Health inspection·December 4, 2025

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 interviews and record review, the facility failed to notify the resident's representative and hospice services when there were changes in the resident's physical, mental, or psychosocial status for 1 of 11 residents (Resident #1) reviewed for notification of changes.The facility failed to notify Resident #1's hospice agency and her RP of a falls on [DATE] and [DATE] The facility failed to notify Resident #1's hospice agency and her RP of bruising to her hand and foot on [DATE]. The facility failed to notify Resident #1's RP of behavioral changes or medication changes on [DATE]. The facility failed to notify Resident #1's RP of two falls, behavioral changes, and medication changes on [DATE].The facility failed to notify Resident #1's RP of a fall on [DATE]. These failures could place residents at risk of not receiving adequate and timely intervention and a decline in condition. Findings included:Record review of Resident #1's face sheet dated [DATE] indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included cerebral infarction (stroke-disruption of blood flow to the brain causing tissue damage), hemiplegia and hemiparesis (paralysis (unable to move) and/or muscle weakness on one side of the body) of right side, mood disorder, anxiety disorder, Alzheimer's (progressive brain disorder that causes gradual memory loss, abnormal thinking, difficulty with daily activities and leads to brain shrinkage and death), weakness lack of coordination, repeated falls, and abnormality of albumin (protein in blood). Resident #1's RP was listed on the face sheet.Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood and sometimes understood others. She was unable to complete the BIMS because she was rarely/never understood. Resident #1 required substantial/maximal assistance from staff for most ADLs. Resident #1 was always incontinent of bowel and bladder. Resident #1 had no falls since prior assessment. Resident #1 was receiving hospice services.Record review of Resident #1's undated Care Plan indicated she was receiving hospice services related to terminal diagnosis of Alzheimer's and decline was expected. Resident #1 used anti-anxiety medications (used to treat anxiety) and on [DATE] resident was noted flailing arms and constantly attempting to roll and scoot out of the bed. Resident #1 was an elopement risk and resided on the secured unit. Resident #1 was at risk for falls related to confusion, deconditioning, and gait/balance problems; on [DATE] she scooted onto the floor, no injuries noted, on [DATE] she slid off the bed onto the fall mat with no injuries noted, on [DATE] resident rolled out of the bed, no injuries noted, on [DATE] resident rolled out of the bed onto the fall mat, no injuries noted, and [DATE] bruises noted to resident's body. Resident #1 had fall interventions including following the facility fall protocol, was noted with terminal restlessness and agitation, flailing in bed, and hospice was notified and medications reviewed dated initiated [DATE].Record review of Resident #1's nurse's note dated [DATE] at 6:42 PM indicated RN A documented she was notified by the CNA (not named) that resident slid off the bed in low position to fall mat before she could get to her. RN A assessed the Page 1 of 10 676069 676069 12/04/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident, and she had no signs of pain, redness/bruising to any area and could move all extremities. There was no documentation that RN A notified Resident #1's RP or hospice service of the fall. Record review of Resident #1's nurse's note dated [DATE] at 10:30 AM indicated LVN B documented the resident slid onto the floor with no injury or concerns. There was no documentation that LVN B notified Resident #1's RP or hospice service of the fall.Record review of Resident #1's nurse's note dated [DATE] at 7:42 AM indicated LVN B documented the aide (not named) noticed bruising on resident's right hand pinky and middle finger knuckle and bruising on top of her left foot. LVN B documented she evaluated the rest of Resident #1's body and did not see anything else out of the way. There was no documentation LVN B notified Resident #1's RP or hospice services of the bruising. LVN B documented at 12:34 PM, Resident #1 was hitting her hands on the dining table, upset, trying to hit the CNAs, and acting out with other residents, and LVN B administered her anxiety and pain medication. LVN B documented an order was received from the hospice physician to give Ativan 2 mg (anti-anxiety medication) and hydrocodone 7.5 mg one hour before scheduled time if needed for increased agitation or mood swings. There was no documentation LVN B notified Resident #1's RP of behavior changes or medication changes. Record review of Resident #1's nurse's note dated [DATE] at 7:00 AM indicated LVN B documented resident rolled out of the bed onto the fall mat with pillow under her and there was no injury. LVN B documented there was no new bruising at that time. LVN B notified hospice service and was instructed to monitor resident. There was no documentation LVN B notified Resident #1's RP of fall. LVN B