Health inspection·November 14, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure all allegations involving abuse and neglect were immediately reported no later than 24 hours after an allegation was made for 1 of 2 residents (Resident #1) reviewed for grievances, in that: The facility failed to report Resident #1's allegation of verbal abuse to the State Agency within 24 hours. Resident #1's family filed a grievance on 10/18/23 that stated Resident #1 told them that staff were not changing her wound dressing, her wound was worsening, and she would not ask staff for assistance because staff yelled at her when she asked. This deficient practice could place residents at risk of abuse or neglect. Findings included: Record review of Resident #1's face sheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE], discharged to the hospital ER on [DATE], her own RP, and with diagnoses including encounter for surgical aftercare following surgery on the digestive system, type 2 diabetes mellitus without complications, moderate protein-calorie malnutrition, muscle wasting and atrophy not elsewhere classified and multiple sites, unspecified lack of coordination, unspecified feeding difficulties, generalized muscle weakness, cognitive communication deficit, dysphagia (difficulty swallowing foods or liquids), unspecified depression, adjustment disorder with depressed mood, presence of urogenital implants, and unspecified dementia. Record review of Resident #1's comprehensive MDS assessment, dated 08/28/23, reflected a BIMS score of 14, indicating her cognition was intact. Resident #1 was not rated in urinary continence and always incontinent with bowel. Resident #1 required extensive assistance of 1 person with bed mobility and personal hygiene, physical help in part with bathing activity, and was dependent of 1 person with toilet use. Resident #1 was at risk of developing pressure ulcers and had no unhealed pressure ulcers. Record review of Resident #1's clinical record reflected she did not have a baseline and comprehensive care plan. Record review of the facility's grievance/complaint form, dated 10/18/23, reflected Resident #1's family filed a grievance. The incident occurred on multiple dates. The time was night shift. The nature of the grievance/complaint indicated, Wound dressing not being changed, wound worsening. Resident will not ask for assistance. 'Is scared because staff yells at her when she asks.' There were no Page 1 of 12 676475 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few persons involved or witnesses listed. Actions or recommendations to be taken included, Action towards nighttime nurses and aides needs to be addressed by administrator to prevent this from continuing to happen. Resident #1's family reported to BOM. BOM notified Admin. The grievance was received by BOM on 10/18/23. Record review of Resident #1's progress note, dated and documented on 10/18/23 at 3:20 p.m. by the SSD, reflected the following: Resident #1's family reported to the BOM on 10/18/2023, that Resident #1 stated that she is scared to ask for help because staff yells at her when she pushes the call light and asks for help. Resident #1's family stated that this has happened multiple times and it has gotten to the point that the wounds are getting worse on the resident, due to them not being changed frequently enough. BOM, filled out a grievance form, BOM passed it along to social services. Social services took grievance to the administrator to see what further action/recommendations needs to be taken and administrator stated that he will talk to Resident #1 and handed the grievance form back to social services. There were no other related progress notes. An attempt to interview Resident #1 was made on 11/14/23 at 3:41 p.m., but Resident #1 was not at the facility. During an interview on 11/14/23 at 4:45 p.m., BOM stated she was receiving and processing grievances for the facility because the facility did not have a social worker. BOM also stated Resident #1's grievance was filed and given to the ADM on 10/18/23. BOM stated Resident #1's grievance was ongoing . BOM stated the ADM told her he would speak with Resident #1 or Resident #1's family about the grievance when she handed the form to him on 10/18/23. BOM stated she did not know if the ADM spoke with Resident #1 or Resident #1's family about the grievance. During an interview on 11/14/23 at 5:12 p.m., ADM stated the facility did not have a social worker. ADM stated the BOM was acting as the social worker and received grievances. ADM stated the BOM did not notify him of Resident #1's grievance filed on 10/18/23. ADM also stated he was not provided Resident #1's grievance filed on 10/18/23. ADM also stated he did not report Resident #1's verbal abuse allegation to the State Agency because this was the first time he heard of Resident #1's grievance filed on 10/18/23. ADM stated he was the abuse and neglect coordinator. ADM also stated he, the BOM, and the ADON could report