Health inspection·June 4, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medications errors for one of one (Resident #1) of three residents reviewed for significant medication errors. Residents Affected - Some The facility failed to ensure Resident #1 was administered her prescribed Bactrim (antibiotic) until seven days after receiving positive UTI results on 04/11/25, causing her to be in increased pain and dysuria (pain with urination). This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, diabetes, muscle wasting and atrophy (wasting away), and history of UTIs. Review of Resident #1's quarterly MDS assessment, dated 03/13/25, reflected a BIMS score of 10, indicating a moderate cognitive impairment. Section H (Bladder and Bowel) reflected she did not require a catheter and was always incontinent. Review of Resident #1's quarterly care plan, dated 01/26/25, reflected she had a history of urinary tract infections with an intervention of monitoring lab work as ordered and reporting results to her physician. Review of Resident #1's progress notes, dated 04/09/25 at 6:30 PM an documented by LVN A, reflected the following: MD in to evaluate [Resident #1], she reported dysuria to MD. Received new order for UA. Review of Resident #1's lab results, reflected a urine specimen was collected on 04/09/25 and the results were reported to the facility on [DATE]. The C&S reported a high microbial load of Escherichia coli (rod-shaped bacteria), indicating a UTI was present. Review of Resident #1's progress notes, dated 04/14/25 at 2:26 PM and documented by LVN B, reflected the following: Page 1 of 6 676044 676044 06/04/2025 Avir at Magnolia 1105 N Magnolia Luling, TX 78648

F 0760 Received new order for Bactrim DS 1 tab po BID x7 days for UTI. Level of Harm - Actual harm Review of Resident #1's physician order, dated 04/14/25, reflected Bactrim DS oral tablet - 800-180 MG Give 1 tablet by mouth two times a day every 7 day(s) related to urinary tract infection. Residents Affected - Some Review of Resident #1's MAR, April of 2025, reflected she was administered one dose of Bactrim on 04/14/25 in the evening by the ADON. No other doses were administered and there was a D/C date of 04/17/25. Review of Resident #1's physician order, dated 04/18/25, reflected Bactrim DS oral tablet - 800-160 MG Give 1 tablet by mouth two times a day related to urinary tract infection. Review of Resident #1's MAR, April of 2025, reflected she was administered all 14 doses of Bactrim from 04/18/25 - 04/24/25 by either MA C or the ADON. Review of Resident #1's progress notes, from 04/12/25 - 04/17/25, reflected no documentation as to why she was not administered her antibiotics. During an interview on 06/04/25 at 10:02 AM, Resident #1 stated when she had a UTI and did not get her antibiotics on time, she was in increased pain. She stated when she was on antibiotics the pain would go away. She stated she remembered a time in the middle of April (2025) where she had a UTI and went many days without getting antibiotics. She stated it hurt to urinate and she had a radiating pain that went up to her belly button. She stated she was not sure why she did not get her antibiotics on time but she kept asking the nurses. She stated she was scared to not get antibiotics when she had a UTI because it could affect her kidneys and she worried about kidney damage. During an interview on 06/04/25 at 10:47 AM, LVN A stated when UA results came back from the lab, it was the nurse's responsibility to call the doctor and to get orders. She stated it was important to contact the doctor the same day. She stated it would not be normal or right to start an antibiotic seven days later. She stated a negative outcome could be going into septic shock at any time, renal failure, or renal disfunction. She stated receiving one dose of antibiotics and then getting back on it days later could cause antibiotic resistance as well as continued or worsening of symptoms, such as pain. She stated she remembered collecting Resident #1's urine sample in April (2025) but was not the nurse that received the results from the lab. During a telephone interview on 06/04/25 at 10:58 AM, the NP stated she had only been working with the facility for a short time and was not privy to Resident #1's UTI in April (2025). She stated if UA results came back positive, her expectation, as a general rule, would be that she was notified within 24 hours. She stated they have someone in the building every single day, so the sooner the better. She stated a negative outcome of not starting an antibiotic until days after a positive result could cause worsening of the infection because it was not getting treated with the needed antibiotics. She stated worsening of an infection could lead to sepsis. During a telephone interview on 06/04/25 at 11:21 AM, LVN B stated she did not remember why it took four days to get an order of antibiotics for Resident #1. She stated sometimes when they ran the culture and sensitivity it would take a few days to get the results back. She stated she really could not remember the situation as it was so long ago. She stated the normal process was when a nurse received lab results, they were to notify the NP and put in the orders they were given. She stated a negative outcome for not receiving antibiotics when needed could be sepsis or a much worse situation 676044 Page 2 of 6 676044 06/04/2025 Avir at Magnolia 1105 N Magnolia Luling, TX 78648