documented at 10:58 AM, Resident #1 was really agitated this morning trying to get out of the bed on her own, aides were having to watch her and sit with her because she would not stay in chair or bed, constantly moving and wanting up and out. There was no documentation LVN B notified Resident #1's RP of behaviors. LVN B documented at 12:45 PM, Resident #1 rolled out of the bed onto the fall mat with pillow, no injuries, resident will not stay in bed or chair today ([DATE]), very agitated even after medication. LVN B documented she notified hospice services but there was no documentation she notified Resident #1's RP of fall or increased behaviors. LVN B documented at 3:10 PM, Resident #1 was in bed and highly agitated and the hospice nurse came and assessed the resident, and orders were received to discontinue hydrocodone and Ativan (tablets) and added lorazepam (anti-anxiety) liquid every four hours as needed and morphine liquid every two hours for pain and shortness of breath medication as needed. There was no documentation LVN B notified Resident #1's RP of medication changes or behaviors.Record review of Resident #1 nurse's notes dated [DATE] did not reveal any documentation of resident falling between 4:00 AM-4:30 AM or notification of Resident #1's RP of fall. LVN C was the nurse on duty during that time.Record review of Resident #1's nurse's note dated [DATE] at 10:10 AM indicated LVN B documented the DON asked her to make sure the resident's family had been called about the fall and the RP said she was unaware until early this morning when hospice called her. LVN B documented there was no documentation of the fall, hospice was not called, and DON was not aware. LVN B documented there was no injury noted other than prior bruising.Record review of nurses' notes from [DATE]-[DATE] indicated the resident was on end-of-life comfort care and expired on [DATE].Record review of photograph's provided by Resident #1's RP dated [DATE] at 11:44 AM revealed multiple bruises to arms, legs, foot, and chin in multiple stages of healing from yellow (normally indicated 10-14 days old), green in color (normally indicated it 5-10 days old), to purple in color (normally indicated 1-2 days old), and red (normally indicated it was new).During an interview on [DATE] at 12:14 PM, Resident #1's RP said she knew Resident #1 had a change starting [DATE]-[DATE] because she had reviewed Resident #1's chart at the facility and she saw where Resident #1 had multiple falls, and the facility had not notified her nor hospice of the falls or of her thrashing in her bed and 676069 Page 2 of 10 676069 12/04/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few falling out and appearing restless. Resident #1's RP said finally a nurse notified hospice on [DATE] and said there was something wrong and hospice came and diagnosed her with terminal restlessness and that was when they decided to just do comfort care. Resident #1's RP said on [DATE] she came to the facility and spoke with DON E and asked why resident #1 was covered in bruises and why she nor hospice had been notified of her multiple falls and DON E said he did not know why, and he was unaware. Resident #1's RP said DON E and the ADM went to the secured unit and did a full body assessment and Resident #1 was covered in bruises in different stages of healing. Resident #1's RP said DON E and the ADM said they were very sorry and that was not what they expected of their staff, and she should have been notified. Resident #1's RP said she thought everything would be better after that, but the very next morning CNA G came in to bathe her and found Resident #1 in the floor thrashing around and CNA G hollered for twenty minutes trying to get help and there was not anyone else in the secured unit. Resident #1's RP said CNA G ended up moving Resident #1 to where she felt safe to leave her because there was a television on a bedside table that she was afraid would fall on Resident #1 and had to go outside the secured unit to get the nurse. Resident #1's RP said the night shift nurse (LVN C) did not document anything about the incident in Resident #1's chart and the facility did not notify her until the day shift nurse (LVN B) called her six hours later, but the hospice agency had already notified her. Resident #1's RP said the facility should have notified her sooner of the incident.During an interview on [DATE] beginning at 3:01 PM, Hospice Representative H said apparently the hospice aide, CNA G, had gone in early the morning of [DATE] and found Resident #1 on the floor and CNA G called her after getting the facility nurse because CNA G thought the facility was mad at her for not getting the nurse sooner. Hospice Representative H said CNA G told her Resident #1 was thrashing and rolling around on the floor and CNA G did not think she could leave Resident #1 right then and moved the television away that was on a bedside table, so it did not fall on Resident #1. Hospice Representative H said CNA G told her she opened Resident #1's door and kind of hollered out for help but not too loud because she did not want to wake everyone up. Hospice Representative H said CNA G decided to get Resident #1's bed changed so