Health inspection·September 6, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for 1 (Resident #6) of 6 residents reviewed for resident rights. Residents Affected - Few The facility failed to obtain a signed consent for antipsychotic medication Ziprasidone and antidepressant medications Zoloft and Trazodone prior to their administration to Resident #6. This failure could place residents at risk of receiving medications without their, or that of their responsible party's prior knowledge or consent, placing residents at risk of inability to make decisions regarding their plan of care and an increased risk for adverse reactions to the medications. Findings included: Record review of Resident #6's face sheet dated 09/04/2024, indicated Resident #6 was an [AGE] year-old male admitted to the facility initially on 11/08/2023 with diagnoses which included: Alzheimer's disease (a progressive brain disorder that damages memory and thinking skills); Parkinsonism (brain conditions that cause slowed movements, stiffness and tremors); bipolar disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels); anxiety disorder (a group of mental health conditions that involve persistent and uncontrollable feelings of fear or worry that can significantly impact a person's life); schizoaffective disorder, bipolar type (a mental health condition that causes people to experience psychotic symptoms and mood disorder symptoms, including mania and depression); and major depressive disorder (a serious mental illness that affects how people feel, think, and function in their daily lives). Resident #6 was his own RP. Record review of Resident #6's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9, indicating moderate cognitive impairment. Record review of Resident #6's Care Plan, accessed 09/04/2024 and updated on 02/26/2024, indicated Resident #6 had a problem area of behavioral symptoms, problem start date: 11/08/2023, indicating the resident received a psychotropic medication for schizophrenia/schizoaffective disorder. The long-term goal was the resident will receive the lowest possible dose to achieve/maintain the therapeutic benefits, maintain safety and quality of life, function and well being and will have side effects and interactions kept to a minimum. Approaches included to administer medications as ordered, discuss continued need for medication with RP and or resident during care plan meetings, monitor and document behaviors, and signs/symptoms of side effects. Another problem area listed under Other was, Page 1 of 25 676292 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0552 Level of Harm - Minimal harm or potential for actual harm Resident has a diagnosis of depression and is at risk for fluctuations in mood, little interest or pleasure in doing things and decreased socialization. The long-term goal was the resident will have fewer or no episodes of depression and will voice positive feelings about self over the next quarters. The first approach listed was, Administer medications as ordered, monitor labs - report abnormals to MD. Residents Affected - Few Record review of Resident #6's Order Recap Report, accessed 09/04/2024, revealed the orders: Trazodone tablet: 50 mg; amt: ½ tablet; oral. Administer ½ tablet of 50 mg = 25 mg daily at bedtime. Start date: 01/29/2024. Ziprasidone HCL capsule; 40 mg; amt: 1 capsule; oral. Administer 1 capsule BID with meals, 8:00 AM, 6:00 PM. Start date: 06/15/2024. Zoloft (sertraline) tablet: 100 mg; 1 tablet; oral. Administer one tablet daily. Start date: 01/25/2024. Record review of Resident #6's Medication Administration Records for August 2024 and September 01 - 04 2024 revealed facility staff administered the medications Trazodone, Ziprasidone and Zoloft daily as ordered. Record review of Resident #6's EHR, accessed on 09/04/2024, revealed there were three consent forms uploaded for the medication Ziprasidone. All three forms were missing a signature from Resident #6 or his RP. There were no consent forms for the medications Trazodone or Zoloft in any section of the EHR. During an interview on 09/05/2024 at 10:30 AM the Regional Nurse stated there were three consent forms for Ziprasidone in Resident #6's EHR, and none of them had the resident or the resident's RP signature. She further stated the facility's former DON had uploaded two of the forms and it was unusual she had not uploaded a signed version of the form. There were no consent forms for the antidepressant medications Trazodone and Zoloft, and she could not explain why they were missing. Consent must be obtained and consent forms for antipsychotic and antidepressant medications must be signed prior to administering any psychotropic or antidepressant medications. Record review of facility policy, Psychotropic Medication Policy and Procedure, undated, revealed: Standards: 2. Consents will be obtained by the resident/responsible party upon admission and as needed for any psychotropic medication. 8. Psychotropic medications include: antianxiety/hypnotic, antipsychotic and antidepressant classes of drugs. Record review of the facility provided document Federal Resident Rights revealed: Planning and implementing care. 4. The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment alternatives or treatment options and to choose the alternative or option you prefer. 676292 Page 2 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Residents #3 and #33) reviewed for care plans. The facility failed to ensure that: 1. Resident #3's order for Xarelto (a medication used to treat/prevent blood clots) was reflected in the resident's current comprehensive care plan. 2. Resident #33's use of Sertraline (a medication used to treat depression, also known as Zoloft) was reflected in the resident's current comprehensive care plan. This deficient practice could affect residents by contributing to missed or inaccurate care. The findings included: 1. Record review of Resident #3's face sheet, dated 09/06/2024, revealed a [AGE] year-old resident initially admitted on [DATE] with diagnoses including Epilepsy (a disorder that causes seizures), Hemiplegia ( condition that causes partial or complete paralysis on one side of the body) affecting left dominant side, cerebral palsy (movement/muscle disorder present since birth), and personal history of traumatic brain injury. Record review of Resident's #3's Physician Orders dated 09/06/2024 revealed an order for Xarelto (rivaroxaban) tablet; 10mg; amt: 1 tablet; oral. Special Instructions: Administer 1 tablet daily. Record review of Resident #3's MDS annual assessment dated [DATE] reflected that Resident #3 was taking an anti-coagulant and had a BIMS of 5, indicating severe cognitive impairment. Record review of Resident #3's Care Plan, dated 07/26/2024, reflected that Resident #3 had traumatic brain injury, but did not include a focus area addressing use of an