F 0760 than if they had taken care of it. Level of Harm - Actual harm During an interview on 06/04/25 at 1:33 PM, MA C stated she did not remember why she started administering Resident #1 antibiotics on 04/18/25. She stated she just administered residents the medications that were listed on their MAR. Residents Affected - Some During an interview on 06/04/25 at 1:51 PM with the ADM and ADON, the ADM stated it was the nurse's responsibility to notify the NP immediately after receiving lab results. The ADON stated she was not made aware of Resident #1's positive UTI results on 04/11/25 and she administered a dose of Bactrim on 04/14/25 because she was working as a medication aide it must have popped up on her MAR. The ADON stated she discontinued the antibiotic on 04/17/25 because she noticed Resident #1's MAR had not been getting checked off for it. The ADON stated she got a new order for seven days. The ADON stated Resident #1 could have gone septic. The ADON stated going days without antibiotics after receiving once dose would cause the resident to not get the full effect of the antibiotics. The ADM stated the situation did not meet her expectations and she could not understand how the ball was dropped. Review of the facility's Administering Medications Policy, revised April 2019, reflected the following: Medications are administered in a safe and timely manner, and as prescribed. . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 676044 Page 3 of 6 676044 06/04/2025 Avir at Magnolia 1105 N Magnolia Luling, TX 78648

F 0773 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Actual harm Residents Affected - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly notify the ordering physician or nurse practitioner of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #1) of three residents reviewed for laboratory services. The facility failed to ensure Resident #1 was administered her prescribed Bactrim (antibiotic) until seven days after receiving positive UTI results on 04/11/25, causing her to be in increased pain and dysuria (pain with urination). This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, diabetes, muscle wasting and atrophy (wasting away), and history of UTIs. Review of Resident #1's quarterly MDS assessment, dated 03/13/25, reflected a BIMS score of 10, indicating a moderate cognitive impairment. Section H (Bladder and Bowel) reflected she did not require a catheter and was always incontinent. Review of Resident #1's quarterly care plan, dated 01/26/25, reflected she had a history of urinary tract infections with an intervention of monitoring lab work as ordered and reporting results to her physician. Review of Resident #1's progress notes, dated 04/09/25 at 6:30 PM an documented by LVN A, reflected the following: MD in to evaluate [Resident #1], she reported dysuria to MD. Received new order for UA. Review of Resident #1's lab results, reflected a urine specimen was collected on 04/09/25 and the results were reported to the facility on [DATE]. The C&S reported a high microbial load of Escherichia coli (rod-shaped bacteria), indicating a UTI was present. Review of Resident #1's progress notes, dated 04/14/25 at 2:26 PM and documented by LVN B, reflected the following: Received new order for Bactrim DS 1 tab po BID x7 days for UTI. Review of Resident #1's physician order, dated 04/14/25, reflected Bactrim DS oral tablet - 800-180 MG Give 1 tablet by mouth two times a day every 7 day(s) related to urinary tract infection. Review of Resident #1's MAR, April of 2025, reflected she was administered one dose of Bactrim on 676044 Page 4 of 6 676044 06/04/2025 Avir at Magnolia 1105 N Magnolia Luling, TX 78648