it would be ready for her to get put back in as she waited for someone in the secured memory unit. Hospice Representative H said CNA G told her when she still did not find anyone, CNA G went outside the secured unit to get the nurse. Hospice Representative H said after CNA G told her what had gone on, she reported off to Hospice Representative J who reported off to Resident #1's RP and their hospice RN made a visit to assess Resident #1. Hospice Representative H brought Hospice Representative J into the call. Hospice Representative J said they were not notified of the resident falling on [DATE] or [DATE]. She said they were notified related to behavioral issues on [DATE] and made medication changes. Hospice Representative J said they were also not notified on [DATE] of a fall. Hospice Representative J said their nurse made a routine visit on [DATE] and noted bruising on Resident #1's hands, arms and elbows but did not do a full skin assessment because the resident was up in the wheelchair and calm. Hospice Representative J said they were notified on [DATE] of the early morning fall and then made a visit later that day. Hospice Representative H and Hospice Representative J said they never suspected Resident #1 had been abused. Hospice Representative J said Resident #1 had behaviors they were trying to manage with medications, and they had multiple fall mats and a mat against the wall because she was very active and would flail her arms and legs and fall off the bed. Hospice Representative J said the bed was kept in a low position. Hospice Representative J said Resident #1 had been diagnosed with terminal restlessness and was nearing end of life. Hospice Representative H said during the times in question there were management changes going on at the facility and there had been a lack of communication, but the current 676069 Page 3 of 10 676069 12/04/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few management was working hard at changing that and it had definitely gotten better. Hospice Representative H and Hospice Representative J said they would expect to be notified when one of their hospice residents falls so, they could make the determination whether they needed to make a visit, to adjust frequency of visits, medication changes, and to be informed of what was going on with the resident.During an interview on [DATE] at 3:15 PM, CNA G said she worked for the hospice agency and had come to the facility around 4:00 AM to give Resident #1 a bath and had gone to the linen closet to get her supplies prior to going to Resident #1's room. CNA G said when she entered Resident #1's room, Resident #1 was on the floor. CNA G said she did not remember seeing any staff in the secured unit when she entered, but they could have been in a resident's room. CNA G said Resident #1 was in the floor and was scooting around in circles in the floor and she put some pillows behind her and moved the bedside table with the television away from her so it would not fall on her if she hit it. CNA G said she then opened Resident #1's door and kind of said Hey, Hey but did not holler loud because she did not want to wake everyone up. CNA G said she did not see or hear anyone in the hallway. CNA G said she then went out in the hallway and looked in the dining area and did not see anyone and came back to make sure Resident #1 was safe and then went to the nurses' station outside the secured unit and got the nurse to come help. CNA G said the nurse got a CNA to help her, but she did not remember if the aide was in the secured unit or not when they went back to the secured unit. CNA G said Resident #1 was only in the floor, maybe 5 to 6 minutes from the time she found her to when she went and got the nurse. CNA G said she bathed Resident #1 three days a week and had only been seeing her for about two weeks at the time of the incident. CNA G said Resident #1 had old bruises on her legs and arms, when she first started seeing her and did not know if they had been reported previously.During an interview on [DATE] at 4:07 PM, LVN C said she worked for a nurse staffing agency. LVN C said she had documented a timeline of events the morning of [DATE] and CNA G came in at 4:02 AM and went to the secured unit and came back to the nurses' station at 4:28 AM and said Resident #1 was on the floor when she went in her room. LVN C said CNA G had already made Resident #1's bed and everything. LVN C said something did not seem right because CNA G had waited over twenty minutes to come get help to get Resident #1 up out of the floor. LVN C said she called DON E at 4:32 AM because it just did not feel right. LVN C said she asked DON E if she needed to do an incident report and DON E told her she did not need to do a report because Resident #1 was care planned for it. LVN C said she even had DON E repeat that she did not need to do an Incident Report. LVN C said next thing she knew, they took her off the schedule and DON E said it was because she did not notify the family of the fall. LVN C said what would she be notifying them of, if it was not a fall and did not need an incident report. LVN C said HA F was inside the secured unit just inside the nook of the secured unit