Health inspection·December 7, 2022

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral feeding received the appropriate treatment and services to prevent potential complications for 1 of 1 resident reviewed with feeding tubes. (Resident #34) The facility did not ensure Resident #34's enteral feeding was initialed, timed and dated when hung as required by facility policy and standard of care. This failure could place residents with feeding tubes at risk for dehydration, calorie deficiency, infection and/or metabolic abnormalities. Findings included: Record Review of Physician orders dated 12/06/22 indicated resident #34 admitted on [DATE] was [AGE] years old with diagnoses of chronic respiratory failure with hypoxia (inability of maintain oxygen levels in the blood), disorder of the skin and subcutaneous tissue, unspecified and dependence on respirator [ventilator] status (unable to breathe without assistance). An order dated 10/12/22 indicated she received Isosource via G tube feeding at 50 ml per hour per feeding pump. Record review of MDS dated [DATE] for Resident #34 indicated she was in a comatose state, was unaware of her surroundings and received enteral feedings per gastrostomy tube. Record review of care plan dated 11/30/22 indicated Resident #34 received interventions including continuous feedings per pump via gastrostomy tube. During an observation on 12/05/22 at 11:55 AM Resident #34 was lying in bed with G-tube feeding infusing at 50 ml/per hour. The feeding bag and a bag of water were not labeled with date, initials, order for formula, rate, and route and of administrations as required by policy. A piston syringe (a large syringe used for aspiration of stomach contents and flushing the g-tube) at bedside was not labeled with time, room number or initials as required by policy. During an interview on 12/05/22 at 12:00 PM LVN A said not labeling G tube feeding bags, water bags or piston syringes, could cause in increased risk of infection due to spoiled feeding. LVN A said all gastric tube feedings, bags, tubing, and syringes should be changed out daily to prevent infection and labeled with documentation of date, time, and initials. She said without a date and time there would not be a way to ensure how much of the feeding had infused or how long the feeding had been hanging to ensure no harmful bacterial load in the feeding. Page 1 of 19 675846 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/05/22 at 12:16 PM the ADON said she had worked at the facility for 3 ½ years and recently transitioned into the ADON position after the DON left. The ADON said not labeling G Tubes feedings, water bags and syringes could cause an increased risk of infection due to spoiled feeding infusing. She said that all enteral feeding, water bags and syringes should be changed at least out every 24 hours or more often depending on orders. The ADON said that the nurse hanging the feeding was responsible for labeling and changing out the piston syringes and bags containing enteral feedings as required by policy and it is her expectation that all G-tube feedings, water bags and syringes be labeled with time, date, and initials. She said she makes rounds daily but had not done so this morning. Record Review of a Nursing Policy and Procedure: Subject- Enteral Formula via: Feeding tube, bolus, gravity, pump (closed/open) administration, effective date 12/2018, Policy: It is the policy of this home that the resident, who utilizes enteral nutrition will be free, to the extent possible, from complications related to enteral nutrition Procedure General Administration 5. The syringe and bag should be changed every 24 hours. 6. The syringe, bag and or bottle should be labeled with the resident's name, room number, date changed and the nurses' signature/initials. The bag should specify the physician order for formula, rate, route and means of administration. 675846 Page 2 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0695 Provide safe and appropriate respiratory care 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 observations, interviews and record reviews, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice and their care plans for 5 of 15 residents (Resident #4, #6, #10, #15, #34) observed for respiratory care and services. Residents Affected - Some Resident # 4, who required oxygen had nasal cannula tubing and prefilled humidifier bottle attached to oxygen concentrator was not labeled with date or initials. Resident # 6, who required oxygen as needed had prefilled humidifier bottle connected to oxygen concentrator labeled 11/10/22. Resident # 10, who was oxygen dependent had prefilled humidifier bottle connected to oxygen concentrator dated 11/21/2022 and the nasal cannula tubing was not labeled with date or initials. Resident # 15, who was oxygen dependent had prefilled humidifier bottle and nasal cannula not labeled with date or initials. Resident # 34, who was ventilator dependent had prefilled humidifier bottle not labeled with date or initials. These deficient practices could place residents who receive respiratory care and services at risk of developing respiratory infections and complications. Findings: 1. Record review of face sheet dated 12/06/2022 indicated Resident # 4 admitted [DATE] with diagnosis of dementia. Record review of physician order report for Resident # 4 indicated an order on 09/23/2022 for oxygen at 1-2 liters per nasal cannula as needed and change bubble humidification and nasal cannula every Monday on night shift. Record review of Quarterly MDS dated [DATE] indicated Resident # 4 had a BIMS of 04 indicating impaired cognition and required oxygen therapy. Record review of care plan dated 10/26/2022 indicated Resident # 4 required oxygen as needed. During an observation on 12/05/22 at 10:37 AM Resident # 4 had an oxygen concentrator at bedside with nasal cannula and humidifier bottle not labeled with date or staff initials. During an observation on 12/05/22 at 10:46 AM Resident # 4 was sitting in a wheelchair in her room with oxygen in place per portable oxygen tank at 2 liters per minute. Nasal cannula connected to portable oxygen was not dated or initialed. During an interview on 12/05/2022 at 10:48 AM Resident # 4 stated she wore her oxygen every day but could not recall when her oxygen supplies were last changed. 