Health inspection·February 18, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 8 residents (Resident #21) reviewed for accidents/hazards. The facility failed to remove a worn and damaged mechanical lift sling from service on 2/17/2025 and 2/18/2025. This deficient practice could place residents at risk of a loss of quality of life due to injuries. Findings included: Record review of a face sheet for Resident #21 dated 2/18/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of diffuse traumatic brain injury (an injury caused by a forceful bump, blow, or jolt to the head), hemiplegia and hemiparesis following cerebral infarction (paralyzed on one side of the body), and aphasia following cerebral infarction (difficulty speaking following a stroke). Record review of a Quarterly MDS Assessment for Resident #21 dated 11/22/2024 indicated he had moderate impairment in thinking with a BIMS score of 12. He was dependent on staff with chair/bed to chair transfers. Record review of a care plan for Resident #21 dated 12/23/2024 indicated he required a Hoyer lift for transfers with interventions to transfer him via Hoyer lift with staff member x2. During an observation and interview on 2/17/2025 at 9:20 AM, Resident #21 was in his room sitting up in a wheelchair. He was alert and oriented to person, place, and time. He was dressed and said he had been at the facility for 6 months. He was sitting on a mechanical lift sling in the wheelchair that was faded in color. He said the staff used a mechanical lift to transfer him with two people. During an observation on 2/17/2025 at 3:21 PM, Resident #21 was sitting in a wheelchair in the dining room on a mechanical lift sling that was faded in color. During an observation on 2/18/2025 at 8:34 AM, Resident #21 was sitting in a wheelchair in the dining room on a mechanical lift sling that was faded in color. During an interview on 2/18/2025 at 3:02 PM, CNA D was on the hall where Resident #21 resided. She Page 1 of 10 675408 675408 02/18/2025 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said she had been employed at the facility for 2 years and worked the day shift from 6 am-6 pm. She said when she arrived to work on 2/18/2025, staff had Resident #21 up in his wheelchair and the night shift staff were responsible for getting residents up before they left for their shift. She said Resident #21 was a 2-person transfer with using the mechanical lift. She said the staff were to check the lift slings before use to make sure there were not any tears, rips, or strings, and it they found it was not sturdy they were told to take it to the Administrator. She said they also checked to make sure the colors were correct and not faded in color. During an observation and interview on 2/18/2025 at 3:06 PM, Resident #21 was in the dining room still sitting on the lift sling that was faded in color. CNA D looked at the sling and said it was faded in color but sturdy. She said she was not sure if it could be used or not because it was still sturdy, and tags were not visible with any writing. During an observation and interview on 2/18/2025 at 3:08 PM, the Laundry Supervisor observed the sling that was underneath Resident #21 in the dining room. She said the tag was frayed and one of the labels said it was an Invacare brand. She said they washed the slings on cycle-regular #3, no bleach and they were hung to air dry. She said it was faded and was probably bleached. She said they should not be bleached, and the sling should not be in use. She said the sling should not be bleached according to the manufacturer label. She said there was a risk for tears, and she usually checked for tears when she washed them and could also be a hazard to the resident resulting in a fall. She said she thought that the sling was an old one and they had newer ones in the facility. She said she would inform the DON. During an interview on 2/18/2025 at 3:15 PM, the DON said she was not aware of Resident #21 having a faded sling. She said she was not sure how they washed the slings in the facility or if they used bleach. She said if the staff could not tell the color of the rings on the sling, they could put the wrong color of the ring on the lift and cause it to become unbalanced which might cause a fall. During an interview on 2/18/2025 at 3:43 PM, the Administrator said he was made aware of the sling for Resident #21 being faded in color by staff that day. He said they had new ones in the facility. He said he was not sure how they washed them. He assumed they used the chemicals that were supplied. He said they would probably need to get rid of the sling. He said staff were to ensure they were using the right sling for the right resident. Record review of a facility policy titled mechanical lift sling guidelines dated 3/11/2024 indicated, .2. Regular inspections of lifting slings must be carried out in accordance with the manufacturer's instructions, with a minimum of every 6 months 5. Wash and sanitize according to manufacturer's instructions . Record review of the Owner's Operator and Maintenance Manual for patient slings for Invacare undated indicated, .Care: Note: laundering should always be done with dark colors. Do not bleach. Refer to tagged washing instructions on the sling. Warning: after each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken sling are unsafe and could result in injury. Discard immediately . 