slips and falls. The ADM said she planned to in-service staff going forward to ensure showers were cleaned properly between residents. Record review of a facility policy titled Homelike Environment, dated revised February 2021, indicated .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment. 675217 Page 2 of 2