when she went into the secured unit with CNA G and herself and HA F got Resident #1 up out of the floor. LVN C said she assessed Resident #1, and she did not have any noted injuries. LVN C said DON E did not actually tell her not to call the family, but it was something that would usually be reported off to the day shift nurse because it was 4:00 AM in the morning and it was care planned. LVN C said she would take accountability for not calling the family. LVN C said she knew she was supposed to notify the physician, DON, and RP and do an incident report but since coming in, DON E was very adamant to call him about everything and he would guide her on what to do since she was agency staff and DON E told her not to do an Incident Report. LVN C said she should have also documented the incident in the nurse's notes. LVN C said Resident #1 had some minor bruises when she had worked with her before. LVN C said she relieved DON E on [DATE] and even did a walk through with him and DON E showed her Resident #1's heavily bruising in multiple areas of her body. LVN C said she felt the bruises were 676069 Page 4 of 10 676069 12/04/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few more from her disease process and end of life because of the inconsistencies of them, but some could have been from her falls. LVN C said she was following the direction of DON E however he did not say to not notify the family. LVN C said she did not document the incident because DON E told her not too. During an interview on [DATE] at 4:37 PM, DON E said he received a call from the LVN C early in the morning on [DATE] and LVN C told him the resident was on the floor and had found some bruises. DON E said he told LVN C to do an Incident Report and contact the family and LVN C did not notify the family. DON E said he had the day shift nurse, LVN B, call the family to ensure they had been called, and they had not but the hospice agency had called them already. DON E said hospice service and RP should be called once they ensure the resident was safe and taken care of. DON E said if staff did not notify hospice agencies or RPs, it could affect the care for the resident or how perceived by the family. DON E said the hospice agency diagnosed Resident #1 with terminal restlessness (intense physical and emotional distress, including confusion, anxiety, and inability to rest, often happening in the final days or hours of life) and she would flail her arms and legs hitting objects such as her bed or table, and fall from the bed, which resulted in bruises. DON E said Resident #1 was on a daily low dose aspirin, had protein malnutrition, and nearing end of life, which could have contributed to her bruising easily along with her falls and flailing of arms and legs.During an interview on [DATE] at 4:47 PM, CNA K said she reported bruising to Resident #1's legs and arms to the charge nurse but could not remember when, maybe a couple weeks, before she passed away. CNA K said Resident #1 would sling her legs out of the bed and sling her arms, hitting the bed or tables, and they struggled to keep her from falling out of the bed.During an interview on [DATE] at 4:52 PM, RN A said she was the ADON. RN A said she was not aware Resident #1 was on hospice services at the time of her fall on [DATE]. RN A said it was not an actual fall, Resident #1 just slid off the bed and it was in the lowest position. RN A said she was pretty sure she notified the family on the incident on [DATE]. RN A said she should had done an incident report and thought she did, but she could have forgotten to do it. RN A said the hospice agency and the resident's RP should be notified of any falls immediately, so they were aware and knew what was going on and sometimes the hospice agency may want to come assess the resident or determine whether to send them out to the hospital.During an interview on [DATE] at 4:59 PM, LVN B said Resident #1 was falling a lot and her RP was upset there was not a lot documented about her falls and bruises in her chart and not being notified of falls and bruising. LVN B said they were documenting, just not every day. LVN B said Resident #1 would roll out of bed a lot before she passed away. LVN B said the resident's hospice agency and RP should be notified of any incidents, falls, bruises, behavior changes, and/or medication changes. LVN B said there was confusion on when/what to document on Resident #1 because DON E had told her she did not have to document when she slid out of the bed and had no injuries because she was care planned for it. LVN B said Resident #1's RP should have been notified when Resident #1 slid out of the bed on [DATE], increased behaviors and medication changes on [DATE] and [DATE], and of falls on [DATE] and [DATE]. LVN B said Resident #1's hospice agency should have been notified on [DATE] of sliding onto the floor and [DATE] of bruising. LVN B said the resident's RP should be notified to ensure they know what was going on with the resident and the hospice agency should be notified so they can determine if they need to see the resident, review medications, or make changes to their treatment plan.During an interview on [DATE] at 2:21 PM, DON D said she had