Health inspection·July 6, 2023

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 provide pharmaceutical services, including procedures that assured the accurate accountability of controlled drugs on 4 of 4 medication carts. The Change-of-Shift Record of Control Substance Log for the 100/200, 400/500 medication carts were missing signatures. These failures could place residents receiving medications in the facility at risk for in-effective therapeutic outcomes, and drug diversion. The findings include: Record Review on 7/5/23 revealed nurses were in serviced on narcotic audit results training, drug diversion, narcotic Count, and med administration on 4/5/23. Record review on 7/5/23 of the Control Card Count revealed the sheets were missing signatures on the following dates and shifts.: May Station 100/200 - 5/6 off going shifts signatures missing June- 100/200 6/15 oncoming 10-6 shift, 6/16 off going signature 10/6 shift, 6/12 2-10 of going shift signature, 6/28 2-10 on coming signature and off going signature. 6/19/23 2-10 shift off going signature June Station 500/600 prn control drug count sheets: 6/1/23 6-2 oncoming shift signature and 6-2offgoing shift signature missing. 6/27/23, 6/28/23, 6/29/23 10-6 off going nurse signatures and on coming 10-6 shift signatures were missing. June 500/600 routine narcotics control drug count sheets: 6/10/23 6-2 oncoming shift nurse signature and 6/2/23 off going nurse shift signature, 6/27/23, Page 1 of 7 455574 455574 07/06/2023 Avir at Weatherford 521 W 7th St Weatherford, TX 76086

F 0761 6/28/23, 6/29/23, 10-6 off going nurse signatures and on coming nurse 10-6 shift signatures, Level of Harm - Minimal harm or potential for actual harm June 400/500 prn narcotics control drug count sheets: 6/27/23, 6/28/23, 1 off going nurse signatures and on coming 10-6 nurse signatures missing. Residents Affected - Some June 500/600 routine narcotics control drug count sheets: 6/27/23, 6/28/23, 10-6 off going nurse signatures and 10 -6 on coming nurse signatures, June 400/500 routine narcotics control drug sheets: 6/27/23,6/28/23, 6/29/23 off going Nurse signature 10-6 missing, and 6/28/23 on coming nurse 10- 6am nurse signature missing. During an interview on 7/05/19 at 11:01 AM with the ADON, she said staff should be signing in and out when taking possession of the medication cart and be documenting medications in the MAR when they are signed out of the Narcotic Log. She said it is the responsibility of the charge nurse to monitor the sign in sheets as well as review they are being completed. She stated nurses were to count drugs at the beginning and end of their shift with the oncoming nurse, and both shifts should sign the log signifying that they accepted the count of the narcotics as correct, and they are accepting responsibility for the contents of the cart. During an interview with the DON on 7/05/23 at 11:30 am, she confirmed that the signatures were missing for the Control Drug Card Count for July 1, 2023. She verified there were missing signatures on the April, May, June, and July 2023 control drugs card count sheet. She confirmed she had in-serviced all nursing staff regarding counting and signing the count sheets stating that all narcotics were counted and reconciled at the beginning and end of each shift by the nurse coming on duty and the off going nurse. She said that staff should be signing the sign in and out narcotic log (Control Card Count) when they take possession of the cart. She stated the DON and ADON should be monitoring to see that it is done. She stated failure to count narcotics, could result in a drug diversion. Review of facilities Policy narcotic count revealed the following: It is the policy of this home that nursing staff must count narcotics at the beginning and end of each shift to ensure compliance with state and federal laws and regulations in the handling, storage, and record keeping of controlled substances. Procedure: The nurse coming on duty and the nurse going off duty must count and justify narcotics supply for each individual resident at the change of shift. Each nurse counting must record the date and his or her signature verifying the count is correct at the beginning and end of each shift. If the count is not correct the nurse going off duty is not to leave until the count is reconciled. Any discrepancy in the count is to be reported to the Director of Nurses promptly. 455574 Page 2 of 7 455574 07/06/2023 Avir at Weatherford 521 W 7th St Weatherford, TX 76086

