Health inspection·November 8, 2023

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on interview and observation the facility failed to ensure the residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service for 8 of 8 residents (Residents #33, #40, #47, #53, #80, #82, #85 and #405) reviewed for rights to forms of communication. Residents Affected - Some The facility did not implement a system for delivering mail on Saturday. This failure could place the residents at risk of not receiving mail in a timely manner and a diminished quality of life. Findings include: During a group interview on 11/07/2023 at 9:30 a.m., Residents #40, #47 and #85 said they knew the mail came in on Saturday, was not delivered to them until Monday. Resident #47 said the mail was kept in a lock box in the front office. During an interview on 11/07/2023 at 10:25 a.m., the Activity Director said she does not know how the weekend mail was handled. She said the business office gave her the mail during the week and she delivered it. She said she's not sure who did the mail on the weekend. During an interview on 11/07/2023 at 10:34 a.m., the HR Manager said the weekend mail was placed in a locked box in the receptionist office, because some of the mail was tampered with and they wanted to secure it. She said locking it in the lock box was supposed to have been a short-term fix, but she was not sure how the mail was being handle now. The HR Manager contacted the weekend receptionist-B on her phone at 10:58 a.m. and he said, he locked the weekend mail in a locked box on the receptions desk until Monday. He said the Business Office sorted the mail and then residents' mail was delivered to the residents. During an observation of the receptionist desk drawer, the HR Director received a key from the receptionist on duty and opened the pad lock on a bottom drawer of the receptionist desk. During an interview with the Administrator on 11/07/2023 at 10:44 a.m., he said the weekend receptionist received the mail on the weekend and he held the mail over for Monday. He said the BOM would sort the mail on Monday and the residents mail was then delivered to them. Record review of the facility's Policy and Procedures for Resident Mail Services dated 07/2022, reflected 1. Incoming mail: a. Mail Delivery: Mail received for residents will be delivered to the designated staff person responsible for mail distribution, within 24 hours of being delivered by the United States Postal Service including a post office box. Page 1 of 6 455485 455485 11/08/2023 Avir at Petal Hill 900 S Baxter Ave Tyler, TX 75701

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate the assessment of 1 of 4 residents (Resident #90) reviewed for the pre-admission screening and resident review (PASRR) program and PASRR assessments and evaluations. Residents Affected - Few The facility failed to ensure Residents #90 had an accurate PASRR Level 1 Screening which indicated diagnoses of mental illness. This failure could affect residents with psychiatric diagnoses who may not be evaluated for PASRR services and place them at risk of not receiving services for care and treatment. Findings include: Record review of Resident #90's PASRR Level 1 Screening completed on 05/19/2023 indicated in section C0100 this resident did not have evidence of having a mental illness. Record review of Resident #90's hospital discharge orders dated 05/18/2023 indicated Resident #90 was to be admitted to the facility with diagnoses which included bipolar disorder and medication orders which included aripiprazole (an antipsychotic for the treatment of bipolar disorder). Record review of a face sheet dated 11/08/2023 indicated Resident #90 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness). Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated Resident #90 had a BIMS(Brief Interview for Mental Status) score of 12 which indicated moderately impaired cognition. The MDS section, Preadmission Screening and Resident Review, indicated Resident #90 did not have a serious mental illness. The MDS section I, Active Diagnoses, indicated Resident #90 had a diagnosis of bipolar disorder. Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated Resident #90 was receiving an antipsychotic medication (aripiprazole) on a routine basis. Record review of physician orders dated 11/08/2023 indicated Resident #90 had a diagnosis of bipolar disorder and an order for aripiprazole daily for the treatment of schizophrenia(a disorder that affects a person's ability to think, feel, and behave clearly). During an interview with the DON on 11/07/2023 at 9:45 AM, she said the facility did not have an MDS (Minimum Data Set) Nurse and said the Corporate MDS Nurse was assisting with tasks related to the PASRR and MDS processes. The DON said she was not working at the facility in March 2023 and did not know the rationale behind the coding of the 05/19/2023 PASRR Level 1 screening. During an interview with the Corporate Nurse on 11/08/2023 at 10:50 AM, she said the facility did not check the accuracy of the PASRR screening tool nor was it noted by whoever did the coding of the admission MDS. She said she understood the importance of PASRR Level 1 Screenings being accurate because the facility needed to make sure eligible residents were receiving the correct services. 455485 Page 2 of 6 455485 11/08/2023 Avir at Petal Hill 900 S Baxter Ave Tyler, TX 75701

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of 1 of 4 halls (Tradition Hall locked unit) reviewed for activities Residents Affected - Some The facility failed to ensure there were organized activities provided to the residents during scheduled activity time. This failure could place residents at risk for a diminished quality of life, isolation, boredom, lack of stimulation, and a decline in mental status. Findings include: Record review of the facility's November 2023 Activities Calendar, reflected on 11/06/23 the planned activities were as follows:10:00 AM Arts and Crafts with music 2:00 PM Nail Care Record review of the facility's November 2023 Activities Calendar, reflected 11/07/23 the planned activities were as follows: 10:00 AM Morning Exercise 3:00 PM Movie and Popcorn Observation on 11/06/23 from 10:20 AM - 12:15 PM revealed residents on the Tradition Hall, locked unit, were observed standing and sitting in the communal area talking to each other. Music videos were being played on the TV; no arts and crafts were being provided. The Activity Director nor her assistant were present. During observation of the Tradition Hall locked unit on 11/07/23 at 10:18 a.m., revealed no activity was being provided for the residents. Several of the residents were standing and sitting in the communal area. The TV was on, showing a preacher, preaching a sermon. The residents did not appear to be interested in the TV and the Activity Director or the Activity Assistant were present providing any activity. During observation of the Tradition Hall locked unit, on 11/07/23 at 3:13 p.m., residents were standing and sitting in the communal area of the unit. There was no activity being provided, the Activity Director nor the Activity Assistant were present. During an interview on 11/06/22 at 11:34 a.m., CNA-C said watching TV was supposed to be the activity. She said the residents were supposed to sit and watch the music videos. She said otherwise, there were no other activities for the residents. She said, the videos were only being played because the state survey agency was there. During an interview on 11/06/23 at 11:40 a.m., CNA-D said there were no activities for the 455485 Page 3 of 6 455485 11/08/2023 Avir at Petal Hill 900 S Baxter Ave Tyler, TX 75701