only worked at the facility since [DATE]. DON D said any incident staff were to notify herself, they should notify the physician, the resident's RP, and their hospice agency, and then she would report off to the ADM. DON D said there should be an incident report on all falls. DON D said there should be documentation on all falls and incident reports and 676069 Page 5 of 10 676069 12/04/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there should be documentation that the appropriate persons were notified of the incidents. DON D said any bruising on a resident should be documented until they were gone and should have an incident report done. DON D said she would expect the facility's policies to be followed. DON D said the family could be upset and non-trusting if the facility was not notifying the RP when incidents occurred, bruising, behavior changes, or medication changes, and it could make the facility look bad or like they were trying to hide something, could be presumed as abuse if hospice or RP were not notified. DON D said not notifying hospice could potentially change the relationship between the hospice agency and the facility and could affect the resident's treatment. DON D said sliding off the bed onto a fall mat was a fall and should be documented as a fall and an incident report done. DON D said the resident's RP and hospice agency should be notified of any changes, including falls, bruises, behavioral changes, and medication changes.During an interview on [DATE] at 2:44 PM, the ADM said she had been the ADM at the facility since [DATE]. The ADM said the staff reported they had been told not to document incidents by the previous DON (DON E) and there was confusion on when/what to report. The ADM said the hospice agency and the resident's RP should be notified for all falls/incidents and bruises, and then if the hospice agency wanted to call the family again then that was on them. The ADM said she would expect the facility policies to be followed. The ADM said the risk to the resident of not notifying the hospice agency or resident's RP, really depended on the type of fall/incident and could potentially affect the resident's treatment with medication changes, etc. The ADM said it could cause the resident some anxiety if family was not notified but may not affect them as much if they had dementia. The ADM said she would expect all falls, incidents, bruising and anything should be reported to the appropriate persons, such as the physician, hospice agency, and the resident's RP. Record review of the facility's policy titled Change in a Resident's Condition or Status dated revised February 2021, indicated . Our facility promptly notifies the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status . 1. The nurse will notify the resident's attending physician or on-call physician when there has been . a. an accident or incident involving the resident . b. discovery of injuries of an unknown source . d. a significant change in the resident's physical/emotional/mental condition . e. need to alter the resident's medical treatment significantly . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions . c. requires interdisciplinary review and/or revision to the care plan . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when . a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source . b. there is a significant change in the resident's physical, mental, or psychosocial status .Record review of the facility's policy titled Assessing Falls and Their Causes dated revised [DATE], indicated . The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . After a Fall . 5. Notify the resident's attending physician and family in an appropriate time frame . 8. Complete an incident report for resident falls no later than 24 hours after the fall occurs . Defining Details of Falls . 2. For each individua, distinguish falls into the following categories . a. rolling, sliding, or dropping from an object, such as from bed or chair to floor . b. falling while attempting to stand up from a sitting or lying position . c. falling while already standing and trying to ambulate . Documentation . When a resident falls, the following information should be recorded in the resident's medical record . 1. The condition of the resident . 2. Assessment data . 3. Interventions . administered . 4. Notification of the 676069 Page 6 of 10 676069 12/04/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0580 Level of Harm - Minimal harm or potential for actual harm physician and family, as indicated . 8. The signature and title of the person recording the data . Reporting . 1. Notify the following individuals when a resident falls . a. the resident's family b. the attending physician c. the Director of Nursing . 