anti-coagulant. Record review of Resident #33's face sheet dated, 09/06/2024, revealed a [AGE] year-old resident admitted on [DATE] with diagnosis including cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain); Type 2 diabetes mellitus with other diabetic kidney complication (a long term condition in which the body has trouble controlling blood sugar and using it for energy); and Irritability and Anger. Record review of Resident #33's Physician Orders dated 09/06/2024 reflected Resident #33 was prescribed Zoloft (Sertraline) 50mg 1 tab once a day, start date 02/21/2024. Record review of Resident #33's annual MDS Assessment, dated 08/14/2024, reflected Resident #33 was taking antidepressant medication and had a BIMS score of 12, indicating moderate cognitive impairment 676292 Page 3 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #33's Care Plan, dated 08/14/2024, reflected that Resident #33 had a history of behavioral issues, but did not include a focus area addressing use of an anti-depressant. During an interview with the Regional MDS Nurse on 09/06/2024 at 10:02 a.m., the Regional MDS Nurse confirmed that the Care Plan for Resident #3 did not address the use of Xarelto, an anti-coagulant, and she also confirmed that the Care Plan for Resident #33 did not address the use of Sertraline, an anti-depressant. The Regional MDS Nurse noted that the Care Plans should have included the use of these medications and stated that not having accurate care assessments could result in the resident's care needs not being met Record review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered dated March 2022 reflected, The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. Further review revealed, The comprehensive, person-centered plan: . describes the services that are to be furnished .and reflects currently recognized standards of practice for problem areas and conditions. 676292 Page 4 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 8 residents (Resident #34) reviewed for hygiene, in that. Residents Affected - Few Nursing staff failed to ensure Resident #34 received a shower and changed his stained shirt when his shower was scheduled on 09/04/2024. This deficient practice could place residents who were dependent on staff for ADL care at risk for loss of dignity, and/or a diminished quality of life. The findings were: Record review of Resident #34's face sheet, dated 09/06/2024, revealed a [AGE] year-old male with an admission date of 03/16/2023, and diagnoses which included: cerebral infarction (serious condition that occurs when b rain tissue dies due to a lack of blood flow); Hemiplegia and hemiparesis (a condition that causes partial or complete paralysis on one side of the body)affecting left dominant side; Type 2 Diabetes mellitus (a long-term condition in which the body has trouble regulating blood sugar) nicotine dependence; generalized anxiety disorder and weakness. Record review of Resident #34's quarterly MDS assessment, dated 06/19/2024, reflected Resident #34's BIMS score was a 12, indicating moderate cognitive impairment. It further reflected he needed partial/moderate assistance for showering and dressing self and maximal assist for tub/shower transfer. Record review of Resident #34's Physician Orders dated 09/06/2024 revealed an order for Shower Day Every shift on Wed., Sat 0:600am -02:00 pm. Record review of Resident #34's care plan, dated 03/15/2024 reflected mobility impairment: [x] decreased functional limitation in ROM [range of motion]. Observation in South Hall on 09/03/2024 at 03:27pm revealed Resident #34 propelling himself down the hallway in his wheelchair, wearing a white t-shirt with large circular coffee-colored stain on the left shoulder. Further observation of Resident #34 on 09/04/2024 at 09/04 a.m.revealed Resident #34 lying in bed, legs covered wth a blanket, wearing the same stained T-shirt. Observation and interview of Resident #34 on 09/05/2024 at 03:38 a.m. revealed Resident #34 lying in bed in his room, wearing the same stained T-shirt. Interview of Resident #34 revealed he only changes his clothes when he showers, except for his shorts, which he changes daily. Resident #34 said he last took a shower 2 weeks ago. Resident #34 stated that staff always want to help shower him when it was his smoke break time, so he would tell them no, and ask them to come help him later, but they never come back. Resident #34 stated I don't like it, I don't want to smell like pee. Interview on 09/05/2024 at 03:40 p.m. with CNA - C, revealed that all the residents had a scheduled day for showers listed on their orders, and if they refused, they (the CNA's) should wait a little bit and ask again later. If the resident still refused, the CNA should report the refusal to the 676292 Page 5 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse, who will counsel with the resident. She noted all refusals should be documented on the shower sheets and in the electronic record. Review with CNA-C on 09/05/2024 of Resident #34's shower sheets, revealed Resident #34 had last received a shower on 08/28/2024 Interview on 09/06/2024 at 11:05 a.m. with Regional RN revealed that resident showers should be documented in Matrix (electronic health record), under POC (point of care) section. Regional RN checked the POC and discovered that Resident #34 had a shower documented on 08/28/2024, but not on 09/04/2024, both scheduled shower days for him. Review of the POC with the Regional RN showed did not occur, was entered for his shower on 09/04/2024 by CNA-A. The Regional RN revealed that it was her expectation that each resident received a shower on their scheduled day, and if not possible, the shower be provided as soon as possible. The Regional RN noted that not showering residents on a regular schedule, could result in the resident developing skin problems or body odor. During an Interview with CNA-A on 09/06/2024 at 10:37 a.m., CNA-A confirmed that Resident #34 had not received a shower on 09/04/2024 because she had been called away to transport another resident to an appointment, and when she returned to facility discovered that none of the other CNA's had been able to help shower Resident #34 that shift. CNA-A stated that not providing the residents showers' when scheduled could result in bad body odor. Record review of facility policy titled Shower/Tub Bath revised October 2010 reflected that the following information should be recorded on the resident's ADL record: the date and time the shower/tub bath was performed.; if thte resident refused the shower/tub bath, the reason(s) why and the intervention taken, and to Notify the supervisor if the resudent refuses the shower/tub bath. 676292 Page 6 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 the environment remained as free of accident hazards as is possible for 1 of 23 Residents (Resident #22) reviewed for