Health inspection·January 13, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 2 of 5 residents (Resident #1 and Resident #2) reviewed for quality of care.The facility failed to ensure Resident #1 and Resident #2 were assessed for injury following a motor vehicle accident on 12/19/2025 in the facility transport van.This failure could place residents at risk for not receiving appropriate care and treatment and/or decline in their health.Findings included:1. Record review of an admission Record for Resident #1, dated 1/12/2026, indicated he was an [AGE] year-old male, admitted [DATE], readmitted [DATE], with diagnoses that included focal traumatic brain injury with loss of consciousness (brain injury), dementia with other behavioral disturbance (decline in thinking, memory and reasoning), and fusion of spine, thoracic region (permanent connects two or more vertebrae).Record review of an Annual MDS Assessment for Resident #1, dated 11/10/2025, indicated he had a BIMS score of 12 which indicated mild cognitive impairment. He required substantial/maximal assistance with transfers. He required the use of a manual wheelchair for mobility. Record review of a care plan for Resident #1, revised 9/09/2025, indicated ADLs functional status/rehabilitation potential with interventions that included, Transfers amount of assist: 1 staff member assist, some days I may require more assistance than others. Record review of Resident #1's EMS Patient Care Record, dated 12/19/2025 at 12:58 p.m., indicated, No visible injuries were noted upon observation. Pt denied LOC, denied head strike and taking blood thinners. Record review of a facility nursing progress note for Resident #1, dated 12/19/2025 at 5:45 p.m. written by LVN A, indicated, While transporting back to facility, transport van rear ended by another vehicle. Police and EMS called at that time. EMS eval and tx resident, no injuries occurred and was released by EMS to be transported back to facility. No pain or discomfort verbalized. RP notified of incident. NP also notified and aware at this time. Record review of a facility nursing progress note for Resident #1, dated 12/20/2025 at 12:09 p.m. written by LVN B indicated, Resident is s/p MVA with complaints of back pain and bilateral hip pain. Resident is alert and oriented x4. Respirations are even and unlabored with no signs of acute distress. Medication given per MAR and NP was notified. New orders were given for Xrays of L-spine, C-spine and bilateral hips. RP notified of COC and new orders. Record review of a facility nursing progress note, dated 12/21/2025 at 12:09 p.m. written by the ADON, indicated, X-ray results sent to NP. No acute injuries noted. Continue to c/o stiffness and mild pain. Routine pain meds given qid. Record review of x-rays of the cervical spine, bilateral hips, and lumbar spine, dated 12/20/2025, indicated no acute changes noted. Record review of facility skin assessment of Resident #1 not completed due to no skin assessment was completed after the accident on 12/19/2025. 2. Record review of an admission Record for Resident #2, dated 1/12/2026, indicated he admitted [DATE] and was [AGE] years old with diagnoses that included malignant neoplasm of the colon (colon cancer), history of transient ischemic attack and cerebral infarction (stroke), and age-related Residents Affected - Few Page 1 of 3 675408 675408 01/13/2026 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cognitive decline (problem thinking).Record review of a Significant change MDS Assessment for Resident #2, dated 11/11/2025, indicated he had severe impairment in thinking with a BIMS score of 3. He required supervision/touching assistance with walking.Record review of a care plan for Resident #2, revised 9/24/2025, indicated ADLs functional status/rehabilitation potential with interventions that included, Ambulation/Transferring amount of assist: supervision, assist x 1-2. Record review of EMS Patient Care Record, dated 12/19/2025 at 12:58 p.m., for Resident #2 indicated, No visible injuries were noted upon observation. Pt denied LOC. Denied head strike and taking blood thinners. Record review of a facility nursing progress note for Resident #2, dated 12/19/2025 at 5:42 p.m. written by LVN A, indicated, While transporting back to facility, transport van rear ended by another vehicle. Police and EMS called at that time. EMS eval and tx resident, no injuries occurred and was released by EMS to be transported back to facility. RP notified of incident. No pain or discomfort verbalized. NP notified and aware at this time. Record review of facility skin assessment for Resident #2, dated 12/24/2025 completed by ADON, indicated Resident #2 did not have any skin issues. During an interview on 1/12/2026 at 10:10 a.m., Resident #1's family member said they felt like after the accident Resident #1 should have been sent to the hospital to be evaluated. Resident #1's family member said when Resident #1 arrived back to the facility after the accident he had to crawl out of the side of the van to exit the vehicle due to the wheelchair ramp not working on the van. Resident #1's family member said the day after the accident Resident #1 had bruising noted to his right-hand index finger and to the left cheek and eye area. During an interview on 1/12/2026 at 12:00 p.m., LVN A said on the day of the accident (12/19/25) there were two residents on the van, Resident #1 and Resident #2., LVN A said the transporter told her she was rear ended in the van by another vehicle. She said the transporter told her EMS checked Resident #1 and Resident #2 out and said they were ok to go. She said when they returned to the facility Resident #1 rolled himself into the dining room and did not complain of any pain. She said CNA C helped Resident #1 out of the van due to the wheelchair ramp not working after the accident. She said she did not assess Resident #1 or Resident #2 for injury upon return to the facility because she thought EMS evaluated the residents and they were cleared at the scene of the accident. During an interview on 1/12/2026 at 12:14 p.m., the ADON said she received a call from LVN A regarding the wreck involving the facility van and Resident #1 and Resident #2. She said they had called the police and EMS to the scene. The ADON said she asked if LVN A had checked on the residents and if they were ok. She said she told the transporter to call EMS. She said the next day Resident #1 was complaining of pain and stiffness, so she notified the NP to get an order for x-rays. The ADON said Resident #1 told her he crawled over the seat to get out of the van. During an interview on 1/12/2026 at 12:47 p.m., Resident #1 said he went to a doctor's appointment on the day of the accident 12/19/2025. He said on their way back to the facility someone hit them from behind, on the side where he was seated in his wheelchair. He said EMS arrived and stood at the front driver's door and asked him if he was alright. He said he told EMS he felt fine. He said no one asked him if he wanted to go the hospital. He said he probably would not have wanted to go get checked out. He said he could not get out of the van because the ramp would not work. He said when he got to the facility, he had to crawl over the seat to get out of the van. He said the next day his neck and back were hurting him, so they x-rayed him at the facility. He said the pain went away in a few days. Resident #1 said the pain went away but he had chronic pain due to rods and pins in his back and knee. During an interview on 1/12/2026 at 1:25 p.m., Resident #2 said on the day of the accident they were sitting at a stop sign and got hit from behind. He said that no one checked him at the scene of the accident. He said no one checked him when he got back to the facility. He said he was sore for a 675408 Page 2 of 3 675408 01/13/2026 Avir at Overton 1110 Hwy 135 S Overton, TX 75684

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few few days after the wreck but other than that he did not have any other injuries. During an interview on 1/12/2026 at 1:29 p.m., CNA C said he was asked to help get Resident #1 out of the van. He said he let the back seats down and got him out of the wheelchair and then got his wheelchair out and then he picked up Resident #1 and put him in his wheelchair. During an interview on 1/12/2026 at 1:40 p.m., the transporter said she was a CNA and the backup driver for a sister facility and was helping out this facility because they did not have a transporter. She said she was returning from the doctor's appointment and was stopped at the yield sign when the on-coming car hit them. She said neither of the residents were hurt. She said police and EMS came to the scene of the accident. She said she was talking with the police at the scene and could not see from where she was if EMS evaluated the residents on the van. She said she notified the administrator and the DON and was told to let the residents get checked out by EMS. She said EMS told her they were free to go, and they drove to the facility. She said the back of the van would not open so her and CNA C had to get Resident #1 out of the van through the side door. During an interview on 1/13/2026 at 1:00 p.m., the DON said the ADON received a call about the residents being in a wreck and was told they were ok. She said the Administrator handled the situation. During an interview on 1/13/2026 at 1:10 p.m., the Administrator said as far as she knew the residents were evaluated at the scene of the accident and were cleared with no injuries to return to the facility. She said she found skin assessments done on Resident #1 upon returning to the facility, but none were provided prior to surveyor exit. Record review of the facility's policy, Transportation Policy undated, indicated, To outline procedures for safe, dignified, and compliant transportation for residents to medical appointments. Record review of the facility Driver Checklist undated indicated, .in the event of an emergency, dial 911 then facility at [phone number] and follow instructions. Record review of the facility policy Change in a Resident's Condition or Status, dated April 2025, indicated, .3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the interact SBAR communication form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 675408 Page 3 of 3