Health inspection·April 10, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure personal privacy for 1 of 3 residents (Resident #52) reviewed for privacy while receiving wound care. Residents Affected - Few The facility failed to ensure the privacy of Resident #52 by not closing the door all the way or pulling a privacy curtain during wound care. This failure could place residents at risk of loss of privacy and dignity. Findings include: Record review of the undated Face Sheet for Resident #52 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure with Hypoxia (lungs cannot properly exchange gases causing abnormal levels of oxygen and carbon dioxide in the blood, causing difficulty breathing and can be fatal), Obesity Body Mass Index 70 or greater, adult, (morbid obesity which can lead to a range of health problems including heart disease, high blood pressure, breathing, difficulties), and need for assistance with personal care. Record review of the Optional State assessment dated [DATE] for Resident #52 reflected he had a BIMS score of 15 indicating intact cognitive status. Observation on 04/09/2025 at 2:24 PM revealed of Resident #52 who was receiving wound care. The MD had her back to the door and a large area of Resident #52's skin was visible from his door which was partially open. No privacy curtain was drawn in the room. In an interview on 04/09/2025 at 2:29 PM LVN B stated the wound for Resident #52 was in his groin area and the door to that room does not close properly and needed to be slammed to make it close. She stated there was no curtain in that room. She stated by leaving the door partially open with no curtain it was a dignity and privacy issue for the resident. In an attempted interview on 04/09/2025 at 3:00 PM, Resident #52 did not want to discuss his wound care. In an interview on 04/10/2025 at 9:45 AM the Housekeeping Manager stated Resident #52 did not have a line with hooks to put a curtain up in his room. In an interview on 04/10/2025 at 10:06 AM the DON stated she stated it was a dignity issue if the door was open during wound care and no curtain was pulled. She stated the door should have been Page 1 of 33 676475 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0583 closed but since that incident, the facility had installed a privacy curtain in Resident #52's room. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/10/2025 at 12:27 PM the ADM stated there should be privacy curtains and the door should be closed during wound care. She stated it was a was a dignity issue for the resident. Residents Affected - Few Record review of an undated facility Policy and procedure titled Promoting/Maintaining Resident Dignity reflected Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 676475 Page 2 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 of 10 residents (Resident #21, Resident #65, Resident #10 and Resident #7) and 1 of 1 shower rooms (A Hall) reviewed for resident rights. A) The facility failed to ensure Resident #21's room and shower was clean. B) The facility failed to ensure the A Hall shower room was clean and free of mold, trash and soiled washcloths. C) The facility failed to ensure Resident # 65's tray table was in good repair. D) The facility failed to ensure there were intact privacy curtains in Resident #10 and Resident #7's room. These failures could place residents at risk of not having a safe, clean, sanitary, comfortable and homelike environment. Findings included: A) Record review of Resident #21's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Malignant neoplasm of Larynx (cancerous cells in the voice box), Tracheostomy (opening in the neck to insert a tube into the trachea or windpipe that acts as a passageway for air to and from the lungs), and cognitive communication deficit (communication difficulties stemming from underlying thinking processes). Record review of Resident #21's Quarterly MDS dated [DATE] reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #21's Care Plan dated 12/19/2024 reflected he had a communication problem r/t hearing deficit. The care plan dated 02/09/2025 reflected he had an enteral nutritional tube for an alternate method of nourishment. Observation on 04/08/2025 at 9:11 AM in Resident # 21's room revealed debris on the floor including two plastic drink tops, a packaged enteral syringe, 2- 4 X 4 gauze pad packages, and an insect egg casing. The shower floor had brown, black grime and a soiled wet washcloth on the shower seat. B) Observation on 04/08/2025 at 9:25 AM in the A Hall shower room revealed a soiled washcloth on a shower seat, a used, inside out glove on the floor under the sink, and a soiled washcloth on the floor. The shower stall had black mold on all the grout from waist level down and on the floor. There was a soiled, wadded up Band-Aid on the shower floor. 676475 Page 3 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 04/09/2025 at 8:14 AM revealed the A Hall shower room still had black mold in the shower and the soiled Band-Aid was in a different location and still stuck on the shower floor. C) Record review of Resident #65's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke where part of the brain is damaged or dies due to lack of blood supply). Record review of Resident #65's Quarterly MDS dated [DATE] reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Observation and interview on 04/08/2025 at 10:38 AM in Resident #65's room revealed his tray table was missing a wheel and was wobbly. Resident # 65 stated he had asked aides to fix his tray table and they said We'll look into that but they never got back with him. D) Record review of Resident #10's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, without behavioral disturbance (decline in mental process involved in knowing, learning and understanding things where the specific cause or type is not identified), and Cognitive Communication Deficit (communication difficulties stemming from problems with underlying thinking processes). Record review of Resident #10's Quarterly MDS dated [DATE] reflected he was unable to complete a BIMS assessment. Record review of Resident #7's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Undifferentiated Schizophrenia (hallucinations, delusions, disorganized thinking and difficulties with daily functioning), and Cognitive Communication Deficit (communication difficulties stemming from problems with underlying thinking processes). Record review of Resident #7's Quarterly MDS dated [DATE] reflected he had a BIMS score of 13 indicating intact cognitive status. Observation on 04/08/2025 at 11:54 AM in Resident #10 and Resident #7's room revealed the privacy curtain between their beds was hanging down and broken. In an interview and observation on 04/10/2025 at 9:35 AM the Housekeeping Supervisor observed the broken curtain and missing curtain in Resident #10 and Resident #7's room. She stated they would be replaced. In an interview on 04/10/2025 at 9:45 AM the Housekeeping Supervisor stated the staff were supposed to clean the shower rooms twice a day. She stated the floors in every room were supposed to be mopped and cleaned every day and her staff had been trained to do this. She stated she had spoken to the Maintenance Supervisor about the curtains that were broken and missing in Resident #10 and Resident #7's room. In an interview on 04/10/2025 at 12:27 PM the ADM stated there should be privacy curtains in the 676475 Page 4 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some rooms. She stated cleanliness was a high priority and there should be daily sweeping and mopping of each room. She stated the showers should be kept clean. She stated residents should not be taking a bath in someone else's filth and it was an issue with infection control. She further stated it was a safety issue with the dirty gloves and used Band-Aid being on the floor in the shower room on Hall A. In an interview on 04/10/2025 at 2:40 PM CNA H stated she had worked at the facility since November 2022. She stated if she sees something that needs fixing, she will go to the Maintenance man or put it in the Maintenance book. In an interview on 04/10/2025 at 2:41 PM CNA G stated she had worked at the facility for almost one year and she knew to put any needed repairs into the repair log. Record review of the work request log on 04/10/2025 at 2:00 PM reflected none of the repair issues observed during the survey had been put into the log. In an interview on 04/10/2025 at 2:45 PM the Maintenance Director stated if the staff had a request, they would write it in the work request log and unless it was an emergency he would repair it within 24 hours. He stated he made rounds on the halls, but did not generally pay attention to the curtains. He stated he thought the CNAs would notice what needs to be repaired. He stated he checked the work request log when he arrived at the facility and before going home. Upon exit on 04/10/2025, no policy specific to facility maintenance had been received from the facility. 