Health inspection·July 19, 2024

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 observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for five of six residents (Residents #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for quality of life/ADL care. Residents Affected - Some The facility failed to ensure nailcare was completed for Resident #1, Resident #2, Resident #3, and Resident #4's and to ensure Resident #5 received a timely response for incontinent care. This failure could place residents at risk for poor hygiene, infections, dignity issues, embarrassment, humiliation, and decreased quality of life. Findings include: 1. Record Review of Resident #1's Face Sheet dated 07/18/2024 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of Traumatic Brain Injury (a head injury causing damage to the brain), Unspecified convulsions (uncontrollable muscle contractions), Mixed hyperlipidemia (high cholesterol), Seizures (sudden disturbance in the brain that causes behavior, movements, and consciousness), anxiety disorder (intense, excessive worry), and other specified disorders of the brain (diverse group of brain conditions that do not fit in another category). Record review of Resident #1's Quarterly MDS Assessment, dated 06/24/2024, reflected the resident had a BIMS score of 7 which indicated severely impaired cognition. Resident #1 required a one person assist from staff for personal hygiene, dressing, toileting, bathing, and oral hygiene. Record review of Resident #1's Comprehensive Care Plan dated 07/05/2024 reflected Resident #1 was dependent on staff for completion of ADL tasks. Intervention: Resident #1 required extensive assistance for bathing and hygiene. Resident #1 did not receive nail care daily between 6:00am and 2:00pm, per care plan. Interview and observation on 07/18/2024 at 4:14 pm reflected Resident #1 had a blackish/brownish substance underneath all nails on his right and left hand. The residents' nails were about one quarter of an inch past the end of his fingertip. Resident #1 stated he would like his nails trimmed. 2. Page 1 of 6 455489 455489 07/19/2024 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident # 2's Face Sheet dated 7/18/2024 revealed a [AGE] year-old female admitted on [DATE] with diagnoses Cerebral infarction, unspecified (stroke), Type 2 diabetes mellitus with unspecified complications (complications from the body's inability to produce insulin), Heart failure, unspecified (reduced blood supply to the heart), Gastrostomy status (feeding tube), Chronic obstructive pulmonary disease (trouble breathing, wheezing), Hypertensive heart disease with heart failure (the heart ceases to function caused by high blood pressure), and Muscle weakness (inability for the muscles to perform). Record review of Resident #2's Quarterly MDS Assessment, dated 06/26/2024, reflected the resident had a BIMS score of 2 which indicated severely impaired cognition. Resident #2 required extensive and total assistance staff for personal hygiene, dressing, toileting, bathing, and oral hygiene. Record review of Resident #2's Comprehensive Care Plan dated 07/10/2024 reflected Resident #2 was dependent on staff for completion of ADL tasks. Intervention: Resident #1 was fully dependent on staff for assistance with ADL's. The care plan did not address nail care for the resident. Interview and observation on 07/18/2024 at 9:07 am reflected Resident #2 had a blackish/brownish substance underneath all nails on her right hand, left hand was not visible. The residents' nails were about one quarter of an inch past the end of her fingertip. Resident did not respond to interview questions. Therefore, she was not interviewed. 3. Record Review of Resident #3's Face Sheet dated 07/18/2024 revealed an [AGE] year-old female admitted on [DATE] with diagnoses of Unspecified Dementia (symptoms that affect memory and daily life), and Chronic Obstructive Pulmonary Disease (persistent breathlessness and cough), Hypertension (high blood pressure). Review of the MDS for Resident #3 was not available due to international Microsoft issues. Per resident roster provided by the ADM, the facility identified Resident #3 as a resident that could participate in an interview. Record review of Resident #3's Comprehensive Care Plan dated 06/06/2024 reflected Resident #3 required assistance from staff for completion of ADL tasks. Intervention: Resident #3 required extensive assistance for bathing, hygiene, dressing, grooming. Nailcare was not addressed in the care plan for Resident #3. Interview and observation on 07/18/2024 at 4:45 pm reflected Resident #3 had long fingernails exceeding one half inch past the tips of her fingers. Resident #3 stated she would like to have her nails cut back by half the length. Two of the nails had a light brown substance underneath the nails. Resident stated she also had an ingrown toenail. 