675846 Page 3 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of a facility face sheet dated 12/06/2022 indicated Resident #6 admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (lung disease), hypertension (high blood pressure), restless leg syndrome (movement of legs), and peripheral vascular disease (disease of lower leg veins). Record Review of Quarterly MDS dated [DATE] indicated Resident # 6 had a BIMS score of 13 indicating intact cognition. Record review of physician order dated 10/27/2022 for Resident # #6 indicated to change nasal cannula and bubble humidifier once a week on Mondays and as needed. Record review of physician order dated 10/27/2022 for Resident # 6 indicated oxygen via nasal cannula as needed at 1- 4 liters per minute every shift. Record review of MAR dated 12/07/2022 indicated no staff initials for weekly change of nasal cannula and bubble humidifier on 12/05/2022. During an observation on 12/05/2022 at 10:10 AM Resident # 6's prefilled humidifier bottle attached to oxygen concentrator was dated 11/10/2022. During an interview on 12/05/2022 at 10:10 AM Resident # 6 stated that he did not use oxygen very often and could not remember the last time he used it. During an interview on 12/06/2022 at 2:55 PM LVN A stated Resident # 6 only used the oxygen approximately once every couple of weeks and it is documented on the treatment administration record. 3. Record review of facility face sheet dated 12/06/2022 indicated Resident # 10 admitted [DATE] with diagnosis of acute respiratory failure (inability to breath on your own). Record review of physician order dated 04/05/2022 for Resident # 10 indicated bubble humidification on oxygen concentrator and nasal cannula are to be changed Mondays on night shift. Record review of Quarterly MDS dated [DATE] indicated Resident # 10 had a BIMS of 11 indicating moderately impaired cognition and required oxygen therapy. Record review of comprehensive care plan dated 11/16/2022 indicated Resident # 10 required oxygen related to diagnosis of respiratory failure and history of tracheostomy and ventilator dependence. During an observation on 12/05/22 at 10:16 AM Resident # 10 had oxygen at 2 liters per nasal cannula in place. Prefilled humidifier bottle was dated 11/21/2022 and nasal cannula was not labeled with date or initials. During an interview on 12/05/2022 at 10:18 AM Resident # 10 stated she wears her oxygen at all times and is not sure when the facility last changed her oxygen supplies. 4. Record review of face sheet dated 12/06/2022 indicated Resident # 15 was admitted on [DATE] with diagnosis of myocardial infarction (heart attack). Record review of physician orders for Resident # 15 indicated start date of 03/03/2021 indicated 675846 Page 4 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0695 Oxygen 1-3 liters per NC to keep oxygen saturation greater than 88%. On Level of Harm - Minimal harm or potential for actual harm 04/05/2022 order indicated to change bubble humidification and nasal cannula every Monday on night shift. Residents Affected - Some Record review of Quarterly MDS dated [DATE] indicated Resident # 15 had a BIMS of 13 indicating intact cognition and required oxygen therapy. Record review of comprehensive care plan dated 11/23/2022 indicated Resident # 15 required oxygen therapy as needed. During an observation on 12/05/22 at 10:46 AM Resident # 15 had oxygen in place per nasal cannula at 2 liters. The nasal cannula and prefilled humidifier bottle were unlabeled with date or staff initials. During an interview on 12/05/2022 at 10:47 AM Resident #15 was unsure on when oxygen supplies were last changed. 5. Record review of facility face sheet dated 12/06/2022 indicated Resident #34 admitted [DATE] with diagnoses of chronic respiratory failure with hypoxia (lack of oxygen), disorder of the skin and subcutaneous tissue, unspecified and dependence on respirator [ventilator] status. Record review of Quarterly MDS dated [DATE] indicated Resident #34 was in a comatose state and unaware of surroundings. Resident # 34 required oxygen therapy and mechanical ventilation. Record review of care plan dated 10/22/22 indicated Resident #34 received constant high flow oxygen therapy per ventilator via trach collar. Record review of physician order dated 10/11/2022 indicated bubble humidification was to be changed every week on Sunday. During an observation on 12/05/2022 at 12:27 PM Resident #34 was lying in bed with high flow oxygen per trach collar attached to tubing, and prefilled humidifier bottle attached to oxygen concentrator was not labeled with date or staff initials. During an interview on 12/05/2022 at 11:25 AM LVN A stated that oxygen tubing and prefilled