abuse and neglect to the State Agency. ADM also stated the facility must report abuse or neglect to the State Agency within 24 hours if there was no serious injury to the resident and within 2 hours if there was a serious injury to the resident. ADM stated if a resident alleged they were abused or neglected by a staff member, he was trained to suspend the alleged perpetrator(s), investigate the alleged incident, and terminate the staff despite the results. ADM stated he would report Resident #1's allegation to the State Agency when he was back at the facility on 11/15/23. ADM explained he was not at the facility on 11/14/23 because he was sick. During an interview on 11/14/23 at 5:53 p.m., BOM and ADON stated any staff member could report abuse and neglect to the State Agency. BOM and ADON stated the ADM investigated and reported to the State Agency all allegations or suspicions of abuse and neglect, per the most recent in-service training given to staff on abuse and neglect. BOM and ADON stated they did not know if the ADM spoke with Resident #1 or her family about Resident #1's grievance. BOM stated she followed-up with Resident #1's family and asked them if they wanted staff to report the allegation to the State Agency, but Resident #1's family told them that they did not have any concerns or issues. BOM stated she learned Resident #1's family made the allegation of verbal abuse when they filed the grievance on 10/18/23. BOM 676475 Page 2 of 12 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and ADON stated abuse or neglect allegations or suspicions should be immediately reported to the State Agency. BOM stated she gave Resident #1's grievance form to the ADM when she filed the grievance on 10/18/23. BOM and ADON stated residents could be negatively affected by staff not reporting abuse and neglect to the State Agency. During an observation on 11/14/23 at 5:55 p.m., there were three postings at the facility's nursing station indicating, Administrator Notification: The Administrator MUST be notified immediately for any issues concerning residents such as Incidents/Accidents, Falls, Change in Condition, Transfer to Hospital, Death, Abuse and Neglect etc. Signed, ADM. During an interview on 11/14/23 at 6:08 p.m., CNA A stated she would report abuse and neglect to her charge nurse. CNA A stated she would report any tasks not being completed or suspicions or allegations of abuse or neglect to her charge nurse. CNA A stated the ADM was the abuse and neglect coordinator and reported allegations or suspicions of abuse and neglect to the State Agency. Record review of the facility's incident log from 10/01/23 through 11/14/23 revealed Resident #1's alleged verbal abuse incident was not listed. Record review of TULIP reflected no intakes reported by the facility related to Resident #1 prior to 11/14/23. Record review of the facility's in-services from September 2023 through November 2023 reflected staff were trained on the following: *wound vacs on 09/21/23, *resident rights on 10/12/23, *abuse and neglect on 10/18/23, *rounding on 10/31/23, and *abuse and neglect coordinator on 11/02/23. Record review of the facility's abuse investigation and reporting policy and procedure revised in July 2017 reflected the following: Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: 676475 Page 3 of 12 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0609 a. The State licensing/certification agency responsible for surveying/licensing the facility; Level of Harm - Minimal harm or potential for actual harm b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; Residents Affected - Few d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 3. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone. Record review of the facility's undated policy and procedure on abuse and neglect reflected the following: Facilities (A) Any facility staff who has caused to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse or neglect caused by another person shall report the abuse or neglect caused by another person shall report the abuse or neglect. (B) Each employee of the facility must sign a statement that the employee realizes that the employee may be criminally liable for failure to report abuse. These statements must be available for inspection by the Texas Department of Human Services. (C) Oral reports of abuse or neglect must be made immediately to the department, no later than five days after the oral report is made, a written report shall be filed with the department. Reporting Incidents and Complaints Definitions: The following words and terms, when used in this manual, shall have the following meanings, unless the context clearly indicates otherwise. 