4. Record Review of Resident #4's Face Sheet dated 07/18/2024 revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Cerebral Infarction (stroke), Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (weakness or paralysis from the stroke), Dysphagia (difficulty swallowing), Asymptomatic human immunodeficiency virus [HIV] (virus affecting the immune system), and Type 2 diabetes mellitus with diabetic polyneuropathy (nerve pain caused by Diabetes). 455489 Page 2 of 6 455489 07/19/2024 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the MDS for Resident #4 was not available due to international Microsoft issues. Per resident roster provided by the ADM, the facility identified Resident #4 as a resident that could participate in an interview. Record review of Resident #4's Comprehensive Care Plan dated 06/26/2024 reflected Resident #4 was dependent on staff for completion of ADL tasks. Intervention: Resident #4 required extensive assistance for bathing, hygiene, dressing and grooming. Nailcare was not addressed in the Care Plan for Resident #4. Interview and observation on 07/18/2024 at 4:15 pm reflected Resident #4 had a blackish/brownish substance underneath most nails. The resident's nails were more than one half inch past the end of her fingertip. Resident #4 stated she would like her nails trimmed. 5. Review of face sheet dated 7/17/2024 for Resident #5 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Encephalopathy (condition that affects brain structure and function), Hyperlipidemia (high cholesterol),Hypertension (high blood pressure), Congestive Heart Failure (the hearts inability to fill up and pump blood), Bipolar Disorder (mental illness characterized by extreme mood swings), Acquired absence of left leg above knee amputation (no left leg below the knee), and Chronic kidney disease (kidneys cannot filter properly). Review of the MDS assessment for Resident #5 was not available due to international Microsoft issues. Per resident roster provided by the ADM, the facility identified Resident #5 as a resident that could participate in an interview. Review of the Care Plan dated 06/04/2024 for Resident #5 identified a Bowel/Bladder Incontinence problem. The interventions included wearing briefs, Depends, or pantiliners when out of bed, check for incontinence as needed, and keep call light in easy reach. Observation on 07/17/2024 at 10:30 am revealed Resident #5 was sitting in her wheelchair in her room. Resident #5 stated she pressed her call light over three hours ago and no one had come to check on her. A puddle of urine was dripping onto the floor, underneath Resident #5's wheelchair. The resident was tearful and stated, It makes me feel like an invalid. Interview on 7/18/2024 at 5:20pm with LVN - F revealed they had worked at the facility for four months, and stated the nurses and CNAs were responsible to provide nail care to residents. Adverse outcomes were identified as, they could scratch themselves. LVN - F stated, There was no acceptable reason why the resident was left soiled for more than three hours, especially if the nurse is making the required rounds every two hours. Identified adverse outcomes were, Bed sores and red bottoms. Interview on 7/19/2024 at 9:36am with CNA - D revealed they had worked at the facility for eighteen years. CNA - D stated nail care was performed when they gave the residents their showers, and cleaned underneath and clipped their nails. CNA - D stated there was no acceptable reason the resident was left soiled for more than three hours. Identified adverse outcomes were, breakdown, sores, rashes and it will weaken the skin. Interview on 7/19/2024 at 9:50am with LVN - F revealed they had worked at the facility for six months. LVN F said all nursing staff were responsible to ensure the residents had proper nailcare. The 455489 Page 3 of 6 455489 07/19/2024 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nurses took care of the residents with Diabetes. Adverse outcomes were identified as, Scratch themselves, infection, eat something that's bad for them. LVN - F said residents were checked-on by the CNAs every two hours and those that wet more often, were checked every hour by the CNAs. LVN - F said there was no reason for why the resident was left soiled for more than three hours. Interview on 7/19/2024 at 10:20am with the ADON revealed (he/she) had been employed at the facility for five years. The ADON stated, The nursing staff were responsible to provide nail care to the residents. They should have done nailcare on their assigned shower day, and on Sundays. They should get nails checked every day because they play in their poop. The ADON stated there was no acceptable reason for prolonged wetness. Interview on 7/19/2024 at 11:00am with the ADM, stated the expectation was that each resident had their nails checked every Sunday and as needed. She stated the CNAs and nurses are responsible for providing nail care to ensure residents do not scratch themselves or get infections. The ADM revealed the expectation was that residents were checked every two hours and there was no acceptable reason for why a resident was wet for more than three hours. Record review of the facility policy on Fingernails/Toenails Care, revised in February 2018, reflected the following: Purpose - The purposes of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections. General Guidelines 1. Nail care includes daily cleaning and regular trimming. 