accident hazards in that: The facility failed to ensure Resident #22 was safe from hazards when there a small refrigerator (19x32 inches) placed on top of clothes drawer that was positioned near the head of the resident's bed. This deficient practice could place residents at risk of remaining in an environment that was not free of accident hazards and being injured as a result of the hazard. The finding included: During an observation on 9/3/24 at 11:20am in Resident # 22's room revealed a personal resident refrigerator which measured approximately 19x32 inches which was placed on top of a 4 drawer clothes dresser which measured approximately 30x30 inches. The refrigerator was noted to be directly beside the head of the Resident # 22's bed. Record review of the face sheet dated 9/4/24 for Resident #22 revealed resident admitted to the facility on [DATE] with diagnoses of type 2 diabetes (a condition in which the body has trouble controlling blood sugar), schizophrenia ( a disorder that affects a person's ability to think, feel, and behave clearly), and major depressive disorder( a mental disorder that can cause persistent low mood and loss of interest) Record review of the quarterly MDS assessment for Resident #22 revealed a BIMS score of 15 ( which indicates intact cognition). Record review of the care plan for Resident #22 initiated on 3/4/24 revealed care concern areas including decreased vision, fall risk, and assistance needed with ADL's. During an interview on 9/3/24 at 11:25 am Resident #22 stated that the refrigerator in his room has been on top of his clothes dresser for several months. He stated that he was worried that at some point it would fall over on top of him. During an Interview on 9/3/24 at 1:50pm with the Maintenance Director he stated that he would move Resident #22's refrigerator off of the top of the clothes dresser. The Maintenance Director stated that having the refrigerator on top of the clothes dresser would present a safety concern for Resident #22. Record review of the facility's policy on Maintenance Service dated 12/2009 stated The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. It stated that the building is to be maintained in good repair and free of hazards. 676292 Page 7 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day , 7 days a week and employ a full time DON for 74 of 184 days reviewed in that: Residents Affected - Some The facility failed to have an RN scheduled on 74 dates that were reviewed and has not had a fulltime DON since 7/31/24. This deficient practice could place residents at risk of not the nursing services received by the residents properly supervised. Record review of the facility's RN staffing hours from the time period of 3/1/24 through 8/31/24 revealed that an RN was not working in the building for an 8 hour shift on the following dates: 3/2/24, 3/3/24, 3/10/24, 3/16/24, 3/17/24, 3/21/24, 3/22/24, 3/24/24, 4/14/24, 4/21/24, 4/28/24, 4/29/24,4/30/24, 5/1/24, 5/4/24, 5/6/24, 5/7/24, 5/8/24, 5/13/24, 5/14/24, 5/15/24, 5/18/24, 5/19/24, 5/20/24, 5/21/24, 5/22/24, 5/26/24, 5/27/24, 5/28/24, 5/29/24, 6/1/24, 6/2/24, 6/3/24, 6/4/24, 6/5/24, 6/9/24, 6/14/24, 6/15/24, 6/16/24, 6/18/24, 6/19/24, 6/22/24, 6/23/24, 6/29/24, 7/6/24, 7/7/24, 7/13/24, 7/14/24, 7/19/24, 7/20/24, 7/21/24, 7/27/24, 7/28/24, 8/1/24, 8/2/24, 8/3/24, 8/4/24, 8/5/24, 8/8/24, 8/9/24, 8/10/24,8/11/24, 8/12/24, 8/16/24, 8/17/24, 8/18/24, 8/19/24, 8/20/24, 8/23/24, 8/24/24, 8/25/24, 8/28/24, 8/29/24, and 8/30/24. Met with the Administrator and Regional Nurse RN on 9/5/24 at 4:30pm and they confirmed that the facility did not have an RN working on the previous dates indicated for the months of March/April/May/June/July/August of 2024. The Regional RN stated that the facility has not had a full-time DON since 7/31/24. The Administrator and Regional RN stated they were unable to have a RN available on the schedule for the selected dates The Regional RN stated that the facility had hired a DON who would be starting her employment at the facility in several weeks. The Regional RN and Administrator stated that having an RN on the schedule for the selected dates would have provided better clinical oversight of the nursing services provided to the residents. Record review of the facility's job description for Director of Nursing dated 02/24 revealed that The primary role of the Director of Nursing (DON) is to plan, organize, and direct the day-to day functions of the Nursing Services Department in accordance with current Federal, State, and local regulations as well as maintain compliance with policies and procedures. The DON ensures that the highest degree of quality care is maintained. 676292 Page 8 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and documentation of what, if any, action has been taken to address them, for 2 of 8 residents (Residents #3 and #33) whose records were reviewed for pharmacy services. The facility failed to ensure the Physician provided a clinical response to the consulting pharmacist's recommended changes which consisted of: 1. To ensure monitoring for side effects for Resident #3's Xarelto (a medication used to treat and prevent blood clots, commonly referred to as an anti-coagulant.); and 2. To clarify diagnosis for use of an anti-depressant, and for dose reduction consideration for that anti-depressant for Resident #33. This failure could place residents at risk for significant health status declines. The findings included: Record review of Resident #3's face sheet, dated 09/06/2024, revealed a [AGE] year-old resident initially admitted on [DATE] with diagnoses including Epilepsy (disorder that causes seizures), Hemiplegia (condition that causes partial or complete parlaysis on one side of the body) affecting left dominant side, cerebral palsy (movement/muscle disorder present since birth), and personal history of traumatic brain injury. Record review of Resident #3's annual MDS assessment dated [DATE] reflected that Resident #3 was taking an anti-coagulant. Record review of Resident #3's Care Plan, dated 07/26/2024, reflected that Resident #3 had traumatic brain injury, but did not include a focus area addressing use of an anti-coagulant. Record review of Resident #3's MRR, dated 05/19/2024 revealed a recommendation for Nursing to monitor for side effects of Xarelto (a medication used to treat and prevent blood clots, commonly referred to as an anti-coagulant), including elevated PT/INR (lab tests which measure how quickly blood clots), blood in urine, and bleeding gums. The Xarelto was prescribed for traumatic brain injury. Record review of Resident's #3's Physician Orders dated 09/06/2024 revealed an order for Xarelto (rivaroxaban) tablet; 10mg; amt: 1 tablet; oral. Special Instructions: Administer 1 tablet daily. Further review of Physician Orders dated 09/06/2024 revealed there were no orders to monitor for side effects