humidifier bottles should be changed weekly and as needed. She stated that weekend RN is was responsible for changing the tubing and humidifier out. She stated oxygen supplies should be dated and signed as well as signed out on the treatment administration record. She stated the risk would be nasal irritation, poor oxygen delivery, and infection. During an interview on 12/05/2022 at 11:31 AM RRT stated the Respiratory Therapist was responsible for changing the oxygen tubing and humidifiers on the ventilator hall but the nurses on the other halls are responsible for changing out their own oxygen supplies. She stated the tubing and humidifier should be changed weekly and as needed and should be dated and initialed when changed. RRT stated when oxygen supplies are changed it is documented on the treatment administration record. RRT stated the risk could be improper oxygen delivery and infections. During interview on 12/06/2022 at 10:52 AM the ADON stated she had worked at the facility for over 675846 Page 5 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3 years. She stated oxygen tubing and prefilled humidifier bottles are to be changed weekly and as needed. She stated when oxygen supplies are changed, they should be dated and initialed. The ADON stated the nurses on the floor were responsible for making sure oxygen supplies were changed weekly and as needed and the respiratory therapist were responsible for ventilator residents. The risk to the resident would be infection control. The ADON stated the plan was to reeducate all staff on the policy and procedure for oxygen therapy and monitor to make sure that the policy was being followed. The ADON stated the facility would work together to make sure the error was corrected. During an interview on 12/06/2022 at 4:15 PM the ADM stated this failure could place the residents at risk for infections. ADM stated her expectation was that all staff were following the facility policy and procedure for oxygen therapy, and she would monitor weekly with the ADON to see that the error is corrected. Record review of facility policy and procedure dated 12/01/2018 titled Respiratory Therapy Equipment indicated, . #3. [NAME] bottle with date and initials upon opening and discard after seven days or as needed, #6. Change the prefilled humidifier when water level becomes low at a minimum every 7 days, #7. Change oxygen cannula and tubing every 7 days and as necessary 675846 Page 6 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 6 residents (Resident # 10 and Resident #15) and 1 of 3 staff (LVD D) reviewed for pharmacy services. Resident # 10 had a blood pressure of 106/62 and received spironolactone 25mg 1 tablet by mouth and carvedilol 3.125 mg 1 tablet by mouth when order indicated to hold medications if systolic blood pressure was less than 110. Resident # 10 received aspirin 81 mg 1 tablet by mouth when order indicated to administer aspirin 81 mg 2 tablets by mouth. Resident # 15 received simethicone 80 mg 1 tablet by mouth when the order indicated to administer simethicone 125 mg 1 tablet by mouth. LVN D did not ensure Resident # 15 took her medication before leaving resident room. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization. Findings: 1. Record review of facility face sheet dated 12/06/2022 indicated Resident #10 admitted [DATE] with diagnosis of acute respiratory failure (inability to breath on your own). Record review of physician order report for Resident #10 indicated order dated 02/02/2019 Aspirin 81 mg 2 tabs by mouth once a day. Order dated 08/23/2019 indicated spironolactone 25 mg 1 tablet by mouth once a day with special instructions to hold if SBP less than 110. Order dated 03/19/2020 indicated carvedilol 3.125 mg 1 tablet by mouth twice a day with special instructions to hold if SBP less than 110. Record review of Quarterly MDS dated [DATE] indicated Resident #10 had a BIMS of 11 indicating moderately impaired cognition. Record review of care plan dated 11/16/2022 indicated Resident # 10 required diuretic (fluid pill) and anti-hypertensive (high blood pressure) medications to control fluid volume overload and hypertension. During a medication administration observation on 12/06/2022 at 07:14 AM LVN D assessed Resident #10's blood pressure and the result was 106/62. LVN D prepared Resident # 10's medication and administered spironolactone 25 mg 1 tablet by mouth and carvedilol 3.125 mg 1 tablet by mouth, and aspirin 81 mg 1 tablet by mouth. Resident #10 had an order that indicated to hold spironolactone and carvedilol if systolic blood pressure was less than 110 and to administer aspirin 81 mg 2 tablets by mouth daily. 675846 Page 7 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of face sheet dated 12/06/2022 indicated Resident #15 admitted on [DATE] with diagnosis of myocardial infarction (heart attack). Record review of physician order report indicated Resident #15 had order dated 04/09/2022 for simethicone 125 mg 1 tablet by mouth before meals and at bedtime and an order dated 03/02/2022 for potassium chloride 20 mEq/15ml give 7.5 ml to equal 10 mEq once a day with special instructions to dilute in water. Record review of Quarterly MDS dated [DATE] indicated Resident #15 had a BIMS of 13 indicating intact cognition. Record review of care plan dated 11/23/2022 indicated Resident #15 to give medications as ordered due to hypertension (high blood pressure) and diuretic use. During a medication administration observation on 12/06/2022 at 07:43 AM LVN D administered Resident #15 