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide 3 of 3 residents (Resident #1, Resident #2 and Resident #3) the therapeutic diet prescribed by the attending physician. Physician orders required thicken liquids due to swallowing dysfunction (difficulty swallowing). The facility neglected to provide proper thickening for Resident #2 and Resident #3 drinks and allowing access to thin liquids for Resident #1. This failure could place residents at risk for health complications related to in adherence to prescribed diet order. Findings included: Review of Resident #1's undated Face Sheet revealed Resident #1 was an [AGE] year-old male who was re-admitted to the facility on [DATE] with a diagnosis of dysphasia (difficulty swallowing), cerebral infarction (stroke) high blood pressure, bipolar disorder (mood disorder in which mood alternates from manic to depression) and Dysarthria (difficulty speaking because the muscles you use for speech are weak) Review of Resident #1's annual MDS assessment dated [DATE]/01/2023 revealed Resident #1 had a BIMS score of 9 indicating moderate impaired cognition. Review of Resident #1's MDS Section (K) (Swallowing/Nutritional Status) on 07/23/2023 at 2:00 PM, K0100 (signs and symptoms of possible swallowing disorder) question Z. was checked (none of the above) meaning no swallowing deficit. Review of Resident #1's Care Plan dated 02/09/2022 revealed Resident #1 was at risk for swallowing problems, such as aspiration pneumonia, related to dysphagia following CVA (cardiovascular accident) Resident #1's intervention including serve thickened with each meal due to dysphasia. Review of Resident #1's Physician Orders dated 02/28/2023 delegated speech therapist to evaluate and treat the therapeutic diet related to dysphagia Review of Speech Therapist notes dated 04/22/2022 revealed: Modified barium swallow conducted summary- The potential for aspiration or aspiration pneumonia risk found present in the Modified Barium Swallow study recommended thicken drinks. During an observation and interview on 07/03/2023 at 12:25 PM, Resident #1 was eating in his room with a tray placed on his bedside table. Resident #1 asked surveyor if he saw his thickened drink, he said he only sees his thickened cranberry juice he was drinking from. Observation by surveyor at this time saw 2 cups one with thin water (no thickener added as ordered) and one with thin tea (no thickener added as ordered) on his tray. Thickened cranberry juice was behind another cup of thin water. Surveyor moved the thin water behind the thickened cranberry juice making it available to Resident #1 and out of Resident #1's reach. During an interview and observation with DON standing outside of Resident #1's room on 07/03/2023 455574 Page 3 of 7 455574 07/06/2023 Avir at Weatherford 521 W 7th St Weatherford, TX 76086

