Health inspection·June 11, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 17 residents (Resident #28 and Resident #39) reviewed for resident rights. 1. The facility failed to ensure COTA G treated Resident #28 with respect, had a dignified existence, and was not pulled backwards in a geriatric reclining rolling chair. 2. The facility failed to ensure CNA L assisted Resident #39 with eating in a dignified manner on 6/09/25. These failures could place residents at risk of humiliation, diminished quality of life, loss of dignity and self-worth. Findings included: 1. Record review of Resident #28's face sheet dated 6/10/25 indicated she was [AGE] years old and was admitted to the facility on initially on 4/15/19 and re-admitted [DATE]. Resident #28 had diagnoses which included Parkinsonism (broad term referring to various neurodegenerative diseases (progressive loss of function and death of nerve cells affecting memory, movement, and/or thought) that manifest with motor symptoms such as rigidity (stiffness), tremors (involuntary shaking or movement affecting hands, legs, face, and head), and bradykinesia (slowness of movement), abnormality of gait, anxiety disorder (feeling of worry, dread, and uneasiness), dementia (progressive forgetfulness), repeated falls, age related physical debility, major depression disorder (persistent sadness), and lack of coordination. Record review of Resident #28's quarterly MDS assessment dated [DATE] indicated Resident #28 was rarely understood and rarely understood others. Resident #28 was unable to complete the BIMS because she was rarely understood. Resident #28 had severely impaired cognitive skills for daily decision making. Resident #28 had other behavioral symptoms not directed toward others. Resident #28 required a wheelchair for mobility. Resident #28 was dependent on staff for all ADL's. Record review of Resident #28's Care Plan indicated she used anti-anxiety medications related to anxiety and she was at risk for falls due to poor safety awareness and cognition. During an observation on 6/10/25 beginning at 2:42 PM, COTA G pulled Resident #28 backwards, with one hand on the handle on the back of her geriatric reclining rolling chair, out of the therapy room Page 1 of 51 676069 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and down the hallway of Hall 6, around the nurses' station and down approximately ¾ of the hallway on Hall 4 to Resident #28's room. During an interview on 6/10/25 at 2:46 PM, COTA G said he had worked at the facility for approximately two months. COTA G said therapy with Resident #28 depended on her anxiety level and it depended on if she had received her anxiety meds. COTA G said Resident #28 got tight and anxious and needed rest periods during therapy. COTA G said the geriatric reclining rolling chair was easier to maneuver pulling backwards than it was pushing it forward and less likely to run over other residents. COTA G said he can see it could cause Resident #28 some discomfort, but he only did it when he knew there was obstacles and tight spaces. COTA G said if there were wide open spaces, he would push the geriatric reclining rolling chair forward to make sure to keep her safe. COTA G said Resident #28 would also kick her legs over the sides at times. COTA G said he could see where it could be an issue pulling the geriatric reclining rolling chair backwards, but he wanted to keep Resident #28 safe. During an interview on 6/11/25 at 10:34 AM, the MDS Coordinator said she had been the ADON prior to taking the MDS Coordinator position in February 2025. The MDS Coordinator said it would not be appropriate to pull a resident down the hallway backwards. The MDS Coordinator said they train the CNAs and nurses to not pull residents backwards because it was a dignity issue. The MDS Coordinator said the geriatric reclining rolling chair were able to be pushed forward. The MDS Coordinator said being pulled backwards could affect the resident's independence. The MDS Coordinator said the resident could not see where they were going and would not know where they were taking them if being pulled backwards. The MDS Coordinator said it could affect the resident emotionally. The MDS Coordinator said it was a dignity issue. During an interview on 6/11/25 at 11:12 AM, RN E said it was not appropriate, nor were you supposed to, pull a resident backwards in a geriatric reclining rolling chair or wheelchair. RN E said it was a dignity issue to her and did not look right. RN E said she would not want anyone doing her mom like that. RN E said if the resident had some awareness, it would be confusing and it would be upsetting to residents and they would be upset, she said I would be. RN E said the resident in a geriatric reclining rolling chair could be hurt if they turned sideways in the chair or could do anything and you would not see it because you were not visualizing the resident. RN E said not paying attention to resident, they could be doing something as you were pulling them and you would not know. During an interview on 6/11/25 at 11:24 AM, the ADON said staff were not supposed to pull residents backwards in a geriatric reclining rolling chair or wheelchairs. The ADON said if pulling the resident backwards it was a safety issue, and the resident could not see where they were going. The ADON said the geriatric reclining rolling chairs were sometimes hard to steer and staff may need to turn the chair backwards to maneuver through tight spaces, but then should turn it back to the forward position. The ADON said the resident could get hurt being pulled backwards. The ADON said the residents that had dementia could get agitated from not being able to see where they are going. The ADON said being pulled backwards could affect the resident's dignity just from not having control of where they were going. During an interview on 6/11/25 at 11:28 AM, CNA F said she had worked at the facility for approximately a month. CNA F said it was not appropriate to pull a resident backwards in a wheelchair or a geriatric reclining rolling chair. CNA F said it was a dignity issue. CNA F said being pulled backwards probably made the resident feel embarrassed or incapable. CNA F said if someone pulled her backwards in a wheelchair it would make her feel like a child. CNA F said it would affect the resident's dignity to be pulled backwards. 676069 Page 2 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/11/25 at 1:02 PM, the DON said it was not appropriate to pull a resident backwards in a geriatric reclining rolling chair or wheelchair because you could not visualize the resident. The DON said it was a dignity thing and was like dragging them. The DON said if staff were pulling the resident backwards, they could not visualize the resident to ensure the safety of the resident, therefore, it was a safety issue. The DON said it was a safety issue and anything could happen to the resident if not visualizing the resident during transport. The DON said it was a dignity and safety issue. The DON said everyone was responsible for ensuring the residents were transported appropriately in a geriatric reclining rolling chair or wheelchairs and for promoting the residents' dignity. During an interview on 6/11/25 at 1:30 PM, the DOR said she had worked at the facility for about a year and had been the DOR for approximately six months. The DOR said it was not appropriate to pull residents backwards in a geriatric reclining rolling chair or wheelchairs. The DOR said residents should be transported facing forward, so the resident could see where they were going. The DOR said she had just always been taught to go forward when transporting residents in a geriatric reclining rolling chair or wheelchair. The DOR said it was important to transport a resident going forward because it was a dignity thing and so the resident could know where they were going. The DOR said it could take the resident's sense of knowing where they were going and acknowledgement of who they were and just being considered a human being person. The DOR said COTA G had only been working at the facility for a few months and had a background in home health and probably was unaware that pulling the resident backwards was a dignity issue. The DOR said all department heads were responsible for ensuring staff were transporting residents appropriately and promoting the resident's dignity. During an interview on 6/11/25 at 1:39 PM, the ADM said it was not appropriate to pull a resident backwards in a geriatric reclining rolling chair or wheelchair. The ADM said it was a dignity issue. The ADM said the resident did not know where they were going if being pulled backwards. The ADM said it could affect the resident emotionally and it could even put the resident at risk for injury. The ADM said department heads were responsible for in-servicing staff on appropriate transporting and dignity concerns. The ADM said she would expect staff to transport residents appropriately and promote their dignity. 2. Record review of Resident #39's face sheet dated 6/9/25 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #39 had diagnoses including muscle weakness, age related physical debility (physical weakness, especially as a result of illness), and malignant neoplasm (is an abnormal growth of cells that invades and can spread to other parts of the body) of left lung and brain. Record review of Resident #39's annual MDS assessment dated [DATE] indicated Resident #39 was sometimes understood and usually had the ability to understand others. Resident #39 had adequate hearing and vision and unclear speech. Resident #39 was rarely/never understood, and a BIMS score was not able to be assessed. Resident #39 had short-and-long term memory recall issues. Resident #39 had moderately impaired cognitive skills for daily decision making. Resident #39 required supervision for eating. Record review of Resident #39's care plan dated 2/5/25 indicated Resident #39 had experienced self-care deficit related to diagnosis and decline in physical function. Intervention included Resident #39 was able to feed self once tray was brought and set up. Resident #39 sometimes used hands to eat certain foods. 676069 Page 3 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 6/9/25 at 12:06 p.m., Resident #39 was sitting in the dining room at a table. CNA L assisted Resident #39 with her magic cup (frozen, fortified nutritional snack). CNA L stood up next to Resident #39 and fed her the magic cup until it was finished. During an interview on 6/11/25 at 11:42 a.m., RN E said staff should be sitting eye level to the residents when assisting with meals. She said it was a dignity issues when staff stood over residents when feeding them. She said she would not want someone standing over her while eating. She said the resident could become anxious while being fed by staff member who was standing. She said she was not in the dining room when CNA L was feeding Resident #39. She said if she had witnessed the incident, she would have instructed CNA L to sit down to assist Resident #39. During an interview on 6/11/25 at 12:46 p.m., CNA L said staff should sit bedside the residents when assisting with meals. She said she may have stood up to feed Resident #39 when she passed by and noticed her not eating. She said it was important to sit bedside the resident to watch them swallow their food and to know if they were choking. She said standing over a resident while feeding them could make them feel uncomfortable. During an interview on 6/11/25 at 2:35 p.m., the DON said staff assisting a resident with meals should be sitting and, on the resident's, weak side. She said it was a dignity issue when staff stood over the residents while feeding. She said when the staff stood over the resident, it could make them feel inferior. She said the LVN on duty should ensure the CNAs sat down when assisting residents with meals. She said she was normally on the secure unit during meal service to help and monitor the staff and residents. During an interview on 6/11/25 at 3:35 p.m., the ADM said she expected the CNAs and LVNs to sit when assisting a resident with meals. She said she knew the table space was limited but they should still sit down next to the residents. She said when the staff sat down and assisted the resident, it made them feel secure, taken care of, and not rushed. She said the resident could feel rushed, hurt their dignity, and would not have eye contact with the staff member if they were standing. She said the nursing administration should ensure the staff members were sitting at eye level, with the residents when providing a service. Review of the facility's policy titled Resident Rights dated revised February 2021 indicated . employees shall treat all residents with kindness, respect, and dignity . federal and state laws guarantee certain basic rights to all residents of this facility . these rights include the resident's right to . a dignified existence . be treated with respect, kindness, and dignity . Review of the facility's policy titled Dignity dated revised February 2021 indicated . each resident shall be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . residents were treated with dignity and respect at all times . demeaning practices and standards of care that compromise dignity were prohibited . staff were expected to treat cognitively impaired residents with dignity and sensitivity . Record review of a facility's Assistance with Meals policy revised 10/2009 indicated, . residents shall receive assistance with meals in a manner that meets the individual needs of each resident . residents who cannot feed themselves will be fed with attention to safety, comfort and dignity .not standing over residents while assisting them with meals . 676069 Page 4 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote resident self-determination through support of resident choice for 1 of 15 residents reviewed for resident rights. (Resident #17) The facility failed to assist Resident #17 out of bed after he requested to be gotten out of bed. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Findings included: Record review of a face sheet dated 06/10/25 indicated Resident #17 was [AGE] years old and admitted to the facility on [DATE]. Resident #17 had diagnoses which included heart failure, anxiety disorder, and muscle weakness. Record review of an annual MDS assessment dated [DATE] indicated Resident #17 was understood and understood others. The MDS indicated Resident #17 had a BIMS of 07 which indicated she had severe cognitive impairment. The MDS indicated Resident #17 was dependent on staff for chair/bed-to-chair transfers. Record review of Care Plan last revised 03/21/25 indicated Resident #17 was able to propel self in his wheelchair, short distances and long distances with multiple stops and breaks. The care plan indicated Resident #17 had to be transferred using the mechanical lift with assistance from 2 staff member. During an observation on 06/09/25 at 11:28 a.m. revealed a housekeeping staff member telling CNA F that Resident #17 wanted to get out of bed. During an observation and interview on 06/09/25 at 11:31 a.m., Resident #17 was in bed. Resident #17 said he had asked to get out of bed. He said his wheelchair was broken and he had not been able to get out of bed. He said he wants to get out of the bed. He said before he was able to use someone else's wheelchair. During an observation on 06/09/25 at 12:41 p.m., Resident #17 was in bed. During an observation on 06/09/25 at 2:22 p.m., Resident #17 was in bed. During an observation and interview on 06/09/25 at 3:51 p.m., Resident #17 said he had not been out of bed all day. He said he did not know why they did not get him up out of bed this morning. I guess they are waiting on my wheelchair to get out of the shop. He said they did offer him a wheelchair but it will throw me out of the floor. He said he asked every single day to be gotten out of bed. He said, I have been tired of this bed. He said he had been in the bed for close to a month. During an observation on 06/10/25 at 8:28 a.m., Resident #17 was sleeping in bed. During an observation on 06/10/25 at 10:05 a.m., Resident #17 was sleeping in bed. 676069 Page 5 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0561 Level of Harm - Minimal harm or potential for actual harm During an interview on 06/10/25 at 1:50 p.m., CNA H said Resident #17 was usually gotten out of bed every day. She said the handrails to his usual wheelchair broke and it was sent out to be fixed. She said there was another wheelchair he could use but he had slid out of it in the past. She said his wheelchair had been broken 6 - 7 days. She said she did not work on 06/09/25 but if she had to guess the wheelchair was the reason he was not gotten out of bed. Residents Affected - Few During an interview on 06/11/25 at 9:00 a.m., Resident #17 said he was assisted out of bed on 06/10/25. He said they put him in the wheelchair they normally used to take him to the hospital in. He said he never refused to get out of bed and if anyone said he had they were lying. He said he wanted to get up every day. During an interview on 06/11/25 at 9:18 a.m., CNA F said she was Resident #17's aide on 06/09/25. She said she did not get him up out of bed on 06/09/25. She said she did not get him up because he did not have a wheelchair. She said his wheelchair was being repaired. She said, he has been in the bed about a week now. She said they did have a wheelchair they used to transport him to the hospital. She said she was not sure if that wheelchair was available on 06/09/25 or not. During an interview on 06/11/25 at 10:20 a.m., LVN J said they did normally get Resident #17 up out of bed daily. She said on 06/09/25 his wheelchair was being worked on and he was told he could not get up . She said they had to make sure he had a stable chair so he would not slide out. She said he was told he could not get up because of this. She said he was gotten up on 06/10/25. She said the chair he used on 06/10/25 was not used on 06/09/25 because they had to make sure it was stable. She said there was no negative outcome because the resident was educated concerning his safety and wellbeing. During an interview on 06/11/25 at 12:47 p.m., the DON said Resident #17 had a custom chair and it was broken. She said it has been broken for approximately 9 days. She said they were waiting on the company to come to see if it could be repaired. She said he had another chair, but he had slid to the front of the chair when the chair did not have footrest. She said he had been mad and upset ever since his custom chair broke. She said on 06/10/25 they were able to get him up in the other chair he had with footrest. She said she would not have expected staff to have gotten him up 06/09/25 without the footrest on the chair they have. She said they had encouraged to sit him up on the side of the bed. She said he only sat up on the side of the bed one day. She said the negative effect for him not being gotten up was that he could not be mobile like he wanted to be. She said with his condition he needed to be up. She said he had congestive heart failure. She said they tried to offer alternatives such as using the one chair with the footrest and sitting up on the side of the bed and he was not agreeable to that. During an interview on 06/11/25 at 12:57 p.m., the Administrator she said they were having issues with Resident #17's wheelchair. She said the company was coming out the week of 06/09/25 and they had obtained a bid for a new wheelchair in case it could not be repaired. She said they had concerns about safety issues. She said with him asking to get up, staff should have put forth the effort to find a wheelchair that would have worked for him and at least attempted to have gotten him up. She said being left in the bed could cause depression and he it was not utilizing his physical abilities. Record review of a Resident Rights facility policy last revised in February 2021 indicated, .