675408 Page 2 of 10 675408 02/18/2025 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 2 of 3 months (July 2024 and August 2024) reviewed for Quarter 4 of the fiscal year 2024. The facility did not have RN coverage for 4 days in July 2024. The facility did not have RN coverage for 1 day in August 2024. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: Record review of the RN punch detail hour report for July 2024 indicated there were no RN hours worked on the following dates: July 6, 2024, July 7, 2024, July 13, 2024, and July 21, 2024. Record review of the RN punch detail hour report for August 2024 indicated there were no RN hours worked on the following day: August 4, 2024. Record review of the CMS Payroll Based Journal (PBJ) report for the fourth quarter of 2024 (July 1, 2024, through September 30, 2024) indicated there were no RN hours for the following dates: 07/06 (SA); 07/07 (SU); 07/13 (SA); 07/21 (SU); 08/04 (SU). During an interview on 2/18/2025 at 2:48 PM, the ADON said she and the DON were responsible for doing the schedules for the nurses and nurse aides. She said they currently had a weekend RN who worked every other weekend. She said a RN should be in the facility 8 hours every day. She said most of the time if a LVN could not handle the situation, then the RN would help them for changes in condition or a death and should be in the facility daily. She said she was not aware there were some days in July or August 2024 when there was not a RN in the facility. During an interview on 2/18/2025 at 3:19 PM, the DON said the ADON was responsible for staffing the nurse and nurse aides in the facility. She said the facility had staffing issues since she hired July 2023 and the facility recently hired 2 RNs at the end of November of 2024. She said back in July and August 2024, she was working a lot of days as nurse aides and charge nurses in the facility and was told her hours would not count toward the RN 8 hours that was required daily. She said the facility should have an RN in the facility 8 hours a day. She said there could be a delay in response times and assessing the patient when there was a change in condition if a RN was not in the facility. During an interview on 2/18/2025 at 3:35 PM, the Administrator said he was aware of the facility not having RN hours for the fourth quarter of 2024 and at that time they went through a lot of needed staff turnover and in turn some days were missed. He knew there was a requirement for a RN, and they should be in the facility 8 hours daily. He said the facility currently had a RN covering every other weekend now and the other weekends the DON would be covering. Record review of a facility policy titled Staffing revised September 2023 indicated, .Our center 675408 Page 3 of 10 675408 02/18/2025 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0727 Level of Harm - Minimal harm or potential for actual harm provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety. 4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week . Residents Affected - Some 675408 Page 4 of 10 675408 02/18/2025 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (2/17/2025 and 2/18/2025) for nurse staffing posting. Residents Affected - Many The facility failed to post the daily staffing information in a prominent place on 2/17/2025 and 2/18/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included: During an observation on 2/17/2025 at 10:01 AM, the daily staff posting was not in or around the front entrance. The daily staff posting was dated 2/16/2025 and on a wall by the nurse station partially blocked by two medication carts that was not clearly visible to see. During an observation 02/17/25 3:33 PM, the daily staff posting was dated 2/17/2025 and on a wall by the nurse station partially blocked by two medication carts that was not clearly visible to see. During an observation on 2/18/2025 at 10:55 AM, the daily staff posting was dated 2/18/2025 on a wall by the nurse station partially blocked by two medication carts that was not clearly visible to see. During an interview on 2/18/2025 at 2:48 PM, the ADON said she was responsible for completing the schedules for the nurses and nurse aides. She said the night nurse put up the daily staff positing and would get the information from the schedule. She said the daily posting was on the wall by the medication carts. She said it had always been on that wall. She said where it was placed visitors would not be able to see the information. During an interview on 2/18/2025 at 3:19 PM, the DON said the ADON was responsible for staffing in the facility for the nurses and nurse aides. She said the daily staff posting was the responsibility of the night charge nurse. She said the posting was to be placed in the plastic sleeve on the wall by the fire alarm and by the medication carts. She said the location was where it had always been. She said she did not see anything wrong with the location the posting was located, and it could be seen by anyone in the facility. During an interview on 2/18/2025 at 3:35 PM, the Administrator said the night nurse or ADON was responsible for putting out the daily staff posting. He said the current location on the wall by the medication carts, someone entering the facility would not know to look for it there and it was not in a good location. He said it was moved by front entrance that day. He said the purpose of the staff posting was so anyone would be able to see how many staff were in the facility. Record review of a facility policy titled Staffing revised September 2023 indicated, .Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety. 8. Staffing levels for direct care staffing are updated each shift and posted in a public area . 