676475 Page 4 of 12 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Abuse: Any act, failure to act, or incitement to act done willfully, knowingly or physical injury or harm or death to a client. This includes verbal, sexual, mental/psychological, physical abuse (including corporal punishment), involuntary seclusion, or any other mistreatment within this definition. (A) Verbal Abuse: The use of any oral, written, or gestured language that includes disparaging or derogatory terms to a resident or within the resident's hearing. (E) Mental/psychological abuse: The mistreatment within the definition of abuse in this paragraph which does not result in physical hare and includes, but is not limited to, humiliation, harassment, threats of punishment, deprivation or intimidation. Neglect: A deprivation of life's necessities of food water or shelter or a failure of an individual to provide services, treatment or care to a resident which causes or could cause mental or physical injury or harm or death to the resident. Record review of the facility's resident rights policy and procedure revised in December 2016 reflected the following: Policy Statement: Employees shall treat residents with kindness respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; u. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; v. have the facility respond to his or her grievances. 676475 Page 5 of 12 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission that included instructions for providing effective and person-centered care for the resident and met professional standards of quality care for 1 of 5 residents (Resident #1) reviewed for care plans, in that: The facility failed to develop and implement a baseline care plan for Resident #1. This deficient practice could place residents at risk of not having their immediate care needs met or not receiving continuity of care. Findings included: Record review of Resident #1's face sheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE], discharged to the hospital ER on [DATE], her own RP, and with diagnoses including encounter for surgical aftercare following surgery on the digestive system, type 2 diabetes mellitus without complications, moderate protein-calorie malnutrition, muscle wasting and atrophy not elsewhere classified and multiple sites, unspecified lack of coordination, unspecified feeding difficulties, generalized muscle weakness, cognitive communication deficit, dysphagia (difficulty swallowing foods or liquids), unspecified depression, adjustment disorder with depressed mood, presence of urogenital implants, and unspecified dementia. Record review of Resident #1's comprehensive MDS assessment, dated 08/28/23, reflected a BIMS score of 14, indicating cognitively intact. Resident #1 was not rated in urinary continence and always incontinent with bowel. Resident #1 required extensive assistance of 1 person with bed mobility and personal hygiene, physical help in part with bathing activity, and was dependent of 1 person with toilet use. Resident #1 was at risk of developing pressure ulcers and had no unhealed pressure ulcers. Record review of Resident #1's clinical record reflected she did not have a baseline care plan. During an interview on 11/14/23 at 2:45 p.m., BOM stated she checked Resident #1's EHR on 11/14/23 and found Resident #1 did not have a baseline care plan. BOM also stated the MDS nurse completed residents' care plans. BOM stated she did not know why Resident #1 did not have a baseline care plan. During an interview on 11/14/23 at 2:47 p.m., MDS nurse stated she got behind on completing residents' care plans. MDS nurse also stated she was responsible for completing residents' MDS assessments and comprehensive care plans. MDS nurse stated LVNs were responsible for completing residents' baseline care plans. MDS nurse stated LVNs did not complete Resident #1's baseline care plan. MDS nurse stated residents' baseline care plans must be completed by the 3rd day of a resident's admission. MDS nurse also stated baseline care plans covered the resident's first 30 days in the facility. MDS nurse stated she did not know why Resident #1's baseline care plan was not completed. MDS nurse also stated she believed residents not having a baseline care plan could not affect their care or treatment. MDS nurse explained staff looked at weekly nursing assessments to determine a resident's care and needs. Record review of the facility's resident rights policy and procedure revised in December 2016 676475 Page 6 of 12 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0655 reflected the following: Level of Harm - Minimal harm or potential for actual harm Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: Residents Affected - Few 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: p. be informed of, and participate in, his or her care planning and treatment. Record review of the facility's baseline care plans policy and procedure revised in December 2016 reflected the following: Policy Statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and implementation: 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 676475 Page 7 of 12 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans, in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1. This