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .self-determination . 676069 Page 6 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 15 residents (Resident #39) reviewed for quality of care. The facility failed to notify the NP/MD of Resident #39's swallowing difficulties observed on 6/9/25 and 6/10/25. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. Findings included: Record review of Resident #39's face sheet dated 6/9/25 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #39 had diagnoses including muscle weakness, age related physical debility (physical weakness, especially as a result of illness), history of falls, repeated falls, and malignant neoplasm (is an abnormal growth of cells that invades and can spread to other parts of the body) of left lung and brain. Record review of Resident #39's annual MDS assessment dated [DATE] indicated Resident #39 was sometimes understood and usually had the ability to understand others. Resident #39 had adequate hearing and vision and unclear speech. Resident #39 was rarely/never understood, and a BIMS score was not able to be assessed. Resident #39 had short-and-long term memory recall issues. Resident #39 had moderately impaired cognitive skills for daily decision making. Resident #39 used a wheelchair. Resident #39 required partial assistance for shower/bathe self, dressing, personal hygiene, and supervision for toileting hygiene and eating. The MDS did not reflect a swallowing disorder. The MDS did not reflect a mechanically altered diet. Record review of Resident #39's care plan dated 4/28/25 indicated Resident #39 received hospice services from a local hospice company related to terminal disease process: malignant neoplasm of left lung. Intervention included notify hospice nurse and MD for any decline in resident's condition. Record review of Resident #39's care plan dated 5/8/25 indicated: *Resident #39 had impaired nutrition related to terminal disease of lung cancer with metastasis and at risk for weight loss and may be unavoidable. Interventions included ensure resident is in proper position for eating, evaluate resident's physical ability to eat, and eat meals in a monitored environment. *Resident #39's nutritional status regular diet, regular texture, thin liquids. Interventions include determine resident's ability to chew and swallow and modify diet as appropriate according to resident's food tolerance and preference. During an observation on 6/9/25 starting at 11:57 a.m., Resident #39 was sitting in a wheelchair with a cup of water in her hand. Resident #39 brought the cup of water to her mouth and as she tipped 676069 Page 7 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the cup, a lot of the water did not make it to her mouth. When Resident #39 swallowed some of water she started coughing. A nursing staff member handed Resident #39 some medication, unable to determine if it was pill or liquid form, and Resident #39 started coughing. The staff member asked CNA A what was going on. CNA A said she noticed Resident #39 did the same thing at breakfast but did not think anything of it. The nursing staff member instructed CNA A to notify RN E. RN E came to the dining room and told CNA A she would observe her at lunch. During an observation on 6/9/25 at 12:06 p.m., Resident #39 was sitting at the dining room table with her meal tray. Resident #39 had a regular tray with thin liquids. RN E sat bedside Resident #39 and observed her take a few bites of food. Resident #39 struggled to feed herself and used her fingers to eat. RN E told CNAs she would get Resident #39's meat changed to chopped meats. RN E observed Resident #39 drink one swallow of thin liquids and Resident #39 did not cough or choke. RN E stopped observing Resident #39 and left the dining room. Toward the end of Resident #39's lunch meal, she drank some more liquid and coughed. During an interview on 6/10/25 at 4:09 p.m., CNA O said on some days Resident #39 drank good and other days she spurted. She said she worked 4 days on and 2 off. She said in the four shifts she worked. Resident #39 spurted when drinking. She said she had not reported to the nurse Resident #39 sometimes spurted when drink thin liquids. She said it was important to report swallowing problems to the nurse because the resident could be aspirating. She said if a resident was aspirating and it was not addressed, they could develop pneumonia. During an interview on 6/10/25 at 4:30 p.m., CNA B said she noticed Resident #39 was spurting when she drank thin liquids. She said she reported in LVN D last week. She said last week Resident #39 drank something and then coughed the liquid on to her clothes. She said before the incident happened to her, other staff had warned her Resident #39 did that sometimes. She said coughing, choking, or spurting with thin liquids could indicate Resident #39 was aspirating. She said if the swallowing problem was not addressed Resident #39 could choke and get pneumonia. She said the nurses were the only staff members that could document swallowing problems in the resident's chart. She said CNAs should report the spurting to the nurses immediately. During an interview on 6/10/25 at 11:42 a.m., RN E said staff members had reported to her on Monday (6/9/25) that Resident #39 had choked of liquid. She said she observed Resident #39 drink and Resident #39 did not choke. She said Resident #39 functioning ability had recently declined. She said Resident #39 could feed herself but now needs assistance or used her fingers. She said if Resident #39 choked after she left on Monday (6/9/25), then CNAs should have told her. She said she did not know about other reported events of Resident #39 spurting with liquids. She said she expected the CNAs to tell her those types of things. She said if a nurse observed Resident #39 choking or coughing with food or liquids they should report it to hospice. She said hospice would possibly order a speech evaluation. She said coughing or choking while drinking or eating could indicate aspiration. She said if the swallowing problem was not reported or addressed, it placed the resident at risk for hospitalization. During an interview on 6/11/25 at 12:46 p.m., CNA L said she told RN E, Resident #39 was spilling liquid when she drank. She said she thought Resident #39 may need a swallow test or sippy cup to control the flow. She said coughing or choking on food or liquid could indicate a swallowing problem. She said RN E was supposed to change Resident #39's meat to chopped so she could pick it better. She said Resident #39's functional ability was declining. She said CNAs should report to the nurse immediately when they noticed swallow issues. 676069 Page 8 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/11/25 at 1:52 p.m., LVN D said the last time she worked with Resident #39 was on Monday (6/9/25), the evening shift. She said no CNAs had reported to her that Resident #39 was coughing with thin liquids. She said Resident #39's health was declining. She said Resident #39 was having more falls and declining in her feeding ability. She said CNAs should have reported to her immediately if Resident #39 was coughing while drinking. She said it could indicate aspiration. She said Resident #39 needed a speech evaluation and possible diet change. She said untreated aspiration could lead to pneumonia. During an interview on 6/11/25 at 2:35 p.m., the DON said, the CNAs should notify the nurses if a resident had swallowing issues. She said the charge nurse should notify the NP or MD. She said Resident #39 could need a speech evaluation. She said coughing or spurting on food or liquid could indicate dysphagia (difficulty swallowing food or liquids). She said if the dysphagia was not addressed then the resident could aspirate or affect the resident's eating. During an interview on 6/11/25 at 3:35 p.m., the ADM said the CNAs should immediately report to the charge nurse any swallowing issues observed. She said the charge nurse should notify the NP/MD. She said she also expected the charge nurse to fully assess the resident's swallowing issues. She said Resident #39 needed a speech evaluation. She said Resident #39 could be aspirating. She said if left untreated, the resident could require hospitalization or develop pneumonia. During an interview on 6/12/25 at 1:08 p.m., Hospice RN X said she saw Resident #39 weekly. She said she was seeing Resident #39 today (6/12/25). She said Resident #39 had recently started requiring assistance with meals. She said she had not been notified of Resident #39's difficulty swallowing. She said she was okay with the facility monitoring the issues until her visit today. She said hospice needed to be notified of new issues, decline, and med changes. She said hospice would want to know if Resident #39 was having difficulty swallowing. She said hospice would possibly get an order for thickened liquid. She said she knew the facility was changing her meat to chopped for smaller pieces. She said Resident #39 had a primary care physician but they really worked with NP Y. During an interview on 6/12/25 at 1:31 p.m., NP Y said she could not answer questions about Resident #39 because she did not know my identity. She said she could answer general practitioner questions. She said if a resident was displaying dysphagia (difficulty swallowing) or mastication (is the process of chewing food, the mechanical breakdown of food in the mouth using teeth) issues, she expected the nurse to assess the resident. She said the nurse should auscultate the resident's lungs and watch the resident eat or drink. She said if the resident coughed or choked one time, the facility may not notify her. She said if the dysphagia or mastication issue continued, it could be a sign of a change of condition and should be notified immediately. She said she would need more information to determine if it was a change of condition. She said she would order a chest x-ray, speech consult, diet change, and change liquid consistency to nectar or honey until the speech consult was done. She said if the dysphagia or mastication was not treated it could lead to dehydration and aspiration. She said it could also indicate a urinary tract infection (is an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra). She said reporting to the NP/MD prevented further decline and to know what was going on. Record review of a facility's Guidelines for Notifying Physicians of Clinical Problems policy revised 04/2007 indicated, .to help ensure that .medical care problems are communicated to the medical staff in a timely, efficient and effective manner .all significant changes in resident status are assessed and documented in the medical record .the charge nurse or supervisor should contact the Attending Physician at any time if they feel a clinical situation requires immediate discussion and 676069 Page 9 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0580 Level of Harm - Minimal harm or potential for actual harm management .non-immediate notification situations .the following types of problems should be reported to the Physician, but not necessarily immediately .in general .any substantial change in physical condition or functional status that does not require immediate notification should be addressed with the Physician .decline in function . Residents Affected - Few 676069 Page 10 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from abuse for 2 of 11 residents (Resident's #20 and #38) reviewed for resident abuse. The facility failed to ensure Resident #20, and Resident #38 were free from physical abuse, when Resident #20 pulled Resident #38's ear, and Resident #38 bit Resident #20 on the right wrist, on 05/27/25. The non-compliance was identified as past non-compliance. The noncompliance began on 05/27/25 and ended on 05/27/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: 1. Record review of the face sheet, dated 06/10/25, reflected Resident #20 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified convulsions (seizures), bipolar disorder (mental health condition that causes extreme mood swings), severe dementia with anxiety (memory loss), history of alcohol abuse with alcohol-induced dementia (memory loss), paranoid schizophrenia (characterized by intense paranoia and delusional thinking), and panic disorder (anxiety disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress). Record review of the quarterly MDS assessment, dated 05/14/25, reflected Resident #20 had clear speech and was understood by others. Resident #20 was usually able to understand others. The MDS reflected Resident #20 had a BIMS score of 5, which indicated severe cognitive impairment. The MDS reflected Resident #20 had disorganized thinking that did not fluctuate. Resident #20 had delusions (misconceptions or beliefs that are firmly held, contrary to reality). No other behaviors were included on the MDS assessment. Record review of the comprehensive care plan, initiated on 05/27/25, reflected Resident #20 had episodes of verbal and physical aggression. Resident #20 grabbed another resident's ear on 05/27/25. The interventions included: Administer medication per orders, anticipate behaviors and redirect, notify doctor and family, ensure staff is aware of behaviors and successful interventions, maintain calm environment, psychiatric consult per orders, every 15 minute checks, separate residents, and monitor right wrist bruising until resolved. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #20 walked into the main dining area and pulled another resident's ear and he bit her on the right wrist. The immediate action taken included: residents were separated from each and redirected, assessed for injury, small area noted to right wrist, no break in skin, resident denies pain at this time. Injuries included: hematoma to right wrist. The incident report reflected Resident #20 did not like it when Resident #38 talks loudly, which is his normal due to hearing impairment. The incident report reflected the family, physician, and DON were notified of the incident. 676069 Page 11 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the skin assessment, dated 05/27/25, reflected Resident #20 had bruising to her right wrist. The area was small, but no measurements were indicated. 2. Record review of the face sheet, dated 06/10/25, reflected Resident #38 was an [AGE] year-old male who initially admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (brain condition that progressively damages memory, thinking, and learning skills). Record review of the quarterly MDS assessment, dated 05/18/25, reflected Resident #38 had clear speech and was usually understood by others. Resident #38 was sometimes able to understand others. The MDS reflected Resident #38 had a BIMS score of 1, which indicated severe cognitive impairment. Resident #1 had inattention that did not fluctuate. The MDS reflected Resident #38 had no behaviors or refusal of care during the look-back period. Record review of the comprehensive care plan, initiated 05/27/25, reflected Resident #38 had episodes of verbal and physical aggression. Resident #38 bit another resident. The interventions included: Administer medications per orders, anticipate behaviors and redirect, encourage to attend social activities, maintain calm environment, monitor and chart behaviors every shift and report to doctor as needed, provide psychiatric consult per orders, refer to social services as needed, resident immediately separated, refer to psychiatric services at next visit, and 15 minute monitoring. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #38 was in the dining room and another resident pulled his ear and Resident #38 responded by biting her on the right wrist. The immediate action taken included: Residents were separated from each other immediately and assessed for injury, none found. The incident report reflected the doctor, DON, and responsible party were notified of the incident. Record review of the skin assessment, dated 05/27/25, reflected Resident #38 had no injuries or skin concerns. During an interview on 06/09/25 beginning at 11:39 AM, CNA A stated Resident #20 and Resident #38 were constantly yelling, cursing, or hitting at each other. CNA A stated when Resident #20 and Resident #38 started acting out, she notified RN E. CNA A stated these behaviors happened almost every day. CNA A stated she kept the residents separated and redirected them when the behaviors started. CNA A stated on 05/27/25, Resident #20 walked up to Resident #38 and pulled his ear. CNA A stated Resident #38 turned his head and bit Resident #20 on the wrist. CNA A stated both residents were separated and placed on 15 minute checks. CNA A stated Resident #20 had a small bruise to her wrist, but no further injuries occurred. CNA A stated Resident #20 and Resident #38 had no changes in their behaviors related to the incident. During an interview on 06/09/25 beginning at 2:50 PM, the Psychiatric Consultant stated she visited with several residents on the secured unit every month. The Psychiatric Consultant stated Resident #38 and Resident #20 were visited. The Psychiatric Consultant stated Resident #38 talks loudly because he was hard of hearing. She said she had never had any behavioral issues with either resident, but the staff reports they were non-cooperative with cares. During an interview on 06/10/25 beginning at 3:37 PM, LVN D stated she was hired in December of 2024 and recently switched to part time status. LVN D stated she normally worked 2-10 shift on the secured unit. LVN D stated Resident #20 and Resident #38 did not hit each other regularly. LVN D stated there was an incident approximately a few weeks ago. LVN D stated Resident #20 pulled Resident #38's 676069 Page 12 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ear, and Resident #38 bit Resident #20. LVN D stated it was documented and 15 minute checks were initiated. LVN D stated when resident to resident altercations happened, the staff documented in the electronic charting system, notified the DON, family, and doctor, and placed it on the 24 hour report sheet for continued monitoring. LVN E stated they were trained to separate the residents, attempt to redirect them, and usually place them on 15 minute checks. LVN D stated it had not been reported that Resident #20 and Resident #38 had verbal or physical altercations daily. During an interview on 06/10/25 beginning at 3:48 PM, the DON stated it was brought to her attention on 05/27/25 that Resident #20 and Resident #38 had a physical altercation. The DON stated it was reported that Resident #20 pulled Resident #38's ear, and he bit her in response. The DON stated it had not been reported that verbal or physical behaviors happened daily between Resident #20 and Resident #38. The DON stated if physical or verbal behaviors happened, she expected it to be reported. The DON stated on 05/27/25, Resident #20 and Resident #38 were separated immediately and placed on 15 minute checks. She stated they were assessed, and Resident #20 had a small bruise to her right wrist. The DON stated in-service education was provided to the staff to include abuse and neglect, and resident to resident altercations. The DON stated the Administrator was on vacation during the incident, so it was reported to her regional compliance nurse. The DON stated the family, doctor, and herself were notified after the incident. The DON stated no further incident has occurred. During an interview on 06/11/25 beginning at 7:14 AM, RN E stated it had not been reported Resident #20 and Resident #38 had verbal or physical altercations daily. RN E stated approximately a few weeks ago, Resident #20 pulled Resident #38's ear and Resident #38 bit her. RN E stated both residents were immediately separated and placed on 15 minute checks. RN E stated Resident #20 was aggressive and was moved off the female secured unit because she was hitting the other female residents. RN E stated staff were to ensure the residents were supervised and redirected as needed. RN E stated when resident to resident altercations happened, the staff documented in the electronic charting system, notified the DON, family, and doctor, and placed it on the 24 hour report sheet for continued monitoring. LVN E stated they were trained to separate the residents, attempt to redirect them, and usually place them on 15 minute checks. RN E stated no further incidents have occurred since 05/27/25. Record review of the Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy, revised April 2021, reflected residents have the right to be free from abuse .this includes but is not limited to freedom from . physical abuse . protect residents from abuse . by anyone including . other residents . Record review of the Resident-to-Resident Altercations policy, revised September 2022, reflected All altercations, including resident to resident abuse, are investigated and reported to DON and Administrator .if two residents are involved in an altercations, staff: separate the residents, and institute measure to calm the situation, identified what happened, notify family, doctor, and facility management, make any changes to care plan, document in the record, complete an incident report, consult with psychiatric services The facility had corrected the non-compliance on 05/27/25 by the following: 1. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #20 walked into the main dining area and pulled another resident's ear and he bit her on the right wrist. The immediate action taken included: residents were separated from each and redirected, assessed for injury, small area noted to right wrist, no break in skin, resident denies pain at this time. Injuries included: hematoma to right wrist. The incident report reflected Resident #20 did not like it 676069 Page 13 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0600 Level of Harm - Minimal harm or potential for actual harm when Resident #38 talks loudly, which is his normal due to hearing impairment. The incident report reflected the family, physician, and DON were notified of the incident. 2. Record review of the skin assessment, dated 05/27/25, reflected Resident #20 had bruising to her right wrist. The area was small, but no measurements were indicated. Residents Affected - Few 3. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #38 was in the dining room and another resident pulled his ear and Resident #38 responded by biting her on the right wrist. The immediate action taken included: Residents were separated from each other immediately and assessed for injury, none found. The incident report reflected the doctor, DON, and responsible party were notified of the incident. 4. Record review of the skin assessment, dated 05/27/25, reflected Resident #38 had no injuries or skin concerns. 5. Record review of the 15 Minute Checks Sheet, dated 05/27/25, 05/28/25, and 05/29/25 reflected 15 minute checks were completed for Resident #20 and Resident #38. 6. Record review of the comprehensive care plan, initiated on 05/27/25, reflected Resident #20 grabbed another resident's ear on 05/27/25. The interventions included: . every 15 minute checks, separate residents, psychiatric referral, and monitor right wrist bruising until resolved. 7. Record review of the comprehensive care plan, initiated 05/27/25, reflected Resident #38 bit another resident. The interventions included: . resident immediately separated, refer to psychiatric services at next visit, and 15 minute monitoring. 8. Record review of the abuse and neglect in-service training, dated 05/27/25, reflected staff was provided education. There were approximately 34 staff signatures. 9. Record review of the resident to resident altercation in-service training, dated 05/27/25, reflected staff was provided education. There were approximately 34 staff signatures. 10. During interviews between 06/09/25 at 11:39 AM and 06/11/25 at 1:49 PM, Housekeeper R, CNA A, CNA B, CNA C, CNA F, CNA H, CNA S, MA Q, LVN D, LVN J, RN E, the Maintenance Supervisor, and the Housekeeping Supervisor (different shifts who worked in the secured unit) were able to verbalize the different types of abuse, when to report abuse, and the abuse coordinator. The staff were able to outline the policy and procedure for resident to resident altercations including separating the residents and notifying the abuse coordinator. The noncompliance was identified as PNC. The noncompliance began on 05/27/25 and ended on 05/27/25. The facility had corrected the noncompliance before the survey began. 676069 Page 14 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 24 hours after the allegation was made, for 2 of 11 residents (Resident's #20 and #38) reviewed for abuse on the male secured unit. The facility failed to report an allegation of resident-to-resident physical abuse on 05/27/25 to HHSC within 24 hours. This failure could place the residents at increased risk for abuse and neglect. The findings included: 1. Record review of the face sheet, dated 06/10/25, reflected Resident #20 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified convulsions (seizures), bipolar disorder (mental health condition that causes extreme mood swings), severe dementia with anxiety (memory loss), history of alcohol abuse with alcohol-induced dementia (memory loss), paranoid schizophrenia (characterized by intense paranoia and delusional thinking), and panic disorder (anxiety disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress). Record review of the quarterly MDS assessment, dated 05/14/25, reflected Resident #20 had clear speech and was understood by others. Resident #20 was usually able to understand others. The MDS reflected Resident #20 had a BIMS score of 5, which indicated severe cognitive impairment. The MDS reflected Resident #20 had disorganized thinking that did not fluctuate. Resident #20 had delusions (misconceptions or beliefs that are firmly held, contrary to reality). No other behaviors were included on the MDS assessment. Record review of the comprehensive care plan, initiated on 05/27/25, reflected Resident #20 had episodes of verbal and physical aggression. Resident #20 grabbed another resident's ear on 05/27/25. The interventions included: Administer medication per orders, anticipate behaviors and redirect, notify doctor and family, ensure staff is aware of behaviors and successful interventions, maintain calm environment, psychiatric consult per orders, every 15 minute checks, separate residents, and monitor right wrist bruising until resolved. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #20 walked into the main dining area and pulled another resident's ear and he bit her on the right wrist. The immediate action taken included: residents were separated from each and redirected, assessed for injury, small area noted to right wrist, no break in skin, resident denies pain at this time. Injuries included: hematoma to right wrist. The incident report reflected Resident #20 did not like it when Resident #38 talks loudly, which is his normal due to hearing impairment. The incident report reflected the family, physician, and DON were notified of the incident. Record review of the skin assessment, dated 05/27/25, reflected Resident #20 had bruising to her right wrist. The area was small, but no measurements were indicated. 676069 Page 15 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of the face sheet, dated 06/10/25, reflected Resident #38 was an [AGE] year-old male who initially admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (brain condition that progressively damages memory, thinking, and learning skills). Record review of the quarterly MDS assessment, dated 05/18/25, reflected Resident #38 had clear speech and was usually understood by others. Resident #38 was sometimes able to understand others. The MDS reflected Resident #38 had a BIMS score of 1, which indicated severe cognitive impairment. Resident #1 had inattention that did not fluctuate. The MDS reflected Resident #38 had no behaviors or refusal of care during the look-back period. Record review of the comprehensive care plan, initiated 05/27/25, reflected Resident #38 had episodes of verbal and physical aggression. Resident #38 bit another resident. The interventions included: Administer medications per orders, anticipate behaviors and redirect, encourage to attend social activities, maintain calm environment, monitor and chart behaviors every shift and report to doctor as needed, provide psychiatric consult per orders, refer to social services as needed, resident immediately separated, refer to psychiatric services at next visit, and 15 minute monitoring. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #38 was in the dining room and another resident pulled his ear and Resident #38 responded by biting her on the right wrist. The immediate action taken included: Residents were separated from each other immediately and assessed for injury, none found. The incident report reflected the doctor, DON, and responsible party were notified of the incident. Record review of the skin assessment, dated 05/27/25, reflected Resident #38 had no injuries or skin concerns. During an interview on 06/10/25 beginning at 3:48 PM, the DON stated it was brought to her attention on 05/27/25 that Resident #20 and Resident #38 had a physical altercation. The DON stated it was reported that Resident #20 pulled Resident #38's ear, and he bit her in response. The DON stated the Administrator was on vacation during the incident, so it was reported to her regional compliance nurse. The DON stated the Regional Compliance Nurse instructed her the incident was not reportable to HHSC. The DON stated the facility recently switched corporations, and she knew with the previous company, the incident would have been reportable to the state. The DON stated she did not report the incident but investigated the incident and kept a soft file just in case. The DON stated she believed the incident should have been reported. The Regional Compliance Nurse's phone number was requested. The DON stated her phone recently messed up and she was unable to find the Regional Compliance Nurse's phone number. She stated she would ask around for the number. The number was not provided upon exit of the facility. During an interview on 06/11/25 beginning at 2:30 PM, the Administrator stated the allegation of resident-to-resident physical abuse between Resident #20 and Resident #38 should have been reported to HHSC. The Administrator stated she was on vacation when the incident happened, and the new company made the decision to not report the incident. The Administrator stated it was important to ensure all incidents of abuse were reported to HHSC to maintain resident safety, prevent recurring incidents, and to ensure all regulatory requirements were met. Record review of the Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy, revised April 2021, reflected . investigate and report any allegations within timeframes required by federal requirement . 676069 Page 16 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 17 residents (Resident #5) reviewed for MDS assessment accuracy. Residents Affected - Few The facility failed to accurately reflect Resident #5's active diagnoses to not include a diagnosis of schizophrenia (a disorder that affected a person's ability to think, feel, and behave clearly) on her 3/07/25 MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #5's face sheet dated 6/09/25 indicated she was [AGE] years old and admitted to the facility on originally on 2/29/24 and re-admitted on [DATE]. Resident #5 had diagnoses which included dementia (progressive or persistent loss of intellectual functioning including impairment of memory, thinking, and personality changes due to disease of the brain), bipolar disorder (episodes of mood swings ranging from depressive (sadness) lows to manic highs(excitability with high energy)) with psychotic features (mental disorder characterized by a disconnection from reality with symptoms of delusions-false belief of reality; hallucinations-seen, heard, touched, tasted, or smelled something that was not really there; talking incoherently; and agitation) and depression (feelings of sadness, tearfulness, angry outbursts, irritability or frustration even over small matters). Record review of Resident #5's annual MDS assessment dated [DATE] indicated Resident #5 had a BIMS of 14 which indicated she was cognitively intact. The MDS indicated Resident #5 had an active diagnosis of schizophrenia. Record review of Resident #5's undated care plan indicated she required a psychotropic medication related to bipolar disorder. Resident #5 required an antidepressant related to depression. Resident #3 had memory problems related to dementia. Record review of Resident 5's Nurse Practitioner Visit Note dated 5/17/25 did not indicate Resident #5 had a diagnosis of schizophrenia. During an interview on 6/10/25 at 12:15 PM, the MDS Coordinator said she just took over the position of MDS nurse the middle of February 2025. The MDS Coordinator said she would have to look into why Resident #5 was being coded for schizophrenia on the MDS. The MDS Coordinator said she could see that a schizoaffective disorder diagnosis was inputted in May of 2024 but was deleted 6/11/24. The MDS Coordinator said she would have to research it and would get back to surveyor. During an interview on 6/11/25 at 9:33 AM, the ADM said her staff searched Resident #5's chart all day yesterday (6/10/25) for documentation of a diagnosis of schizophrenia and her staff could only find a diagnosis of bipolar disorder for Resident #5. The ADM said they think it was a mis-keyed item on the MDS assessment. During an interview on 6/11/25 at 10:34 AM, the MDS Coordinator said she had looked at Resident #5's documents and the only thing she had found was Resident #5 had a diagnosis of bipolar disorder. 676069 Page 17 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The MDS Coordinator said the purpose of the MDS assessment was for gathering information based off the assessment and based off the care the resident needed and it helped create the care plan. The MDS Coordinator said the MDS should be accurate to stay on top of what services the resident may or may not need and to get the right reimbursement. The MDS Coordinator said if the MDS assessment was not accurate, it could set the facility back with payment and if not correct, it could affect what the resident may or may not need. The MDS Coordinator said the MDS Coordinator would be responsible for ensuring the MDS assessment was accurate, but it was a collective effort from nursing, therapy, and all departments involved in the resident's care. During an interview on 6/11/25 at 1:02 PM, the DON said she had been the previous MDS Coordinator until sometime in February 2025. The DON said she guessed the schizophrenia on Resident #5's MDS assessment was a miscoded and was marked in error. The DON said the purpose of the MDS assessment was to paint an accurate picture of the resident and it showed what care and needs the resident required. The DON said the resident could possibly miss care and not get everything the resident needed to promote quality of life if the MDS assessment was not accurate. The DON said the RN was responsible for the accuracy of the MDS assessment and had to sign off on the MDS assessment. During an interview on 6/11/25 at 1:39 PM, the ADM said she would expect the MDS assessments to be accurate. The ADM said the MDS assessment should be accurate so they could address and treat all their residents' needs. The ADM said if the MDS assessment was not accurate, there was a risk of the resident not receiving services or care they needed. The ADM said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. Record review of the facility's policy titled Resident Assessments dated revised March 2022 indicated . a comprehensive assessment of every resident's needs was made at intervals designated by OBRA and PPS requirements . the resident assessment coordinator was responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements . the RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments all persons who have completed any portion of the MDS resident assessment form sign the document attesting to the accuracy of such information . Record review of the Resident Assessment Instrument 3.0 User's Manual (RAI) last revised October 2024, revealed . the RAI process was the basis for the accurate assessment of each resident . the RAI process has multiple regulatory requirements . the assessment accurately reflects the resident's status . with an accurate RAI completed periodically, caregivers have a genuine and consistent recorded look at the resident and can attend to that resident's needs with realistic goals in hand . 