Health inspection·September 18, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, in accordance with State and Federal laws, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys on 3 of 7 (Medication Cart #1, Medication Cart #2, and Medication Cart #3) medication carts reviewed for labeling and storage of medication. The facility did not ensure the Medication Cart #1 (medication cart for the secured unit), Medication Cart #2 (nurse's medication cart for the west side of the building) and Medication Cart #3 ((nurse's medication cart for the east side of the building) were secured and unable to be accessed by unauthorized personnel on 9/18/25. This failure could place residents at risk for not receiving drugs and biologicals as needed or a drug diversion.Findings include: 1. During an observation on 9/18/25 at 4:30 a.m. Medication Cart #1 was in of the hallway unsupervised and unlocked. A CNA was walking by Medication cart #1 pushing a resident in their wheelchair down the hallway. 2. During an observation on 9/18/25 at 4:32 a.m. Medication Cart #2 was in of the hallway unsupervised and unlocked. A resident was wheeling themselves in their wheelchair down the hallway past Medication Cart #2. During an interview on 9/18/25 at 4:42 a.m. LVN B said Medication Cart #1 was the med cart for the secured unit and Medication Cart #2 was the nurse's med cart for the west side of the building. LVN B said both med carts had medication in them. LVN B said he did not usually keep the medication carts unlocked. LVN B said the medication cart was unlocked because he had recently used them. LVN B said the importance of keeping medication carts locked was to prevent the loss of medications and to keep residents from getting into them. 2. During an observation on 9/18/25 at 4:36 a.m. Medication Cart #3 was unlocked. LVN A was walking down the hall away from Medication Cart #3 with his back to the med cart. During an interview on 9/18/25 at 4:48 a.m. LVN A said Medication Cart #3 was the nurse's med cart for the east side of the building. LVN A said Med Cart #3 was unlocked because he had been working out of the nurse's med cart, the med aide med cart, and the treatment cart. LVN A said he would lock Medication Cart #3 if the surveyor wanted him to. LVN A said Medication Cart #3 was in his sight. LVN A said the importance of keeping the medication cart locked was so someone did not get into them and take medications. LVN A said Medication Cart #3 had PRN medication in it. 3. During an observation on 9/18/25 at 6:50 a.m. Medication Cart #1 was unlocked in hallway of secured unit with 2 residents sitting in wheelchairs on either side of the med cart. During an interview on 9/18/25 at 6:52 am LVN C said she had left Medication Cart #1 unlocked while trying to get residents' blood pressures so she could pass medication prior to breakfast. LVN C said sometimes she did leave her med cart unlocked. LVN C said the importance in ensuring medication cart were locked was to prevent residents from getting medication out of the medication cart and taking a medication, they were not prescribed. During an interview on 9/18/25 at 8:22 a.m. the Administrator said medication carts should be locked when staff are not getting something out of them. The Administrator said the importance of keeping medication carts locked was to prevent residents from getting in them and taking medication not prescribed to them and to prevent staff from being able to get in the carts and steal medications. During an interview on 9/18/25 at 8:52 a.m. the ADON said medication carts should not be unlocked unless the staff member assigned to that particular cart is actively getting medications out of it or standing directly in front of the medication cart. The ADON said the importance of ensuring medications cart were locked was to prevent anyone else accessing the medications, cream, insulins, etc. that are store on the cart. Record review of the facility's Medication Storage in the Facility policy dated 6/1/22 indicated, Medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675668 If continuation sheet Page 2 of 3 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 675668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mineola 320 Greenville Highway Mineola, TX 75773 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 0761 Level of Harm - Minimal harm or potential for actual harm and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675668 If continuation sheet Page 3 of 3