Avir At Mineola

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

assessed Resident #2's right leg. The DON said Resident #2's right leg was red and swollen. The DON said

she was aware that LVN B had previously wrapped Resident #2's right leg with an ace wrap due to swelling and weeping. The DON said LVN B had not notified the physician or NP to obtain an order for the ace wrap or to notify them of the swelling and weeping to Resident #2's right leg. The DON said the LVN C, had been

the nurse who had discovered and reported to the ADON that Resident #2's right leg was wrapped with an ace wrap. During an interview on 8/29/25 at 10:50 a.m. LVN D said she was working on 8/28/25 and Resident #2 came to her after dinner and showed her what appeared to be a burst blister with drainage to her right leg. LVN D said she applied a non-stick dressing to the area and wrapped it with wrap gauze. LVN D said she had intentions to but never notified the physician or obtained an order for the dressing. During

an interview on 8/29/25 at 10:55 a.m. the DON said she expected staff to notify the physician of changes in condition including skin conditions, swelling, or weeping. During an interview attempt on 8/29/25 at 12:16 p.m. LVN B did not answer the phone and her voicemail was full. During an interview on 8/29/25 at 2:06 p.m. the DON the importance of notifying the physician of a change in condition was to get the appropriate diagnosis and treatment for a resident. Record review of the facility's Change in a Resident's Condition or Status policy last revised 6/2025 indicated, Our facility promptly notifies the resident, his or her attending physician, healthcare provider, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician, healthcare provider, or physician on call when there had been a(an):.b. discovery of injuries of unknown origin.d. significant change

in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly.Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Mineola

320 Greenville Highway Mineola, TX 75773

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

earlier than ordered. The DON said the importance of following the physician's orders and administering as needed medications as ordered was not to overmedicate the resident and be able to signify if a medication was effective within the parameters ordered. The DON said she expected all medications including as needed medications to be documented in the EMR. The DON said the importance of documenting in the EMR was that was the official documentation indicating a medication had been administered and it allowed other nurses to know when a resident least had a medication and the medications effectiveness. Record

review of the facility's Medication Administration-General Guidelines policy dated 6/1/22 indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.A. Preparation.4. Five Rights- right resident, right drug, right dose, right route, and right time, are applied for each medication being administered .5. The medication administration record (MAR) is always employed during medication administration.B. Administration.2.

Medications are administered in accordance with written orders of the prescriber.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Mineola

320 Greenville Highway Mineola, TX 75773

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

swelling, or weeping. During an interview attempt on 8/29/25 at 12:16 p.m. LVN B did not answer the phone and her voicemail was full. During an interview on 8/29/25 at 2:06 p.m. the DON the importance of notifying

the physician of a change in condition was to get the appropriate diagnosis and treatment for a resident.

Record review of the facility's Change in a Resident's Condition or Status policy last revised 6/2025 indicated, Our facility promptly notifies the resident, his or her attending physician, healthcare provider, and

the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician, healthcare provider, or physician on call when there had been a(an):.b. discovery of injuries of unknown origin.d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly.Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Mineola

320 Greenville Highway Mineola, TX 75773

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record reviews, the facility failed to ensure registry verification was received that the individual had met competency evaluation requirements before they were allowed to work as a nurse aide for 1 of 4 (CNA E) employees reviewed for registry verification. The facility failed to ensure CNA E had a current nurse aide certification while employed at the facility and actively providing care for residents from [DATE REDACTED] through [DATE REDACTED]. CNA E certificate expired on [DATE REDACTED]. This failure placed residents at risk for decreased quality of care. Findings included:Record review of CNA E's employee file indicated her nurse aide certification was issued on [DATE REDACTED] and would expire on [DATE REDACTED]. The employee file indicated CNA E's initial nurse aide certification was issued on [DATE REDACTED]. The employee file indicated she applied to the facility on [DATE REDACTED] and was available for work on [DATE REDACTED]. The employee application indicated her nurse aide certification would expire on [DATE REDACTED]. Record review of CNA E's time sheets from [DATE REDACTED] through [DATE REDACTED] indicated other than 4 days of PTO, she had taken CNA E had worked her normal full-time shift at the facility. During an interview on [DATE REDACTED] at 11:50 a.m. the BOM said CNA E's nurse aide certification expired

on [DATE REDACTED]. The BOM said when LVN C brought it to her attention that CNA E had an expired nurse aide certification she pulled the certification in TULIP and saw it had been renewed on [DATE REDACTED]. The BOM said

she did not know how many if any days CNA E had worked with an expired nurse aide certification or why CNA E did not renew her nurse aide certification by [DATE REDACTED]. The BOM said she did not know how LVN C was aware of CNA E's expired nurse aide certification or what date she was notified on. During an interview

on [DATE REDACTED] at 12:35 p.m. the Administrator said he had not been aware CNA E had been working with an expired nurse aide certification until she told them. The Administrator said the facility and corporate do monitor for expired or expiring license and certifications, but CNA E had not showed up on any of their lists.

The Administrator said CNA E told them she had not renewed her certification because she did not know how to work TULIP. During an interview on [DATE REDACTED] at 12:41 p.m. CNA E said her nurse aide certification was expired for several months without her realizing it because she thought the facility would renew it for her like her previous facility did. CNA E said when she realized her nurse aide certification was expired due to her working nights, she had not gone up to the facility to have them assist her with the renewal paperwork. CNA E said there was really no excuse for her nurse aide certification being expired for so long.

During an interview on [DATE REDACTED] at 2:25 p.m. the Administrator said the facility did not have a policy regarding nurse aide certification renewal/expirations/registry. The Administrator said the facility did have an annual employee checklist that was supposed to be completed on all employees annually.

Event ID:

Facility ID:

If continuation sheet