455489 Page 4 of 6 455489 07/19/2024 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

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 and interview, the facility failed to ensure all drugs and biologicals were in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 2 of 4 medication carts (Med Cart #1 and Med Cart #2) reviewed for medication storage in that: The facility failed to prevent: Medication Cart #1 being unattended and unlocked in the doorway to dining room on 7/17/2024. Medication Cart #2 being unattended and unlocked across from the nurses' station on 7/17/2024. This failure could allow residents unsupervised access to prescription and over-the-counter medications. Findings Include: Observation on 07/17/2024 at 9:10 am revealed, Med Cart #1 sitting near the entrance to the dining room. Med Cart #1 was unsupervised and unlocked. Review of the contents of the cart revealed prescription and over-the counter medications and ointments, glucometer supplies, insulin pens, and insulin syringes. The CMA was approximately thirty yards away with her back turned away from cart. The unlocked computer sitting on top of Med Cart #1 had resident information to other residents, visitors and staff walking past the cart. The ADON approached the cart, reminded the CMA to lock the cart when stepping away, and the ADON secured the cart. Observation on 07/17/2024 at 9:13 am revealed, Med Cart #2 sitting across from nurses' station, up against the wall with the drawer's facing outward. Med Cart #2 was unsupervised and unlocked. Review of the contents of the cart revealed prescription and over-the counter medications and ointments, glucometer supplies, insulin pens, and insulin syringes. The nurse assigned to the cart was not in sight. The ADON approached the cart and asked another staff member sitting in nurses' station to page LVN - A. The ADON secured the cart. Interview on 7/18/2024 at 11:13 am with CMA - A revealed they had been in that position for a year and had received training on the facility's medication policy. She stated the facility trained her for the position. CMA - A stated she left the cart unlocked in the doorway of the dining room. However, she was passing medications at the time, and she was in eyesight of the cart. She stated there were residents in the dining room and others were outside smoking. She identified adverse outcomes for residents as the possibility of a resident taking the wrong medication and experience side effects. She stated the keys to the narcotic box were on her person and residents would not have had access to those medications. Interview attempt on 7/18/2024 at 11:39a m with LVN - A. Called and left a voice message was left requesting a return call. Interview on 7/18/2024 @ 5:20 pm with LVN - B revealed (he/she) had worked at the facility for four months. He said the CMAs and nurses were responsible to lock the med carts. He identified adverse outcomes as the potential for others to steal medication from the cart. 455489 Page 5 of 6 455489 07/19/2024 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 7/19/2024 @ 9:36 am with CNA - D revealed (he/she) had worked at the facility for eighteen years. She stated it was the CMA's responsibility to lock the med cart, as they are the only ones that had the keys. She said, It was the DON and ADON who ensure it is actually being done. Interview on 7/19/2024 at 9:50 am with LVN - F revealed (he/she) had worked at the facility for six months. She stated the nurses and CMAs were responsible to lock the med carts. She identified adverse outcomes as the potential for residents to take an unprescribed medication and experience adverse reactions. Interview on 7/19/2024 at 10:20 am with the ADON revealed (he/she) had been employed at the facility for five years. She stated it was everyone's responsibility to lock the med carts and face the drawers towards the wall. She identified adverse outcomes as the potential for others to ramble through the cart and take medications or equipment. Interview on 7/19/2024 at 11:00 am with the ADM, she stated her expectation was that the nurses and CMAs locked the med carts. 455489 Page 6 of 6