simethicone 80 mg 1 tablet by mouth and order indicated to administer simethicone 125 mg 1 tablet by mouth before meals and at bedtime. LVN D prepared potassium chloride 20 mEq/15 ml 7.5 ml and left medication at the bedside With surveyor intervention, LVN D returned to room and observed Resident # 15 finish her liquid potassium chloride. During an interview on 12/06/2022 at 07:54 AM LVN D stated she forgot that medications could not be left for the resident to finish. During an interview on 12/06/2022 at 3:51 PM LVN D stated she had been employed at the facility for about 4 weeks and she was properly trained on medication administration. She stated she looked at the MAR and just overlooked the parameters for Resident # 10's spironolactone and carvedilol and that Resident #10 took 2 not 1 tab of Aspirin 81mg daily. She stated she was nervous and made the mistake. She stated Resident # 15 should have gotten 125 mg of simethicone not 80 mg and she thought the supply on the medication cart was the correct dose. She stated she should have looked at the medicine and MAR more closely to make sure she was giving the correct dose of medicine. LVN D stated she left the potassium chloride liquid for Resident #15 to finish drinking but should never leave medicine at the bedside. LVN D stated she should have stayed in the room to ensure Resident # 15 took her medicine. LVN D stated she reported the administration errors to the RCN and ADON and Resident #10 and #15 were reassessed with no adverse reactions. She stated the risk of residents not receiving their medications as ordered could be exacerbation of their disease processes and the risk to leaving medicine at the bedside could be the resident not taking their medicine or another resident could have taken the medicine. During an interview on 12/06/2022 at 4:00 PM the ADON stated LVN D was properly trained and checked off on medication administration and that when she passed medications with her, she did it correctly. ADON stated the errors have been reported to the physician and each resident was monitored for adverse reactions. She stated she would begin retraining her and overseeing that she can properly administer medications safely and as ordered. During an interview on 12/06/2022 at 4:05 PM RNC stated the risk of improper medication administration could be exacerbation of illnesses. Her expectation was that all medications were given safely and as ordered. RNC stated each resident was reassessed and their physicians were notified of the 675846 Page 8 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication errors. She stated her plan will be to retrain, monitor medication pass with all nurses, and audit all orders with current available medications in the facility and on the medication carts. During an interview on 12/06/2022 at 4:12 PM the ADM stated her expectation was for all nurses administering medications to do so correctly. She stated she would oversee that the ADON closely monitors LVN D and all nurses to see that medications are administered correctly. ADM stated the facility had followed their policy for medication administration. Record review of nurse proficiency dated 12/02/2022 indicated LVN D had been properly trained on medication administration. Record review of facility policy and procedure dated 12/01/2018, titled Medication - Unusual Occurrences indicated, .it is the policy of this home to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. Record review of facility policy and procedure dated 12/01/2018, titled Medication - Administration indicated, .3. Medications are administered at the time they are prepared. 13.Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label 675846 Page 9 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0759 Ensure medication error rates are not 5 percent or greater. 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 a medication error rate of less than 5 percent. The facility had a medication error rate of 15.63%, based on 5 errors out of 32 opportunities, involving 2 of 6 residents (Resident #10 and Resident #15) and 1 of 3 staff (LVN D) reviewed for medication errors. Residents Affected - Some LVN D administered spironolactone 25mg 1 tablet by mouth to Resident # 10 that had a blood pressure of 106/62 and order indicated to hold the medication if the systolic blood pressure (top number) was less than 110. LVN D administered carvedilol 3.125 mg 1 tablet by mouth to Resident # 10 that had a blood pressure of 106/62 and order indicated to hold the medication if the systolic blood pressure (top number) was less than 110. LVN D administered aspirin 81 mg 1 tablet by mouth to Resident # 10 and order indicated to administer aspirin 81 mg 2 tablets by mouth. LVN D administered simethicone 80 mg 1 tablet by mouth to Resident # 15 and order indicated to administer simethicone 125 mg 1 tablet by mouth. LVN D prepared potassium chloride (20 mEq/15 ml) 7.5 ml by mouth and left medication at Resident # 15's bedside. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications. Findings: 1. Record review of facility face sheet dated 12/06/2022 indicated Resident #10 admitted [DATE] with diagnosis of acute respiratory failure (inability to breath on your own). Record review of physician order report for Resident #10 indicated order dated 02/02/2019 Aspirin 81 mg 2 tabs by mouth once a day. Order dated 08/23/2019 indicated spironolactone 25 mg 1 tablet by mouth once a day with special instructions to hold if SBP less than 110. Order dated 03/19/2020 indicated carvedilol 3.125 mg 1 tablet by mouth twice a day with special instructions to hold if SBP less than 110. Record review of Quarterly MDS dated [DATE] indicated Resident #10 had a BIMS of 11 indicating moderately impaired cognition. Record review of care plan dated 11/16/2022 indicated Resident # 10 required diuretic (fluid pill) and anti-hypertensive (high blood pressure) medications to control fluid volume overload and hypertension. During a medication administration observation on 12/06/2022 at 07:14 AM LVN D assessed Resident #10's blood pressure and the result was 106/62. LVN D prepared Resident # 10's medication and administered spironolactone 25 mg 1 tablet by mouth and carvedilol 3.125 mg 1 tablet by mouth, and aspirin 675846 Page 10 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0759 Level of Harm - Minimal harm or potential for actual harm 81 mg 1 tablet by mouth. Resident #10 had an order that indicated to hold spironolactone and carvedilol if systolic blood pressure was less than 110 and to administer aspirin 81 mg 2 tablets by mouth daily. 2. Record review of face sheet dated 12/06/2022 indicated Resident #15 admitted on [DATE] with diagnosis of myocardial infarction (heart attack). Residents Affected - Some Record review of physician order report indicated Resident #15 had order dated 04/09/2022 for simethicone 125 mg 1 tablet by mouth before meals and at bedtime and order dated 03/02/2022 for potassium chloride 20 mEq/15ml give 7.5 ml to equal 10 mEq once a day with special instructions to dilute in water. Record review of Quarterly MDS dated [DATE] indicated Resident #15 had a BIMS of 13 indicating intact cognition. Record review of care plan dated 11/23/2022 indicated Resident #15 to give medications as ordered due to hypertension (high blood pressure) and diuretic use. During a medication administration observation on 12/06/2022 at 07:43 AM LVN D administered Resident #15 simethicone 80 mg 1 tablet by mouth and order indicated to administer simethicone 125 mg 1 tablet by mouth before meals and at bedtime. LVN D prepared potassium chloride 20 mEq/15 ml 7.5 ml and left medication at bedside. With surveyor intervention, LVN D returned to room and observed Resident # 15 finish her liquid potassium chloride. During an interview on 12/06/2022 at 07:54 AM LVN D stated she forgot that medications could not be left for the resident to finish. During an interview on 12/06/2022 at 3:51 PM LVN D stated she had been employed at the facility for about 4 weeks and she was properly trained on medication administration. She stated she looked at the MAR and just overlooked the parameters for Resident # 10's spironolactone and carvedilol and that Resident #10 took 2 not 1 tab of Aspirin 81mg daily. She stated she was nervous and made the mistake. She stated Resident # 15 should have gotten 125 mg of simethicone not 80 mg and she thought the supply on the medication cart was the correct dose. She stated she should have looked at the medicine and MAR more closely to make sure she was giving the correct dose of medicine. LVN D stated she left the potassium chloride liquid for Resident #15 to finish drinking but should never leave medicine at the bedside. LVN D stated she should have stayed to make sure she took it. LVN D stated she reported the administration errors to the RCN and ADON and Resident #10 and #15 were reassessed with no adverse reactions. She stated the risk of residents not receiving their medications as ordered could be exacerbation of their disease processes and the risk to leaving medicine at the bedside could be the resident not taking it or another resident taking the medicine. During an interview on 12/06/2022 at 4:00 PM ADON stated the medication error rate should be below 5%. ADON stated the facility followed their policy for reporting medication errors and each resident was reassessed with no adverse reactions. She stated LVN D was properly trained and checked off on medication administration and that when she passed medications with her, she did it correctly. She stated she would begin retraining her and overseeing that she can properly administer medications safely and as ordered. 675846 Page 11 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/06/2022 at 4:05 PM RNC stated the medication error rate should be below 5%. RNC stated each resident was reassessed with no adverse reactions and each physician was notified of the medication errors. the risk of improper medication administration could be exacerbation of illnesses. Her expectation is that all medications are given safely and as ordered. She stated her plan will be to retrain, monitor medication pass with all nurses, and audit all orders with current available medications in the facility and on the medication carts. During an interview on 12/06/2022 at 4:12 PM the ADM stated her expectation was to have a medication error less than 5 % and will reeducate and see that the ADON closely monitors LVN D to see that she was properly administering medications. ADM stated she would follow the facility policy for medication errors. Record review of nurse proficiency dated 12/02/2022 indicated LVN D had been properly trained on medication administration. Record review of facility policy and procedure dated 12/01/2018, titled Medication - Unusual Occurrences indicated, .it is the policy of this home to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. Record review of facility policy and procedure dated 12/01/2018, titled Medication - Administration indicated, .3. Medications are administered at the time they are prepared. 13.Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label 675846 Page 12 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