2. Report other information in accordance with facility policy and professional standards of practice . Residents Affected - Few 676069 Page 7 of 10 676069 12/04/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical record maintained for each resident were complete and accurately documented for 1 of 11 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN C documented the incident/fall on 11/20/2025 reported by the hospice aide (CNA G). This failure could place residents at risk for delayed interventions, appropriate interventions, health complications and decreased quality of life. Findings include:Record review of Resident #1's face sheet dated 12/03/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included cerebral infarction (stroke-disruption of blood flow to the brain causing tissue damage), hemiplegia and hemiparesis (paralysis (unable to move) and/or muscle weakness on one side of the body) of right side, mood disorder, anxiety disorder, Alzheimer's (progressive brain disorder that causes gradual memory loss, abnormal thinking, difficulty with daily activities and leads to brain shrinkage and death), weakness lack of coordination, repeated falls, and abnormality of albumin (protein in blood).Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood and sometimes understood others. She was unable to complete the BIMS because she was rarely/never understood. Resident #1 required substantial/maximal assistance from staff for most ADLs. Resident #1 was always incontinent of bowel and bladder. Resident #1 had no falls since prior assessment. Resident #1 was receiving hospice services.Record review of Resident #1's undated Care Plan indicated she was receiving hospice services related to terminal diagnoses of Alzheimer's and decline was expected. Resident #1 used anti-anxiety medications (used to treat anxiety) and on 11/17/25 resident was noted flailing arms and constantly attempting to roll and scoot out of the bed. Resident #1 was an elopement risk and resided on the secured unit. Resident #1 was at risk for falls related to confusion, deconditioning, and gait/balance problems. Resident #1 had fall interventions including following the facility fall protocol, was noted with terminal restlessness and agitation, flailing in bed, and hospice was notified and medications reviewed dated initiated 11/19/25.Record review of Resident #1 nurse's notes dated 11/20/25 did not reveal any documentation of resident falling between 4:00 AM-4:30 AM or notification of Resident #1's RP of fall. LVN C was the nurse on duty during that time.During an interview on 12/03/2025 at 12:14 PM, Resident #1's RP said the morning of 11/20/2025 the hospice aide, CNA G came in to bathe Resident #1 and found Resident #1 in the floor thrashing around and CNA G hollered for twenty minutes trying to get help and there was not anyone else in the secured unit. Resident #1's RP said CNA G ended up moving Resident #1 to where she felt safe to leave her because there was a television on a bedside table that she was afraid would fall on Resident #1 and had to go outside the secured unit to get the nurse. Resident #1's RP said the night shift nurse (LVN C) did not document anything about the incident in Resident #1's chart. Resident #1's RP said she had reviewed Resident #1's chart on 11/20/2025 with the day shift nurse (LVN B) and there was no documentation from the night shift nurse (LVN C) of the incident or the fall.During an interview on 12/03/2025 beginning at 3:01 PM, Hospice Representative H said apparently the hospice aide, CNA G, had gone in early the morning of 11/20/2025 and found Resident #1 on the floor and CNA G called her after getting the facility nurse because CNA G thought the facility was mad at her for not getting the nurse sooner. Hospice Representative H said CNA G told her Resident #1 was thrashing and rolling around on the floor and CNA G did not think she could leave Resident #1 right then and moved the television away that was on a bedside table, so it did not fall on Resident #1. Hospice Representative H said CNA G 676069 Page 8 of 10 676069 12/04/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few told her she opened Resident #1's door and kind of hollered out for help but not too loud because she did not want to wake everyone up. Hospice Representative H said CNA G decided to get Resident #1's bed changed so it would be ready for her to get put back in as she waited for someone in the secured memory unit. Hospice Representative H said CNA G told her when she still did not find anyone, CNA G went outside the secured unit to get the nurse. Hospice Representative H said after CNA G told her what had gone on, she reported off to Hospice Representative J who reported off to Resident #1's RP and their hospice RN made a visit to assess Resident #1. Hospice Representative H brought Hospice Representative J into the call. Hospice Representative H and Hospice Representative J said they never suspected Resident #1 had been abused. Hospice Representative J said Resident #1 had behaviors they were trying to manage with medications, and they had multiple fall mats and a mat against the wall because she was very active and would flail her arms and legs and fall off the bed. Hospice Representative J said the bed was kept in a low position. Hospice Representative J said Resident #1 had been diagnosed with terminal restlessness and was nearing end of life. During an interview on 12/03/2025 at 3:15 PM, CNA G said she worked for the hospice agency and had come to the facility around 4:00 AM to give Resident #1 a bath and had gone to the linen closet to get her supplies prior to