deficient practice could place residents at risk of not having their individual care needs met or diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE], discharged to the hospital ER on [DATE], her own RP, and with diagnoses including encounter for surgical aftercare following surgery on the digestive system, type 2 diabetes mellitus without complications, moderate protein-calorie malnutrition, muscle wasting and atrophy not elsewhere classified and multiple sites, unspecified lack of coordination, unspecified feeding difficulties, generalized muscle weakness, cognitive communication deficit, dysphagia (difficulty swallowing foods or liquids), unspecified depression, adjustment disorder with depressed mood, presence of urogenital implants, and unspecified dementia. Record review of Resident #1's comprehensive MDS assessment, dated 08/28/23, reflected a BIMS score of 14, indicating cognitively intact. Resident #1 was not rated in urinary continence and always incontinent with bowel. Resident #1 required extensive assistance of 1 person with bed mobility and personal hygiene, physical help in part with bathing activity, and was dependent of 1 person with toilet use. Resident #1 was at risk of developing pressure ulcers and had no unhealed pressure ulcers. Record review of Resident #1's clinical record reflected she did not have a comprehensive care plan. During an interview on 11/14/23 at 2:45 p.m., BOM stated she checked Resident #1's EHR on 11/14/23 and found Resident #1 did not have a comprehensive care plan. BOM also stated the MDS nurse completed residents' care plans. BOM stated she did not know why Resident #1 did not have a comprehensive care plan. During an interview on 11/14/23 at 2:47 p.m., MDS nurse stated she got behind on completing residents' care plans. MDS nurse also stated she was responsible for completing residents' MDS assessments and comprehensive care plans. MDS nurse stated comprehensive care plans must be completed by the 7th day the MDS assessment was completed. MDS nurse also stated she missed completing Resident #1's comprehensive care plan. MDS nurse also stated she believed residents not having a comprehensive care plan could not affect their care or treatment. MDS nurse stated staff did not look at residents' comprehensive care plans to provide care to residents. MDS nurse explained staff looked at weekly nursing assessments to determine a resident's care and needs. 676475 Page 8 of 12 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0656 Record review of the facility's resident rights policy and procedure revised in December 2016 reflected the following: Level of Harm - Minimal harm or potential for actual harm Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Residents Affected - Few Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: p. be informed of, and participate in, his or her care planning and treatment. Record review of the facility's comprehensive person-centered care plans policy and procedure revised in December 2016 reflected the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 676475 Page 9 of 12 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

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 interviews and record reviews, 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 nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #1) reviewed for personal hygiene, in that: Residents Affected - Some The facility failed provide showers to Resident #1 in compliance with her shower schedule. This deficient practice could place residents who are dependent on staff for ADL care at risk of poor hygiene, grooming, and diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE], discharged to the hospital ER on [DATE], her own RP, and with diagnoses including encounter for surgical aftercare following surgery on the digestive system, type 2 diabetes mellitus without complications, moderate protein-calorie malnutrition, muscle wasting and atrophy not elsewhere classified and multiple sites, unspecified lack of coordination, unspecified feeding difficulties, generalized muscle weakness, cognitive communication deficit, dysphagia (difficulty swallowing foods or liquids), unspecified depression, adjustment disorder with depressed mood, presence of urogenital implants, and unspecified dementia. Record review of Resident #1's comprehensive MDS assessment, dated 08/28/23, reflected a BIMS score of 14, indicating cognitively intact. Resident #1 was not rated in urinary continence and always incontinent with bowel. Resident #1 required extensive assistance of 1 person with bed mobility and personal hygiene, physical help in part with bathing activity, and was dependent of 1 person with toilet use. Resident #1 was at risk of developing pressure ulcers and had no unhealed pressure ulcers. Record review of Resident #1's care plans reflected she did not have a baseline and comprehensive care plan. Record review of the facility's undated AM and PM shower list reflected