of Xarelto. Record review of Resident #3's MAR's for August and September 2024 did not reveal any documentation for monitoring of side effects of Xarelto. Record review of Resident #33's face sheet dated, 09/06/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnoses including cerebral infarction (the pathologic process 676292 Page 9 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0756 Level of Harm - Minimal harm or potential for actual harm that results in an area of dead tissue in the brain); Type 2 diabetes mellitus (long-term condition where the body has trouble controlling blood sugar) with other diabetic kidney complication; and Irritability and Anger. Record review of Resident #33's annual MDS Assessment, dated 08/14/2024, reflected Resident #33 was taking antidepressant medication. Residents Affected - Few Record review of Resident #33's Care Plan, dated 08/14/2024, reflected that Resident #33 had a history of behavioral issues, but did not include a focus area addressing use of an anti-depressant. Record review of Resident #33's MRR, dated 7/31/24 revealed recommendations to: 1. clarify diagnosis for Sertraline (an anti-depressant also known as Zoloft and can be used to treat depression, PTSD, OCD and panic disorder) and; 2. to consider dose reduction of his Sertraline 50mg every morning. Further review of Resident #33's MRR revealed there was no documented response to this recommendation from the pharmacist by the physician. Record review of Resident #33's Physician Orders dated 09/06/2024 reflected Resident #33 was still prescribed Zoloft (Sertraline) 50mg 1 tab once a day (start date was 02/21/2024), and the diagnosis listed for Zoloft was Irritability and anger. During interview with Regional RN on 09/06/2024 at 08:30 a.m., the Regional RN stated the consulting pharmacist reviewed medications once a month, and any recommendations were then put in PDF format and sent to the physicians or psychiatric provider by the DON, and the physicians would then review, sign and return back to the DON. The Regional RN stated that the facility did not currently have a DON, and had been without a DON for periods of time this past year, and because of this she was unable to locate any documentation showing that the pharmacy recommendations for Resident's #3 and #33 had been sent to the physicians or had been reviewed by the physicians, The Regional RN stated this could result in physicians not being aware of or acting upon pharmacist recommendations, that could have other consesquences such as Resident #33 possibly receiving unnecessary medication or Resident #3 not being monitored for serious side effects from an anti-coagulant Record review of the facility Medication Regiment Reviews Policy revised May 2019, reveals that within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity, and The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. Further review reflects that If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director. 676292 Page 10 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #33) of 8 residents reviewed for unnecessary medications, in that: Resident #33 was prescribed a psychotropic drug for depression without a documented diagnosis of depression in the clinical record. This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. The findings included: Record review of Resident #33's face sheet dated, 09/06/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnoses including cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain); Type 2 diabetes mellitus (long-term condition in which body has trouble controlling blood sugar) with other diabetic kidney complication; and Irritability and Anger. Record review of Resident #33's annual MDS Assessment, dated 08/14/2024, reflected Resident #33 was taking antidepressant medication. Record review of Resident #33's Care Plan, dated 08/14/2024, reflected that Resident #33 had a history of behavioral issues, but did not include a focus area addressing use of an anti-depressant. Record review of Resident #33's MRR, dated 7/31/24 revealed recommendations that included: 1. clarify diagnosis for Sertraline (an anti-depressant also known as Zoloft and can be used to treat depression, PTSD, OCD and panic disorder) and; Further review of Resident #33's MRR revealed there was no documented response to this recommendation from the pharmacist by the physician. Record review of Resident #33's Physician Orders dated 09/06/2024 reflected Resident #33 was still prescribed Zoloft (Sertraline) 50mg 1 tab once a day (start date was 02/21/2024), and the diagnosis listed for Zoloft was Irritability and anger. During an interview with the Regional RN on 09//06/2024 at 08:30 a.m., the Regional RN confirmed Resident #33 was prescribed a psychotropic medication for depression without a documented diagnosis of depression in the clinical record and that the pharmacist's recommendation for clarification of the diagnosis had not been addressed. The Regional RN further stated the process for the medication regimen review was the consultant pharmacist reviewed each residents' medication regimen and sent the recommendations to the DON, usually within 24 hours, and the DON sends them to the attending physicians or prescribing physicians box. The Regional RN noted that the facility did not currently have a DON, and had been without a DON for periods of time this past year, and because of this she was 676292 Page 11 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unable to locate any documentation showing that the pharmacy recommendations for Resident's #33 had been sent to the physicians or had been reviewed by the physicians, The Regional RN stated this could result in physicians not being aware of or acting upon pharmacist recommendations. Record review of the facility Medication Regiment Reviews Policy revised May 2019, reveals The MRR involves a thorough review of the resident's record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses or without clinic indication. and d. inadequeste monitoring for adverse consequences. 