675408 Page 5 of 10 675408 02/18/2025 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in one of one kitchen reviewed for dietary services. Residents Affected - Some The facility did not ensure the dish machine was working properly on 02/17/2025. The facility did not ensure that raw foods were thawed appropriately on 02/17/2025. These failures could place residents who eat from the kitchen at risk of foodborne illnesses. Findings included: During an observation on 02/17/25 at 9:08 am the dish machine was tested with Dietary Aide. The dish machine wash temperature was 120 degrees Fahrenheit and rinse temperature was 125 degrees Fahrenheit, but the sanitizer did not register on the test strip. The Dietary Aide was not sure what to do and went to get her dietary manager. During an interview on 02/17/2025 at 9:10 am the Dietary Aide said she was trained on the sanitizer testing but did not always use the strips and watched for the solution to drop in the water. She said the Dietary Manager tested the machine herself this morning and it was working correctly. She said the dish machine temperature and sanitation should be checked every day. She said if the dishes were not properly sanitized it could cause infections. During an interview on 02/17/2025 at 9:14 am the Dietary Manager said she had tested the dishwasher this morning and there were no issues. She said she tested the machines herself to ensure it was done but the Dietary Aide had been trained on the dishwasher temperature checks and proper sanitizer numbers. She said she would contact the dishwasher company to have it inspected. She said if dishes weren't properly sanitized it could cause infections. During an observation on 02/17/2025 at 9:35am there were bags of frozen food items thawing in the kitchen sink. The items included 3 bags of peas and carrots, 1 bag mashed potatoes, 2 bags of gravy mix and 3 bags of chicken breast. During an interview on 02/17/2025 at 9:37 am the [NAME] said that when frozen foods were pulled to thaw, they should be in the refrigerator or in a sink with cold running water running continuously. She said raw meat should not be thawing with other items and by not properly thawing food it could cause bacteria growth and residents could become sick. She said she had been trained on the proper method of thawing foods and was in a hurry this morning. During an observation and interview on 02/17/2025 at 12:00 pm a dish machine repair worker was present and checking the dishwasher. He said the tubing for the sanitizer had come unattached from the container and the tubing was reapplied and cycle complete with sanitizer at 100-200 ppm. He said he provided retraining with the dietary aide and dietary manager. During an interview on 02/17/2025 at 1:03 pm The Dietary Manager said that she had seen the food thawing in the sink and should have said something to the cook. She said the cook had been trained on 675408 Page 6 of 10 675408 02/18/2025 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the proper thawing process of foods and would retrain all staff. She said that she was responsible for the kitchen and its staff and if the staff were not correctly preparing food it could cause residents to become sick. During an interview on 02/17/2025 at 1:45 pm the Administrator said the Dietary Manager was responsible for the kitchen and expected all staff knew and followed the proper process for cleaning and sanitizing dishes and thawing foods. He said all the staff have had many hours of training and he would oversee that they were retrained. He said that he expected the staff to follow the kitchen sanitation in all areas and by not doing so it could cause illness. Record review of temperature/sanitizer log for dish machine dated February 2025 indicated the dish machine had been tested and working properly 17 of 17 days of the month. Record review of an undated facility policy titled Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment indicated, .The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 2. Make sure that the automatic detergent dispenser and/or liquid sanitizer injector is working properly. f. A test kit or other device that accurately measures the parts per million concentrations of the solution must be available and used . Record review of an undated facility policy titled Food Storage indicated, .To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines . i. Once frozen food has been thawed, it must be maintained at 41°Fahrenheit or less prior to cooking . 675408 Page 7 of 10 675408 02/18/2025 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and sanitary environment for residents on hallway B (Women's locked Unit, Resident #8) and C (men's locked unit), 1 of 3 dining rooms (main dining room) and main dining room patio reviewed for physical environment. The facility failed to provide Resident #8 a safe, clean and sanitary environment on 02/17/25 to 2/18/25 when the mattress on her bed was stained with a brown substance, the wall next to her bed was smeared with a dirty yellow, red and brown substance and had exposed sheetrock. The facility failed to maintain the wall in Resident #8's bathroom leaving the sheetrock exposed at the sink and non- working soap dispenser in the bathroom. The facility failed to maintain walls, doors, doorways, and floors to residents residing on Hallways A and B. The facility failed to maintain the main dining room ceiling and vents. The facility failed to maintain tiles covering the dining room patio. These