Avir At Johnson City

#14's incomplete care plan.

The DON stated care plans should include services and interventions

triggered care were as in the MDS assessment should be carried over to the care plan.

The DON

stated she worked for the facility for almost 4 years.

She confirmed she had been appropriately oriented, trained, and in-serviced on relevant topics for her position. CNA D stated the importance of care plans was to determine residents' needs.

She stated if she saw an incomplete service plan, she would ask the appropriate staff member or bring it to their attention.In an interview on [DATE] at 3:05 PM, LVN A stated he had worked for the facility for 3 months. He stated that he had been oriented, trained, and in-serviced on relevant topics for his position, including care plans. He stated that care plans needed to be complete to provide the residents with the best therapeutic care possible. He stated that focus were as such as hospice and pneumonia should be included in a resident's care plan. He stated a possible negative outcome of an incomplete care plan would be decreased health.In an interview on [DATE] at 3:15 PM, the ADM stated that she could not speak directly to the contents of a comprehensive care plan and would defer to the facility's MDS nurse.

The ADM stated that a possible negative outcome of an incomplete comprehensive care plan was that the resident would not receive adequate care.

Record review of the facility's policy entitled, Care Plans, Comprehensive Person-Centered states:A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident.Furthermore, the policy interpretation and implementation states:1.The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7.The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes;b. describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.c. includes the resident's stated goals upon admission and desired outcomes.d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem were and conditions.

676486 06/04/2026

Avir at Johnson City 206 Haley Rd.

Johnson City, TX 78636

within the resident's reach. He stated there had been a clip on the call light so that it could be kept

the resident. He stated that residents were checked every couple of hours to ensure the call lights

reach for their safety. He stated that his in-service training had been 3 months ago, when he was hired. He stated that the resident could have been injured if the call light was not within reach.

An interview on 06/04/2026 at 2:13 PM with the ADON, she stated that call lights should have been within the resident's reach.

She stated if a resident moved to a recliner, the call light should have been moved with the resident.

She stated that if the resident's call light was not within reach, the resident could have been injured.

She stated that she talked to the residents about the importance of the call light being close.

She stated that the resident could have fallen and not gotten help.

She stated that call lights were talked about daily with the staff.

An interview on 06/04/2026 at 3:09 PM with the ADM, she stated the call light should be within reach of the resident when the resident was in the room.

She stated the call light should be moved if the resident goes to a recliner.

She stated that the call light should always be within the resident's reach while the resident is in the room.

She stated that all staff meet every month to remind staff about the call lights.

Record

Review of the facility's policy titled Lifting Machine, Using a Mechanical revised July 2017 revealed:1.Before using a lifting device, assess the resident's current condition, including:a.Physical:i.Can the resident assist with transfer?ii.Is the resident's weight and medical condition appropriate for the use of a lift?b.Cognitive/Emotional:i.Can the resident understand and follow instructions?ii.Does the resident express fear or appear anxious about the use of a lift?iii.Is the resident agitated, resistant, or combative?2.

Measure the resident for proper sling size and purpose, according to the manufacturer's instructions.3.

Select a sling bar that is appropriate for the resident's size and the task.12.

Attach sling straps to sling bar, according to manufacturer's instructions.a.

Make sure the sling is securely attached to the clips and that it is properly balanced.b.

Check to make sure the resident's head, neck, and back are supported.c.

Before resident is lifted, double check the security of the sling attachment.d.

Examine all hooks, clips or fasteners.e.

Check the stability of the straps.f.

Ensure that the sling bar is securely attached and sound.

Record review of the call light policy dated January 2025 reflected the following.

Policy:Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. 1.Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor.

Record review of the facility's policy and procedures entitled Dining Room Service dated 2023 stated: Dining room staff should check the individual name and diet on the meal identification (ID) card/ticket to verify that the meal was served to the correct person, check items on the plate/tray to ensure accuracy for food preferences, therapeutic or modified consistency diets.

