Health inspection·July 24, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few communication impairment, bed/chair bound with intervention TRANSFER: The resident requires Mechanical Lift with 2 staff assistance for transfers.During an interview on 07/23/2025 at 10:35 am NA A stated she worked the 6pm-6am shift on 7/9/2025. NA A stated while transferring Resident #1 from chair to bed independently using the mechanical lift, Resident #1 fell out of the mechanical lift sling when she [NA A] went to move the mechanical lift towards Resident #1's bed and the top right strap of the mechanical lift came apart. NA A stated Resident #1 slid out of the mechanical lift and fell and hit her head. NA A stated, After she fell, she was pressed to the side because she was still connected, I unhooked the bottom left part of the sling, so she [Resident #1] was not on her arm. I asked the roommate to push the light. I ran to call the nurses. They hurried down to the room. NA A stated Resident #1 had an injury to the back of her head to the right side.NA A stated RN B, and LVN C went to Resident #1's room and Resident #1 was assessed, EMS notified, and Resident #1 was sent to the ER. NA A stated she was aware mechanical lift transfer required 2 staff, they [CNAs, NAs, MAs,] were not supposed to transfer residents independently but she asked for help from other staff, and everyone was busy. NA A stated the nurses would usually complain when the NAs and CNAs took a long time to put the residents to bed, so they [NAs and CNAs] tried to get it done immediately. NA A stated she mentioned needing help to transfer Resident #1 to RN B and, but RN B was passing medications. NA A stated a mechanical lift required 2 persons to transfer to prevent accidents, to have someone there to help when things like that happen and it was important for resident's safety. NA A stated she was trained on mechanical lift transfers when she first started working at the facility. NA A stated NAs were supposed to provide direct care with a CNA, and they were not supposed to provide direct patient care by themselves. NA A stated she transferred Resident #1 independently because the facility was short staffed, she asked for help, and nobody provided help. NA A stated, whenever they were short-handed with staff and she asked for help and no one helped her, she transferred residents independently. NA A stated she was asked to go home after the incident and had not yet been back to the facility.During an interview on 07/23/2025 at 12:26 pm, RN B stated, she got a call from one of the staff on the night of 07/09/2025 to go to Resident #1's room. RN B stated by the time she got to Resident #1's room, LVN C was already there along with all the aides. RN B stated Resident #1 was on the floor, they had a pack of gauze at her head. RN B said LVN C had already called EMS because Resident #1 was bleeding from the head. RN B stated they gathered Resident #1's papers for transfer to the ER. RN B said they did not move Resident #1 due to her bleeding and did not know the extent of her injury prior to going to the ER. RN B said she did not have to check vital signs because EMS got to the facility fast. RN B stated Resident #1 was at her baseline prior to being transfer to the ER. RN B stated Resident #1 returned to the facility about 4 hours later with staples at her head due to laceration and CT scan (a medical imaging technique that uses X-rays to create detailed, cross-sectional images of the body) was negative for bleeding. RN B stated when she asked NA A what had happened, NA A said the mechanical lift sling broke; RN B said she got the mechanical lift sling out of the trash, and it did not appear to be broken. RN B stated, I think it was hooked improperly. RN B stated NA A did not ask her for help to transfer Resident #1. RN B stated she called the MD, left a message for Resident #1's RP, notified the Administrator and the DON, and completed an incident report. RN B stated NA A was sent home after the incident and she had not seen her back in the facility. RN B stated they were in-serviced on transfers, how mechanical lift required 2 people at all times, using the proper sling and abuse and neglect. RN B said they did mechanical lift check-off as well. During an interview on 07/23/2025 at 12:54 pm CNA D stated she was in-serviced on abuse and neglect after the incident with Resident #1 regarding the mechanical lift. CND D stated it was a big in-service (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676044 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 676044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Magnolia 1105 N Magnolia Luling, TX 78648 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few where the Administrator told them to always have 2 staff whenever they had to do mechanical lift transfers, never 1 person, which they already knew. CNA D stated they had to do return demonstration during the mechanical lift check-off, a post test for the mechanical lift and abuse and neglect. CNA D stated the DON asked questions about the mechanical lift every day since the incident with Resident #1.CNA D stated 2 persons were needed for mechanical lift transfer to prevent injury to the residents and staff.During an interview on 07/23/2025 at 1:06 pm, NA