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents. She said the nurses and the CNA's were always bringing things in, just to try an provide an activity for the residents. During an interview and observation on 11/06/23 at 11:44 a.m., LVN-E said the residents never had any activities. She said the Activity Director would provide activities to the residents on the other halls but did not provide any activities for the resident on this hall. She said she was so up-set over not having activities for the residents, she filed a grievance with her supervisor. She said ever since the Activity Director was there, activities had almost been nonexistent and in the past two weeks, there were no activities for the residents on the Tradition Hall locked unit. During observation of the communal area of the Tradition Hall locked unit on 11/06/20 at 11:58 a.m. revealed the residents were standing and seated and were not attentive to the music video being played on the TV. The Activity Director nor the Activity Assistant were present. During an interview on 11/07/23 at 9:40 a.m., the Activity Director said they did several activities on the Tradition Hall locked unit. She said they colored, chef taste, ball toss, aroma therapy and snacks. She said aroma therapy was being done now. When asked how this was an activity for the residents, the Activity Director did not have a reply. During an interview on 11/07/23 at 4:06 p.m., CNA -E said, there had not been any activities on the locked unit in the last week and maybe 1 in the past week and a half. During an interview on 11/07/23 at 4:11 p.m., LVN-F said there had not been any activities on the locked unit since the new Activity Director got there. She said there were no activities in the past month. During an interview on 11/08/23 at 2:56 p.m., the DON said, she received a grievance on the Activity Director, regarding no activities on the Tradition Hall locked unit. She said the grievance was received on 10/27/23, it was given to the Activity Director for a response, and they had not heard from her yet. During an interview on 11/08/23 at 3:20 p.m., the Activity Director said she was going to do better with activities for the residents on the Tradition Hall locked unit and she wanted to let the State Surveyor know they did not do fingernail painting on 11/06/23. She said she was afraid the residents would put their fingers in their mouth. Record review of the facility's policy, Activities, dated 05/2022, reflected: It is the policy of this facility to provide an ongoing program to support resident in their choice of activities . 455485 Page 4 of 6 455485 11/08/2023 Avir at Petal Hill 900 S Baxter Ave Tyler, TX 75701

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure that a resident who need respiratory care was provided such care, consistent with professional standards of practice, for 1 of 3 residents (Resident #251) reviewed for respiratory care. Residents Affected - Some 1. The facility failed to ensure Resident #251's O2 tubing was covered and labeled. 2. The facility failed to ensure Resident #251's nebulizer tubing was covered. 3. The facility failed to ensure Resident #251's BiPAP tubing was clean and covered. 4. The facility failed to ensure Resident #251's O2 Humidifier bottle was dated and not empty. These failures could affect residents who were dependent on respiratory care and could contribute to upper respiratory infections and worsening of their physical condition. Findings included: Observations on 11/6/2023 to 11/08/2023 between 9:00 AM and 3:30 PM in Resident #251's room the following was observed: O2 tubing was not covered and labeled. Nebulizer tubing was not covered or dated. Resident BiPAP tubing was dirty and not covered. O2 Humidifier bottle not dated and empty. During an observation and interview on 11/7/2023 at 12:07 PM, Resident #251 said she used her Bi - Pap at night. The Bi - Pap and O2 tubing was observed to have no date of when the tubing was changed. Resident #251 said it had not been changed this week. In an interview on 11/08/2023 at 1:40 PM, RN A said the oxygen tubing was changed weekly and the oxygen tubing was placed in a zip lock bag for infection control to prevent contamination. She saidthe CPAP mask was to be cleaned after each use and placed inside a zip lock bag. RN A stated this was done on the night shift, but she would change the tubing. In an interview and record review on 11/08/2023 at 2:00 PM with the DON/IP, she said the night shift nurse on Sunday's was responsible for changing O2 tubing and was the DON's responsibility to perform infection control audits to review the policies were being followed. Record review reflected the night shift was signing tasks as being done., she said the oxygen tubing and Bi - PAP mask should be placed in a zip lock bag after each use. She said, the facility did not have an Infection Control policy for cross contamination it was best practice to bag the items as a best practice for infection control. She said it was a system failure that the facility was not monitoring this to ensure it was being done and residents were at risk for respiratory infections. During a record review of physician orders for Resident #251, dated 10/29/23, indicated the 455485 Page 5 of 6 455485 11/08/2023 Avir at Petal Hill 900 S Baxter Ave Tyler, TX 75701

F 0695 following: Level of Harm - Minimal harm or potential for actual harm [Oxygen, Nebulizer, CPAP, BPAP] tubing and delivery device (mask, nasal cannula) is to be stored in bag when not in use. Change O2 tubing/water every week and PRN, Clean BPAP mask and tubing with antibacterial soap, rinse with H20 until clear and hang to dry weekly on Monday mornings and PRN. Humidification with distilled water/No humidification. Residents Affected - Some 455485 Page 6 of 6