676486 06/04/2026

Avir at Johnson City 206 Haley Rd.

Johnson City, TX 78636

Review of the facility's policy titled Lifting Machine, Using a Mechanical, revision date July 2017,

principles of safe lifting using a mechanical lifting device. It is not a substitute for the manufacturer's training or instructions.

676486 06/04/2026

Avir at Johnson City 206 Haley Rd.

Johnson City, TX 78636

Based on observations, interviews, and record review, the facility failed to ensure the safe storage of

cart on 100 hall) reviewed for pharmacy services.

The facility failed to prevent the storage of expired medication and supplies in the medication cart on 100 hall.

This deficient practice could place residents at risk of the medications and supplies not being as effective and dealing with the symptoms that the meds were supposed to treat.The findings included: Observation on 06/03/2026 at 02:20 pm showed that the following medication and supplies were expired in the medication cart of the 100 Hall: 1. OCuSoft Lid Scrub Plus, which was used as an Eyelid Cleanser for moderate-severe conditions, expired on 12/2025.2.

Nystop.

Nystatin Topical Powder, USP 100,000 USP Units Per Gram (Treat fungal infections) expired on 05/31/2026.In an interview on 06/03/2026 at 02:51 p.m., LVN B stated she had been working at the facility for about 3 months. LVN B stated she checked expired medication every couple of weeks. LVN B stated that expired medication can affect its potency, becoming either stronger or weaker in its effects. LVN B stated that she will check more promptly, at least once a week, to prevent expired medication from being in the medication cart. LVN B stated she had been trained to check for expired medication and immediately removed the found expired medications from the medication cart. In an interview on 06/04/2026 at 02:18 p.m., ADON stated that the negative outcome of expired medication was: Expired medication cannot get the full chemicals of the medication and not fully absorbed, which can cause a negative reaction. ADON stated that interventions could be implemented to prevent expired medication from being administered to residents, such as regularly checking stock levels. ADON stated it was the responsibility of the nursing staff to check the expired medication, and anyone assigned to the medication cart. ADON stated she checks the medication cart every month. In an interview on 06/04/2026 at 02:32 p.m., DON stated that a negative outcome of expired medication could be a medication error because one could mistakenly pass that medication and potentially cause patient harm, or the medication may not be therapeutic. DON stated that an intervention can be taken to prevent expired medication from being administered to residents, which includes the following: cart checks being performed in mid-month, not only by the ADON, but also by nurses, who should check the expiration date with each medication administration. In an interview on 06/04/2026 at 03:16 p.m., ADM stated that she would refer to her clinical staff regarding the negative outcomes associated with expired medications. ADM stated that interventions could be taken to prevent expired medication from being administered to residents by checking the medication cart monthly. ADM stated that it is the responsibility of the nursing staff and the ADON to check for expired medication.

Review of the facility's policy titled Medication Labeling and Storage, revision date February 2023, revealed under the Medication Storage: 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding resuming or destroying items.

it had been an infection control issue, and residents could have gotten sick.An interview on

responsible for cleaning.

She stated that the ice machine scoop had not belonged in the ice machine.

refrigerator or the kitchen area.

She stated that doing these things could have put residents at risk by spreading an infection.

She stated that the dietary manager had been responsible for in-service training for all kitchen staff.

She stated that she would have reviewed all in-service training with the dietary manager to ensure staff had been updated on policies for labeling, dating, and kitchen cleaning.

She stated that if these things had not been done then items could have been contaminated and caused the residents to get sick.

Record review of the Labeling and Dating Policy dated November 2022 reflected the following. 2.

Foods belonging to residents are labeled with the resident's name, the item, and the use by date.3.Food code was reviewed.

Record review of the Sanitation Policy that was not dated reflected the following.

Food and nutrition services staff will maintain kitchen sanitation by complying with a comprehensive written cleaning schedule.

676486 06/04/2026

Avir at Johnson City 206 Haley Rd.

Johnson City, TX 78636