676475 Page 5 of 33 676475 04/10/2025 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 observations, interviews, and record review, the facility failed to develop a comprehensive care plan to meet the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #5) of 19 residents reviewed for care plans. The facility failed to ensure Resident #5's comprehensive care plan reflected a plan of care for her left-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) with interventions for the care and treatment of her left-hand contracture. These failures could place residents at risk for not receiving appropriate care and treatment. Findings included: Review of Resident #5's face sheet dated 04/09/2025 reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia), muscle wasting and atrophy, left hand, hemiplegia (a symptom that involves one-sided paralysis), unspecified affecting left nondominant side. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was assessed to have a BIMS sore of 12 indicating moderate cognitive impairment. Resident #5 was assessed to not have behavior of rejecting care. Resident #5 was further assessed to have functional limitations in range of motion with impairment on one side for her upper and lower extremities. Resident #5 was assessed to not have a restorative nursing program that included passive and active range of motion or splint or brace assistance. Review of Resident #5's comprehensive care plan reflected a focus area dated 04/11/2022 and revised on 02/07/2025 I have limited/impaired physical mobility and require assistance with ADL's due to left hemiparesis/ hemiplegia with history of CVA . Interventions included personal hygiene to check nail length and trim and clean on bath days and restorative nursing program if indicated. Resident #5' care plan did not address her left-hand contracture or provide staff with interventions for the care and treatment of the left-hand contracture. Review of Resident #5's task documentation (administer nail care) for a look back of 14 days (03/27/2025 to 04/09/2025) reflected no documentation of nail care administration. Review of Resident #5's occupational therapy recertification and updated plan of treatment dated 02/08/2025 reflected a diagnosis of contracture to left hand with an onset date of 08/12/2024. In an interview on 04/10/2025 at 9:00 am the DON stated that Resident #5's care plan should address her left-hand contracture and the plan of care should have specific interventions for her care including maintenance care that included nail care and hand rolls. She stated Resident #5 was combative at time but would allow staff to provide care. The DON stated failure to have an individualized care plan for her left-hand contracture could lead to increased contracture, or pressure ulcers. She 676475 Page 6 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated nails for resident should be trimmed on shower days by the CNAs to prevent them from digging into her hands and causing sores. In an interview on 04/10/2025 at 11:37 am the Administrator stated her expectations for contracture management was to have staff identify contractures, inform the MD and therapy. She stated staff should develop an individualized care plans for the resident and train the direct care staff on the implementation of the plan. In an interview on 04/10/2025 at 11:57 am the MDS coordinator stated resident should have a care plan for her contracture with individualized interventions for the management for her contracture. she stated it could lead to decreased mobility, increased contractures with pain and pressure. Record review of facility undated policy titled Care Plans, Comprehensive Person-Centered reflected 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. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 676475 Page 7 of 33 676475 04/10/2025 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 observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living (ADL) to maintain good grooming and personal hygiene for 4 of 4 Residents (Residents #65, Resident 56, Resident #22, and Resident #24) reviewed for ADL care. Residents Affected - Some The facility failed to ensure Resident #65, Resident #56, Resident #22, and Resident #24's nails were trimmed, cleaned, and filed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: Record review of Resident #65's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke where part of the brain is damaged or dies due to lack of blood supply). Record review of Resident #65's Quarterly MDS dated [DATE] reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Section GG - Functional Abilities reflected he had impairment on both upper extremities that interfered with daily functions. He required supervision and setup with personal hygiene. Record review of Resident #65's Care Plan dated 02/20/2025 reflected he had an ADL self-care performance deficit r/t activity intolerance. He required set up for hygiene tasks. In an interview and observation on 04/08/2025 at 10:38 AM Resident #65 stated he had asked the aides to clip his toenails and they never had. Observation of his bilateral feet revealed the first through fourth toes were approximately ½ inch long past the end of his toes and the nails on his fifth toes (little toes) were curling under and poking into the skin on the bottom of his toes. In an interview on 04/09/2025 at 2:06 PM of Resident #65 stated no one had trimmed his toenails. In an interview on 04/09/2025 at 2:09 PM CNA I looked at Resident #65's toenails and noted they were long and needed trimming. She stated his right foot's little toenail was long and could grow into the skin and cause an infection that could get into the blood stream. Record review of Resident #56's undated Face Sheet reflected he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Cerebral Infarction (stroke where part of the brain is damaged or dies due to lack of blood supply) and Expressive Language Disorder (difficulty using language both written and spoken). Record review of Resident #56's Quarterly MDS dated [DATE] reflected he had a BIMS score of 13 indicating intact cognitive status. Section GG - Functional Abilities reflected he required Substantial/maximal assistance for personal hygiene where the helper provides more than half of the effort. Record review of Resident #56's Care Plan dated 09/29/2023 and revised on 10/01/2024 reflected he 676475 Page 8 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was at risk for a decline in and ADL self-care performance r/t right hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), and impaired balance. Interventions/Task: Personal hygiene: Check nail length if applicable and trim and clean on bath day and as necessary. Observation on 04/08/2025 at 10:26 AM of Resident #56's fingernails on both hands revealed his fingernails were approximately ½ to ¾ inches long and jagged. An interview was attempted but Resident #56 was unable to verbalize, however, he kept holding his hands up to show the surveyor. Observation on 04/09/2025 at 2:04 PM of Resident #56 whose nails on both hands were still long and jagged with brown debris underneath. Record review of Resident #22's undated Face Sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (long term condition in which the body has trouble controlling blood sugar and using it for energy) with Diabetic Neuropathy (a type of nerve damage that can occur with diabetes most often affecting the legs and feet), Muscle weakness (generalized), and Blindness right eye. Record review of Resident #22's Quarterly MDS dated [DATE] reflected he had a BIMS score of 15 indicating intact cognitive status. Section GG: Resident required partial/moderate assistance for personal hygiene. Record review of Resident #22's Care Plan dated 11/19/2024 reflected he had an ADL self-care performance deficit r/t right hand 2nd finger amputation, weakness. Personal hygiene: needs assistance of one staff. He is at risk for impairment to skin integrity r/t fragile skin. Avoid scratching, keep fingernails short. In an observation and interview on 04/08/2025 at 11:29 AM, Resident #22's nails on bilateral hands were approximately 1/4 to 1/2 inch