failures could place residents and visitors at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe environment. Findings included: Record review of a face sheet for Resident #8 dated 2/18/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (disorganized thoughts) and anxiety disorder (feeling of nervousness). Record review of an Annual MDS Assessment for Resident #8 dated 02/09/2025 indicated she had severe impairment in thinking with a BIMS score of 3 and ambulated independently. During an observation and interview on 2/17/2025 at 09:55 am, Resident #8 resides on the B hall (Women's locked unit) in room [ROOM NUMBER]. Resident #8 was dressed, sitting on her unmade bed, her mattress had a 2 x 2-foot brown stain that was wet. On the wall beside Resident #8's bed there was an area 3 feet wide and 2 feet tall that the paint was chipped and was covered with yellow, red, and brown smeared substance. Resident #8 said she sometimes vomits at night, and she wipes it there. Resident #8's bathroom soap dispenser is torn off the wall exposing sheetrock. The soap dispenser was sitting on top of the paper towel dispenser, making it unusable. During an observation and interview on 2/17/2025 at 10:10 am hallway B (Women's locked unit), rooms [ROOM NUMBERS] doors and doorways in the hallway are gouged, marred and paint is missing. room [ROOM NUMBER] has floor tile missing. CNA B said she had worked at the facility for about 7 months and received training on infection control and safety. She said housekeeping cleans the women's unit every day and she cleans up spills and messes made by the residents on the unit when needed. She said she didn't know when the wall in Resident #8's room had been cleaned. She said the resident #8 wipes body substances on the wall beside her bed. CNA B said the staff should log any items that need to be 675408 Page 8 of 10 675408 02/18/2025 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some repaired in the maintenance request book at the nurse's station. She said that living in an unsanitary environment could cause sickness and spread infection. During an observation on 2/17/2025 at 12:00 pm the patio used for smoking area, beside the dining room. The patio had 5 missing ceramic tiles with a tile not adhered, sitting cross ways, and creating a trip slip hazard. The dining room ceiling was sagging, and the sheetrock ceiling had cracks, the top layer is pulling away from the sheetrock. The ceiling had three large areas that appeared to have old water damage. The areas were sagging and crumbling. The dining room was open to the public and residents. There were dried water rings near a dirty vent. The filter inside the air vent was layered with dust and dirt. Multiple vents in the dining area are covered with layers of dust. During an interview on 2/17/2025 at 12:45 pm the Maintenance Man said it was his responsibility to maintain the facility. He said he had worked at the facility for over 2 years. He said he cleans the air vents when needed and changes out vent filters usually monthly. He said the staff log maintenance needs in a book at the nurses' station and he checks it daily for issues. During an observation and interview on 2/18/2025 at 8:30 am the substances on Resident #8 wall beside her bed area were 3 feet wide and 2 feet tall that the paint was chipped and was covered with yellow, red, and brown smeared substance unchanged from 2/17/2025. CNA C said she had worked at the facility for 7 months and she doesn't know how often Resident #8's wall gets cleaned, she said housekeeping cleans it once a week or so. During an interview on 2/18/2025 at 8:45 am Housekeeper A said if the wall looks real bad bedside resident #8's bed she would scrub it down. Housekeeper A said the wall looked bad beside Resident #8 bed and needed to be scrubbed and repainted. During an observation 02/18/2025 at 2:30 pm Hallway C (men's locked unit) room [ROOM NUMBER] and room [ROOM NUMBER] doors and doorways in the hallway are gouged, marred and paint was missing. The vinyl flooring in room [ROOM NUMBER] has tears and was pulling apart from the concrete underneath which was a trip slip hazard. The sheetrock was exposed in areas on the hallway C with paint missing. During an interview on 2/18/2025 at 2:45 pm the Administrator said it was the policy of the facility to maintain a clean, sanitary, and orderly environment. He said that not maintaining the environment could lead to decreased quality of life, infections, and hazards. The Administrator said he had bids for replacement of flooring but had not received funds from corporate for replacement. Record Review of a maintenance work order book, requests for maintenance dated 2/18/2025 to 07/01/2024 indicated no requests for doors, hallways, ceilings, vents, or resident rooms to be repaired. Record Review of a facility policy, Homelike Environment dated 2/2021 indicated: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible . Policy Interpretation and Implementation 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 675408 Page 9 of 10 675408 02/18/2025 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0921 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Level of Harm - Minimal harm or potential for actual harm a. clean, sanitary, and orderly environment. Residents Affected - Some b. comfortable (minimum glare) yet adequate (suitable to the task) lighting; c. inviting colors and décor; d. personalized furniture and room arrangements; e. clean bed and bath linens that are in good condition; 675408 Page 10 of 10