676292 Page 12 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assist residents in obtaining routine dental care for 1 of 8 residents (Residents #33) reviewed for dental services in that: Residents Affected - Some The facility failed to assist Resident #33 in obtaining needed dental services following referral to an oral surgeon for tooth extraction after being diagnosed with abscessed tooth. These failures could lead to pain and infection of teeth and gums. The findings included: Record review of Resident #33's face sheet dated, 09/06/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnosis including cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain); Type 2 diabetes mellitus with other diabetic kidney complication; and periapical abscess without sinus (a pocket of pus at the root of a tooth caused by an infection that doesn't involve the sinuses). Record review of Resident #33's annual MDS Assessment, dated 08/14/2024, reflected Resident #33 had been coded as being independent in oral hygiene and under Oral/Dental Status no problems with gum or teeth were noted. Record review of Resident #33's Care Plan, last reviewed 6/26/2024, reflected that Resident #33 had dental concerns, with ordered antibiotic for tooth. Record review of event history progress notes for Resident #33 for the months of February through September 2024 reveal the following entries concerning tooth infection and pain: a. Progress note dated 02/26/2024 revealed Resident #33 was prescribed amoxicillin tablet [an antibiotic] 500mg; amt: 1 tablet; oral Special Instructions: Administer 1 tablet tid [three times a day]x7 days for a tooth infection. b. Progress note dated 2/27//2024 @ 01:44pm revealed Resident day 2/7 antibiotic for abscess dental. Denies pain, just hurts when he chews. Afebrile. c. Progress note dated 2/28/2024 @ 07:55am revealed Resident #33 continues on ATB [antibiotics] for Tooth abscess. No complaints voiced at this time. d. Progress note dated 07/22/2024 @ 6:59pm revealed Resident #33 complain of toothache to right side lower, asked for dental appointment. LULING Dental called appointment made for Tuesday morning at 8am. Resident informed, aware of $50 charge. e. Progress note dated 07/23/2024 at 04:04 p.m. revealed Resident with abscess to tooth will start ATB, referral to oral surgeon for tooth extraction. Resident informed of consultation and cost of 130$. f. Progress note dated 09/04/2024 @03:03 p.m. revealed Resident #33 with toothache rated 3 out of 10 by resident to this writer. Resident states he will ask nurse for pain medication if he needs it. 676292 Page 13 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Facility is working on getting oral surgeon appointment to have tooth extracted. Resident is eating 50-100% of meals and denies pain with chewing. Weights are stable. Interview with Resident #33 on09/04/24 at 02:25 PM revealed he was only able to shake his head affirmatively or negatively to indicate yes or no, when answering questions, but did shake his head affirmatively to indicate yes when asked if he was still experiencing tooth pain. He was unable to indicate how bad his pain was. When asked if he was ever taken to see oral surgeon to have tooth removed, he shook his head negatively (side to side) to indicate no. During an interview with Regional RN on 09/04/2024 at 03:25 p.m. the Regional RN confirmed that Resident #33 was treated with antibiotics for a tooth infection in February 2024, had been seen by dentist on 03/06/2024 and was referred to oral surgeon for extraction, but never made it to the oral surgeon. She was not able to provide any documentation that Resident #33 had been seen by the dentist on 03/06/2024 and did not know why he was not sent to oral surgeon. Further interview with Regional RN revealed that Resident #3 was treated for another tooth infection on 07/22/2024, referred to oral surgeon on 07/23/2024, and had appointment with the oral surgeon scheduled for 08/06//2024, but he never made it to the appointment. The DON stated she did not know why the appointment with oral surgeon was not kept. The Regional RN stated that not having the recommended tooth extraction could lead to increased pain and infection for Resident #33. Record review of the facility policy titled Dental Services dated December 2016, revealed Routine and 24-hour emergency dental services are provided to our residents .and Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. 676292 Page 14 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for four of four residents (Residents #17, #20, #32 and #37) reviewed for food meeting residents' needs, in that: The DM did not puree the peach cobbler to a pudding or mashed potato consistency as required for Residents #17, #20, #32 and #37 who were ordered a pureed diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to choking, poor intake, and/or weight loss. The findings included: Record review on 09/05/2024 of the resident menu for 09/05/2024 for residents whose diet order was a pureed diet was: Pureed spaghetti with meat sauce, pureed sauteed peas with onions, pureed dinner roll, pureed peach cobbler, and a beverage. Record review on 09/05/2024 of the electronic health records of Residents #17, #20, #32 and #37 revealed four residents had the diet order: Regular diet, Pureed texture, and Thin liquids. Observation on 09/05/2024 at 11:55 AM in the room of Residents #17, #20 and #37 during the lunch meal revealed the pureed peach cobbler on all the residents' trays had the consistency of a nectar-thick liquid. When a spoonful of the dessert was turned to the side, the dessert poured out of the spoon and back into the serving dish. The texture of the dessert did not resemble pudding or mashed potatoes. During an interview on 09/05/2024 at 11:56 AM with CNAs B, C, and A, who fed Residents #20 (Bed A), #17 (Bed B) and #37 (Bed C), respectively, all three CNAs stated the consistency of the peach cobbler was thin and runny and not appropriate for residents who received a pureed diet. CNA B stated she poured the dessert over Resident #20's spaghetti and mixed it in, which was this resident's preference as he liked his food sweet, but the dessert should not have been of a pourable consistency. Resident #17 did not eat the dessert, and CNA A fed the dessert by spoon to Resident #37, who consumed half of it. Attempted interviews on 09/05/2024 at 11:40 PM and 12:15 PM with Residents #17, #20, #32 and #37 were unsuccessful as they were not interviewable. During an interview on 09/05/2024 at 1:20 PM, the Regional Nurse stated the pureed peach cobbler served on the test tray was not the appropriate texture for residents ordered a pureed diet and she would discuss the issue with the DM. During an interview on 09/05/2024 at 1:30 PM, CNA A, stated Resident #32 was self-feeding, ate in his room, and the tray had been removed from his room. She did not know if he had consumed the pureed peach cobbler. During an interview on 09/05/2024 at 1:52 PM, the DM, stated the texture of the pureed peach 676292 Page 15 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cobbler should have resembled mashed potatoes or pudding and it was not the proper texture. She had a recipe but had not followed it and just pureed the peaches with some of the liquid. She understood serving residents ordered a pureed diet a food item of an incorrect texture could lead to choking. Record review of the recipe for Pureed Fruit Cobbler for 5 servings provided by the facility revealed, Ingredients: Fruit Cobbler 3 ¾ cups, Juice from base, ¾ cup. Place prepared fruit cobbler and juice in a washed and sanitized food processor; blend until smooth. Portion with a #6 scoop. *Note: Any liquid specified in the recipe is a suggested amount of liquid (if needed). Some recipe items will require no liquid added to achieve the desired consistency. 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. Record review of Dysphagia Puree (Level 1) Diet, Chapter 2: Consistency Alterations, [NAME] & Associates, Inc., 2019, provided by the facility, revealed: This diet is used only for people who have severe chewing and or swallowing problems. All foods are pureed to simulate a soft food bolus, eliminating the whole chewing process . all foods must be the consistency of moist mashed potatoes or pudding. 676292 Page 16 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