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 1 of 1 kitchen reviewed for food storage. Residents Affected - Few There was left over lasagna in the refrigerator dated 12/1/22 with a use by date of 12/4/22. This failures could place the residents at risk of foodborne illnesses. Findings include: During an observation on 12/5/22 at 9:40 a.m., in the dining room there was Lasagna listed as the substitute for the lunch time meal. During an observation on 12/5/22 at 9:42 a.m., there was left over Lasagna in the refrigerator dated 12/1/22 with a use by date of 12/4/22. During an interview on 12/5/22 at 9:45 a.m., the DM, she said the Lasagna was the substitute for the noon meal. She said she did not know it had a use by date of 12/4/22. She said she would throw it away. During an interview on 12/7/22 at 10:00 a.m., the DM said she had been the DM for two and a half years. She said it was her responsibility to train her staff to check the refrigerator for expired food. She said she had already talked to the Administrator, and it had been the responsibility of the evening cook to check the refrigerator for expired food and discard it. She said the Administrator and her had decided to switch the responsibility of checking the refrigerator to the morning cook. The DM said that way she could better monitor that it was getting done. She said if she had pulled the Lasagna out, she would have seen the dates, and discarded it and changed the substitution for the lunch meal. She said eating expired food could make the residents sick. During an interview on 12/7/22 at 10:30 a.m., the Administrator said she had already talked to the DM about the expired Lasagna, and they decided to change the responsibility of checking the refrigerators for expired food from the night cook to the day cook so the DM could better monitor that it was being done. She said there would be additional training and monitoring. She said the DM would in-service the kitchen staff on checking all foods in the kitchen for expiration and use by dates. Review of the facility's policy, Cooling and Reheating Foods date approved 4/16/19, indicated: POLICY: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be cooled and reheated according to state and US Food Codes and HACCP (Hazard Analysis Critical Control Point) guidelines. And reused within 72 hours. vii. Leftover food must be labeled, dated, and reused within 72 hours. 675846 Page 13 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 develop a policy to ensure safe and sanitary storage of resident's food items for 2 of 15 residents (Residents #8 and Resident #15) reviewed for food safety. Residents Affected - Few The facility did not implement the personal food policy related to personal refrigerators for Resident #8 and #15. The personal refrigerator for Resident #8 had expired food items. The personal refrigerator for Resident #15 had expired food items. These failures could place the residents at risk for food borne illnesses. Findings: 1. Record review of facility face sheet dated 12/06/2022 indicated Resident #8 was [AGE] years old and admitted [DATE] with diagnosis of chronic systolic heart failure (inability of the heart to pump), acquired absence of right hip joint and unspecified abdominal hernia without obstruction or gangrene. Record review of Quarterly MDS dated [DATE] indicated Resident #8 had a BIMS score of 14 indicating intact cognition. During an observation on 12/05/22 at 10:00 AM Residents #8 had a jar of pig's feet in his personal refrigerator with a best by date of 9/13/2022. During an interview on 12/05/2022 at 10:01 AM Resident #8 stated he keeps and eats a few items in his personal refrigerator. Resident #8 stated he had the pig feet in his refrigerator for several months. Resident #8 stated the facility staff maintain and clean his refrigerator but did not know how often it was cleaned. 2. Record review of face sheet dated 12/06/2022 indicated Resident #15 admitted [DATE] with diagnosis of myocardial infarction (heart attack). Record review of Quarterly MDS dated [DATE] indicated Resident #15 had a BIMS of 13 indicating intact cognition. During an observation on 12/05/22 at 10:37 AM Resident # 15's personal refrigerator was observed with 2 containers of Activia yogurt with expiration date of January 21, 2022, and 1 carton of chicken broth that was open without an opened date. The Chicken broth carton directions indicated to dispose of after 10 days of opening. During an interview on 12/05/2022 at 10:38 AM Resident #15 stated her family member brings her food items and heats up the chicken broth when she wants it. She stated she had yogurt recently, but it didn't taste bad. She stated she did not know who was responsible for cleaning out her refrigerator or when it was last cleaned. 