E stated they had a big meeting in the dining hall not too long regarding abuse and neglect, and mechanical lift transfers. NA E stated the Administrator, DON, HR staff and the ADON were the ones doing the talking. NA E stated they were told it was always 2 persons when transferring a resident via mechanical lift, never 1 person. NA E said NAs should get a CNA or a nurse to assist with mechanical lift transfers. NA E stated they were taught how to use the right sling, how to put the sling under the residents, to check the sling, and report damaged slings. NA E stated she had to do a test after the in-services on abuse and neglect, mechanical lift transfers and there were also situation base questions. NA E stated it was the corporate nurse doing the demonstration on the mechanical lift transfers. NA E stated they were asked questions every day on mechanical lifts.During an interview on 07/23/2025 at 1:17 pm NA F stated she was in-serviced on abuse and neglect and mechanical lift transfers. NA F stated she was trained that mechanical lift transfer was always 2 persons and never 1 person. NA F stated it was 2 persons because 1 person was there to guard the resident while the other person maneuvered the mechanical lift. She stated it was 2 persons to prevent accident/incidents from happening. During an interview on 07/23/2025 at 1:3 pm the DON stated he expected staff to follow the facility's policy regarding mechanical lift and transfer which was at least 2 staff for transfer and the use of the proper sling. The DON stated staff were trained on mechanical lift transfers upon hire and every year after that. The DON stated, after the incident with Resident #1 on the night of 07/9/2025, the facility held an in-service on abuse and neglect and mechanical lift transfers. The DON stated all the NAs, CNAs, and nurses were trained on the mechanical lift with return demonstration and posttest. The DON stated the facility audited all the charts for residents needing mechanical lift transfer to make sure their care plans were up to date. The DON stated he had been auditing mechanical lift transfers daily, and had daily questionnaire on mechanical lifts to verbally reinforce what the staff already knew.During an interview on 07/23/2025 at 1:45 pm the Administrator stated mechanical lift transfer always required 2 people due to safety issues. The Administrator stated, after the incident regarding Resident #1 on 07/09/2025, Resident #1 was sent to the ER, she [Resident #1] got 4 staples to the back of her head and the skin tear to her right knee. The Administrator stated staff that worked the night of 07/09/2025 were in-service by RN B on abuse and neglect and mechanical transfers. The Administrator stated, the facility conducted competency skills for all staff, with repeat demonstration, the facility ordered 22 more slings for the mechanical lift, and the facility's management staff were asking staff questions every day on mechanical lift transfers. The facility did sensitivity training that was situation based on the mechanical lift. The Administrator stated the facility held an Ad hoc QAPI on 7/10/2025. She stated NA A had been suspended pending the investigation but would be terminated and not allowed back in the facility. She had not worked since the night of the incident (07/09/25). Observation on 07/23/2025 at 2:24 pm revealed Resident #1 in her geri-chair, awake, unable to express herself. Later at 3:53 pm, skin assessment of Resident #1 done with RN H reflected redness to Resident #1's right side head, no hematoma, no staples present, right knee skin tear had healed.Observation on 07/23/2025 at 3:25 pm revealed mechanical lift transfer on Resident #2 by CNA D and CNA G from bed to wheelchair. Staff provided privacy, locked wheelchair and bed, explained to the Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676044 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 676044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Magnolia 1105 N Magnolia Luling, TX 78648 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few what they were about to do. CNA D checked sling to ensure it was in good working condition. Staff rolled Resident from side to side while putting the sling under resident. CNA D was controlling the mechanical lift while CNA G was guarding the Resident, protecting feet, holding and positioning chair, protecting his head. Both CNAs were communicating to each other and the resident during the process. The Resident was carefully put in the chair and removed sling from hooks. CNAs asked the Resident if he was comfortable, and Resident said yes.During an interview on 07/23/2025 at 3:36 pm CNA G stated she was aware of the incident with Resident #1 and the mechanical lift. CNA G stated she was in-serviced on abuse and neglect and Mechanical lift transfers after the incident with Resident #1. CNA G stated they were trained on the proper way to transfer a Resident using the mechanical lift, checking the sling, attaching the sling to the resident correctly and always have two staff for transfer. CNA G said they did check off on the mechanical lift, posttest on the mechanical lift and abuse and neglect and every day since the incident, they got a daily questionnaire on mechanical lifts. During an interview on 