676069 Page 18 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for residents 1 of 1 secure unit reviewed for activities, in that: Residents Affected - Some The facility failed to ensure there were organized activities available to secured unit residents on 6/9/25 and 6/10/25. The facility failed to ensure a current activities calendar was posted in the resident's room. The facility failed to ensure the posted activities calendar was followed. These failures placed residents at risk for a diminished quality of life, behaviors, isolation, and lack of stimulation. Findings included: During an observation of the women's secured unit on 6/9/25 starting at 9:48 a.m., eleven out of eleven residents had May 2025 calendar posted in their rooms. During an observation of the women's secured unit on 6/9/25 at 9:58 a.m., the centrally located group activities board indicated: *10am: Worship, 12pm: Lunch, 2pm: Puzzle, 4pm: Movie, 5pm: Music and Relaxation *7am: Breakfast, 10am: Sit N Be Fit, 12pm: Lunch, 2pm: Memory Game, 4pm: Bingo, 5pm: Music and Relaxation *10am: Daily Bread/Coffee, 12pm: Lunch, 2pm: Kick Ball, 4pm: Bucket Toss, 5pm: Music and Relaxation *10am: Sit N Be Fit, 12pm: Lunch, 2pm: Movie Time, 4pm: Bingo, 5pm: Music and Relaxation *7am: Breakfast, 10am: Worship, 12pm: Lunch, 2pm: Snack/Social, 4pm: Yahtzee, 5pm: Music and Relaxation *10am: Sit N Be Fit, 12pm: Lunch, 2pm: Sorting Activities, 4pm: Bingo, 5pm: Music and Relaxation *10am: Bored Boards, 12pm: Lunch, 2pm: Library, 4pm: Movies, 5pm: Music and Relaxation, 7am: Breakfast During an observation on 6/9/25 at 10:00 a.m., six Residents were in the dining room with CNA A. One resident had a baby doll and toy on a bedside table. One resident was sitting in a wheelchair with a baby doll. All of residents were sitting quietly in the dining room or wandering the hall. No scheduled activities were observed. During an observation on 6/9/25 at 2:26 p.m., four residents (Resident #13, Resident #25, Resident 676069 Page 19 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #39, Resident #10) were observed in the dining room. Resident #13 was quietly sitting at a table and then got up to wander. Resident #25 was asleep in her wheelchair. Resident #39 was initially asleep with her head on the table then woke up and started pushing her wheelchair in a circle. Resident #10 was wandering in and out of the dining room. No scheduled activities were observed. During an interview on 6/9/25 at 4:26 p.m., a family member of a women's secured unit resident said she visited her family 2-3 times a week. She said she made random visits to visit her family member. She said on the days she visited during the day shift, there were no observed activities provided to the residents. During an observation on 6/10/25 at 9:02 a.m., newer line dance music was playing, and a ball toss game was observed. Seven residents (Resident #25, Resident #10, Resident #29, Resident #1, Resident #4, Resident #39, and Resident #13) were observed in the dining room with CNA A. Resident #25 and Resident #10 were the only residents playing the ball toss game. Resident #29 was holding a baby doll in her wheelchair. Resident #1 was asleep in her wheelchair. Resident #4 and Resident #39 were quietly sitting in their wheelchairs. Resident #13 was wandering in and out of the dining room. During an observation on 6/10/25 at 11:31 a.m., six resident (Resident #4, Resident #10, Resident #25, Resident #13, Resident #29, and Resident #39) were observed in the dining room with CNA A. The television was on, but no residents were watching it. Resident #25 was tearful and holding a baby doll. During an observation on 6/10/25 at 1:37 p.m., four residents (Resident #29, Resident #39, Resident #10, and Resident #18) were in the dining room with CNA A. No activities were observed. During an observation on 6/10/25 at 3:56 p.m., residents sitting in quiet dining room with no activities observed. CNA B eventually pulled out cards and played a game with Resident #18. During an interview on 6/10/25 at 4:09 p.m., CNA O said she had been working at the facility for 3 weeks. She said she worked the 2-10pm shift. She said she did not know what activities were provided on the day shift. She said when she arrived for her shift things needed to be done to get the residents ready for dinner and bedtime. She said no one told the CNAs what activities to provide the residents. She said some of the residents would participant in structured activities. She said activities were important to help the residents with their memory. She said when activities were not provided residents could have increase in behaviors, hurt themselves, or falls. During an interview on 6/10/25 at 4:30 p.m., CNA B said she normally worked the 2pm-10pm shift. She said she occasionally worked the 6am-2pm shift. She said the activity calendar was posted in the secured unit hallway. She said the posted activity calendar was not update. She said the old AD never changed the posted activity calendar. She said the old AD would come to the secured unit and get certain residents for activities on the non-secured side. She said since the AD had recently quit, the CNAs were supposed to do activities with the women's secured unit residents. She said the facility had not instructed the CNAs on what activities to provide the residents or when to do the activities. She said she felt only 2 out of the 11 residents on the women's secured unit would do structured activities. She said Resident #25, Resident #1, and Resident #32 enjoyed music. She said it was important to do activities with the women's secured unit to keep them stimulated and their minds going. She said the secured unit residents could become depressed if activities were not provided. During an interview on 6/11/25 at 10:54 a.m., MR T said she was helping the facility provide 676069 Page 20 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some activities for the residents on the non-secured side. She said since the AD quit, the CNAs were responsible for activities on the secured units. She said she was a certified AD. She said she had been providing the non-secured unit residents with activities from the old calendar for the last 2-3 days. She said activities were important for the resident's quality of life, keeping the residents active, upbeat, and positive mood, helped with socialization and hand and eye coordination. She said good activities for the dementia resident included music therapy, activity boards, ball toss, and dancing. She said when activities were not provided to the secured unit residents, they could become bored, idle, and isolated. She said scheduled activities should be provided to the secured unit residents three to four times a day. She said the staff members should review the secured unit resident's care plan and activity assessment to know what activities to provide. During an interview on 6/11/25 at 11:42 a.m., RN E said the AD left about a month ago. She said the CNAs were now responsible for providing activities to the secured unit residents. She said the secured unit had games and baby dolls to provide the secured unit residents for activities. She said some of the secured unit resident were able to attend the general population scheduled activities. She said the women's secured unit was not getting scheduled activities, but the staff put toys out for the resident to use. She said the CNAs should not play current generation music but oldies and worship music. She said activities for the secured unit were important to keep the resident occupied and stimulated. She said the residents could become depressed, sicker, and have behaviors. She said when a resident was admitted , the AD performed an activity assessment. She said Resident #13 enjoyed the numbered blocks, but she also wandered. She said Resident #25 and Resident #1 enjoyed gospel or worship music. She said Resident #39 would be passive interaction. She said Resident #10 had labile cognition. She said it depended on the time of day what activities interested Resident #10. During an interview on 6/11/25 at 12:46 p.m., CNA L said the CNAs tried to do activities on the women's secured unit. She said the facility had not told them what activities to provide and when to provide the scheduled activities. She said activities were important to keep the resident's mind occupied. She said the residents could have behaviors when activities were not provided. During an interview on 6/11/25 at 1:52 p.m., LVN D said on 6/9/25, MR T took some residents from the secured unit to do, activities in the main dining room. She said the secured unit had card games for the residents. She said some of the secured unit residents attended bingo with the general population residents. She said on Monday, 6/9/25, the men's secured unit had activities being provided by the CNAs but not the women's secured unit. She said scheduled activities were important so the residents stayed active, would not be bored, and made them feel purposeful. She said when activities were not provided to the residents, they could become depressed. During an interview on 6/11/25 at 2:35 p.m., the DON said the previous AD took some of the secured unit residents to the general population activities. She said the CNAs were responsible for the secured unit activities until another AD was hired. She said the residents should receive daily structured and non-structured activities. She said several of the secured unit residents enjoyed music. She said she expected the CNAs to engage with the residents unless ADLs were being provided. She said she expected the staff to follow the resident's activity preferences. She said she felt the secured unit residents benefited from structure activities. She said the secured unit residents could become bored and unstimulated when activities were not provided. She said it placed residents at risk for behaviors, wandering, and depression. During an interview on 6/11/25 at 3:35 p.m., the ADM said the AD quit in the middle of May 2025. She said she expected the CNAs to provided activities to the secured unit residents who did not attend 676069 Page 21 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0679 Level of Harm - Minimal harm or potential for actual harm outside activities. She said she expected the CNAs to look on the activity calendar board to know what and when activities needed to be provided, to the secured unit residents. She said the women's secured unit had an activity closet with things to provide the residents. She said activities helped with the resident's anxiety and engagement. She said not providing activities to the women's secured unit could cause behaviors. Residents Affected - Some Record review of Resident #1's Activities-Quarterly/Annual Participation review dated 04/23/25 indicated Resident #1 attended and participated 50 percent of group activities. Resident #1 enjoyed morning worship, music, and social events. Record review of Resident #9's Activities-Quarterly/Annual Participation review dated 5/9/25 indicated Resident #9 did independent and group activities. Resident #9 enjoyed bingo, morning worship, music, and movie time. Record review of Resident #10's Activities-Quarterly/Annual Participation review dated 5/13/25 indicated Resident #10 attended and participated in 95 percent of activities. Resident #10 enjoyed bingo, arts and crafts, social/music table games, and worship service. Record review of Resident #13's Activities-Quarterly/Annual Participation review dated 5/13/25 indicated Resident #13 attended and participated in 50 percent of activities. Resident #13 sat at the table for short periods of time. Resident #13 enjoyed music, singing songs, conversations, and walks. Record review of Resident #25's Activities-Quarterly/Annual Participation review dated 5/9/25 indicated Resident #25 had 1:1 visits. Resident #25 enjoyed gospel music and bible reading. Record review of Resident #29's Activities-Quarterly/Annual Participation review dated 4/1/25 indicated Resident #29 attended and participated in activities 80 percent of the times. Resident #29 enjoyed bingo, nursery, sorting activities, and social. Record review of a facility's Programming for Residents with Cognitive Impairments and Other Special Needs policy revised 08/2006 indicated, .Activity programs are provided for the maintenance and enhancement of each resident's quality of life while promoting physical, cognitive, and emotional health. The facility will offer meaningful programs for residents with cognitive impairments that use reality and sensory awareness techniques . 676069 Page 22 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 memory care units (Women's Memory Care) and 2 of 5 residents (Resident #39 and Resident #25) reviewed for adequate supervision and assistive device to prevent accidents. The facility failed to ensure the residents in the Women's Memory Care were supervised while CNA O was in a resident's room with the door closed and CNA B left the Women's Memory Care unit to go to the Men's Memory Care unit on 6/10/25 for at least five minutes. The facility failed to ensure Resident #39's wheelchair brakes engaged on 6/9/25 and 6/10/25. The facility failed to ensure Resident #25 had proper footwear on 6/9/25, 6/10/25 and 6/11/25. These failures could place residents at an increased risk for injury. Findings included: 1. Record review of Resident #1's face sheet dated 06/10/25 indicated Resident #1 was an 81-years-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), severe with agitation (is a state of restlessness and uneasiness, often accompanied by physical and mental symptoms), age-related physician debility (physical weakness, especially as a result of illness), muscle weakness, abnormalities of gait and mobility, muscle wasting and atrophy (shortening), and mood disorder (is a mental health condition that primarily affects your emotional state). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and usually had the ability to understand others. Resident #1 had severely impaired vision. Resident #1 had a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #1's care plan dated 4/30/25 indicated Resident #1 was an elopement risk/wanderer as evidenced by impaired safety awareness, wandered aimlessly, impaired vision, and impaired cognition and resided on the secure unit due to behaviors such as loudly cursing and yelling at inappropriate times. Intervention included provide structured activities. Record review of Resident #1's care plan dated 05/28/25 indicated Resident #1 was/had potential to be verbally aggressive. Interventions included analyze key times, places, circumstance, triggers, and what de-escalates behavior and document. Record review of Resident #1's fall risk evaluation dated 6/6/25 indicated, .intermittent confusion .legally blind .requires use of assistive devices .fall risk score .11 . A score of 11 indicated at risk. Record review of Resident #9's face sheet dated 6/11/25 indicated Resident #9 was an [AGE] year-old female admitted on [DATE]. Resident #9 had diagnoses including age-related physical debility (physical weakness, especially as a result of illness), mood affective disorder (is a mental health 676069 Page 23 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some condition that primarily affects your emotional state), dementia (is a term for several diseases that affect memory, thinking, and the ability to perform daily activities), muscle weakness, and muscle wasting and atrophy (shortening). Record review of Resident #9's quarterly MDS assessment dated [DATE] indicated Resident #9 was sometimes understood and sometimes had the ability to understand others. Resident #9 had impaired vision. Resident #9 had a BIMS score of 4 which indicated severe cognitive impairment. Record review of Resident #9's care plan dated 6/3/25 indicated Resident #9 had impaired cognitive function/dementia or impaired thought process. No interventions were indicated. Record review of Resident #9's care plan dated 11/12/24 indicated: *Resident #9 was at risk for falling related to unsteady gait, visual disturbances, and medication usage. Interventions included provide resident an environment free of clutter. *Resident #9 had a diagnosis of exit seeking and wandering related to dementia and currently resides in secure unit. Interventions included attempt to make resident feel secure/safe. Record review of Resident #10's face sheet dated 6/11/25 indicated Resident #10 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #10 had diagnoses including dementia (is a term for several diseases that affect memory, thinking, and the ability to perform daily activities) with psychotic disturbance (severe mental illnesses characterized by a disconnection from reality, involving symptoms like hallucinations, delusions, and disorganized thinking), muscle wasting and atrophy (shortening), and muscle weakness. Record review of Resident #10's annual MDS assessment dated [DATE] indicated Resident #10 was understood and had the ability to understand others. Resident #10 had a BIMS score of 5 which indicated severe cognitive impairment. Record review of Resident #10's care plan dated 2/15/25 indicated Resident #10 was at risk related to change in environment/new admission to facility. Interventions included provide resident an environment free of clutter. Record review of Resident #10's care plan dated 5/1/25 indicated: *Resident #10 was an elopement risk/wanderer as evidenced by disoriented to place, impaired safety awareness. Interventions included provide structured activities. *Resident #10 had impaired cognition function/dementia or impaired thought process related to dementia. Interventions included keep routine consistent and try to provide consistent care givers. Record review of Resident #10's fall risk evaluation dated 2/7/25 indicated, .intermittent confusion .fall risk score .6 . A score of 6 indicated at risk. Record review of Resident #18's face sheet dated 6/11/25 indicated Resident #18 was a 66-years-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #18 had diagnoses including muscle wasting and atrophy (shortening), muscle weakness, dementia (is a term for several diseases that affect memory, thinking, and the ability to perform daily activities), and age-related 676069 Page 24 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0689 physical debility (physical weakness, especially as a result of illness). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #18's quarterly MDS assessment dated [DATE] indicated Resident #18 sometimes was understood and rarely/never had the ability to understand others. Resident #18 had short-and-long term memory recall problem. Resident #18 had severely cognitive skills for daily decision making. Resident #18 had a fall with injury since admission/reentry or prior assessment. Residents Affected - Some Record review of Resident #18's care plan dated 5/1/25 indicated Resident #18 was an elopement risk/wanderer as evidenced by disoriented to place, impaired safety awareness. Interventions included to provide structured activities. Record review of Resident #18's care plan dated 6/5/25 indicated: *Resident #18 had impaired social interaction. Intervention included monitor interactions with others. *Resident #18 had impaired cognition function/dementia or impaired thought process related to dementia. Intervention included keep routine consistent and try to provide consistent care givers. Record review of Resident #18's quarterly fall risk assessment dated [DATE] indicated, .disoriented times 3, diminished safety awareness .poor visual impairment .one to two falls in the last 3 months .12 . indicated at risk . Record review of Resident #29's face sheet dated 6/11/25 indicated Resident #29 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #29 had diagnoses including dementia (is a term for several diseases that affect memory, thinking, and the ability to perform daily activities), muscle wasting and atrophy (shortening), muscle weakness, and age-related debility (physical weakness, especially as a result of illness). Record review of Resident #29's annual MDS assessment dated [DATE] indicated Resident #29 was understood and usually had the ability to understand others. Resident #29 was unable to complete the BIMS score assessment. Resident #29 had short-and-long term memory recall problem. Resident #29 had moderately impaired cognitive skills for daily decision making. Record review of Resident #29's care plan dated 1/22/25 indicated history of falling and was at risk for subsequent falls related to cognitive impairment, confusion, weakness, and care deficits. Interventions included observe frequently and place in supervised area when out of bed. Record review of Resident #29's care plan dated 5/1/25 indicated: *Resident #29 was an elopement risk/wanderer as evidence by disoriented to place, impaired safety awareness. Intervention included provide structured activities. *Resident #29 had impaired cognition function/dementia or impaired thought process related to dementia, impaired decision making and long-term memory loss. Interventions included keep routine consistent and try to provide consistent care givers. During an observation on 6/10/25 beginning at 3:42 p.m., the state surveyor entered the Women's Memory Care unit. Five residents (Resident #9, Resident #10, Resident #18, Resident #29, and Resident 676069 Page 25 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #32) were sitting in the main dining room. The television was on, but no residents were observed watching it. CNA B was outside, in the courtyard area, providing a smoke break for Resident #1. CNA B brought Resident #1 back into the main dining room then exited the courtyard door again. CNA B walked across the courtyard and entered the Men's Memory Care unit. Resident #1 started yelling loudly. Resident #10 and Resident #9 wandered in and out of the main dining room. There were several other residents that were lying in their beds. At 3:46 p.m., Hospice CNA N came from the shower room with Resident #39 and placed her at a table. At 3:47 p.m., CNA B returned to the Women's Memory Care unit through the courtyard door. At 3:51 p.m., CNA O came out of a resident's room. 2. Record review of Resident #39's face sheet dated 6/9/25 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #39 had diagnoses including muscle weakness, age related physical debility (physical weakness, especially as a result of illness), history of falls, repeated falls, and malignant neoplasm (is an abnormal growth of cells that invades and can spread to other parts of the body) of left lung and brain. Record review of Resident #39's annual MDS assessment dated [DATE] indicated Resident #39 was sometimes understood and usually had the ability to understand others. Resident #39 had adequate hearing and vision and unclear speech. Resident #39 was rarely/never understood, and a BIMS score was not able to be assessed. Resident #39 had short-and-long term memory recall issues. Resident #39 had moderately impaired cognitive skills for daily decision making. Resident #39 used a wheelchair. Resident #39 required partial assistance for shower/bathe self, dressing, personal hygiene, and supervision for toileting hygiene. Resident #39 had 1 fall with no injury and 1 fall with minor injury since prior assessment. Record review of Resident #39's care plan dated 4/27/25 indicated Resident #39 was at high risk for falls related to gait/balance problems, poor communication/comprehension, unaware of safety needs, vision/hearing problems. Resident #39 had a history of repeated falls and rolling out of bed. Interventions included apply soft helmet and dropped wheelchair seat on new wheelchair. Record review of Resident #39's fall risk evaluation dated 5/22/25 indicated, .1-2 falls in past 3 months .disoriented times 3 at all times (Not Oriented to Person, Place, and Time) .balance problem while standing .fall risk score .7 . During an observation on 6/9/25 at 2:26 p.m., revealed Resident #39 was sitting in her wheelchair at the dining room table. Resident #39's wheelchair brakes were engaged. Resident #39 started pushing back in the wheelchair with her feet. Resident #39's wheelchair moved after each push. During an observation on 6/10/25 at 1:37 p.m., revealed Resident #39 was sitting in her wheelchair at the dining room table with CNA A bedside her. Resident #39's wheelchair brakes were engaged. Resident #39 started pushing back in the wheelchair with her feet. Resident #39's wheelchair moved after each push. CNA A said, Why is your wheelchair moving if it is locked! During an interview on 6/10/25 at 3:06 p.m., COTA M said about a month ago she noticed Resident #39's wheelchair moved when locked. She said she reported the issue to the DOR. She said a resident's wheelchair should not move when it was locked. She said Resident #39 pushed back on her wheelchair when it was locked. She said she believed Resident #39 got a new wheelchair after she reported the issue. She said she recently noticed Resident #39's new wheelchair also moved when it was locked. She said when a resident's brakes did not lock, the resident could fall out of the chair or roll over other residents. She said it was a safety hazard. 676069 Page 26 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/10/25 at 3:30 p.m., the DOR said COTA M reported Resident #39's wheelchair was moving when the lock was on. She said she normally verbally reported wheelchair issues to Maintenance P. She said she could not recall if Maintenance P was told about Resident #39's wheelchair brakes not working. She said wheelchair brakes locking was important for the safety of the residents. She said a resident's wheelchair needed properly maintained equipment. She said brakes on a wheelchair placed the residents at risk for falls. She said she should have reported Resident #39's wheelchair brake issue to Maintenance P or told hospice to fix it. During an interview on 6/10/25 at 3:48 p.m., Hospice CNA N said Resident #39 was new to her caseload. She said Resident #39 was restless in her wheelchair. She said she noticed Resident #39's wheelchair moved a little when the brakes were locked. She said it moved when Resident #39 had her tennis shoes on. She said she did not know if the facility had reported Resident #39's wheelchair to hospice. She said Resident #39's wheelchair should not move when the brakes were locked. She said it was a safety risk. She said the resident could hurt themselves and fall out of the wheelchair. During an observation on 6/10/25 at 3:58 p.m., the DOR arrived on the memory care unit and looked at Resident #39's wheelchair. She locked the brakes and Resident #39's wheelchair moved. Resident #39 started pushing back in the wheelchair with her feet. Resident #39's wheelchair moved after each push. During an interview and observation on 6/10/25 at 4:09 p.m., CNA O was sitting near Resident #39. Resident #39's wheelchair brakes were engaged. Resident #39 started pushing back in the wheelchair with her feet. Resident #39's wheelchair moved after each push. CNA O said Resident #39 could unlock her wheelchair but not lock it back. She said sometimes Resident #39 wiggled and her chair moved when it was locked. She said Resident #39 could fall but someone was always with her. She said if a resident had wheelchair issues, she would tell the nurse or maintenance. She said she did not know CNA B was off the floor and the residents were alone in the dining room on 6/10/25 at 3:42 p.m. She said the women's memory care unit usually had two CNAs so the residents would not be left alone. She said if one CNA was inside a room with the door closed, one CNA should be with most of the residents. She said the women's memory care unit residents needed supervision because something could happen. She said the residents could fight when they were unsupervised. During an observation on 6/10/25 at 4:28 p.m., revealed Maintenance P arrived on the women's memory care unit. Maintenance P wiggled Resident #39's wheelchair lock and it was loose on the frame. Resident #39 was removed from the chair so Maintenance P could work on it. During an interview on 6/10/25 at 4:30 p.m., CNA B said she noticed Resident #39's wheelchair moved even with the brakes locked. She said she noticed it about two weeks ago and reported it to the DON. She said the residents' wheelchair brakes should lock so they would not fall. She said the wheelchair could slip from under the residents when it was not locked. She said she took Resident #1 outside to smoke on 6/10/25, in the courtyard outside the women's memory care unit. She said CNA O was in the dining room when she took Resident #1 outside. She said the CNA should be in the area, where the majority of the residents were. She said the residents needed supervision so nothing would happen to them or get into anything. She said Resident #4, Resident #10, and Resident #9 were combative and should not be unsupervised for a long period of time. During an observation on 6/10/25 at 4:47 p.m., revealed Maintenance P demonstrated Resident #39's wheelchair brakes locked when engaged. 676069 Page 27 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/10/25 at 4:49 p.m., Maintenance P said the last time Resident #39's wheelchair was placed in maintenance book, her wheelchair seat needed to be lowered. He said the request was made on 4/29/25 but there was no name on the request form. He said on 5/8/25, staff finally placed Resident #39's name on the request form. He said the staff never reported to him Resident #39 had wheelchair brake issues. He said the left brake on Resident #39's wheelchair was loose. He said he tightened it. He said the staff should verbally tell him or place the issue in the maintenance book. He said if a resident's wheelchair did not lock, they could injury themselves or roll around and injury other residents. During an interview on 6/11/25 at 11:42 a.m., RN E said she was made aware today of Resident #39's wheelchair issue. She said the facility had been constantly working on Resident #39's wheelchair. She said the brakes were on, the wheelchair should not move. She said the resident could fall out of the wheelchair. She said about two weeks ago, Resident #39 could unlock her brakes but not anymore. She said two CNAs were assigned on the memory care unit. She said the residents should not be left alone. She said the CNAs should communicate with each other to ensure the memory care unit resident were not left alone if someone needed to leave the floor. She said the residents could be injured if left unsupervised. She said Resident #1, Resident #10, Resident #4, and Resident #25 were aggressive and should not be left alone with other residents. She said Resident #1 hollered out a lot which agitated the other residents. She said the situation on Tuesday (6/10/25) was not okay. 3. Record review of Resident #25's face sheet dated 6/10/25 indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #25 had diagnosis including pseudobulbar affect (is a neurological condition characterized by sudden, involuntary outbursts of crying or laughter that are not connected to the person's actual mood), mood disorder (is a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling), manic episodes (is a period of abnormally elevated or irritable mood, increased energy, and activity levels), anxiety disorder (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks)), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following infarction (stroke) affecting right dominant side, repeated falls, and Alzheimer's disease (is a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was sometimes understood and sometimes had the ability to understand others. Resident #25 had adequate hearing, unclear speech, and impaired vision with corrective lenses. Resident #25 was unable to complete the BIMS score assessment. Resident #25 had short-and-long term memory recall problem. Resident #25 had severely impaired cognitive skills for daily decision making. Resident #25 experienced inattention which changed in severity and disorganized thinking that was continuously present without fluctuation. Resident #25 required substantial/maximal assistance for all ADLs except toilet hygiene which she was dependent. Resident #25 required substantial/maximal assistance to walk 10 feet. Resident #25 had one fall with no injury and one fall with a minor injury since the prior assessment. Record review of Resident #25's care plan dated 5/9/25 indicated Resident #25 was at risk for falls related to confusion, deconditioning, and gait/balance problems. Interventions included follow facility fall protocol. During an observation on 6/9/25 starting at 9:48 a.m., revealed Resident #25 was sitting in a high back wheelchair in the dining room. Resident #25 had on white socks with a light gray heel. The socks did not appear non-skid. Resident #25 was crying, anxious, and made repeated attempts to get out 676069 Page 28 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0689 of the wheelchair. Level of Harm - Minimal harm or potential for actual harm During an observation on 6/9/25 at 11:57 a.m., revealed Resident #25 was sitting in a high back wheelchair, in the dining room at a table. Resident #25 was crying, anxious, and made repeated attempts to get out of the wheelchair. Resident #25 had on white socks with a light gray heel. The socks did not appear non-skid. Residents Affected - Some During an observation on 6/10/25 at 9:02 a.m., revealed Resident #25 made repeated attempts to get out of the wheelchair. Resident #25 had on white socks with a light gray heel. The socks did not appear non-skid. During an observation on 6/10/25 at 11:31 a.m., revealed Resident #25 was in a high back wheelchair, sitting in the dining room at a table. Resident #25 was crying, anxious, and made repeated attempts to get out of the wheelchair. Resident #25 had on white socks with a light gray heel. The socks did not appear non-skid. During an interview on 6/11/25 at 12:46 p.m., CNA L said on Monday (6/9/25), hospice dressed Resident #25. She said Resident #25 should have on non-skid socks. She said the family had brought Resident #25 some regular socks. She said non-skid socks prevented falls. She said she did not notice Resident #25 wearing regular socks instead of non-skid ones. During an observation and interview on 6/11/25 at 2:14 p.m., revealed Resident #25 was lying in bed. CNA B lifted Resident #25's blanket to expose her feet. Resident #25 had on white socks with a light gray heel and a slightly discolored area on the bottom portion. The discolored area appeared to be dirt. The socks were not non-skid. CNA B said Resident #25 normally had on regular socks and tennis shoes. During an interview on 6/11/25 at 2:35 p.m., the DON said she was not aware Resident #39's wheelchair brakes did not work. She said the wheelchair should not move when the brakes were locked. She said brakes not locking could cause falls. She said she expected CNAs to report wheelchair issues to the nurse then placed in the maintenance book. She said the memory care unit residents should always be supervised. She said the CNAs should communicate if they need to leave the floor. She said the residents needed to be supervised due to behaviors and safety. She said the residents could fall, have resident to resident altercations, spills, and elopements. She said residents should have on non-skid socks or closed toe shoes. She said the CNAs and LVNs should make sure the residents were wearing proper footwear. She said the DON should ensure the staff were putting proper footwear on the residents. She said the resident could fall or slip if they were not wearing non-skid socks. During an interview on 6/11/25 at 3:35 p.m., the ADM said she was not aware Resident #39's wheelchair brake was not working. She said whoever saw the issue should have reported it. She said the CNAs should tell the nurse then they contacted maintenance. She said if a resident's wheelchair brakes did not work then they could fall and have injuries. She said she expected the nursing staff to ensure residents' wheelchair brakes worked. She said she expected the residents on memory care unit to always be supervised. She said the residents needed to be supervised because of behaviors, the safety of the residents, and the need for redirection. She said when the residents were not supervised, altercations and falls could happen. She said depending on the resident's care plan, what fall intervention were put in place for the resident. She said she expected the residents to wear non-skid socks. She said non-skid socks prevented falls. She said not wearing non-skid socks placed the resident at risk for injuries. She said the CNAs should make sure the resident's wore non-skid socks. She said 676069 Page 29 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0689 the charge nurses to ensure the CNAs were putting proper footwear on the residents. Level of Harm - Minimal harm or potential for actual harm Record review of a Fall Prevention in-service dated 3/29/25, conducted by the DON, indicated, .do not place slippers on resident .non-skid socks that fit and closed toe, closed heel shoes . Residents Affected - Some Record review of a facility's Safety and Supervision policy revised 12/2007 indicated, .our facility strives to make the environment as free from accident hazards as possible .resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Record review of a facility's Fall and Fall Risk, Managing policy revised 4/2018 indicated, .based on previous evaluations and current data .the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling .environmental factors that contribute to the risk of falls included .improperly fitted or maintained wheelchairs .and footwear that is unsafe or absent . 676069 Page 30 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 2 of 5 residents (Resident #4 and Resident #25) reviewed for unnecessary medications. Residents Affected - Few The facility failed to ensure Resident #4 had monitoring for diuretic (are medicines that help reduce fluid buildup in the body) related to edema (swelling caused by excess fluid trapped in your body's tissues). The facility failed to ensure Resident #25's behaviors were documented to provide indication of use for antidepressant and antianxiety medications. These failures could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the use of medicines) and receiving unnecessary medications. Findings included: 1. Record review of Resident #4's face sheet dated 6/9/25 indicated Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses including dementia (is a general term for loss of memory and other thinking abilities that are severe enough to interfere with daily life), senile degeneration of brain (is a progressive decline in cognitive function that can affect memory, thinking, and daily activities), hemiplegia (paralysis of one side of the body) affecting left non dominant side and edema (is a buildup of fluid in the body's tissues). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4 was understood and usually had the ability to understand others. Resident #4 had a BIMS score of 00 which indicated severe cognitive impairment. Resident #4 received a diuretic during the last 7 days of the assessment period. Record review of Resident #4's care plan dated 11/14/24 indicated Resident #4 was at risk for dehydration, electrolyte imbalance, weight fluctuations due to taking diuretic medication, Lasix. Interventions included assess skin turgor (refers to the skin's elasticity and its ability to return to its normal shape after being pinched or pulled), oral mucosa, and weight loss. Record review of Resident #4's consolidated physician's orders dated 5/1/25 indicated Furosemide 40mg, give 1 tablet orally one time a day related to edema. Start date 4/11/25. The consolidated physician's order did not indicate assessment or monitoring for edema. Record review of Resident #4's medication administration record dated 5/1/25-5/31/25 indicated Furosemide 40mg, give 1 tablet orally one time a day related to edema. Start date 4/11/25. Resident #4 received 29 out of 31 doses. The MAR did not indicate assessment or monitoring for edema. Record review of Resident #4's progress notes dated 05/10/25-06/09/25 did not reflect assessment or monitoring for edema. 