675846 Page 14 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/05/2022 at 11:29 AM LVN A stated that personal refrigerators are usually cleaned by housekeeping but if a resident ask anyone can clean them out. She stated the risk of not removing expired food items could be food borne illnesses. During an interview on 12/05/2022 at 11:33 AM HSK B stated he had been employed at the facility for almost a year. He stated that the housekeeping supervisor was responsible for checking and cleaning the refrigerators in the resident's rooms but if a resident asked, he would check them and remove items if they needed it. He stated that expired foods could make a resident sick. During an interview on 12/05/2022 at 11:51 AM HSK C stated she was responsible for cleaning and removing expired items from the resident's personal refrigerators. She stated she tried to get to them at least 2 times a month and as needed. She stated they used a form in the past to date and sign when personal refrigerators were checked and cleaned but had not been using it recently. HSK C was not sure why they were no longer using the form but she would start back using the form in order to track when they are done. She stated the risk to resident could be infections and sickness. During an interview on 12/05/2022 at 11:55 AM LVN D stated Resident # 15 does ask to have chicken broth heated for her at times, but her family member was the one who usually does it. She stated she was not aware that Resident #15 had expired items in her refrigerator or that after 10 days of opening the chicken broth it had to be disposed. She stated the risk of a resident consuming expired food items could be sickness. During an interview on 12/05/2022 at 12:00 PM CNA E stated she had not gotten any food items out of Resident # 15's personal refrigerator for her to eat. She stated she had observed her family member bringing in food and giving her items from the refrigerator. She stated that the housekeepers were responsible for cleaning the personal refrigerators. She stated the risk of a resident consuming expired items could be getting sick to their stomach. During an interview on 12/05/2022 at 12:32 AM Resident # 15's family member stated they did not know anything about food items in the refrigerator being expired. She stated her family members bring those things. She stated Resident #15 rarely does not eat the food at the facility but when she does not eat well her family member would warm her up some chicken broth. She stated the facility staff manage the refrigerator, but she would clean it out today while she was present. During an interview on 12/06/2022 at 4:14 PM ADM stated the risk to residents consuming expired food could be sickness. She stated her expectation regarding personal refrigerators was that the policy and procedure was followed. She stated she would meet with the housekeeping supervisor and ensure she knew the facility policy and would oversee those personal refrigerators are cleaned weekly. Record review of facility policy and procedure dated 12/01/2018 titled Refrigerator-Personal indicated, .1. the housekeeping supervisor/designee will monitor resident's refrigerator weekly, 3. clean and remove expired food as needed . 675846 Page 15 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0880 Provide and implement an infection prevention and control program. 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 did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 resident reviewed for infection control. (Resident # 197) Residents Affected - Few The facility did not ensure LVN D wore gloves, a gown and did not perform hand washing after providing care for Resident #197 who had physician orders for droplet isolation. Findings included: Record review of Physician Orders dated 12/05/22 indicated Resident #197 readmitted on [DATE] and was an [AGE] year-old female. She was sent back to the hospital on [DATE] and diagnosed with Influenza due to identified novel influenza A virus with pneumonia. Other diagnoses include:, Acute on chronic diastolic (congested) heart failure (Primary, Admission), Influenza due to Candidas (yeast) identified novel influenza A virus with pneumonia, DM, Chronic Kidney disease stage 3, Systemic inflammatory response syndrome of noninfectious origin without acute organ disfunction, (Body Pain, arthritis, myalgia, (Muscle pain), ( Chronic obstructive pulmonary disease with (acute) exacerbation, Alzheimer's disease late onset, Psychotic disorder with hallucination due to known physiological condition, Major depressive disorder, recurrent severe without psychotic features. Record review of MDS dated [DATE] indicated Resident #197 was cognitively impaired and required limited to extensive assist with ADL's. Record review of care plan initiated 12/05/22 for Resident #197 indicated droplet precautions due to increased risk of infection. Resident #197 had been diagnosed with Flu A, with interventions to wear personal protective equipment PPE properly. Follow facility infection control policy, inform staff and visitors of resident's precaution requirements. Record review of a physician order dated 12/05/22 indicated Resident #197 was to be placed in Droplet Precautions (dx Influenza A) isolation. During an observation on 12/05/22 at 1:00 p.m., a sign posted on Resident #197's door read .Please see nurse before entering room droplet precautions . A container was sitting outside the door containing gowns, gloves, masks. During an observation on 12/06/22 at 5:30 p.m., LVN D was observed standing over resident #197, adjusting her oxygen tubing. LVN D was not wearing a gown or gloves from an isolation kit outside the resident's door. LVN D came out of the resident's room without washing her hands and was standing at the nurse's cart. During an interview on 12/06/22 at 5:35 p.m., surveyor asked LVN D if the resident was alright, and she said yes. She then said and you are who? LVN D would not look at surveyor. Surveyor then asked LVN D doesn't the resident have the flu, and she answered yes. During an