long past the fingertips. There was brown, crusty debris under the four fingernails on each hand. He was missing his fourth finger on each hand. He stated he lost his legs and his fingers due to a blood infection. In an observation and interview on 04/09/2025 at 2:08 PM Resident #22's toenails were still long, and he stated no one had trimmed his nails. In an interview on 04/09/2025 at 2:09 PM CNA I stated she had become a CNA in June 2024 but had worked as an aide for ten years. She stated aides were supposed to clean resident's nails, trim them with clippers, and use a cuticle stick to clean dirt from under the nails. She stated she performed those tasks every time she assisted a resident with a bath. She observed Resident #56's nails and noted they were jagged and could use trimming and cleaning. She stated Resident #22 needed to have his fingernails trimmed and his nails would need to be soaked to get some of the crust out from underneath. She stated there could be bacteria from his nails that could get into his mouth when he was eating. Review of Resident #24's face sheet, dated, 04/09/2025, reflected a [AGE] year-old female who was admitted on [DATE]. Resident #24 had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( memory loss, difficulty with communication, and problems with reasoning without any behaviors), limited 676475 Page 9 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some activities due to disability (restrictions or reductions in a person's ability to perform daily activities because of a disability such as chronic diseases, injuries, and mental health disorders), and unspecified lack of coordination (a motor - skill impairment where movements are uncoordinated) Review of Resident #24's Annual MDS, dated [DATE], reflected the resident had a BIMS score of 3, which indicated his cognition was severely impaired. Resident #24 required partial/moderate assistance (helper does less than half the effort) with personal hygiene, and upper body dressing. She required substantial/maximal assistance (helper does more than half the effort) with showers and lower body dressing. Resident #24 was dependent on staff for toileting. Resident #24 did not reject any care. Resident #24 had an ADL Self Care Performance Deficit related to dementia, and impaired balance (a condition where a person feels unsteady or dizzy). Adjust assistance and support to accommodate immediate needs. Interventions: Personal hygiene- Resident #24 required assistance of one staff. Check nail length. Trim and clean on bath day and as needed. Observation and interview on 4/08/2025 at 11:20 AM, revealed Resident #24 was in the common area sitting in her wheelchair. She had thick blackish substance underneath all nails on her right and left hands. Resident #24 was not interview able. Observation and interview on 04/09/2025 at 10:30 AM, revealed Resident #24 was sitting in her wheelchair in the therapy room. She had hard thick blackish substance underneath all nails on her right and left hands. Resident #24 was not interview able. Observation and interview on 04/09/2025 at 10:45 AM revealed COTA speaking to Resident #24. The COTA stated Resident #24's nails were very dirty underneath all her nails and it was black substance. COTA stated she was not responsible to assist any resident who was not on her case load. She stated Resident #24 was not on her case load and she was not allowed to touch her or do anything for her. In an interview on 04/10/2025 at 10:50 AM LVN B stated nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. She stated the CNAs were responsible for all other residents' nail care. LVN C stated if a resident had blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill such as stomach problems nausea and vomiting. LVN C stated if a resident refused any type of care, the nurse would document the refusal in the nurse's notes. She stated no one had reported to her Resident #24 refused nail care. She stated she had been in- serviced on nail care, however, she did not recall the date. In an interview on 04/10/2025 at 11:45 AM, CNA H stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA H stated the residents nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. CNA H stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident #24, and she was not aware of Resident #24 refusing nail care. CNA H stated Resident #24 was more receptive of nail care when staff used a warm bath cloth and washed her hands and put it on her fingernails. CNA H stated Resident #24 did put her hands in her diaper when she had a bowel movement and she had reported this to a nurse 676475 Page 10 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a few weeks ago, however, she did not recall the nurse's name. She stated if any resident refused care it was reported to the nurse and the nurse would document the refusal in the nurses note. She stated she was in-serviced on nail care, and she did not recall the date of the nail care in-service. In an interview on 04/10/2025 at 8:17 AM the ADON stated she had worked for the company for one year. She stated she tried to get the aides to check nails every day. She stated some residents would not allow staff to trim their nails. She stated if the resident refused, they would have to come up with other ways to get the residents to let them trim their nails. She stated if a resident's toenails are curling over into the skin, it could cause harm to them. She stated residents with long nails could scratch themselves or someone else and the scratches could get infected. She stated there were all kinds of bacteria under the nails that could lead to an infection and if the resident put their fingers in their mouth, the bacteria could make them sick. In an interview on 04/10/2025 at 10:06 AM the DON stated long nails and toenails could puncture the skin and cause an entryway for microbes (bacteria). She stated the resident could scratch themselves and it could lead to infection. She further stated if they put dirty nails in their mouth they could get a GI upset. She stated the CNAs do ADLS and the DON, ADON and floor nurses should be checking up after them. In an interview on 04/10/2025 at 12:27 PM the ADM stated she expected fingernails and toenails to be trimmed and filed if jagged. She stated the CNAs and Nurses were responsible for performing that task. She stated the potential risk to the resident of long nails could be infection, and cuts, scrapes from nails cutting into the skin. She stated it could cause discomfort. She stated there could be fungus and bacteria under the nails that could lead to infection. Review of a facility policy and procedure titled Nail Care dated 2024 reflected, The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing will be provided on a regular schedule. 6. A. Nails should be kept smooth to avoid skin injury. B. Only licensed nurses shall trim or file fingernails of residents with diabetes. 676475 Page 11 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of six residents (Resident #27) reviewed for quality of care. Residents Affected - Few The facility failed to provide wound care for Resident #27 using professional wound care standards and failed to follow the facility Validation Checklist Wound Care procedure. This failure could place residents at risk of improper wound management, deterioration in existing wounds, leading to infection and pain. Findings include: A) Record review of Resident #27's undated Face Sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses of non-pressure chronic ulcer of left heel and midfoot with necrosis (death of body tissue) of muscle, and Type 2 Diabetes Mellitus without complication (long term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of Resident #27's Quarterly MDS dated [DATE] reflected he had a BIMS score of 15 indicating intact cognitive status. Record review of Resident #27's Care Plan dated 09/16/2024 and revised 10/23/2024 reflected The resident has sunburn blister to left dorsal foot from going to a family reunion. Record review of Resident #27's Physician orders dated 4/09/2025 reflected Clean dorsal foot with wound cleanser. Pat dry. Apply collagen, cover with abdominal pad and kerlix. Observation on 04/09/2025 at 9:28 AM of wound care for Resident #27 revealed LVN B donned gloves and opened a treatment cart drawer. She grabbed a handful of loose 4 X 4 gauze using contaminated gloves and took those and other wound care supplies into the resident's room. LVN B used paper towels to set up a clean field on the bed. She sprayed wound cleanser onto the wound and wiped up and down on the wound on top of Resident #27's foot with 4 X 4 gauze, going from dirty areas to clean, back and forth several times. She applied collagen to the wound, covered it with a small abd pad (used to absorb drainage) and used kerlix gauze to wrap the foot. She placed the contaminated 4 X 4 gauze used during wound care onto the resident's bed. In an interview on 04/09/2025 at 9:58 AM LVN B stated she had a wound care training course when she first started at the facility three years ago. She stated a wound care nurse had trained her. She stated she knew what she had done wrong when performing wound care on Resident #27. She further stated she went from clean to dirty back and forth across the wound and was spreading germs across the wound. She stated she grabbed 4 X 4 gauze out of the cart with contaminated gloves, cross contaminating them. She stated by using them on the wound it could cause an infection that could get progressively worse and possible require surgery. She stated Resident #27 was a diabetic which would put him at higher risk of complications. She stated by putting the contaminated 4 X 4's on the bed after using them on his wound, she was 676475 Page 12 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0684 spreading germs. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/09/2025 at 2:26 PM the MD, a wound care physician, stated by using contaminated 4 X 4 gauze and cleaning across the wound with them and going from a dirty to clean area could contaminate the wound and cause an infection. Residents Affected - Few In an interview on 04/10/2025 at 10:06 AM the DON stated the wound care procedure would be to clean the wound from clean to dirty. She stated Microbes on the outside of the wound could be introduced into the wound if wound care was not performed properly. In an interview on 04/10/2025 at 12:27 PM the ADM stated improper wound care could cause bacteria to transmit infection. She stated she expected the nurse to follow wound care guidelines, going from clean to dirty and disposing of used 4 X 4 gauze. She stated that a nurse should ask for help or guidance if necessary. She stated the nurse could spread bacteria to a wound by using contaminated 4 X 4's. Review of an undated Validation Checklist Wound Care reflected 4. Cleaned bedside table as needed wearing appropriate PPE (Personal protective Equipment. 5. Set up supplies on the bedside table in easy reach. 12. Removed dressing and place in appropriate receptacle. 14. Cleansed wound thoroughly with prescribed cleansing agent, taking care not to contaminate other skin surfaces or other surfaces of the wound. 20. Discarded disposable items and gloves into appropriate receptacles. 676475 Page 13 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1of 3 residents reviewed with limited range of motion (Resident #5), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #5 had interventions in place for her left- hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right hand. This failure placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: Review of Resident #5's face sheet dated 04/09/2025 reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia), muscle wasting and atrophy, left hand, hemiplegia (a symptom that involves one-sided paralysis), unspecified affecting left nondominant side. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was assessed to have a BIMS sore of 12 indicating moderate cognitive impairment. Resident #5 was assessed to not have behavior of rejecting care. Resident #5 was further assessed to have functional limitations in range of motion with impairment on one side for her upper and lower extremities. Resident #5 was assessed to not have a restorative nursing program that included passive and active range of motion or splint or brace assistance. Review of Resident #5's comprehensive care plan reflected a focus area dated 04/11/2022 and revised on 02/07/2025 I have limited/impaired physical mobility and require assistance with ADL's due to left hemiparesis/ hemiplegia with history of CVA . Interventions included personal hygiene to check nail length and trim and clean on bath days and restorative nursing program if indicated. Resident #5' care plan did not address her left-hand contracture or provide staff with interventions for the care and treatment of the left-hand contracture. Review of Resident #5's occupational therapy recertification and updated plan of treatment dated 02/08/2025 reflected a diagnosis of contracture to left hand with an onset date of 08/12/2024. Observation and interview on 04/08/2025 at 9:45 am revealed Resident #5 in bed with her left hand laying by her left side with her fingers curled toward her palm. Resident #5 was confused and when asked if she could open her left hand she did not respond. Resident #5 did raise her hand to reveal her fingernails were long and uneven with a black substance underneath her nails. No splint or hand roll was observed in her hand. Observation on 04/09/2025 at 1:50 pm revealed Resident #5 in room in bed. Resident #5 did not have 676475 Page 14 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a hand roll or splint in place. Observation of Resident #5's left hand revealed her fingernails were long and continued to have a black substance under her fingernails. In an interview 04/09/2025 at 2:00 pm CNA G stated Resident #5's left hand has been closed like that for a while. CNA G stated she was not told to do anything special to Resident #5's hand. She stated sometimes she has a rolled-up wash rag in her hand. CNA G stated the CNAs were responsible for doing nail care. CNA G stated Resident #5's nails were long and dirty and should be cleaned. She stated if her nails stayed long, they could scratch Resident #5 or dig into the palm of her hand. In an interview on 04/10/2025 at 9:00 am the DON stated that Resident #5's care plan should address her left-hand contracture and the plan of care should have specific interventions for her care including maintenance care that included nail care and hand rolls. She stated Resident #5 was combative at time but would allow staff to provide care. The DON stated failure to have an individualized care plan for her left-hand contracture could lead to increased contracture, or pressure ulcers. She stated nails for resident should be trimmed on shower days by the CNAs to prevent them from digging into her hands and causing sores. In an interview on 04/10/2025 at 11:30 AM the PTA stated she did not have an individualized plan for Resident #5's left hand contracture management, she stated Resident #5 was currently on services and getting therapy . She stated she had not trained the CNA's that they were trained in CNA training to do ROM and contracture management. She stated she has not put Resident #5 on a restorative plan for her left-hand contracture. In an interview on 04/10/2025 at 11:37 am the Administrator stated her expectations for contracture management was to have staff identify contractures, inform the MD and therapy. She stated staff should develop an individualized care plans for the resident and train the direct care staff on the implementation of the plan. A policy for contracture management requested on 04/09/2025 at 3:42 pm and 04/10/2025 at 9:04 am was not provided prior to exit. Review of the facility's undated policy Restorative Nursing program reflected It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level .The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences . Residents. as identified during the comprehensive assessment process, v--·ill receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include Passive or active range of motion Splint or brace assistance . 