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some at 12:30 PM was notified of the thin drinks on Resident #1's tray. She said the thin drinks should not have been on his tray she said she would remove the thin drinks from his tray now. She said that there was a kitchen aide who was new and may have not known thin drinks should not be on his tray. She poured out the drinks and said that if the resident would drink the thin drink could potentially harm him. She said Resident #1 is aware he should not drink thin liquid. She said she thought the Dietary Manager was responsible for making sure the diets are correct. Review of Resident #1's tray card dated 07/03/2023 revealed Resident #1 received thickened liquids and the document related to special dietary needs indicated Resident #1 required thicken liquids. Review of the dietary schedule on 07/03/2023 at 1:10 PM provided by the Dietary Manager revealed Resident #1 required thickened liquid drinks ([NAME] that are thicken to the consistency of nectar). During an interview with the Speech Therapist on 07/05/2023 at 8:15 AM, she said a resident who has dysphasia and drinks thin liquids could be dangerous and cause aspiration (when food or liquid is breathed into the airways or lungs, instead of being swallowed). She said there has been a problem with Resident #1 receiving thin liquids last week and ice, she said there was a new dietary aide who put thin drinks on his tray last week. She said she was concerned about thickened drinks given to other residents as well. (Speech therapist did not discuss if she addressed the problem with anyone) During an interview on 07/05/2023 at 10:20 AM with the Administrator, DON and Speech Therapist attending revealed the Administrator said Resident #1 was able to let someone knows he was not supposed to drink thin liquids. The DON said she was there when surveyor told her thin liquids was on his tray and she poured it out. She said Resident #1 was able to tell someone he was not supposed to not drink thin liquids. She admitted that thin liquids should not have been on his tray to begin with. The DON said the dietary aide was new and that could have been the reason for the thin liquids on Resident #1's tray. She said the nurse (LVN A) caught thin liquids on Resident #1's tray last week. During an interview with Dietary Manager on 07/06/2023 at 9:45 AM said they have a new dietary aide who helped put the plated food on the trays and he may have put the thin drinks on Resident #1's tray last week and on Monday (7/03/2023) but the nurse (LVN A) caught it when he put the drinks on the tray last week. She said it may have occurred on Friday. She said she was alerted the dietary aide put in on Resident #1's tray Monday and said she was going to in-service the staff. She said the cooks were responsible for training on how to read the tickets and follow what the residents are supposed to have on their trays. She said the cooks are the responsible for making sure the dietary aides put the correct diets on the trays and relied on the cooks to monitor the meal tickets. She provided in-service with all kitchen staff related to p proper diet for the correct resident. During an interview on 07/06/2023 at 9:50 AM [NAME] #1 said that the cooks are responsible for training dietary aides on how to put the plates on trays following the tickets for each resident. She said she was on vacation on Monday (07/03/2023) and did not train the dietary aide. During an interview on 07/06/2023 at 10:00 AM [NAME] #2 said the cooks are supposed to train dietary aides on how to put the plates on trays following the meal tickets. She said the dietary aide was new and someone called in and she did not have the time to train the dietary aide and probably the reason for Resident #1 getting thin liquids on his tray. She said we normally do orientation and in-service but did not have time. [NAME] #2 admitted that someone with dysphasia and not getting the proper thickened drink could be harmful. 455574 Page 4 of 7 455574 07/06/2023 Avir at Weatherford 521 W 7th St Weatherford, TX 76086

F 0808 Level of Harm - Minimal harm or potential for actual harm Attempted to contact (LVN A) the nurse who intervened with Residents #1's tray with thin liquid was attempted on 07/06/2023 at 1:00 PM without success. Cook #2 said dietary aide called in on Wednesday 07/05/2023 (near start of his shift 5:00 AM) and did not show up today on 07/06/2023 or called in she said she assumed he quite. Residents Affected - Some An attempt to call Dietary Aide for interview on 07/06/2023 at 11:00 AM was unsuccessful. Review of in-services regarding following meal tickets thin on 07/06/2023 at 10:05 AM was provided with all dietary staff being trained. Review of Resident #2's undated face sheet revealed he was a [AGE] year-old-male admitted on [DATE] with the diagnoses of: Dysphagia following cerebral infarction (difficulty swallowing due to muscle weakness caused by a stroke), muscle wasting, cognitive cerebral deficit, and unspecific pain. Review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 13 indicating he was cognitively intact and able to make his needs know. Resident #2 was noted to require a therapeutic diet (honey thicken liquids) by the speech therapist. Review of Resident #2's MDS Section (K) (Swallowing/Nutritional Status) on 07/23/2023 at 2:00 PM, K0100 (signs and symptoms of possible swallowing disorder) question Z. was checked (none of the above) meaning no swallowing deficit. Review of Resident #2's Care Plan revised on 05/26/2023 revealed Resident #2 was at risk for swallowing problems, such as aspiration - Therapeutic Diet as evidenced by: Reg, Puree, Honey thick liquids Record review of Resident #2's Physician Orders dated 03/03/2023 delegated speech therapist to evaluate and treat Resident #2 for therapeutic diet. Review of Resident #2's Modified Barium Swallow study conducted on 09/28/2022 revealed the following: Patient (Resident #2 appears to be at risk for aspiration and pneumonia. Diet recommendations: honey/thickened liquids. During an interview with Resident #2 on 07/03/2023 at 12:50 PM he said that the thickened drink was not thick enough and it has always been a problem and they (facility) always showing me the cartons and they say it shows to be honey thicken consistency. He said, he has never choked but that is not the issue, the issue is it is not correct. He said he told the Dietary Manager the DON and the ADON. Review of Resident #2's tray card dated 07/03/2023 revealed Resident #2 received honey thickened juice and the document related to special dietary needs indicated Resident #2 required honey thickened liquids. During an interview with the Speech Therapist on 07/05/2023 at 8:15 AM, she said a resident who has dysphasia and drinks thin liquids could be dangerous and cause aspiration. When it was revealed Resident #2 was complaining that the drinks he was receiving were not honey thickened she said if that was true it could be a problem. 455574 Page 5 of 7 455574 07/06/2023 Avir at Weatherford 521 W 7th St Weatherford, TX 76086

