Health inspection·October 25, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure the resident environment remains as free of accidents and hazards for one (1) of one facility resident transport van reviewed for accidents and hazards. The facility failed to ensure the facility resident transport van used for dialysis appointments was maintained properly for safety hazards that may result in an injury to a resident. The transport van overheated en route back to the facility, the starter needed to be replaced, and then the engine needed to be replaced. The resident transport van was used 3-4 times a week on average for appointments, activity outings, etc. This failure could place residents at risk of injuries, illness, and hospitalization. Findings included: On 10/25/2023 at 1:30 pm, LVN A stated the van broke down numerous times over the last two months. LVN A said the facility used a rental van to transport residents. LVN A stated this inconvenienced the residents resulting in missed appointments. On 10/25/2023 at 1:50 pm, LVN B stated the van has had issues for a few months. LVN B stated the mechanical issues with the van caused some residents to miss multiple appointments. LVN B stated she sent out a group text message yesterday (10/24) for an update on the van. LVN B stated the BOM responded the van was at the repair shop again. LVN B stated the [NAME] then arrived at the facility and said the van needed a new motor. On 10/25/2023 at 2:15 pm, MA A stated some residents have missed appointments due to lack of reliable transportation. MA A stated on Friday (10/20) the van overheated en route back to the facility. MA A said the facility had to rent another van. MA A stated Corporate had not purchased a new van, nor spent money to have the van properly fixed. On 10/25/2023 at 2:35 pm, the ABOM stated residents missed appointments due to lack of transportation. She stated the BOM contacted other transport companies on Tuesday (10/24), but the transport companies were booked. The ABOM stated the ADM informed Corporate they needed to rent another van. The ABOM stated Corporate knew the van broke down on Friday (10/20) and transportation was needed for Monday (10/23). Corporate did not provide the facility with an update until Monday evening. The ABOM stated it is dangerous for residents to miss necessary appointments that could potentially affect their quality of life. The ABOM stated this is sad and ridiculous. Page 1 of 3 676475 676475 10/25/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 Level of Harm - Minimal harm or potential for actual harm On 10/25/2023 at 3:00 pm, the [NAME] stated she gets the residents to their appointments timely, unless there is an issue with the van. The [NAME] stated this is the third time the van had been in the shop. She stated it is a lot of things wrong with the van. The van broke down in September and they had to rent a van. This last time, they returned the rental van on Tuesday (10/17). The van broke down 3 days later on Friday (10/20). With the van constantly breaking down, residents will potentially continue to miss appointments. Residents Affected - Some On 10/25/2023 at 3:35 pm, CNA A stated the van was inoperable. CNA A stated the van kept breaking down regularly. CNA A stated the facility has resorted to renting vans. CNA A stated the van constantly breaking down caused some residents to miss appointments On 10/25/2023 at 4:40 pm, the BOM stated the van was working fine on Thursday (10/19). The BOM stated the next day on Friday (10/20), on the way back to the facility, the van started smoking. The BOM stated the mechanic picked the van up the same day and informed them the starter went out. The BOM said on Monday, the mechanic informed her the starter was overheating, and she received approval from Corporate to pay the mechanic to fix it. The BOM stated on Tuesday morning, the mechanic notified her the van needed a new motor. The BOM stated she started looking for another accessible van to rent but did not receive approval from the RVP to rent the van until the next day. The BOM stated they first had to rent a van from 9/14 until 10/2 and again from 10/4 until 10/19. The BOM stated on multiple occasions, Corporate had been made aware of the mechanical issues with the van. The BOM stated the ADM has also asked Corporate to purchase a new van. On 10/25/2023 at 5:25 pm, the RVP stated he does not recall the exact date he was informed about the van breaking down. The RVP stated the first time the van broke down was maybe two weeks ago. The RVP stated they had the van sent to the shop and it was returned to the facility the next day. The RVP stated he then received a call from the BOM that the van would not start. The RVP stated he then called the shop to have it fixed and the mechanic informed him it was now an additional part, so he had the mechanic fix it all. The RVP stated the van worked for a few days. The RVP stated on Saturday night (10/21), when he checked his phone, he saw there was another issue with the van. The RVP stated while the van had been in and out of the shop, they had a rental van. The RVP stated they had to return the rental van because another customer had already reserved the van for this particular date. The RVP stated he is in contact with 9 companies attempting to purchase a van or take out a new long-term rental which he has done many times in the past. The RVP stated as soon as they locate a van, it will be delivered to the facility. The RVP stated the normal process when the van requires maintenance is that the facility informs him, and he has the van sent to the shop to be diagnosed. The RVP stated they do not have a set protocol because his vans do not break down. The RVP stated his plan moving forward is to replace the van. The RVP stated it is himself and the ADM's responsibility for the day-to-day operation of the facility. The RVP stated he is the contact person for Corporate whenever financial approval is required. On 10/25/2023 at 06:05 pm, the ADM stated the facility van breaks down all the time. When it breaks down, they take it to the mechanic. He told the RVP they need a new van, or a used van. The ADM stated he does not want to run the facility with this van and the RVP has not purchased him a van yet. The ADM stated sometimes they rent a van and sometimes they do not get a timely approval to rent a van because the RVP likes to do things at the last minute. The ADM stated this is why the residents sometimes miss their appointments. The ADM stated he has a lot of emails that he has sent to the RVP informing him it is against the law, and he is not going to have his license revoked because of him. The ADM stated they need to give him a new van. He stated the RVP sent him a text message this morning (10/25) saying, A new van is coming soon. 676475 Page 2 of 3 676475 10/25/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of a Rental Invoice from a local rental agency reflected the NF rented a 2021 [NAME] Voyager Van from 9/14/2023 until 10/2/2023. Review of a Rental Invoice from a local rental agency reflected the NF rented a 2021 [NAME] Voyager Van from 10/4/2023 until 10/18/2023. Residents Affected - Some Review of a Rental Invoice from a local rental agency reflected the NF rented a 2021 [NAME] Voyager Van starting 10/25/2023. Review of the facility training material titled, Healthcare Transportation Training dated 8/18/2023 reflected (a) The nursing facility is responsible for providing normal transportation for the recipient to medical services outside the facility. Review of the facility undated training material titled, Healthcare Vehicle Inspection Training reflected .we want to provide safe and comfortable transportation to and from resident appointments. To ensure that these standards are met, we must conduct a vehicle inspection regularly. and repair any deficiencies immediately. Review of the facility policy Safety and Supervision of Residents revised July 2017 reflected Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities and 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting processes, QAPI Reviews of safety and incident data and a facility-wide commitment to safety at all levels of the organization. Review of the facility policy Maintenance Service revised December 2009 reflected Maintenance services shall be provided to all areas of the building, grounds, and equipment. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 676475 Page 3 of 3