F 0773 04/14/25 in the evening by the ADON. No other doses were administered and there was a D/C date of 04/17/25. Level of Harm - Actual harm Residents Affected - Some Review of Resident #1's physician order, dated 04/18/25, reflected Bactrim DS oral tablet - 800-160 MG Give 1 tablet by mouth two times a day related to urinary tract infection. Review of Resident #1's MAR, April of 2025, reflected she was administered all 14 doses of Bactrim from 04/18/25 - 04/24/25 by either MA C or the ADON. Review of Resident #1's progress notes, from 04/12/25 - 04/17/25, reflected no documentation as to why she was not administered her antibiotics. During an interview on 06/04/25 at 10:02 AM, Resident #1 stated when she had a UTI and did not get her antibiotics on time, she was in increased pain. She stated when she was on antibiotics the pain would go away. She stated she remembered a time in the middle of April (2025) where she had a UTI and went many days without getting antibiotics. She stated it hurt to urinate and she had a radiating pain that went up to her belly button. She stated she was not sure why she did not get her antibiotics on time but she kept asking the nurses. She stated she was scared to not get antibiotics when she had a UTI because it could affect her kidneys and she worried about kidney damage. During an interview on 06/04/25 at 10:47 AM, LVN A stated when UA results came back from the lab, it was the nurse's responsibility to call the doctor and to get orders. She stated it was important to contact the doctor the same day. She stated it would not be normal or right to start an antibiotic seven days later. She stated a negative outcome could be going into septic shock at any time, renal failure, or renal disfunction. She stated receiving one dose of antibiotics and then getting back on it days later could cause antibiotic resistance as well as continued or worsening of symptoms, such as pain. She stated she remembered collecting Resident #1's urine sample in April (2025) but was not the nurse that received the results from the lab. During a telephone interview on 06/04/25 at 10:58 AM, the NP stated she had only been working with the facility for a short time and was not privy to Resident #1's UTI in April (2025). She stated if UA results came back positive, her expectation, as a general rule, would be that she was notified within 24 hours. She stated they have someone in the building every single day, so the sooner the better. She stated a negative outcome of not starting an antibiotic until days after a positive result could cause worsening of the infection because it was not getting treated with the needed antibiotics. She stated worsening of an infection could lead to sepsis. During a telephone interview on 06/04/25 at 11:21 AM, LVN B stated she did not remember why it took four days to get an order of antibiotics for Resident #1. She stated sometimes when they ran the culture and sensitivity it would take a few days to get the results back. She stated she really could not remember the situation as it was so long ago. She stated the normal process was when a nurse received lab results, they were to notify the NP and put in the orders they were given. She stated a negative outcome for not receiving antibiotics when needed could be sepsis or a much worse situation than if they had taken care of it. During an interview on 06/04/25 at 1:33 PM, MA C stated she did not remember why she started administering Resident #1 antibiotics on 04/18/25. She stated she just administered residents the medications that were listed on their MAR. 676044 Page 5 of 6 676044 06/04/2025 Avir at Magnolia 1105 N Magnolia Luling, TX 78648

F 0773 Level of Harm - Actual harm Residents Affected - Some During an interview on 06/04/25 at 1:51 PM with the ADM and ADON, the ADM stated it was the nurse's responsibility to notify the NP immediately after receiving lab results. The ADON stated she was not made aware of Resident #1's positive UTI results on 04/11/25 and she administered a dose of Bactrim on 04/14/25 because she was working as a medication aide it must have popped up on her MAR. The ADON stated she discontinued the antibiotic on 04/17/25 because she noticed Resident #1's MAR had not been getting checked off for it. The ADON stated she got a new order for seven days. The ADON stated Resident #1 could have gone septic. The ADON stated going days without antibiotics after receiving once dose would cause the resident to not get the full effect of the antibiotics. The ADM stated the situation did not meet her expectations and she could not understand how the ball was dropped. Review of the facility's Administering Medications Policy, revised April 2019, reflected the following: Medications are administered in a safe and timely manner, and as prescribed. . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 676044 Page 6 of 6