676069 Page 31 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 6/11/25 at 2:11 p.m., revealed Resident #4 was sitting in the dining room in a wheelchair. Resident #4 had slight edema noted to her lower extremities, bilaterally (both sides). 2. Record review of Resident #25's face sheet dated 6/10/25 indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #25 had diagnoses including pseudobulbar affect (is a neurological condition characterized by sudden, involuntary outbursts of crying or laughter that are not connected to the person's actual mood), mood disorder (is a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling), manic episodes (is a period of abnormally elevated or irritable mood, increased energy, and activity levels), depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks)), and Alzheimer's disease (is a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was sometimes understood and sometimes had the ability to understand others. Resident #25 had adequate hearing, unclear speech, and impaired vision with corrective lenses. Resident #25 was unable to complete the BIMS score assessment. Resident #25 had short-and-long term memory recall problem. Resident #25 had severely impaired cognitive skills for daily decision making. Resident #25 experienced inattention which changed in severity and disorganized thinking that was continuously present without fluctuation. Resident #25 did not have behaviors during the assessment period. Resident #25 was prescribed antianxiety (used to treat anxiety), antidepressant (used to treat clinical depression and other mental health conditions, including anxiety disorders), and anticonvulsant (used to prevent or treat seizures) during the last 7 days of the assessment period. Record review of Resident #25's care plan dated 5/1/25 indicated: *Use of anti-anxiety medications (Lorazepam (is used to treat anxiety disorders)) related to anxiety disorder. Resident #25 cried often. Interventions included monitor/record occurrence of target behavior symptoms and document per facility protocol. *Use of antidepressant medication (Celexa (is used to treat depression)) related to depression. Intervention included monitor/document/report to MD as needed ongoing signs and symptoms of depression unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, constant reassurance and anxiety. Record review of Resident #25's consolidated physician's order date 6/1/25 indicated: *Behavior Monitoring - Antidepressant Behavior Code: 0. None 1. Withdrawn 2. Loss of appetite 3. Crying 4. Lack of interest 5. Apathy 6. Feeling of helplessness7. Feelings of worthlessness 8. Suicidal ideations 9. Insomnia 10. Other (Document in PN) INTERVENTIONS: Document in PN every shift. Start date 5/1/25. *BEHAVIOR MONTIOR LORAZEPAM BEHAVIOR CODE: 0. None; 1. Restlessness; 2. Pacing; 3. Continuous cry for help; 4. Afraid/ panic; 5. Repetitious movements; 6. Verbalizations of anxiety; 7. Other (Document in in progress notes) INTERVENTION CODES: 0. NONE;1.1 on 1; 2. Activity;3. Adjust room temperature; 4. Backrub; 5. Change position;6.Give fluids;7.Give food; B. Redirect; 9; Refer to nurse's notes; 10. Remove resident from environment 11. Return to room;12. Toilet OUTCOME CODE: I Improved S every 676069 Page 32 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0757 shift. Start date 4/5/25. Level of Harm - Minimal harm or potential for actual harm *Citalopram 20mg, give 1 tablet by mouth one time a day related to depressive episodes. Start date 4/11/25. Residents Affected - Few *Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 3 tablet by mouth one time a day related to anxiety disorder. Start date 4/11/25. *Lorazepam Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth in the evening for anxiety related to anxiety disorder. Start date 4/11/25. *Lorazepam Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth in the morning related to anxiety disorder. Start date 5/16/25. Record review of Resident #25's medication administration record dated 6/1/25-6/30/25 indicated: *Citalopram 20mg, give 1 tablet by mouth one time a day related to depressive episodes. Start date 4/11/25. Resident #25 received 10 out of 10 doses. *Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 3 tablet by mouth one time a day related to anxiety disorder. Start date 4/11/25. Resident #25 received 9 out of 9 doses. *Lorazepam Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth in the evening for anxiety related to anxiety disorder. Start date 4/11/25. Resident #25 received 9 out of 9 doses. *Lorazepam Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth in the morning related to anxiety disorder. Start date 5/16/25. Resident #25 received 10 out of 10 doses. *Behavior Monitoring - Antidepressant Behavior Code: 0. None 1. Withdrawn 2. Loss of appetite 3. Crying 4. Lack of interest 5. Apathy 6. Feeling of helplessness7. Feelings of worthlessness 8. Suicidal ideations 9. Insomnia 10. Other (Document in PN) INTERVENTIONS: Document in PN every shift. Start date 5/1/25. Resident #25 had 0. None documented for day shift (10 out of 10 shifts), evening shift (9 out of 9 shifts), and night shift (9 out of 9 shifts). *BEHAVIOR MONTIOR LORAZEPAM BEHAVIOR CODE: 0. None; 1. Restlessness; 2. Pacing; 3. Continuous cry for help; 4. Afraid/ panic; 5. Repetitious movements; 6. Verbalizations of anxiety; 7. Other (Document in in progress notes) INTERVENTION CODES: 0. NONE;1.1 on 1; 2. Activity;3. Adjust room temperature; 4. Backrub; 5. Change position;6.Give fluids;7.Give food; B. Redirect; 9; Refer to nurse's notes; 10; Remove resident from environment 11. Return to room;12. Toilet OUTCOME CODE: I Improved S every shift. Start date 4/5/25. Resident #25 had NO documented for day shift (10 out of 10 shifts), evening shift (9 out of 9 shifts), and night shift (8 out of 9 shifts). Resident #25 had YES documented on 6/2/25. Record review of Resident #25's progress note dated 5/29/25-6/10/25 indicated on 6/2/25 at 10:09 p.m. a behavior was observed. Resident #25's progress note did not reflect any other documented behaviors. During an observation on 6/9/25 at 9:50 a.m., revealed Resident #25 was sitting in the dining room at a table. Resident #25 was crying, anxious, and made repeated attempts to get out of the 676069 Page 33 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0757 wheelchair. Level of Harm - Minimal harm or potential for actual harm During an observation on 6/9/25 at 11:57 a.m., revealed Resident #25 was sitting in the dining room at a table. Resident #25 was crying, anxious, and made repeated attempts to get out of the wheelchair. Resident #25 was taken to the bathroom by staff. Residents Affected - Few During an observation on 6/10/25 at 9:02 a.m., revealed Resident #25 made repeated attempts to get out of the wheelchair. During an observation on 6/10/25 at 11:31 a.m., revealed Resident #25 was sitting in the dining room at a table. Resident #25 was crying, anxious, and made repeated attempts to get out of the wheelchair. Resident #25 was holding a babydoll. During an interview on 6/10/25 at 3:06 p.m., COTA M said Resident #25 used to be on therapy service. She said when she visited the secured unit to get other residents, Resident #25 was tearful off and on. She said the staff talked to Resident #25 or tried distracting her to calm her. During an interview of 6/10/25 at 3:30 p.m., the DOR said Resident #25 was tearful on and off. She said playing music and talking to Resident #25 calmed her. During an interview on 6/10/25 at 4:09 p.m., CNA O said Resident #25 was tearful and cried throughout the day. She said Resident #25's behaviors should be charted. She said it was important to chart behaviors so there was a history and to know if the medications needed to be increased or decreased. She said when Resident #25 had behaviors, CNAs should tell the nurse so it could be charted. During an interview on 6/10/25 at 4:30 p.m., CNA B said Resident #25 was tearful, anxious, and cried all the time. She said if the nurse was not present, then the CNAs had to report it to the nurse. She said she reported Resident #25's behaviors to the nurses. She said the CNAs could not chart behaviors in the EMR. She said charting a resident's behaviors was important to know they were happening. She said when behaviors were not charted then a resident's medication could be decreased when they needed it. During an interview on 6/11/25 at 11:42 a.m., RN E said edema should be monitored every shift. She said nurses documented monitoring on the resident's MAR. She said Resident #4 had occasional left side edema when she had a fracture. She said Resident #4 currently did not have edema. She said it was important to monitor and document edema to make sure the medication was working. She said the nurses were responsible for monitoring and documenting edema. She said Resident #25 was tearful, anxious, and cried a lot. She said Resident #25's behaviors were labile (liable to change; easily altered) even with medications. She said the behaviors should be documented in the progress notes and the MAR. She said since Resident #25 constantly had behaviors, the staff did not always chart them. She said Resident #25 had behaviors on 6/9/25 when she worked. She said the nursing staff should chart behaviors every shift and when the behaviors occurred. She said the behaviors should also be charted when they were uncontrollable with interventions. She said it was important to chart the behaviors to have a running of what is going with the resident. She said the facility had tried medications to treat Resident #25's pseudobulbar affect disorder but they did not work. She said the facility tried music and holding a baby doll to try calm Resident #25. She said sometimes it was effective. During an interview on 6/11/25 at 2:35 p.m., the DON said when a resident was prescribed a diuretic for edema, the edema should be assessed. She said the edema should be assessed every shift and as 676069 Page 34 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed. She said normally when a medication was ordered that needed monitoring, she placed a supplement documentation order. She said the facility had switched chart systems in April 2025 and she may have forgot to add Resident #4's supplement documentation order. She said it was important to assess a resident's edema to make sure the resident was not fluid overloaded or dehydrated. She said excessive edema could affect the resident's mobility and comfort. She said the DON was responsible for ensuring the supplement documentation was ordered and the nurse documented the assessment of a resident's edema every shift. She said she expected the CNAs to report the resident's behaviors to the charge nurses. She said the facility was currently working on adding the ability for CNAs to chart behaviors in the EMR. She said the behaviors should be charted on the MAR and progress notes. She said the behaviors should be charted every shift and with events. She said it was important to chart the behaviors to make sure the resident was stable on the medication prescribed to treat the diagnosis. She said it was also important to know if the resident needed a psych evaluation and the behaviors were improving. She said when the behaviors were not charted then not addressed, they could become uncontrollable. She said if the behaviors were not addressed, it affected the resident's quality of life. She said if behaviors were not documented then the prescribed medication could be considered unnecessary. During an interview on 6/11/25 at 3:35 p.m., the ADM said if a medication was prescribed to treat edema, then it should be assessed. She said the nursing staff was responsible for monitoring a resident's edema. She said the nursing administration should ensure the nursing staff were assessing and documenting the resident's edema. She said she expected the nursing staff to document the resident's behaviors when they occurred. She said the nursing staff may not witness the behaviors, but they were still responsible for documenting them. She said the nursing administration should ensure the nursing staff were documenting the resident's behaviors. She said it was important to document the behaviors to have a record to provide the doctors. She said the documented behaviors helped plan for a better plan of action to address the issues. She said it also helped to know if the current medication were working. She said if the resident's behaviors were not documented it could appear the medications were not needed. Record review of a facility's Administering Medications policy revised 4/2019 indicated, .medications are administered in a safe and timely manner .as required or indicated for a medication, the individual administering the medication records in the resident's medical record . Record review of a facility's Psychotropic Medication Use policy revised 07/2022 indicated, .residents will not receive medications that are not clinically indicated to treat a specific condition .psychotropic medication management includes .adequate monitoring for efficacy and adverse consequences .consideration of the use of any psychotropic medication is based on comprehensive review of the resident .this includes evaluation of the resident's signs and symptoms in order to identify underlying causes . 676069 Page 35 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 11 errors out of 32 opportunities, resulting in a 34.38 percent medication error rate for 3 of 4 residents reviewed for medication error. (Resident's #6, #16, and #25) Residents Affected - Some The facility did not ensure the following: 1. Resident #25 was given calcium plus vitamin D3 500 mg, citalopram 20 mg (antidepressant), and MiraLAX 17 GM (laxative) as ordered by the physician during the medication pass on 06/10/25. 2. Resident #16 was given aspirin 81mg (delayed release), Senna-S (laxative), potassium 10 mEq, and primidone 50 mg (anticonvulsant) as ordered by the physician during the medication pass on 06/10/25. 3. Resident #16's atenolol (blood pressure medication) was held for a heart rate of 58, according to the ordered parameters of hold for heart rate less than 60 on 06/10/25. 4. Resident #6 was given famotidine 40 mg and Tums 1,000 mg, for indigestion, as ordered by the physician during the medication pass on 06/10/25. 5. Resident #6 was not given zinc 50 mg without a physician order, during the medication pass on 06/10/25. These failures could place residents at risk for adverse reactions or ineffective dosage related to inaccurate drug administration. The findings included: 1. During an observation and interview on 06/10/25 beginning at 07:22 AM, MA Q prepared Resident #25's medications for administration. MA Q placed one tablet from a bottle of calcium 600 mg + D3 in the medication cup. MA Q placed one tablet from a card of citalopram 40 mg into the medication cup. MA Q did not prepare Resident #25's ordered MiraLAX 17 GM. MA Q crushed Resident #25's medications, mixed with a small amount of pudding and administered the medication to Resident #25 with a small glass of ice water. MA Q stated she was finished administering Resident #25's morning medications. Record review of the order summary report, dated 06/10/25, reflected Resident #25 had the following orders: 1. calcium plus vitamin D3 oral 500mg-5mcg - give 1 tablet by mouth one time a day for vitamin replacement, which started on 04/11/25. 2. citalopram 20 mg - give 1 tablet by mouth one time a day related to other depressive episodes, which started on 04/11/2025. 3. MiraLAX 17GM/scoop - give 1 scoop by mouth one time a day for constipation, which started on 04/11/25. 676069 Page 36 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the MAR, dated June 2025, reflected Resident #25 received calcium plus vitamin D3 500 mg, citalopram 20 mg, and MiraLAX 17 GM daily. The MAR further revealed the medications were scheduled to have been given at 7 AM. 2. During an observation and interview on 06/10/25 beginning at 07:31 AM, MA Q obtained Resident #16's blood pressure and heart rate. Resident #16's heart rate was 58 beats per minute. MA Q prepared Resident #16's medications for administration. MA Q placed one tablet from a bottle of aspirin 81 mg - chewable into the medication cup. MA Q placed one tablet from a card of atenolol 25 mg - give 1 tablet by mouth daily, hold for . heart rate less than 60 into the medication cup. MA Q did not prepare Resident #16's ordered Senna-S, potassium chloride, and primidone. MA Q administered Resident #16's medication with a small cup of water. MA Q stated she was finished administering Resident #16's morning medications and had nothing further that was scheduled. Record review of the order summary report, dated 06/10/25, reflected Resident #16 had the following orders: 1. aspirin oral delayed release 81 mg - give one tablet orally one time a day related to cerebral infarction (stroke), which started on 04/11/25. 2. atenolol 25 mg - give 1 tablet by mouth one time a day related to high blood pressure, hold for . heart rate less than 60, which started on 04/11/25. 3. potassium chloride 10 mEq - give 1 tablet by mouth one time a day related to heart disease, which started on 04/11/25. 4. primidone 50 mg - give 1 tablet by mouth one time a day related to heart disease, which started on 04/11/25. 5. Senna-S - give 1 tablet orally two times a day for constipation, which started on 04/11/25. Record review of the MAR, dated June 2025, reflected Resident #16 received, aspirin 81 mg - delayed release, atenolol 25 mg, potassium chloride 10 mEq, primidone 50 mg, and Senna-S daily. Resident #16's documented heart rate was under parameters for the atenolol 25 mg, 3 out of 10 days during June 2025. The MAR further revealed the medications were scheduled to have been given at 8 AM. 3. During an observation and interview on 06/10/25 beginning at 07:48 AM, RN E prepared Resident #6's medication for administration. RN E placed 2 tablets from a bottle of omeprazole 20 mg - 24 hours into the medication cup. RN E placed one tablet from a bottle of zinc 50 mg into the medication cup. RN E did not prepare Resident #6's ordered Tums 1,000 mg. RN E crushed Resident #6's medications and administered them via gastrostomy tube (tube that goes directly into the stomach for eating or administering medication). RN E stated Resident #6 did not receive any more medications until noon. Record review of the order summary report, dated 06/10/25, reflected Resident #6 had the following orders: 1. famotidine 40 mg - give 1 tablet enterally one time a day, which started on 04/11/25. 2. Tums 500 mg - give 2 tablets enterally one time a day for indigestion, which started on 04/11/25. 