676475 Page 15 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for one of four residents reviewed for catheters (Resident #9). The facility failed to ensure Resident #9 received care to prevent urinary tract infections when they placed her catheter tubing under her leg and failed to have a secure catheter device in place to prevent dislodgement of the catheter. These failures could place residents with external catheters at risk for urinary tract infections and traumatic removal of the urinary catheter. Findings included: Review of Resident #9's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses acute and chronic respiratory failure, morbid obesity, COPD (chronic lung disease) and CHF (heart failure). Review of Resident #9's quarterly MDS assessment dated [DATE] reflected she was assessed to have a BIMS score of 15 indicating she cognitively intact. Resident #9 was assessed to have indwelling urinary catheter. Review of Resident #9's comprehensive care plan reflected a focus area dated 04/16/2024 Resident is at risk of infection related to indwelling foley catheter due to obstructive and reflux uropathy. Interventions included Check tubing for kinks each shift, position catheter bag and tubing below the level of the bladder . Resident #9's care plan did not address the use of a catheter secure device. Review of Resident #9's consolidated physician orders reflected an order dated 02/14/2024 Foley Catheter 16 F with 30 cc bulb, change monthly, use catheter anchor and check anchor every shift replace if necessary. Observation on 04/09/2025 at 10:00 am revealed Resident #9 were in bed receiving care from the ADON. Resident #9's urinary catheter was under her right thigh. No secure catheter device was observed to be in place. In an interview on 04/09/2025 at 10:05 am the ADON stated Resident #9 did not have a secure cath device and one should be in place to prevent dislodgement. The ADON further stated her catheter tubing should not have been under her leg it could cause pressure areas or dislodgement of the catheter. In an interview on 04/10/2025 at 9:00 am the DON stated the staff should make sure that catheter tubing was not underneath the resident as it can cause kinks or cause dislodgement. She stated the catheter tubing should be placed over her leg to allow for gravity drainage with a catheter secure device in place to prevent dislodgement. In an interview on 04/10/2025 at 11:37 am the Administrator stated residents with catheters should have the tubing and bags below bladder level to provide drainage and prevent UTI's. She stated they 676475 Page 16 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0690 should have secure caths to prevent traumatic dislodgement or pain to the resident. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy Catheter Care dated 08/2024 reflected It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . The facility's policy on catheter care did not address catheter secure devices or tubing positioning. Residents Affected - Few 676475 Page 17 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #69) of six residents reviewed for pharmaceutical services. The facility failed to ensure MA F waited for Resident #69 to consume her morning medications on 04/08/2025 before leaving the resident's room and to administer medication. The facility further failed to ensure Resident #69 receive antibiotic medication for UTI on 04/08/2025 in PM. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings include: 1) Review of Resident # 69's face sheet, dated 04/10/2025, reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses urinary tract infection ( an infection in your urinary system), type 2 diabetes mellitus with ketoacidosis without coma ( a serious complication of diabetes where the body does not produce enough insulin, leading to a buildup of harmful acids in the blood), essential hypertension ( high blood pressure where the specific cause was not known), sepsis, unspecified organism ( a life-threatening condition that occurs with the body's response to infection damages its own tissues and organs), cutaneous abscess, unspecified ( a localized collection of pus in the skin, meaning the location within the skin was not specified) and, aftercare following joint replacement surgery ( an approach to ensure proper healing, restore function, and minimize complications). Review of Resident #69's admission MDS Assessment, dated 03/04/2025, reflected Resident #69 had a BIMS score of 13 indicating her cognition was intact. Resident #69 had a diagnosis of UTI, diabetes mellitus, hypertension, sepsis, and cutaneous abscess. She received PRN pain medication. Resident #69 had frequent pain and occasionally affected her sleep, with therapy activities and day-to-day activities. Review of Resident #69's Physician Order on 04/08/2025 at 8:40 AM, dated 04/01/2025, reflected Resident #69 had a physician order for Cefdinir Oral Capsule 300 mg. Give 1 capsule by mouth two times a day for UTI for 7 days. Order date was on 04/01/2025. Resident #69 medications may be crush (crushable medications, and/or open capsules and mix with food or jelly). Review of Resident #6's MAR on 04/08/2025 at 8:45 AM reflected MA D did not follow physician order of cefdinir oral capsule 300 mg. Give 1 capsule by mouth two times a day for UTI for 7 days with a begin date on 04/02/2025. MA D did not administer cefdinir PM on 04/07/2025. Observation/interview on 04/07/2025 at 10:50 AM revealed Resident #69 was in her private room sitting in wheelchair with overhead table in front of her. There was a four medications in a medication cup. Interview with Resident #69 stated the nurse brought her medications and left them on her table. She stated the nurse told her to take them when she finished eating breakfast. Resident #69 stated she had taken some of her medication. She stated she did not know the name of the medications she takes on a daily basis. 676475 Page 18 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/09/2025 at 8:44 AM MA F stated she did give Resident #69 morning medications on 04/08/2025. She stated she did leave the medications in Resident #69's room. She stated she was expected to observe Resident #69 swallow her medications. MA F stated she did not make any observation of Resident #69 swallowing any of her medications. MA F stated there was a possibility Resident #69 may throw her medications in the garbage and not take her medicines. She stated there was a possibility Resident #69 may leave her room and another resident may wander into Resident #69 room and swallow Resident #69's medication. MA F stated if another resident swallowed Resident #69 medication there was a potential the other resident may become very ill with allergic reaction to the medication and may need to be hospitalized . She also stated it was a possibility no one would know another resident had taken Resident #69 medication and if the resident became severely sick, the staff would not know what happened to the resident and would not know what to report to the doctor of the accurate information of why the resident became suddenly sick. She stated she had been in-service not to leave a resident without observing the resident swallowing all medications. MA F stated she did not know the date of the in-service. MA F stated she did not why she forgot she left the medications in Resident #69 room. Interview on 04/10/2025 at 10:30 AM LVN C stated under no circumstance was medication to be left in resident room. She stated MA and Nurses was expected to remain with the resident until the resident ingested all of their medications. LVN C stated if medication was left in a resident room there was a possibility the resident may not take their medication and according to what the medications were and the resident's diagnosis, there was a possibility the resident may become physically or mentally ill and require hospitalization. LVN C stated there was a possibility if the resident left their room and another resident wandered into the room the other resident may become severely sick from taking medications not prescribed to them and need to be hospitalized . She stated she had been in serviced on medications and not to leave medications in a resident's room. She did not recall the date of the in-service. Observation on 04/09/2025 at 11:35 AM of medication cart revealed there was one antibiotic pill not taken by Resident #69 on 04/08/2025 in PM . Interview on 04/10/2025 at 8:50 AM the Director of Nurses stated she expected for the Med-Aides and Nurses to remain with the resident until they have ingested all their medications. She stated it was not safe for any medications be left in a resident room. She stated there was a potential the resident may not take their medication and if a resident wandered in the resident room the other resident may take the medication. The Director of Nurses stated if another resident ingested Resident #69's medication there was a potential the other resident become severely sick if allergic to Resident #69 medication such as: drop in blood pressure or blood sugar, increase in heart rate or if the resident was allergic to the medication the resident may die. The Director of Nurses stated if Resident #69 did not take her medication as ordered there was a possibility Resident #69 blood sugar may increase or her blood pressure increase. She stated Resident #69 may need to be hospitalized for further assessment and care. The Director of Nurses stated she was responsible to monitor MA , LVN's, and RN's. She stated all medication was expected to be administered according to the physician order. She stated the antibiotic for Resident #69 was missed on 04/09/2025 in PM. The Director of Nurses stated they were in contact with NP A for a new order to be written for Resident #69 to receive her last dosage of antibiotic on 04/10/2025. She stated the nurses were expected to compare the MAR to the medication for a particular resident. She stated a medication should not be missed if the nurse or MA was following the proper protocol of using the six rights of medication administration such as: right resident, right drug, right dosage, right route, right time, and right documentation. 