Health inspection·January 18, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the progress notes dated [DATE] through [DATE] indicated the physician was not notified of Resident #2's weight loss. The progress notes indicated there was not a dietician consult requested for Resident #2. During an interview on [DATE] at 11:12 a.m. the DON said the ADON received the weights and if a significant weight loss was noted the ADON should notify the physician, ensure supplements and snacks were in place, and request a dietician consult. The DON said the dietician came to the facility monthly. The DON said notifications to the physician and requests for consults should be documented. During an interview on [DATE] at 1:50 p.m. the ADON said she assisted with performing weights on residents. The ADON said she entered weights into the computer except for weekly weights and it was the responsibility of the charge nurses to enter weekly weights into the computer. The ADON said if a resident had a significant weight loss it would be the responsibility of whoever discovered the weight loss to notify the physician. The ADON said physician notification and dietician consult requests should be documented in the progress notes. The ADON said she was not aware of Resident #2 having a weight loss and did not know why a notification to the physician had not been done. During an interview on [DATE] at 2:15 p.m. the ADON said she was unsure about the weight loss on Resident #2. The ADON said she could not confirm whether the recorded weight loss for Resident #2 was a clinical error or not. The ADON said she had performed the weight on Resident #2 on [DATE]. The ADON said she thought she had weighed Resident #2 via mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone). The ADON said Resident #2 had been weight via wheelchair and the wheelchair weight not figured properly it could have been a clinical error. The ADON said all wheelchairs in the facility should be marked with their weight to properly calculate a resident's weight who was weighed in a wheelchair. The ADON said the weight of a resident in a wheelchair might fluctuate depending if the foot pieces were on the wheelchair when the resident was weighed or not. The ADON said there should not be a 9.5 lb. weight difference between a wheelchair weight and a mechanical lift weight. The ADON said Resident #2's family had been at the facility on [DATE] and informed her he had expired. During an interview on [DATE] at 2:32 pm LVN D said she remembered Resident #2. LVN D said she performed Resident #2's weights on [DATE] and [DATE]. LVN D said she had used the same wheelchair and scale when weighing Resident #2 on both days. LVN D she did notice Resident #2's weight loss from [DATE] to [DATE]. LVN D said she had planned on speaking with Resident #2's physician regarding his weight loss, but the physician did not return her call. LVN D said there was no way to prove she had attempted to contact the physician as she did not document it. LVN D said she did not notify anyone else regarding Resident #2's weight loss. LVN D said the importance of reporting the weight loss was that it was a significant change. During an interview on [DATE] at 9:10 a.m. the DON said weight loss was monitored monthly. The DON said once all the weights were entered into the system a monthly report was printed to review any significant weight changes. The DON said if a nurse noticed a significant weight loss, she would expect the nurse to reweigh the resident to determine there was not a discrepancy and to notify the physician. The DON said the importance in recognizing weight losses and reporting weight losses to the physician was to aide in the resident maintaining good nutrition. The DON said maintaining good nutrition could possibly aide in wound healing. Record review of the facility's Weight Management Policy revised on [DATE] indicated, Based on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 2 of 5 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicated otherwise .The following should be documents in the medical record: a. The physician should be informed of a significant change in weight gain or loss and may order nutritional interventions .d. The Registered Dietician or Dietary Manager should be consulted to assist with interventions related to unplanned or undesirable weight gain or loss and subsequent interventions or actions documented in the medical record . Record review of the facility's Change in a Resident's Condition or Status policy revised [DATE] indicated, Our facility promptly modifies the resident, his or her physician, health care provider, and the resident representative of changes in the resident's medical/mental condition and/or status .The nurse will record in the resident's medical record information relative to the changes in the resident's medical/mental condition or status . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 3 of 5 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview, and record review the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician ordersto help prevent the development and transmission of communicable diseases and infections were maintained for the facility for 1 of 2 (Resident #1) residents reviewed for parenteral fluids. Residents Affected - Few The facility did not ensure Resident #1's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order. This failure could place residents at risk for central line associated bloodstream infections. Findings Included: 1. Record review of the face sheet dated 1/18/24 indicated Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (area located below the lumbar spine and above the tailbone), stroke, reduced mobility, lack of coordination, and COPD. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 9 and was moderately cognitively impaired. The MDS indicated Resident #1 was dependent for toileting, showering/bathing, personal hygiene, and transfers. The MDS indicated Resident #1 was receiving antibiotics through her central line. Record review of the care plan updated on 12/14/23 indicated Resident #1 was re-admitted to the facility with a stage IV pressure ulcer (pressure sore that extends below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments) to the sacral area with interventions including staff to apply treatment as ordered via physician. Record review of the physician orders dated 1/16/24 through 1/18/24 indicated Resident #1 had an order to change the central line dressing every 7 days starting 12/20/23. The physician orders indicated Resident #1 had an order to change the central line dressing as needed starting 12/20/23. Record review of the MAR dated 1/1/24 through 1/18/24 indicated Resident #1's central line dressing was changed on 1/1/24, 1/8/24, and 1/15/24. During an observation on 1/17/24 at 10:58 a.m. Resident #1's central line dressing was dated 1/1/24. During an interview and observation on 1/17/24 at 11:35 a.m. RN A said nursing was responsible for changing central line dressings. RN A said central line dressings should be changed every 7 days. RN A observed Resident #1's central line dressing with surveyor present. RN A said Resident #1's central line dressing was dated 1/1/24. RN A said Resident #1's central line dressing had not been changed in over 2 weeks. RN A said the importance of changing a central line dressing every 7 days was for infection control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 4 of 5 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/17/24 at 3:21 p.m. LVN B usually worked day shift on Sundays, Mondays, and Tuesdays. LVN B said she was familiar with Resident #1. LVN B said she could not remember the last time she changed Resident #1's central line dressing. LVN B said on 1/8/24 she just added a tegaderm (thin clear sterile dressing) to the central line dressing due to the dressing lifting and not having a dressing change kit available. LVN B said the central line dressing change kit was supposed to be delivered in the evening of 1/8/24. LVN B said she probably did not document changing the central line and should not have signed off the central line dressing was changed on the MAR. LVN B said the importance of changing central line dressing weekly was to prevent infection. During an interview on 1/17/24 at 3:26 p.m. RN C said she worked as needed at the facility. RN C said she was a graduate nurse. RN C said she had not touched Resident #1's central line dressing. RN C said she had changed Resident #1's central line dressing with her preceptor on 1/15/24. RN C said she dated Resident #1's central line dressing when she changed the dressing. RN C said she did not do any central line dressing change on 1/15/24. RN C said central line dressing changes were done on Tuesdays. RN C said the importance of performing central line dressing changes weekly was for infection control. During an interview on 1/18/24 at 9:10 a.m. the DON said the nurses were responsible for central line dressing changes. The DON said she expected the nurses to change the central line dressing weekly. The DON said the importance of changing the central line dressings weekly was to prevent infection and maintain skin integrity. The DON said the nurses should not sign off on the MAR a central line dressing change was completed when it was not. The DON said if a central line dressing change was signed off on the MAR as completed when it was not then the dressing change would not get done as ordered. Record review of the facility's Infusion Therapy Procedures Dressing Changes for Vascular Access Devices dated 2011 indicated, To prevent local and systemic infection related to the IV (Intravenous) catheter .Central venous access device and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present or for further assessment if infection is suspected. Transparent semi-permeable membrane dressings are changed every 7 days and PRN (Pro re nata (as needed)) . Record review of the facility's Employee Training on Infection Control policy revised January 2022 indicated, The facility shall provide staff with appropriate information and instruction about infection control through various means, including initial orientation and ongoing training programs. Personnel are required to attend and participate in task and job-specific infection control training programs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 5 of 5