676069 Page 37 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0759 3. There was no order for zinc 50 mg or omeprazole 40 mg. Level of Harm - Minimal harm or potential for actual harm Record review of the MAR, dated June 2025, reflected Resident #6 received famotidine 40 mg and Tums 500 mg (2 tablets) daily. The MAR reflected the medications were scheduled to have been given at 9 AM. Residents Affected - Some During an interview on 06/11/25 beginning at 1:58 PM, RN E stated the process for medication administration included opening the MAR and matching the orders with each medication. RN E stated she was nervous on 06/10/25 when the state surveyor was watching her. RN E stated she believed Resident #6 had an order for zinc because she had wounds. RN E stated the order must have only been for a certain number of days and had fallen off the MAR. RN E stated she realized she had forgotten to administer the Tums on 06/10/25 and went back later in the day to give them. RN E stated she substituted the famotidine with the omeprazole because Resident #6 was out of the famotidine, and she believed it was the same medication. RN E stated she should not have given any medication without clarifying it with the physician. RN E stated it was important to ensure the ordered medication was given and the medications were verified prior to administration to prevent medication errors and adverse effects. During an attempted telephone interview on 06/11/25 at 2:07 PM, MA Q did not answer the phone. A brief message was left with a call back number, but the call was not returned upon exit of the facility. During an interview on 06/11/25 beginning at 2:10 PM, the ADON stated she expected the facility staff to ensure they were following the physician orders and checking the medication with the orders to ensure accuracy during the medication pass. The ADON stated MA Q should have held the medication and notified the nurse for clarification if there were discrepancies noted. The ADON stated MA Q should have administered all prescribed medication during the appropriate time frames. The ADON stated MA Q should have held Resident #16's atenolol and notified the nurse if her heart rate was outside of the parameters. The ADON stated no medication should have been administered without an order. She said MA Q had reported being nervous during the medication pass observation. The ADON stated if MA Q was nervous, she should have asked to take a break or paused the medication pass. The ADON stated RN E should have notified the doctor for clarification and checked the medication with the MAR to ensure accuracy. The ADON stated medication administration skills checkoffs were completed once per year and as needed. The ADON stated the pharmacy consultant came in monthly and observed medication pass. The ADON stated it was important to ensure the medications were given accurately to prevent medication errors and adverse reactions. During an interview on 06/11/25 beginning at 2:20 PM, the DON stated she expected staff to notify the appropriate staff and receive clarification from the physician for any medication discrepancies. The DON stated she expected clarification to have been obtained prior to the administration of the medication. The DON stated the facility staff should have followed all parts of the medication order including hold parameters. The DON stated the facility staff should not have given medication without a physician order and expected staff to administer all prescribed medications per the orders. The DON stated the facility recently switched their electronic charting system and pharmacies. The DON stated she had placed all the orders in the electronic monitoring system by herself, so she expressed to the staff to pay attention to the orders and notify her if there were any discrepancies. The DON stated nursing management was responsible to ensure medications were administered accurately. The DON stated it was important to ensure medications were given accurately to prevent medication error and adverse effects. 676069 Page 38 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 06/11/25 beginning at 2:30 PM, the Administrator stated she expected the facility staff to verify the medications given and follow the physician orders during medication pass. The Administrator stated the nursing management staff, ADON and DON, were responsible for monitoring to ensure medications were given accurately. The Administrator stated it was important to ensure medications were given accurately per the physician orders to protect the resident's well-being and ensure their disease processes were treated effectively. Record review of the Administering Medications policy, dated April 2019, reflected Medications are administered in a safe and timely manner, and as prescribed . medications are administered in accordance with prescriber orders, including any required time frame .the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before given the medication . 676069 Page 39 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food stored in the kitchen refrigerator and freezer was labeled and dated on 6/9/25. 2. The facility failed to ensure food stored in the pantry was labeled and dated on 6/9/25. 3. The facility to ensure pitchers of prepared drinks were labeled and dated on 6/9/25, 6/10/25 and 6/11/25. 4. The facility failed to ensure the handwashing sink had paper towels on 6/9/25. 5. The facility failed to ensure refrigerators and freezers temperatures were recorded on 6/9/25. 6. The facility failed to ensure the refrigerator temperature did not get out of range and no record of interventions to correct the temperature on 6/4/25 (AM) and 6/11/25 (AM). 7. The facility failed to properly store raw meat in the refrigerator. 8. The facility failed to ensure the flour and sugar bins did not have cups stored in them on 6/9/25. 9. The facility failed to ensure the oven's stovetop was free of grease buildup on 6/9/25. 10. The facility failed to ensure the oven's splash guard was free of grease and grime buildup and not bent on 6/10/25. 11. The facility failed to ensure the holding area of the ice machine, stored in the kitchen area, was free from a pink film on 6/9/25. 12. The facility failed to ensure a black crate with plastic items was not stored directly on the floor on 6/9/25 and 6/11/25. 13. The facility failed to ensure the drink dispenser internal vent was free of darked colored particles. 14. The facility failed to ensure cookware stored in the dishwasher area was free of carbon build up on 6/9/25 and 6/10/25. 15. The facility failed to ensure the bottom shelves on two black plastic storage rack and one white metal storage rack, in the dishwasher area, were 6 inches from the floor. 16. The facility failed to maintain an appropriate temperature in the main kitchen area, and the 676069 Page 40 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0812 Level of Harm - Minimal harm or potential for actual harm thermostat above the handwashing sick, read HI on 6/10/25. The pantry was 92-degree Fahrenheit on 6/11/25. 17. The facility failed to ensure the back door, to the area behind the kitchen, near the garage bins, was not propped open on 6/9/25 and 6/10/25. Residents Affected - Many 18. The facility failed to ensure flies were not in the kitchen on 6/10/25. 19. The facility failed to ensure a medium size, plastic trash can, near the preparation table was not opened during purees on 6/10/25. These deficient practices could place residents at risk for foodborne illness. Findings included: During an observation on 6/9/25 at 8:42 a.m., revealed the handwashing sink had no paper towels in the holder. During an observation on 6/9/25 at 8:43 a.m., revealed the back door, to the area behind the kitchen, near the garage bins, was propped open. The temperature in the kitchen was warm. During an observation on 6/9/25 at 8:44 a.m., revealed refrigerator #1 had no documented temperature on the temperature log posted on refrigerator #1 for June 9th, 2025. During an observation on 6/9/25 starting at 8:45 a.m., in refrigerator #1 the following was observed: *Ten packages of whipped topping were not dated. The container holding eight of the whipped toppings had a date of 1/20/23. *One box, with approximately 32 small cartons of strawberry flavored mighty shakes was not dated. *One container with approximately forty hard boiled eggs was not dated. *One turkey breast was not dated. *One log of raw meat was not labeled and dated. The log of raw meat was stored directly on the rack and not at the bottom of the refrigerator. Food items were stored underneath it. *One bag of opened salad mix was not dated. During an observation at 8:50 a.m., revealed freezer #1 had no documented temperature on the temperature log posted on freezer #1 for June 9th, 2025. During an observation on 6/9/25 starting at 8:50 a.m., in freezer #1 the following was observed: *Two unopened bags and one opened bag of pork toppings were not dated. During an observation at 8:51 a.m., revealed freezer #2 had no documented temperature on the 676069 Page 41 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0812 temperature log posted on freezer #2 for June 9th, 2025. Level of Harm - Minimal harm or potential for actual harm During an observation on 6/9/25 starting at 8:52 a.m., in freezer #2 the following was observed: *Three bags, of what appeared to be frozen tater tots, were not labeled, and dated. Residents Affected - Many *Sixteen packages, of what appeared to be frozen pancakes, were not labeled, and dated. During an observation on 6/9/25 at 8:55 a.m., the milk refrigerator, in the pantry, had no documented temperature on the temperature log posted on the wall above the milk refrigerator for June 9th, 2025. During an observation on 6/9/25 starting at 8:56 a.m., the following was observed: *Three boxes of [NAME] buddies were not dated. *Seven bags of orange twist drink mix were not dated. *Two cups were noted in the flour bin. * One cup was noted in the sugar bin. During an observation on 6/9/25 at 9:07 a.m., revealed the ice machine located in the main area of the kitchen, had a pink film inside the area that held the ice. During an observation on 6/9/25 starting at 9:08 a.m., in the main kitchen area the following was observed: *Four pitchers of an orange-colored liquid, stored on a preparation table, were not labeled, and dated. *One black, plastic milk crate was directly on the floor with four plastic items inside. *The internal vent on the drink dispenser machine had dark-colored particles on it. During an observation on 6/9/25 starting at 9:11 a.m., in the dishwasher area the following was observed: *Three skillets with carbon build up (black, crusty layer) were hanging from a metal rack. * The bottom shelves on two black plastic storage racks and one white metal storage rack, did not appear to be 6 inches from the floor. During an observation on 6/10/25 starting at 10:39 a.m., the following was observed in the main area of the kitchen: *Grease buildup was noted on the edges of the stove top. *Grime and splatters of grease on to the splash guard, and it was bent at the edge. 676069 Page 42 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0812 *One cookie sheet with carbon buildup was noted on a shelf. Level of Harm - Minimal harm or potential for actual harm *One medium size, plastic trash can, near the preparation table was opened during purees performed by [NAME] K. Residents Affected - Many During an observation on 6/10/25 at 11:58 a.m., revealed one medium size, plastic trash can, near the preparation table was propped opened by a large empty metal during temperature checks. During an observation on 6/10/25 at 12:05 p.m., revealed near the 500 hall, on the hydration cart, had a pitcher of orange colored liquid not labeled or dated. During an observation on 6/10/25 at 1:44 p.m., the following was observed in the main area of the kitchen: *The back door, to the area behind the kitchen, near the garbage bins, was propped open. Approximately four flies were noted in the kitchen. Two food items were uncovered. *The temperature in the kitchen was hot. The thermostat above the handwashing sink, read HI. During an observation and interview on 6/11/25 at 9:27 a.m., revealed one black, plastic milk crate was directly on the floor with four plastic items inside. [NAME] K said everyone was responsible for labeling and dating food items in the refrigerators, freezers, and the pantry. He said the food items should have a received and opened date. He said food items taken out of the original box or packaging should be labeled. He said some of the kitchen staff labeled and dated items differently when it was taken off the delivery truck. He said it was important to know how long it had been opened and if the food items were expired. He said when he arrived on Monday (6/9/25) at 6am, there were no napkins in the holder at the handwashing sink. He said he did not have the key to open the napkin holder. He said they had to wait for housekeeping to open the holder and to refill it. He said napkins at the handwashing sink were important to make sure staff were washing their hands to prevent contamination. He said the refrigerators and freezers temperatures were supposed to be checked and logged when the cook arrived. He said it was important to check the temperatures first thing in the morning to know if something was going on with the fridges and freezers. He said sometimes the evening kitchen staff did not close the fridge good which could cause the food to spoil. He said raw meat was supposed to be stored on a tray at the bottom of the fridge. He said it should be stored that way so if the meat leaked it would not get everywhere. He said whoever placed the raw meat in the fridge should have stored it correctly. He said scoops and cups should not be stored in the bins. He said it was not good because of cross contamination. He said everyone should make sure that was not happening, but the cooks were primarily responsible. He said the cooks were responsible for cleaning the stovetop and splash guard. He said grease buildup was a fire hazard and could cause a grease fire. He said the stovetop and splash guard should be cleaned after every use. He said the ice machine should not have pink residue in it. He said the DM had been cleaning it. He said he did not know why the ice machine should not have pink residue in it. He said the black milk crate should not be stored directly on the floor. He said the items in the crate could get contaminated. He said the drink machine did not work. He said but everyone should be checking the filter. He said when the vent was dirty, stuff could get in the drink line. He said cookware should not have carbon buildup. He said it was a fire hazard. He said the cooks were responsible to make sure cookware did not have carbon buildup. He said the temperature in the kitchen had been over 90 degrees Fahrenheit for about 4 months. He said 4 months ago, the window air conditioner units were placed in the kitchen windows. He said it was still hot with the window unit on. He said the kitchen staff opened the back door because it was so 676069 Page 43 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hot. He said when the back door was propped opened, it let flies in the kitchen and dining room. He said the flies could get in the residents food. He said the trash can lid should be closed. He said food items could get contaminated from things in the trash can. He said if the pantry got too hot, the bread molded faster. He said because the pantry was hot, the facility had to use stuff faster. During an observation on 6/11/25 at 10:01 a.m., a handheld thermostat was placed in the pantry at 9:27 a.m. by the surveyor. At 10:01 a.m., it read 92 degrees Fahrenheit. No bread items were noted in the pantry. During an observation and interview on 6/11/25 at 10:04 a.m., the temperature log on refrigerator #2 reflected documented temperatures of 43 degrees Fahrenheit on 6/3/25 on the AM shift, and 42 degrees Fahrenheit on 6/11/25 on the AM shift. [NAME] K said the door was not good when he arrived for his shift. He said now the temperature was 35 degrees Fahrenheit. During an observation on 6/11/25 at 10:05 a.m., revealed near the 500 hall, on the hydration cart, had a pitcher of purple colored liquid not labeled or dated. During an observation and interview on 6/11/25 at 10:13 a.m., Maintenance P measured the black plastic shelves and reported from the floor to the top part of shelf, was 4 inches. He measured and reported the white metal rack was 3 1/4 inches from the floor to the top part of shelf. During an interview on 6/11/25 at 10:16 a.m., the DM said, the cooks, DAs, and DM were responsible for labeling and dating food items. He said the food items should be labeled and dated when they arrived on the truck and when opened. He said it was important to make sure not to give something that was old. He said it was important to serve fresh food to the residents. He said spoiled food could make the residents sick and get food poisoning. He said the DM should ensure the staff labeled and dated food items. He said he normally went behind the staff to ensure they labeled and dated food items. He said the handwashing station should have soap and napkins. He said on Monday (6/9/25) when he arrived, housekeeping had just brought the kitchen some napkins. He said he had not had a chance to load the napkins in the holder. He said he and housekeeping were the only ones that had keys to the napkin holder. He said napkins at the handwashing station was important to make sure staff hands were clean and to turn off the faucet. He said the cooks and DM were supposed to do the temperatures for the fridge and freezers. He said the temperatures should be done at 6am for AM shift, and 5pm for the PM shift. He said he normally checked the temperature log when he arrived later in the morning to make sure they were done. He said if the temperature was 40 degrees Fahrenheit and not improving after correcting the issue, then the food should be pulled out and placed somewhere else. He said the dietary staff should immediately let the DM know if the fridge or freezer temperatures were out of range. He said the staff should be rechecking the temperatures until it reached the safe range. He said raw meat should be stored on the bottom of the fridge in a pan. He said the cooks and DM were responsible for properly storing raw meat. He said proper storage of raw meat made sure nothing dripped on other foods. He said he should be ensuring the cooks stored the meat properly. He said the DAs, Cooks, and DM should make sure scoops or cups were not in the bins. He said not leaving cups in the bins prevented cross contamination. He said leaving cups in the bins could make the residents sick. He said he should be ensuring staff did not leave cups in the bins. He said the cooks and DM manager was responsible for preventing grease buildup on the stove top and pink residue in the ice machine. He said not having grease build up prevented fires and not having pink residue made sure the ice was clean. He said grease buildup could cause a fire and contaminated ice could make the residents sick. He said he should be ensuring staff cleaned the ice machine. He said he cleaned the ice machine every day at 6pm and even on the weekends. He said items could not be stored directly on the floor. 