676475 Page 19 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She stated if the MA or Nurse compared the MAR to the resident's medication, a resident's medication would not be missed. She stated there has been an in-service on medication administration, however, she did not recall the date. Interview on 04/10/2025 at 12:45 PM attempted to contact MA D via phone and left voice message. MA D did not return phone call. Interview on 04/10/2025 at 12:57 PM NP A stated she expected all medications be given according to the physician orders. She stated Resident #69 would not have any adverse effect of missing the antibiotic on 04/09/2025. NP A stated she had placed a new order on 04/10/2025 for Resident #69 to receive the one dosage of antibiotic on 04/10/2025. Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 1. Keep medication cart clean, organized, and stocked with adequate supplies. 2. Cover and date fluids and food. 3. Identify resident by photo in the MAR (medication administration record). 4. Wash hands prior to administering medication per facility protocol and product. 5. Knock or announce presence. 6. Explain purpose of visit. 7. Provide privacy. 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 9. Position resident to accommodate administration of medication. 10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. 676475 Page 20 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0755 Right dosage Level of Harm - Minimal harm or potential for actual harm d. Right route Residents Affected - Few e. Right time f. Right documentation 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. c. If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.). 13. Identify expiration date. If expired, notify nurse manager. 14. Remove medication from source, taking care not to touch medication with bare hand. Observe resident consumption of medication. 676475 Page 21 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure in accordance with State and Federal Laws, all drugs and biologicals were stored in locked compartments, and had current expiration dates for 1 of 1 medication storage rooms, 1 of 2 medication carts (A Hall medication aide cart), and 1 of 1 treatment carts reviewed for medication storage. A) The facility failed to ensure two medications in the storage room behind the nurse's station were not expired and one medication in the A Hall cart was not expired. B) The facility failed to ensure the wound care treatment cart was locked. These failures could place residents in the facility at risk of receiving expired and ineffective medications, and misuse of medications. Findings include: A) Observation on 04/08/2025 at 3:00 PM in the medication storage room behind the nurse's station revealed two bottles of Fish Oil 1000 mg supplements, expiration dates of 03/2025, and one 8 fluid ounce bottle of liquid Acetaminophen 500 mg/15 ml. Observation on 04/09/2025 at 8:31 AM in the A Hall medication aide cart of revealed one bottle of Vitamin

E 500 mg, expiration date 02/2025. In an interview on 04/09/2025 at 2:29 PM, MA E stated she had worked at the facility for almost five years. She stated the medication aide staff checked the medication carts for expired medications and the ADON checked the carts. She stated sometimes the DON checked the carts as well. She could not give specific times the carts were checked. In an interview on 04/10/2025 at 8:20 AM, the ADON stated she ordered medication every week and she tried to check for expired medications at that time. She stated she audited the medication carts once or twice a week. She stated expired medications would not be as effective as they should be, and the resident would not get as much benefit from the medications. In an interview on 04/10/2025 at 10:06 AM, the DON stated the nurses and medication aides should be checking the carts to ensure medications are not expired. She stated expired medications would be discarded by the pharmacist. She further stated nurses and medication aides were supposed to check their own carts. The DON did not specify how often staff should be checking for expired medications. In an interview on 04/10/2025 at 12:27 PM, the ADM stated expired medications should be removed the day they expired or the day before. She stated the residents could become ill from ingesting expired medications. B) 676475 Page 22 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 04/09/2025 at 2:24 PM in D Hallway revealed the treatment cart was unlocked and the drawers were facing the hallway. Observation on 04/09/2025 at 2:24 PM in D Hallway revealed the treatment was unlocked and the drawers were facing the hallway. No staff were in the vicinity of the cart. LVN B came out of a room and stated the treatment cart was supposed to be locked. In an interview on 04/09/2025 at 2:29 PM, LVN B stated by leaving the treatment cart unlocked and facing the hallway, a resident could have grabbed items out of the cart that could have potentially hurt them. She stated there was wound cleanser in the cart that would not be comfortable if a resident sprayed it in their eyes. In an interview on 04/10/2025 at 8:20 AM, the ADON stated carts were supposed to be locked when not in use. She stated there could be wound care cleaner in the cart and residents could have consumed it or put it in their eyes. She stated that could have caused harm to them and possibly could have caused an allergic reaction. In an interview on 04/10/2025 at 10:06 AM, the DON stated a treatment or medication cart should never be left unlocked if unattended. She stated anyone could get into the cart and ingest a medication or spray it into their eyes. She stated an individual could have an allergic reaction if exposed to the medications, it could affect their vision if sprayed in their eyes, and they could be hospitalized . In an interview on 04/10/2025 at 12:27 PM, the ADM stated the treatment cart should be kept locked if the nurse was not using it and within eyesight of it. No policy and procedure specific to keeping treatment carts locked, or specific to removing expired medications was provided prior to exit from the facility. 676475 Page 23 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve nutritive value for 1 of 1 kitchen reviewed for food and nutrition services. Residents Affected - Some The facility failed to ensure Dietary [NAME] M did not add an unmeasured amount of milk to the bread puree. This failure could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life. Findings included: Observation and interview on 04/09/2025 at 11:05 AM revealed Dietary [NAME] M placed milk into the puree blender. She did not measure the milk. Dietary [NAME] M began to add bread to the puree blender on top of the milk. She stated there were three residents on puree diets and she added four pieces of bread to the pureed blender. Dietary [NAME] M stated the Dietary Consultant trained her that all puree was to be the consistency of something to drink. The puree bread was of liquid consistency. Interview on 04/09/2025 at 11:10 AM, the Dietary Manager stated the Dietary Consultant did re-train all the cooks, however, she did not hear him say to puree food in a liquid consistency. The Dietary Manager stated there had not been any puree food delivered to any resident in a liquid consistency . She stated Dietary [NAME] M did not puree the bread correctly and she would be re-trained on how to puree food. The Dietary Manager stated she was responsible for monitoring the dietary department including the dietary staff. Interview via phone on 04/16/2025 at 1:10 PM, the Dietary Consultant stated he did train Dietary [NAME] M on how to puree food. He stated he did not document the training. The Dietary Consultant stated it was approximately 2 months ago when he did the training. He stated he gave examples of any puree consistency to be of the same texture of pudding. He stated he never trained any dietary cook including Dietary cook M to puree food in liquid consistency where a person could drink the puree. Review of the facility's policy on Puree Food Preparation, dated 2025, reflected It is the policy of this facility to provide puree food that has been prepared in a manner to conserve, nutritive value, palatable flavor, and attractive appearance. Food attractiveness refers to the appearance of the food when served to residents. Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk of scalding or bums. Puree means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding. Puree foods should be prepared in such a manner to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes. 676475 Page 24 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Aide L wore a hair net when standing over the clean dishes and when she placed the clean dishes on the food prep area in the kitchen. 2. The facility failed to ensure Dietary Aide K used proper hand hygiene during preparation of the lunch meal. These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 04/08/2025 at 9:15 AM revealed Dietary Aide L was not wearing a hair net when placing clean dishes from the dishwasher room in the kitchen area. Interview on 04/08/2025 at 9:20 AM, Dietary Aide L stated she was not wearing a hair net when she was standing over clean dishes and when she moved the clean dishes from the dishwashing area to the kitchen on the food prep table. She stated it was a possibility hair may fall in the food while she was standing over the plates. She stated hair was considered to have germs on it and the germs may get on a plate. She stated if a resident was served their meal with a hair on the plate there was a possibility hair may transfer from the plate to the food. She stated there was a possibility a resident may become ill with stomach issues such as vomiting. Dietary Aide L stated she had been in-serviced on wearing hair nets. She did not recall the date of the in-service. 2. Observation on 04/09/2025 at 11:50 AM, Dietary Aide K was not wearing gloves. She picked up a disinfectant small kitchen towel with all of her finger on her right hand and wiped off a tray sitting on the meal tray rack. The Dietary Aide K placed the disinfectant kitchen towel with all of her fingers on her right hand on the food prep area She picked up a tray being used for resident lunch meal with all of her fingers on the right hand. Her middle, ring, little finger, and forefinger touched inside of the tray. Her forefinger and middle finger touched the napkin on the meal tray. The Dietary Aide K did not wash or sanitize her hands in between tasks. Interview on 04/09/2025 at 11:54 AM, Dietary Aide K stated she did pick up the dish towel and it did have disinfectant on the towel. She stated she did wipe a tray on the meal cart with the disinfectant towel. Dietary Aide K stated she placed the disinfectant towel on the food prep table, pick up a meal tray, and touched the napkin on the meal tray. She stated she never sanitized or washed her hands. Dietary Aide K stated she was expected to wash her hands when changing tasks or touching anything not sanitary. She stated the disinfectant kitchen towel was not sanitary and was contaminated with disinfectant. She stated the germs from the kitchen rag may transfer from her hands onto the meal tray and the napkin a resident would use when eating their lunch. She stated if a resident ingested any type of germs or bacteria, it was possible the resident may become ill with some type of stomach issues such as vomiting and diarrhea. Dietary Aide K stated she was in-serviced on hand hygiene when working in the kitchen. She did not recall the date of the in-service. 676475 Page 25 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 04/10/2025 at 10:15 AM, the Dietary Manager stated all staff were expected to wear hair nets in the kitchen. She stated there was a possibility hair may fall on the food, the food preparation table, and clean dishes. She stated if hair was on the food or plate and a resident ingested the hair, there was a potential a resident may become ill with some type of stomach illness. She stated there was bacteria on people's hair and hair was considered contaminated. The Dietary Manager stated all staff were required to wash hands between tasks and whenever they touched anything contaminated. She stated the kitchen towel, with disinfectant on it, was considered contaminated. The Dietary Manager stated the staff was in-serviced on hand hygiene and wearing hair nets. She stated she did not recall the date of the in-service. Interview on 04/10/2025 at 9:20 AM, the Administrator stated any staff working in the kitchen was expected to wear a hair net. She stated it was a possibility hair may fall onto clean dishes, food prep area, or food being prepared for meals. The Administrator stated if a resident ingested the hair the resident may become sick with some type of stomach issue. She stated the Dietary Manager was responsible to monitor the kitchen and she was over the Dietary Manager. The Administrator also stated she expected the dietary staff to wash their hands in between tasks or when they touched any contaminated item. She stated if dietary staff did not wash their hands after touching anything considered contaminated, there was a potential a resident may become ill if they ingested any type of bacteria in their food. The Administrator stated without knowing the type of bacteria, it would be difficult to determine what type of illness. Review of the facility's policy on Handwashing Guidelines for Dietary Employees, dated 2025, reflected Hand washing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean hands in a sink used for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste. Compliance Guidelines: 1. Dietary employees shall keep their hands and exposed portions of their arms clean. 2. Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: a. Every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet. b. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. c. After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.). d. After coughing, sneezing, or blowing your nose, using tobacco products, eating, or drinking. e. After handling chemicals and before beginning to work with food. 676475 Page 26 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0812 f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676475 Page 27 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

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 diseases and infections, for 1 of 15 residents, (Resident # 27) observed for infection control practices. Residents Affected - Few The facility failed to ensure LVN B used proper infection control procedures while proving wound care. This failure could place residents at risk for cross contamination and infection. Findings include: Record review of Resident #27's undated Face Sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses of non-pressure chronic ulcer of left heel and midfoot with necrosis (death of body tissue) of muscle, and Type 2 Diabetes Mellitus without complication (long term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of Resident #27's Quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15 indicating intact cognitive status. Record review of Resident #27's Care Plan dated 09/16/2025 and revised 10/23/2024 reflected The resident has sunburn blister to left dorsal foot from going to a family reunion. Record review of Resident #27's Physician orders dated 4/09/2025 reflected Clean dorsal foot with wound cleanser. Pat dry. Apply collagen, cover with abdominal pad and kerlix. Observation on 04/09/2025 at 9:28 AM of wound care for Resident #27, LVN B donned gloves and opened a treatment cart drawer. She grabbed a handful of loose 4 X 4 gauze using contaminated gloves and took those and other wound care supplies into the resident's room. LVN B used paper towels to set up a clean field on the bed. LVN B sprayed wound cleanser onto the wound and wiped up and down on the wound on top of Resident #27's foot with 4 X 4s, going from dirty areas to clean, back and forth several times. She placed the contaminated 4 X 4's used during wound care onto the resident's bed. She applied collagen to the wound, covered it with a small abd pad (used to absorb drainage) and used kerlix gauze to wrap the foot. LVN B did not change her gloves during the procedure. In an interview on 04/09/2025 at 9:58 AM, LVN B stated she had a wound care training course when she first started at the facility three years ago. She stated a wound care nurse had trained her. She stated she knew what she had done wrong when performing wound care on Resident #27. She further stated she went from clean to dirty, back and forth, across the wound and was spreading germs across the wound. She stated she grabbed 4 X 4 gauze out of the cart with contaminated gloves, cross contaminating them. She stated by using them on the wound it could cause an infection that could get progressively worse and possible require surgery. She stated Resident #27 was a diabetic which would put him at higher risk of complications. She stated by putting the contaminated 4 X 4's on the bed after using them on his wound, she was spreading germs. 