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. 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, in that: 1. The facility failed to store clean plastic cups in a manner that allowed for air circulation. 2. The facility failed to ensure the tabletop can opener blade and base were free of buildup of grime and debris. 3. The facility failed to ensure an opened 5-lb. bag of pancake mix was stored in a sealed bag or container in the dry storage room. 4. The facility failed to ensure the interior racks, walls and floor of the reach-in refrigerator were free of dirt and debris. 5. The facility failed to ensure the low-temperature dishwasher reached 120 degrees Fahrenheit during the wash cycle. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 09/03/2024 at 11:35 AM revealed two plastic trays of clear plastic drinking cups on the clean side of the dish machine. The first tray had 38 cups and the second tray had 20 cups. The cups were stacked with the open side touching the trays without air-drying nets separating the cups from the trays. The trays were wet to the touch. During an interview on 09/03/2024 at 11:36 AM the DM stated the cups should have been separated from the trays with air-drying nets to allow for proper air-drying and prevent the potential growth of microorganisms. 2. Observation on 09/03/2024 at 11:38 AM in the kitchen revealed the tabletop can opener was covered with sticky grime that was black and brown in color. The grime covered the blade portion of the can opener, the adjustable bar, and also surrounded the base that was affixed to the table with screws. During an interview on 04/11/2023 at 11:39 AM the DM stated that the can opener blade, bar and base were covered in sticky grime and should not have been. The DM stated the cooks were responsible for ensuring the can opener and area surrounding the base remained clean and free of debris, and that failing to do so could result in contamination of food from bacteria lingering on the blade and potential foodborne illness. 3. Observation on 09/03/2024 at 11:40 AM in the dry storage room revealed an opened lb. bag of buttermilk pancake mix on a shelf. The bag was approximately ¾ full, and top right side of the bag was opened. The bag was not closed with any type of fastener, and the bag was not enclosed in a 676292 Page 17 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0812 sealed container. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/11/2023 at 11:41 AM the DM stated the bag of pancake mix was not sealed, and the bag should have been stored either in a larger bag with a zip lock or a sealed container. All kitchen staff stored food in the dry storage room, and that failing to ensure food was properly sealed could result in deterioration in food quality and potential contamination from pests. Residents Affected - Many 4. Observation on 09/03/2024 at 11:42 AM in the reach-in cooler revealed all the white wire racks holding stored food were heavily speckled with black and brown spots. The spots were easily removable with fingers, indicating they were dirt, grease and debris. There was also a buildup of stains from spilled liquids at the bottom of the cooler. During an interview on 09/03/2024 at 11:43 AM, the DM stated the racks and interior of the reach-in cooler were dirty and should have been cleaned. She had recently terminated a staff member and was short-handed. 5. Observation on 09/03/2024 at 11:52 AM of Dietary Aide D as she ran the low-temperature dishwasher. The gauge on the machine revealed it reached a temperature of 92 degrees Fahrenheit during the wash cycle. DA D ran the machine again at 11:55 AM, and the temperature gauge on the machine read 109 Degrees Fahrenheit. DA D ran the machine again at 11:57 and 11:59, and the temperature gauge revealed the machine reached a temperature of 110 degrees Fahrenheit during both wash cycles. Record review of the Dish Machine Temperatures and Sanitizing Log for September 2024 revealed the AM wash temperature on 09/03/2024 was 120 degrees Fahrenheit and the sanitizer ppm was 50. During an interview on 09/03/2024 at 12:00 PM, the DM stated the machine needed to reach the temperature of 120 degrees Fahrenheit during the wash cycle and it occasionally took several times for the machine to reach this temperature. The machine reached this temperature earlier in the day. It was important for the machine to reach the proper temperature to ensure the dishes were clean and did not carry germs and bacteria that could make the residents ill, and she would utilize the three-compartment sink for the lunch meal until the machine was fixed. She trained her staff on the proper use of the dishwasher and both she and her staff also received regular training from the consultant dietitian. Record review of facility policy, Sanitization, revised November 2022, revealed, The food service area is maintained in a sanitary manner. 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. 5. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are: b. Low-Temperature Dishwasher (Chemical Sanitization): (1) Wash temperature (120 degrees Fahrenheit); (2) Final rise with 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse; and (3) The chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. 6. Manual washing and sanitizing is a three-step process for washing, rinsing and sanitizing: a. Scrape food particles and wash using hot water and detergent; b. Rinse with hot water to remove soap residue; and c. Sanitize with hot water (at least 171 degrees Fahrenheit for 30 seconds) or chemical sanitizing solution. Chemical sanitizing solutions are used according to manufacturer's instructions. 7. Food service equipment and utensils that are manually washed are 676292 Page 18 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. Record review of facility policy, Food Receiving and Storage, Revised November 2022, revealed: 3. Dry foods and goods are handled in a manner that maintains the integrity of the packaging until they are ready to use. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart. mg/L pH 10 or Less pH 8 or Less 25-49 120 degrees F 120 degrees F 50-99 100 degrees F 75 degrees F 676292 Page 19 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 8 residents (Residents #39 and #47) and 1 of 2 halls (South Hall) reviewed for infection control, in that: Residents Affected - Some 1. During a wound dressing change for Resident #39, LVN-F did not sanitize hands or change gloves in between removal of old dressing and cleansing and application of new dressing. 2. While providing incontinent care for Resident #47, CNA-E did not sanitize her hands in between glove changes when moving between soiled and clean incontinent pads, touched wipes dispenser with dirty gloves, and stored clean gloves in the front pocket of her scrubs where her cell phone was also stored. 3. The facility failed to ensure a shared shower and toilet area was clean and free from sources of infection. These deficient practices could place residents at-risk for infection due to improper care practices. 1. Record review of Resident #39's face sheet dated 09/06/2024 revealed an initial admission date of 06/06/20023 and a re-admission date of 05/31/2024, with diagnoses that included: Cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain); Flaccid hemiplegia affecting left nondominant side (condition that occurs after a stroke, where one side of body is paralyzed or weakened); Cellulitis (bacterial skin infection) of left lower limb; and peripheral vascular disease (PVD - a progressive circulation disorder caused by narrowing or blockage of a blood vessel). Record review of Resident #39's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate impairment. Record review of Resident #39's Care Plan dated 08/27/2024 revealed problem areas which included: Venous wound to right shin and potential for complications, discomfort related to diagnosis of PVD. Record review of Resident #39's Physician Orders dated 09/05/2024 revealed an order to Cleanse wound to right shin with normal saline and pat dry. Cover with calcium alginate and cover with bordered dressing. Change every 3 days. Observation of wound dressing change for Resident #39 on 09/05/24 at 01:53 p.m. revealed LVN-F did not sanitize or change gloves in between removal of old dressing, the cleansing and patting dry of area, and application of alginate dressing on the wound. During interview with LVN-F on 09/05/24 at 02:00 p.m., LVN-F stated she doesn't deal with that many wounds here, and she was not aware of need to sanitize/change gloves between removal of old dressing and application of new dressing. 2. Record review of Resident #47's face sheet dated 09/06/2024 revealed an initial admission date 676292 Page 20 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of 03/28/2024 and a re-admission date of 05//19/2024 with diagnoses that included: cerebral infarction due to thrombosis of precerebral artery (stroke due to blood clot); and Hemiplegia and hemiparesis affecting left non-dominant side (conditions that causes paralysis or weakness one side of body). Record review of Resident #47's Care Plan dated 07/26/2024 revealed problem areas which included: incontinent of bowel and bladder. Record review of Resident #47's Quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment and under toileting functional ability a coding of 1 indicating total dependence on others. Observation of incontinent care for Resident #47 on 09/03/2024 at 12:12 p.m. revealed CNA-E: a. Did not sanitize her hands in between glove changes when moving between soiled and clean incontinent pads, b. Touched wipes dispenser with dirty gloves when obtaining more wipes, c. Obtained stored clean gloves during the provision of incontinence care by reaching into the right front pocket of her scrubs top (where her cell phone was also stored) with the same gloves that were used to remove the soiled pad. During an interview with CNA-E on 09/03/2024 at 12:20pm, CNA-E confirmed that she had not sanitized her hands in between glove changes and stated that they [CNA's] are usually provided with small hand sanitizers, but they were currently out. She also confirmed that she had touched the wipes dispenser with dirty gloves when obtaining wipes during pericare, and that she had obtained clean gloves from her scrubs pocket where her personal cell phone was also stored, with a dirty glove because she was in a hurry and shrugged her shoulders. CNA-E stated that by not sanitizing her hands and touching items with dirty gloves, it could result in germs being spread. During an interview with the Regional RN on 09/05/2024 at 11:57 a.m, the Regional RN verbally confirmed that staff should sanitize hands and change gloves in between moving from dirty to clean areas during wound care, and also that staff should sanitize their hands in between glove changes, not store gloves in their scrub pockets or touch the wipe dispenser with dirty gloves. The Regional RN stated that not following correct infection control procedures could result in cross-contamination and the spread of infection. Record review of facility policy titled Standard Precautions revised September 2022, revealed Hand hygiene is performed with alcohol-based hand rub or soap and water (3) before moving from work on a soiled body site to a clean body site on the same resident; and (5) after removing gloves. Further review reveals Gloves are changed, and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care. 3. Observation of shared shower and toilet room on South Hall on 09/03/2024 at 11:55 a.m. revealed numerous spots of feces and dried yellow/brown stains on the floor around the toilet and in front of the hand sink. The toilet was filled with urine and feces, and there was a small gray wash basin sitting on the floor to the side of the toilet filled with soiled toilet tissue. The room smelled strongly of urine. There was no toilet paper available. There were 3 bedside commodes stored on left side of shower room, one with dirty sheets thrown on top, and on the floor below the bedside commodes 676292 Page 21 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were several pairs of used gloves. A used disposable razor was resting on top of the paper towel dispenser near the sink and another used razor was sticking out of the sharps container on the opposite wall, with the razor portion visible. During an interview with Housekeeper-G on 09/03/2024 at 1:05pm, Housekeeper G confirmed the presence of feces and dried urine on the floor of the shower room, used gloves on floor, and used razors laying out. Housekeeper G stated that the CNA's are supposed to pick up the resident items and clean any feces/urine left after each resident showers. She stated she was responsible for cleaning the shower room at 2pm daily after everyone completes their shower and to ensure adequate supplies such as toilet paper were available. Interview on 09/03/2024 at 1:11pm with the Housekeeping Supervisor revealed that most resident showers occur in the mornings and