676069 Page 44 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many He said it made sure things could not crawl into the items. He said the Cooks, Dishwasher, and DAs were responsible for storage items off the ground. He said he should be ensuring the staff did not store things directly on the floor. He said the drink dispenser worked and was being used. He said he was responsible for cleanliness of the drink dispenser filter. He said he had not noticed the filter was dirty. He said a clean drink filter prevented fires and clogging of the machine. He said the Cooks should notify the DM when cookware had carbon buildup. He said carbon buildup could cause grease fires and make the resident sick. He said he should be ensuring the cooks notified him of cookware with carbon buildup. He said the shelves should be 6 inches from the ground. He said he had not noticed the racks being less than 6 inches from the ground. He said the shelves had been there since he started 5 years ago. He said 6 inches helped prevent spillage to contact the dishes. He said he was responsible for the shelf heights. He said yesterday (6/10/25) was the hottest day in the kitchen. He said he never looked at the thermostat to check the temperature. He said the kitchen should not be overly hot to make sure nothing spoiled and was safe to consume. He said the window units sometimes cooled the kitchen. He said the facility had been working on cooling the kitchen for the last month. He said the dietary consultant had also told the facility the kitchen was too hot. He said the facility got the window units after the dietary consultant told them that. He said the back door should not be opened in the kitchen. He said keeping the back door closed, prevented things from crawling into the kitchen and bugs flying in. He said the bugs could make the residents sick and lead to illnesses. He said the trash can lid should be closed during prep and meal services. He said it prevented smells and cross contamination. He said he and the cooks should make sure the trash can lid was closed. He said he should be ensuring the cooks closed the trash can lids. During an interview on 6/11/25 at 3:35 p.m., the ADM said she expected the DM to ensure there were no fire hazards in the kitchen. She said all staff were responsible for labeling and dating food items and kitchen sanitation. She said it prevented contamination of the food and ensured spoiled food was not served. She said residents could become sick with an upset stomach. She said the DM should ensure the kitchen staff protect the resident from sickness caused by unsanitary conditions or spoiled food. She said the back door and trash can lid should not be open. She said it created unsanitary conditions in the kitchen. She said pest in the kitchen could make the resident sick. She said proper handwashing etiquette included drying your hands. She said everyone was responsible for making sure soap and napkins were at the handwashing station. She said she expected the kitchen cleaning scheduled to be followed. She said the DM should be ensuring the designated kitchen staff completed the cleaning schedule. She said the DM should be doing this by inspecting the listed tasks to ensure they were completed. Record review of a Quality Assurance Monitor, Kitchen/Food Service Observation, completed by the Dietary Consultant on 3/13/24 indicated, .general sanitation and cleanliness .No .ice machine is clean with no lime, rust, or mildew .no .dumpster clean, plugged, and closed .no .trash cans in food prep clean and have lids .comments .oven door broken . Record review of a Quality Assurance Monitor Report, completed by the Dietary Consultant, dated 4/16/25 indicated, .general sanitation and cleanliness .No .ice machine is clean with no lime, rust, or mildew .comments .please clean ice machine .observed with some debris on the white guard . Record review of the Cooler Temperature Log-June 2025 indicated, .Day 4 .6AM .Temperature .43 .[DA W] .Day 11 .6AM .Temperature .42 .[Cook K] . Record review of the Daily Cleaning Schedule: 6/2/2025 to 6/9/25 indicated, .stove top, drip pan, back wall, and side .6/3/25 &6/4/25 .[Cook/DA U] .making sure everything has date on it .6/4/25 676069 Page 45 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0812 .[Cook/DA V] . The ice machine was the assigned to the DM. No date or initials noted. Level of Harm - Minimal harm or potential for actual harm Record review of the Monthly Cleaning Schedule-June 2025 indicated, .remove ice from ice machine .clean and descale .management responsible .DM 6/2 . Residents Affected - Many Record review of a facility's Food Storage policy revised 06/01/2019 indicated, .to ensure that all food served by the facility is of good quality and safe consumption .all food stored according to the state, federal .dry storage rooms .for maximum shelf-life, dry foods should be stored at 50-70 degrees .however, less than 85 degrees is adequate for most products .use a wall thermometer to check the temperature of the dry-storage facility regularly .store scoops covered in a protected area near the food container .date packages .store all items at least 6 above the floor .refrigerators .keep fresh meat, poultry .internal temperature of 41 degrees Fahrenheit or less .date, label .all refrigerated foods .store raw meat and eggs on the bottom shelf to prevent contamination of other foods .temperatures should be checked each morning .when temperature are outside of the designated range, notify maintenance immediately .freezers .labeled and dated . Record review of a facility, Sanitization policy revised 11/2022 indicated, .the food service is maintained in a clean and sanitary manner .all kitchen, kitchen areas .protected from rodents and insects .equipment are kept clean, maintained in good repair and free from .corrosions .ice machine .cleaned and sanitized per manufacturer's instructions . Record review of a Ice Machines policy dated 10/01/2018 indicated, .the facility will maintain the ice machine .in a sanitary manner to minimize the risk of food hazards .the ice machine will be cleaned once per month or more often as needed . 676069 Page 46 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

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 failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 4 (Resident #25, Resident #39, Resident #1 and Resident #13) of 15 residents reviewed for infection control. Residents Affected - Some The facility failed to ensure CNA L performed hand hygiene between going back and forth, several times, feeding Resident #25 and Resident #39 lunch on 06/09/25. The facility failed to ensure COTA M performed hand hygiene between going back and forth, feeding Resident #1 and Resident #13 lunch on 06/09/25. These failures could place residents at risk for cross-contamination and the spread of infection. Findings included: 1. Record review of Resident #25's face sheet dated 6/10/25 indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #25 had diagnosis including pseudobulbar affect (is a neurological condition characterized by sudden, involuntary outbursts of crying or laughter that are not connected to the person's actual mood), mood disorder (is a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling), manic episodes (is a period of abnormally elevated or irritable mood, increased energy, and activity levels), anxiety disorder (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks)), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following infarction (stroke) affecting right dominant side, repeated falls, and Alzheimer's disease (is a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was sometimes understood and sometimes had the ability to understand others. Resident #25 had adequate hearing, unclear speech, and impaired vision with corrective lenses. Resident #25 was unable to complete the BIMS score assessment. Resident #25 had short-and-long term memory recall problem. Resident #25 had severely impaired cognitive skills for daily decision making. Resident #25 experienced inattention which changed in severity and disorganized thinking that was continuously present without fluctuation. Resident #25 required substantial/maximal assistance for all ADL's except toilet hygiene which she was dependent. Record review of Resident #25's care plan dated 5/8/25 indicated Resident #25 nutritional status: Regular Diet, Puree Texture, Thin liquids. Intervention included assist with meals. 2. Record review of Resident #39's face sheet dated 6/9/25 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #39 had diagnoses including muscle weakness, age related physical debility (physical weakness, especially as a result of illness), history of falls, repeated falls, and malignant neoplasm (is an abnormal growth of cells that invades and can spread to other parts of the body) of left lung and brain. Record review of Resident #39's annual MDS assessment dated [DATE] indicated Resident #39 was 676069 Page 47 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sometimes understood and usually had the ability to understand others. Resident #39 had adequate hearing and vision and unclear speech. Resident #39 was rarely/never understood, and a BIMS score was not able to be assessed. Resident #39 had short-and-long term memory recall issues. Resident #39 had moderately impaired cognitive skills for daily decision making. Resident #39 used a wheelchair. Resident #39 required partial assistance for shower/bathe self, dressing, personal hygiene, and supervision for toileting hygiene and eating. The MDS did not reflect swallowing disorder. The MDS did not reflect mechanically altered diet. Record review of Resident #39's care plan dated 5/8/25 indicated: *Resident #39 had impaired nutrition related to terminal disease of lung cancer with metastasis (is the process where cancer cells break away from a primary tumor and spread to other parts of the body, forming new tumors) and at risk for weight loss and may be unavoidable. Interventions included ensure resident is in proper position for eating, evaluate resident's physical ability to eat, and eat meals in a monitored environment. *Resident #39's nutritional status regular diet, regular texture, thin liquids. Interventions include determine resident's ability to chew and swallow and modify diet as appropriate according to resident's food tolerance and preference. 3. Record review of Resident #1's face sheet dated 06/10/25 indicated Resident #1 was an 81-years-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), severe with agitation (is a state of restlessness and uneasiness, often accompanied by physical and mental symptoms), age-related physician debility (physical weakness, especially as a result of illness), muscle weakness, abnormalities of gait and mobility, muscle wasting and atrophy (shortening), and mood disorder (is a mental health condition that primarily affects your emotional state). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and usually had the ability to understand others. Resident #1 had severely impaired vision. Resident #1 had a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #1's care plan dated 5/8/25 indicated Resident #1 nutritional status, regular diet, regular texture, thin liquids. Intervention included place food in bowls. 4. Record review of Resident #13's face sheet dated 6/11/25 indicated Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses including muscle wasting and atrophy (shortening), mild protein-calorie malnutrition (is a condition where protein intake is insufficient to meet the body's needs), and contracture (is a type of scarring in your soft tissues that causes them to tighten and stiffen). Record review of Resident #13's annual MDS assessment dated [DATE] indicated Resident #13 had was rarely/never understood and rarely/never the ability to understood others. Resident #13 was unable to complete the BIMS assessment. Resident #13 had short-and-long term memory recall problem. Resident #13 had severely impaired cognitive skills for daily decision making. Resident #13 required partial/moderate assistance for eating. Record review of Resident #13's care plan dated 5/8/25 indicated Resident #13 nutritional status regular diet, thin liquids. Intervention included assist with meals. 676069 Page 48 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 6/9/25 starting at 12:06 p.m., revealed CNA L was assisting Resident #25 with her lunch tray. CNA L stopped feeding Resident #25 then assisted Resident #39 with her lunch. CNA L did not perform hand hygiene between assistance. COTA M had clear gloves on her hands and was assisting Resident #13 with her lunch tray. COTA M got up from the table with Resident #13 and walked over to Resident #1. COTA M, with the same gloves used for Resident #13, placed Resident #1's fork in her right hand. COTA M then touched Resident #1's bowl holding her meat. COTA M then took Resident #1's dinner roll from her meat and placed in on another bowl. COTA M did not remove her gloves and perform hand hygiene between residents. While CNA L was intermittently assisting Resident #39 with her magic cup, she took out Resident #1's cookie and gave it to her. CNA L did not perform hand hygiene between residents. During an interview on 6/10/25 at 3:06 p.m., COTA M said on Monday (6/9/25), she assisted Resident #13 with her lunch meal. She said she was working with Resident #13 to use her hands to eat meals. She said she remembered giving Resident #1 her fork to assist her with the meat served for lunch. She said she may have touched Resident #1's dinner roll. She said she remembered using one hand for each resident. She said if she used the same gloves on the residents then it would be unsanitary. She said using the same gloves could spread infection or body fluids. She said it was cross contamination. She said it could potentially expose the other resident to a food allergy they may have. During an interview on 6/11/25 at 11:42 a.m., RN E said she did not witness the exchanges between the staff and residents. She said staff were supposed to perform hand hygiene between residents. She said staff could spread an infection to the residents. She said it was cross contamination. During an interview on 6/11/25 at 12:46 p.m., CNA L she was supposed to wash her hands or use hand sanitizer between residents. She said it was important to perform hand hygiene because of germs. She said the germs could make the residents sick. During an interview on 6/11/25 at 2:35 p.m., the DON said she expected staff to use hand sanitizer and hand hygiene when assisting with resident's meals. She said hand hygiene was important because the facility did not want to mix and spread germs or put stuff in the resident's food. She said feeding different residents at the same time was an interruption of the resident's meal. She said it was cross contamination to feed different resident with wash your hands between contact. During an interview on 6/11/25 at 3:35 a.m., the ADM said she expected the staff to perform hand hygiene and use hand sanitizer between the residents. She said it was an infection control issue to not perform hand hygiene when assisting with meals. She said it was cross contamination. She said it could make the residents sick. Record review of a facility's Handwashing/Hand Hygiene policy revised on 04/2012 indicated, .all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection .employee must wash their hands .before and after direct resident contact . 676069 Page 49 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

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 essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: Residents Affected - Few The facility failed to ensure the kitchen's only gas stove did not have two missing burners in the middle of the stovetop. The facility failed to ensure the kitchen's oven door was not broken. The facility failed to ensure the kitchen's oven door was not held in place with a piece of cardboard. These failures could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings included: During an observation and interview on 6/9/25, starting at 8:42 a.m., revealed the kitchen's stovetop was missing two burners, in the middle of the stovetop. One of the oven doors had a piece of brown and black stained cardboard stuck on the side. [NAME] K said the oven door was broken and the facility did not use that side of the oven. He said the piece of cardboard held the oven door closed. During an interview on 6/11/25 at 9:27 a.m., [NAME] K said the middle burners had been missing for seven years. He said he was told the piece to fix the burners were on recall. He said the oven door had also been broken for seven years. He said he was told the spring to fix the broken oven door was on recall. He said the facility never ordered the piece to fix the oven door. He said he did not know if the spring and piece to fix the burners were back in stock to fix the oven door and middle burners. He said it was important for the oven to be in good repair to cook the food better and the right way. He said the food could lose temperature when using a broken stove and oven. During an interview on 6/11/25 at 10:16 a.m., the DM said, the middle burners on the stovetop had been missing for three years. He said the facility had ordered the parts to fix the burners in February 2025 but then were on back order. He said the oven door had also been broken for 3 years. He said the springs on the oven door went out. He said when the facility went to order the springs, the company no longer made the springs. He said it was important for the stovetop and oven to be in good working order to ensure the facility's food was cooked properly. He said it also helped the residents not get sick from low temperature food. During an interview on 6/11/25 at 2:35 p.m., the DON said, the last time she was updated about the oven door, someone was coming to fix it. She said it also was a fire hazard to have a piece of cardboard holding the oven door closed. She said the broken door and missing burners could affect the temperature of the food. She said it placed the resident at risk for upset stomachs. During an interview on 6/11/25 at 3:35 p.m., the ADM said, when the old company owned the facility, she had placed bids on fixing the oven door. She said she reported the oven issues to the new company today (6/11/25). She said she knew about the broken oven door for about six months. She said she did not know the middle burners were missing. She said the oven and stovetop needed to properly work 676069 Page 50 of 51 676069 06/11/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to ensure the timeliness of meals. She said the cardboard holding the door was a fire hazards. She said the DM was responsible for notifying the ADM of equipment issues in the kitchen. Review of a handwritten statement, provided on 6/11/25 by the ADM, indicated, .the communication to purchase a new stove/oven was with our previous company .I do not have any information to provide proof .we will be getting repair or replacement bids for the oven . Record review of a facility's General Kitchen Safety Guidelines dated 10/2018 indicated, the facility will follow basic safety guidelines in order to reduce the risk pf accidents and ensure the safety of employees .keep all equipment in working order and report any malfunctioning to the maintenance department . 676069 Page 51 of 51