07/23/2025 at 3:45 pm RN H stated she was in-serviced maybe a week or 2 ago after the incident with Resident #1 regarding mechanical lifts. RN H stated they were trained on proper technique on how to apply the mechanical lift sling, how to transfer a resident via mechanical lift, and a return demonstration was done. RN H stated there should always be at least 2 staff to transfer a resident via mechanical lift, someone to stabilize the resident while the other maneuvered the mechanical lift.During interviews on 07/24/2025 from 12:34 PM - 1:38 PM, NA I, NA J, CNA K, CNA L, MA M, LVN N, RN H, and LVN O all stated they were in-serviced after the incident on 07/10/2025 on abuse and neglect, safe transfers, mechanical lift transfers, and resident safety. All staff stated their abuse and neglect coordinator was the ADM and stated if they saw any type of abuse or neglect towards residents, they would report it to her immediately. The staff stated before any resident was transferred, they needed to look up their transfer status in their Kardex system (CNAs POC for residents). They all stated if a resident was a two-person transfer, they should never transfer them by themselves. They stated all residents requiring a mechanical lift transfer required two people. They aides stated if they could not find another aide available, they would ask their nurse for assistance. The NAs stated they were not to transfer any resident without a CNA or a nurse. All staff were able to describe the proper mechanical lift transfer process - use the appropriate sling and ensure it was connected, make sure the lift was locked, and ensure there was one person there to move the lift and the other person to guide the resident for their safety. The NAs stated they watched staff perform mechanical lift transfers on residents and they performed demonstration checkoffs with the CNAs.During an interview on 07/24/2025 at 1:46 pm the MDS Nurse stated after the incident regarding Resident #1 and the mechanical lift, she reviewed all the residents with mechanical lift transfer care plans and Kardex to ensure it indicated 2 persons required for transfer. The MDS nurse stated the CNAs could access the Kardex and care plan from their kiosk on the halls, but she usually told them to focus on the Kardex because it was resident specific task. The MDS nurse stated there were 21 Residents who needed the mechanical lift for transfer. During an interview on 07/24/2025 at 1:58 pm the ADON stated the facility had an in-service on 07/10/25 about mechanical lifts and abuse and neglect and sensitivity training after the incident with Resident #1. The ADON stated she was also assisting in the process of training the staff on mechanical lifts, telling them to have 2 staff at all times, a CNA and an NA, making sure the sling is applied correctly, positioning the mechanical lift, checking the resident's comfort level. The ADON nurse said the staff had to do return demonstration on what they were taught.Attempts were made on 07/23/2025 by the State Surveyor and the facility's Administrator to interview LVN C but to no avail. It was reported by the Administrator that LVN C was on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676044 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 676044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Magnolia 1105 N Magnolia Luling, TX 78648 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete vacation and unreachable via phone. Resident #1 was assessed and sent to the ER for evaluation on the night of 07/09/2025 to the morning of 07/10/2025. Staff statements dated 07/09/2025.Review of Resident #1's Neurological checks, dated 07/10/25 - 07/12/25, reflected were completed for 72 hours from and her vitals and motor functions were within normal limits.Review of the facility's QAPI meeting agenda, dated 07/10/25, reflected the ADM, the DON, the ADON, and the MD were in attendance.Review of five residents' care plans and Kardex who required mechanical lift transfers, on 07/25/25, reflected they were documented as requiring two persons for the transfers.Review of CNA Competency Checklists, dated 07/10/25, reflected all aides completed the competency checklist with return demonstrations (mechanical lift transfers).Abuse and neglect in-service with posttest initiated 07/10/2025. Review of an In-service, dated 07/10/25 and conducted by the ADON, reflected all staff were in-serviced on their Abuse and Neglect Policy.Review of an In-service, dated 07/10/25 and conducted by the ADON, reflected all nursing staff were in-serviced on their Hoyer Lift Policy.Review of Mechanical Lift Transfer questionnaires, initiated 07/10/25, reflected staff were being questioned daily with no concerns.Review of facility's policy titled Lifting Machine, using a Mechanical dated July 2017 reflected: Purpose The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.2. Mechanical lifts may be used for tasks that require:a. Lifting a resident from the floor;b. Transferring a resident from bed to chair;c. Lateral transfers;d. Lifting limbs;e. Toileting or bathing; [NAME]. Repositioning. An Immediate Jeopardy (IJ) existed from 07/09/25 - 07/10/25. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. Event ID: Facility ID: 676044 If continuation sheet Page 5 of 5