Resident #1 was not listed. Record review of the facility's shower sheets from October 2023 through November 2023 reflected Resident #1 did not have any shower sheets. Record review of Resident #1's survey reports for showers from October 2023 through November 2023 scored Resident #1as a 01, which indicated dependent - Helper does all the effort, was marked on 10/3/23, 10/10/23, 10/13/23 at 3:26 p.m., 10/14/23, 10/18/23, 10/23/23, and 11/06/23 at 10:52 a.m. Resident #1 was scored as 02, which indicated substantial/maximal assistance - helper does more than half the effort, was marked on 10/02/23, 10/04/23, 10/06/23, 10/09/23, 10/13/23 at 10:43 p.m., 10/15/23 at 4:50 a.m., and 10/19/23 at 2:06 a.m. NA was marked on 10/11/23, 10/15/23 at 3:18 p.m. and 10:54 p.m., 10/19/23 at 11:44 p.m., 10/21/23, 10/22/23, 10/24/23, 10/25/23, 10/28/23 at 2:55 a.m. and 11:37 p.m., 10/30/23, 11/01/23, 11/03/23, and 11/06/23 at 10:40 p.m. During an interview on 11/14/23 at 5:53 p.m., BOM and ADON stated NA on Resident #1's survey logs for showers meant not applicable. BOM and ADON also stated they did not know why staff would indicate 676475 Page 10 of 12 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some NA. ADON stated she witnessed staff give Resident #1 bed baths prior to Resident #1's hospitalization on 11/06/23. During an interview on 11/14/23 at 6:08 p.m., CNA A stated shower aides, nurses, and CNAs showered residents three times a week. CNA A also stated CNAs documented in POC responses when ADL care was given or refused by a resident. CNA A stated if NA was indicated on a survey report for showers, it meant the resident did not get care or refused care. CNA A stated Resident #1 was showered on the morning of 11/06/23. During an interview on 11/14/23 at 6:31 p.m., LVN B stated she did not shower Resident #1 on 11/06/23. LVN B also stated she never provided care to Resident #1. During an interview on 11/14/23 at 6:35 p.m., BOM stated LVN B contacted her and informed her to tell the surveyor that CNA A used her log in to document the shower given to Resident #1 on 11/06/23 because CNA A's log in was not working. During an interview on 11/14/23 at 6:42 p.m., BOM stated she could not find a policy and procedure on giving showers to residents. During an interview on 11/14/23 at 11:10 a.m., MA stated she was trained and in-serviced on resident rights, neglect, quality of life, infection control, physical environment, abuse, administration/personnel, nursing services, and pharmaceutical services. MA also stated she received complaints about residents not receiving showers. MA stated whenever she received those complaints, she asked the CNAs why showers were not given to residents. MA also stated CNAs and shower aides showered residents. MA stated showers given or refused by residents were documented on shower sheets. MA also stated if a resident refused a shower, CNAs were supposed to report it to a nurse. MA stated residents received showers three times a week. During an interview on 11/14/23 at 3:48 p.m., CNA B stated she was trained and in-serviced on resident rights, neglect, quality of life, infection control, physical environment, abuse, administration/personnel, nursing services, and pharmaceutical services. CNA B also stated CNAs and nurses provided showers to residents. CNA B stated showers were given to residents three times a week. CNA B also stated she never received complaints about showers not being given to residents. CNA B stated nurses oversaw and ensured CNAs showered residents and documented showers given or refused on shower sheets. During an interview on 11/14/23 at 4:08 p.m., LVN A stated he was trained and in-serviced on resident rights, neglect, quality of life, infection control, physical environment, abuse, nursing services, and pharmaceutical services. LVN A also stated he never received complaints about residents not receiving showers. LVN A stated CNAs gave residents showers. LVN A also stated residents received showers three times a week. LVN A stated nurses oversaw and ensured CNAs showered residents and documented showers given or refused on shower sheets. During an interview on 11/14/23 at 4:45 p.m., BOM and ADON stated nurses oversaw and ensured CNAs showered residents and documented showers received or refused on shower sheets. BOM stated she was not surprised Resident #1 did not have any shower sheets from October 2023 through November 2023. BOM and ADON stated they were surprised Resident #1 was not listed on the facility's AM and PM resident shower list. 676475 Page 11 of 12 676475 11/14/2023 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0677 Level of Harm - Minimal harm or potential for actual harm An attempt to interview CNA C was made on 11/14/23 at 6:39 p.m., but CNA C did not return the surveyor's call. During an interview on 11/14/23 at 6:42 p.m., BOM stated she could not find a policy and procedure on giving showers to residents. Residents Affected - Some 676475 Page 12 of 12