676475 Page 28 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 04/09/2025 at 2:26 PM, the MD, a wound care physician, stated by using contaminated 4 X 4's and cleaning across the wound with them and going from a dirty to clean area could contaminate the wound and cause an infection. In an interview on 04/10/2025 at 10:06 AM, the DON stated the wound care procedure would be to clean the wound from clean to dirty. She stated Microbes on the outside of the wound could be introduced into the wound if wound care was not performed properly. In an interview on 04/10/2025 at 12:27 PM, the ADM stated improper wound care could cause bacteria to transmit infection. She stated she expected the nurse to follow wound care guidelines, going from clean to dirty and disposing of used 4 X 4 gauze. She stated that a nurse should ask for help or guidance if necessary. She stated the nurse could spread bacteria to a wound by using contaminated 4 X 4's. Review of the undated facility policy Infection Prevention and Control Program did not specifically address wound care however it stated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmissions of communicable diseases as per accepted national standards and guidelines. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. 676475 Page 29 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 2 of 5 residents reviewed for immunizations. (Resident #5 and Resident #67) Residents Affected - Few The facility failed to document, in Resident #5's and Resident #67's medical records, having had received education, whether by self or with responsible party, of the benefits and potential side effects of the influenza immunization and receipt of the of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. This failure could place residents at risk of contracting a viral illness, influenza and pneumococcal, or being informed of the benefits/risk which could cause respiratory complications and potential adverse health outcomes. Findings include: A) Review of Resident #5's face sheet dated 04/09/2025 reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia), muscle wasting and atrophy, left hand, hemiplegia (a symptom that involves one-sided paralysis), unspecified affecting left nondominant side. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was assessed to have been offered and declined the influenza and pneumococcal vaccines. Review of Resident #5's comprehensive care plan reflected no entries related to her immunization status. Review of Resident #5's EMR under vaccines reflected Resident #5 refused the influenza, and pneumovax vaccinations . Further review of Resident #5's EMR reflected no VIS provided to or signed by resident or RP for the vaccine. B) Review of Resident #67's face sheet dated 04/10/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses osteomyelitis (bone infection) of vertebra, sacral and sacrococcygeal region. Review of Resident #67's admission MDS dated [DATE] reflected she was assessed to have a BIMS score of 7 indicating severe cognitive impairment. Further review reflected she was assessed to have been offered and declined the influenza and pneumococcal vaccines. Review of Resident #67's comprehensive care plan reflected no entries related to her immunization status. 676475 Page 30 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #67's EMR under vaccines reflected Resident #67 refused the influenza, and pneumovax vaccinations . Further review of Resident #67's EMR reflected no VIS provided to or signed by resident or RP for the vaccines. In an interview on 04/10/2025 at 12:45 pm, the DON stated she was the infection preventionist and oversaw making sure the residents received the VIS sheets when they refused vaccinations. She stated she did not ensure Resident #5 or Resident #67 was provided with the VIS, or discuss the risk versus benefits of not receiving the vaccination with the resident or RP. She stated without the sheets being provided the residents or the RP would have no chance of knowing the risks verses the benefits. Review of the facility's undated policy Infection Prevention and Control reflected .Influenza and Pneumococcal Immunization: a. Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time. b. Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere. c. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. d. Residents will have the opportunity to refuse the immunizations. e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations . 676475 Page 31 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 2 of 5 residents who were reviewed for immunizations. (Resident #5 and Resident #67) The facility failed to document, in Resident #5's and Resident #67's medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Findings include: A) Review of Resident #5's face sheet dated 04/09/2025 reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia), muscle wasting and atrophy, left hand, hemiplegia (a symptom that involves one-sided paralysis), unspecified affecting left nondominant side. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was assessed to not be up to date on her COVID-19 vaccination. Review of Resident #5's comprehensive care plan reflected no entries related to her immunization status. Review of Resident #5's EMR under vaccines reflected Resident #5 refused the COVID-19 vaccinations. Further review of Resident #5's EMR reflected no VIS provided to or signed by resident or RP for the vaccine. In an interview on 04/10/2025 at 12:45 pm the DON stated she was the infection preventionist and oversaw making sure the residents received the VIS sheets when they refuse vaccinations. She stated she did not ensure Resident #5 was provided with the VIS or discuss the risk versus benefits of not receiving the vaccination with the resident or RP. She stated without the sheets being provided the residents or the RP would have no chance of knowing the risks verses the benefits. B) Review of Resident #67's face sheet dated 04/10/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses osteomyelitis (bone infection) of vertebra, sacral and sacrococcygeal region. Review of Resident #67's comprehensive care plan reflected no entries related to her immunization 676475 Page 32 of 33 676475 04/10/2025 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0887 status. Level of Harm - Minimal harm or potential for actual harm Review of Resident #67's admission MDS dated [DATE] reflected she was assessed to have a BIMS score of 7 indicating severe cognitive impairment. Further review reflected she was assessed to not be up to date on her COVID-19 vaccination. Residents Affected - Few Review of Resident #67's EMR under vaccines reflected Resident #67 refused the COVID-19 vaccinations. Further review of Resident #67's EMR reflected no VIS provided to or signed by resident or RP for the vaccines. In an interview on 04/10/2025 at 12:45 pm the DON stated she was the infection preventionist and oversaw making sure the residents received the VIS sheets when they refuse vaccinations. She stated she did not ensure Resident #67 was provided with the VIS or discuss the risk versus benefits of not receiving the vaccination with the resident or RP. She stated without the sheets being provided the residents or the RP would have no chance of knowing the risks verses the benefits. Review of the facility's undated policy Infection Prevention and Control reflected .8. COVID-19 Immunization . c. Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine . e. Residents or resident representatives will have the opportunity to accept or refuse a COVID-19 vaccination, and change their decision based on current guidance .resident's medical record includes documentation that indicates, at a minimum, the following: 1. That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; . If the resident did not receive the COVID-19 vaccine due to medication contraindications or refusal . 676475 Page 33 of 33