interview on 12/07/22 at 9:20 a.m., with the Administrator she said LVN D was new but had her infection prevention/control training on 11/29/22. She said LVN D had just left the facility 675846 Page 16 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aggressively and she didn't think she would be back, but if she did, she would be reeducated on donning and doffing, (putting on and taking off personnel protective equipment, a gown, mask, and gloves) and receive one on one training with the nurse to prevent the spread of infection. During an interview on 12/07/22 at 9:31 a.m., with the ADON she said when she interviewed LVN D on 12/06/22 and asked why she didn't have on PPE while caring for the resident with the Flu, LVN D just shrugged her shoulders. The ADON said LVN D had been a nurse a long time. The ADON said she made sure LVN D followed proper infection control protocol the rest of her shift by instructing and monitoring her. The ADON said she had talked to LVN D, this morning and she was upset and left the building aggressively, so if she comes back, she will receive additional training before she's allowed to work the floor. LVN D was provided three days of training before she was allowed to work the floor. A policy, Nursing Policy and Procedure, effective 12/2017, POLICY: It is the policy of this home to assure that appropriate precautions will be established to ensure that the necessary isolation techniques are implemented. Precaution notices will be posted when isolation precautions are implemented. Isolation Policy with the effective date 12/20/17 noted .In addition to wearing gloves as outlined under Standard Precautions, wear gloves when entering the room .Wear a disposable gown upon entering the Contact Precautions . During a record review on 12/07/22 03:09 p.m., a policy titled Nursing Policy and Procedure-Infection Control-Precautions dated 12/2017. POLICY- It is the policy of this home to assure that the necessary isolation techniques are implemented. Precautions notices will be posted when isolation precautions are implemented. PROCEDURE 1. Transmission bases precautions have been established to assure that appropriate isolation techniques are implemented in this home when necessary. 4. In addition to Standard Precautions include, but are not limited to: c. Gloves and handwashing: During the course of caring for a resident, change gloves after having contact infective material that may contain high concentration of microorganisms (fecal material and wound drainage.) Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces. d. GOWN In addition to wearing a gown as outlines under Standard Precautions, wear a gown (clean, non-sterile) when entering the room if you anticipate that your clothing will have substantial contact with the infectious material. Remove the gown before leaving the resident's environment. 675846 Page 17 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0880 After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces. Level of Harm - Minimal harm or potential for actual harm 5. In addition to Standard Precautions, DROPLET PRECATIONS must be implemented for a resident documented or suspected or suspected to be infected with microorganisms transmitted by droplets (large particle droplets [larger than 5 microns in size] that can be generated by the resident coughing, sneezing, talking, or the performance of procedures.) Residents Affected - Few 675846 Page 18 of 19 675846 12/07/2022 Avir at San Augustine 902 E Main St San Augustine, TX 75972

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment. Residents Affected - Few The facility did not ensure the stove was in working order. Two of the eight burners on the stove did not light, when the knobs were turned. This failure could place the residents at risk of not having safe operating equipment. Findings included: During an observation on 12/5/22 at 10:15 a.m., in the kitchen, two of six stove burners, the back right and the front middle, did not light automatically when the knob was turned. The DM had to use a striker (a lighter) to light the burners on the stove. During an interview on 12/5/22 at 10:20 a.m., the DM said the service technician had been here a month ago, but the pilot light would not stay lit. She said they had to use a lighter to light the stove because the burner would not light when the knob was turned. She said she had not reported it to the Administrator because the technician was just here a month ago. During an interview on 12/05/22 at 10:45 a.m., the Administrator said she just found out the stove was not working yesterday. She said the technician had just been out in October 2022 and she thought the stove was fixed. She said from now on she would have to check it herself to be sure the technician fixed it. She said the DM had not told her the burners did not light when the knob was turned. She said the burners not lighting when the knobs are turned could cause a fire. During a record review a bill from Commercial Kitchen Sales and Service dated 10/24/22 indicated: the technician replaced the thermostat on the left oven and replaced a knob. He had not serviced the burners on the stove. During a record review of a facility policy titled General kitchen Safety Guidelines, indicated: POLICY: The facility will follow basic safety guidelines in order to reduce the risk of accidents and ensure the safety of employees. .10. Keep all equipment in working order and report any malfunctioning to the Maintenance Department. 675846 Page 19 of 19