Housekeeping is to clean showers first thing in the morning. The Housekeeping Supervisor confirmed the presence of feces and urine on the floor, used gloves on floor, plastic wash basin filled with used toilet tissue, and noted no trash can or toilet paper was available in shower room. She stated it was the responsibility of the CNA's to clean any feces on floor and remove resident items, but that housekeeping should then come and disinfect the floor and area. The Housekeeping Supervisor stated that they are currently short-staffed, and have had a lot of staff turnover, resulting in areas not being cleaned as they should, but we do the best we can. She noted that having urine and feces on the floor, along with used gloves and used razors out could result in the spread of disease/infection. During an interview with Charge Nurse LVN-F on 09/03/2024 at 1:23 p.m, LVN-F confirmed the presence of urine/feces on floor, the used gloves and razors laying out, and stated the area needed to be cleaned immediately, and that whomever found it in that condition should clean it or it could lead to disease and infection. She properly disposed of the used razor into the sharps container on the wall and left to see about getting area cleaned. Record review of facility policy titled Standard Precautions revised September 2022 revealed Environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned and Used disposable syringes and needles, scalpel blades, and other sharp items are placed in appropriate puncture-resistant containers located as close as practicable to the area in which the items were used. 676292 Page 22 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. 1. The facility failed to repair the overhead light in room#4 that had mold inside the cover, remove rust from an overhead pipe above a bed in room [ROOM NUMBER], clean a dirty chair cushion in room [ROOM NUMBER], repair a window sill in room [ROOM NUMBER] that was stripped of paint, remove the mold on the hallway ceiling outside of room [ROOM NUMBER], remove the dust/dirt from two hallway air conditioning vent, across from room [ROOM NUMBER], re-attach the covers for the 2 overhead lights in room [ROOM NUMBER], secure the overhead light to the ceiling in room [ROOM NUMBER], replace the 3 ceiling panels in room [ROOM NUMBER], remove the mold from a side wall vent in room [ROOM NUMBER], remove the mold from a wall area above the door entrance in room [ROOM NUMBER], replace a broken ceiling tile in the hallway near room [ROOM NUMBER], repair a wall penetration in the ice machine room, and repair a broken cabinet hinge in the ice machine room. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: 1. During an observation on 09/3/24 from 1:25 p.m. to 1:50 p.m. with the Maintenance Director. revealed the following: a-Resident room [ROOM NUMBER] had mold inside the overhead light cover which measured approximately 3x1 ft. b. Resident room [ROOM NUMBER] had an area of rust on a ceiling pipe that was running above the bed-B. c. Resident room # 5 had a bed side chair that had a dirty seat cushion marked with black stains. d.-Resident room [ROOM NUMBER] had a window sill that was bare and stripped of paint. e.-The hallway ceiling across from room [ROOM NUMBER] had an area of mold on the ceiling. f.-The two air conditioning unit vents which measured each approximately 2x2 ft across from room [ROOM NUMBER] had dirt and dust in the vents. g. Resident room [ROOM NUMBER] had two overhead lights that had the light covers which were not attached. h.-Resident room [ROOM NUMBER] had an overhead light that was not secured to the ceiling. i-Resident room [ROOM NUMBER] had three missing ceiling tiles which each measured approximately 2x2 ft. 676292 Page 23 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0921 Level of Harm - Minimal harm or potential for actual harm j.-Resident room [ROOM NUMBER] had a 3 inch surface area of mold on the ceiling above the door entrance. k.-Resident room [ROOM NUMBER] had mold inside of the wall air conditioning vent unit which measured approximately 2x1 ft. Residents Affected - Some l.-Resident hallway near room [ROOM NUMBER] had a broken ceiling tile which measured approximately 2x2 ft. m-Ice machine room had a 5 inch wall penetration behind the ice machine. n.-Ice machine room had a broken hinge on a standing two drawer cabinet which measured 4x2 ft. During an interview with the Maintenance Director on 09/3/24 at 1:45 p.m. he stated that he had not been made aware by staff of the noted areas needing to be repaired. The Maintenance Director stated that fixing the areas noted for repair would promote resident safety and a homelike environment. During an interview with the Administrator on 9/3/24 at 1:55 p.m., he stated that fixing the areas noted for repair would provide a more homelike environment for the residents. Record review of the facility's policy on Maintenance Service dated 12/2009 stated The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. It stated that the building is to be maintained in good repair and free of hazards. 676292 Page 24 of 25 676292 09/06/2024 Avir at Luling 501 W Austin St Luling, TX 78648

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 provide a resident environment that was free of pests and rodents for 1 of 1 facility reviewed for effective pest control in that: Residents Affected - Some The facility failed to provide a resident environment that was free of pests and rodents as live roaches were observed in resident rooms and in the kitchen. This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents. The findings included: 1. During an observation on 9/3/24 at 10:45 AM in Resident room [ROOM NUMBER] a live roach was observed on the right wall after entrance to the room. During an interview with CNA A on 9/3/24 at 10:46 AM she revealed that she had also observed the live roach in resident room [ROOM NUMBER]. During an interview with Resident #22 and Resident # 29 on 9/3/24 at 11:20 AM the residents stated that they had observed live roaches on their bedroom floor approximately 2 weeks ago. 2. During an observation on 09/05/2024 at 10:55 AM in the kitchen several live roaches were seen on the floor in front of the stove. During an interview on 09/05/2024 at 10:56 AM the DM stated she periodically saw roaches in the kitchen. The pest control service came monthly to spray for insects, and she anticipated they would be coming soon since it was the beginning of the month. During an interview with the Administrator on 9/5/24 at 5:00 PM he stated that the pest control service came to the facility on a monthly basis, and he would address additional concerns to the pest control company so that the pests (roaches) are corrected in the building. Record review of the facility policy dated 05/2008 revealed, The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 676292 Page 25 of 25