going to Resident #1's room. CNA G said when she entered Resident #1's room, Resident #1 was on the floor. CNA G said she did not remember seeing any staff in the secured unit when she entered, but they could have been in a resident's room. CNA G said Resident #1 was in the floor and was scooting around in circles in the floor and she put some pillows behind her and moved the bedside table with the television away from her so it would not fall on her if she hit it. CNA G said she then opened Resident #1's door and kind of said Hey, Hey but did not holler loud because she did not want to wake everyone up. CNA G said she did not see or hear anyone in the hallway. CNA G said she then went out in the hallway and looked in the dining area and did not see anyone and came back to make sure Resident #1 was safe and then went to the nurses' station outside the secured unit and got the nurse to come help. CNA G said the nurse got a CNA to help her, but she did not remember if the aide was in the secured unit or not when they went back to the secured unit. CNA G said Resident #1 was only in the floor, maybe 5 to 6 minutes from the time she found her, to when she went and got the nurse. During an interview on 12/03/2025 at 4:07 PM, LVN C said she worked for a nurse staffing agency. LVN C said she had documented a timeline of events the morning of 11/20/2025 and CNA G came in at 4:02 AM and went to the secured unit and came back to the nurses' station at 4:28 AM and said Resident #1 was on the floor when she went in her room. LVN C said CNA G had already made Resident #1's bed and everything. LVN C said something did not seem right because CNA G had waited over twenty minutes to come get help to get Resident #1 up off the floor. LVN C said she called DON E at 4:32 AM because it just did not feel right. LVN C said she asked DON E if she needed to do an incident report and DON E told her she did not need to do a report because Resident #1 was care planned for it. LVN C said she even had DON E repeat that she did not need to do an Incident Report. LVN C said next thing she knew, they took her off the schedule and DON E said it was because she did not notify the family of the fall. LVN C said what would she be notifying them of, if it was not a fall and did not need an incident report. LVN C said HA F was inside the secured unit just inside the nook of the secured unit when she went into the secured unit with CNA G and herself and HA F got Resident #1 up off the floor. LVN C said she assessed Resident #1, and she did not have any noted injuries. LVN C said she would take accountability for not calling the family. LVN C said she knew she was supposed to notify the physician, DON, and RP and do an incident report but since coming in, DON E was very adamant to call him about everything, and he would guide her on what to do since she was agency staff and DON E told her not 676069 Page 9 of 10 676069 12/04/2025 Avir at Texarkana 4925 Elizabeth St Texarkana, TX 75503

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to do an Incident Report. LVN C said she should have also documented the incident in the nurse's notes. LVN C said she did not document the incident/fall because DON E told her not too. During an interview on 12/03/2025 at 4:37 PM, DON E said he received a call from the LVN C early in the morning on 11/20/2025 and LVN C told him the resident was on the floor and had found some bruises. DON E said he told LVN C to do an Incident Report and contact the family and LVN C did not notify the family or document the incident/fall. During an interview on 12/04/2025 at 2:44 PM, the ADM said she had been the ADM at the facility since 11/19/2025. The ADM said the staff reported they had been told not to document incidents by the previous DON (DON E) and there was confusion on when/what to report. The ADM said she would expect the facility policies to be followed. Record review of the facility's policy titled Assessing Falls and Their Causes dated revised December 09, 2024, indicated . The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . After a Fall . 5. Notify the resident's attending physician and family in an appropriate time frame . 8. Complete an incident report for resident falls no later than 24 hours after the fall occurs . Defining Details of Falls . 2. For each individua, distinguish falls into the following categories . a. rolling, sliding, or dropping from an object, such as from bed or chair to floor . b. falling while attempting to stand up from a sitting or lying position . c. falling while already standing and trying to ambulate . Documentation . When a resident falls, the following information should be recorded in the resident's medical record . 1. The condition of the resident . 2. Assessment data . 3. Interventions . administered . 4. Notification of the physician and family, as indicated . 8. The signature and title of the person recording the data . Reporting . 1. Notify the following individuals when a resident falls . a. the resident's family b. the attending physician c. the Director of Nursing . 2. Report other information in accordance with facility policy and professional standards of practice . 676069 Page 10 of 10