F 0808 Level of Harm - Minimal harm or potential for actual harm During an interview on 07/05/2023 at 10:20 AM with Administrator, DON and Speech Therapist attending revealed the Administrator said Resident #2 always said his drink were not thick enough and he was worried about aspiration. He is always having behaviors and it has gotten worse. She said the Dietary Manager has shown Resident #2 that the premade cartons show the drink is honey thicken. If it says that on the carton, then we trust it to be true. Residents Affected - Some During an interview and observation on 07/03/2023 at 1:45 PM the Dietary Manager brought 1 pre-made carton of thicken juice and 1 carton of pre-made honey thicken to the conference room where the surveyors were conducting the survey. During observation both consistency of the juices appeared to be the same and confirmed by the dietary manager. She said she will talk to the manufacture about her concerns about the same consistence and again agreed there was no difference. She said if the drinks need to be thicker, they do have commercial thickener available to add to the drinks. During an interview with the Dietary Consultant on 07/05/2023 at 9:15 AM, he said that the premixed thickener was supposed to be accurate in the consistency related to the labeling. The problem could be that the cooks are not shaking it enough to mix the juices. He said the Dietary Manager talked to him about the consistency and was going to get with the manufacture. He said the facility has access to thickener if the consistence was not thick enough. He said they can provide measured containers with premixed thickener until the problems is solved, until then the thickener would be something to consider. Review of Resident #3's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the following diagnoses: dysphasia (difficulty swallowing), unspecific pain, and unspecified dementia. Review of Resident #3's quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 15 indicating she was cognitively intact and able to make her needs know. Review of Resident #3's quarterly MDS Section (K) (Swallowing/Nutritional Status) on 07/23/2023 at 2:00 PM, K0100 (signs and symptoms of possible swallowing disorder) question Z. was checked (none of the above) meaning no swallowing deficit. Review of Resident #3's Care Plan on 07/06/2023 at 3:00 PM, revealed on 06/29/2023 revealed: Resident #3 is on a therapeutic diet, honey thickened liquids. Record review of Resident #3's Modified Barium Swallow study on 02/16/2023 revealed the following: Recommendation moderately thicken honey liquids During an interview observation on 07/03/23 at 1:20 PM Resident #3 said, she is always not getting honey thickened drinks they seem too always be too thin. She said she has not coughed, or it is going gone down the wrong way, but it could. The trays were already picked up at this point and unable to verify meal ticket was accurate. During an interview on 07/05/2023 at 9:30 AM with the Administrator surveyor revealed Resident #1 had thin liquids on his tray, Resident #2 complained about his drinks were not thickened enough and Resident #3 complained about the drinks not being thick enough. She said that Resident #1 drinks could be caused by a new kitchen staff member may have not been aware thin liquids are not to be on his tray, Resident #1 is aware he should not drink thin liquids. She said Resident #2 always says his drinks are not thick enough he has behaviors (schizophrenia) (a mental disorder) that would explain 455574 Page 6 of 7 455574 07/06/2023 Avir at Weatherford 521 W 7th St Weatherford, TX 76086

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the complaint. We have shown him the cartons with the labels on them and he still says it is not thick enough. She said Resident #3 has not mentioned any problems. When surveyor mentioned that she complained about the drinks not thick enough she said she would look into it. The surveyor also mentioned to the Administrator the proper assessment for her MDS section K (swallow assessment) said there were no problems with swallowing even though there was a diagnoses of dysphasia, diet including thicken drinks and a swallow study recommending honey thickened liquids. Administrator again said she would look into it. During a conference interview on 07/05/2023 at 10:30 AM with the Administrator, DON and Speech Therapist, said Resident #3 may have a swallow problem. When revealed by the surveyor that Resident #3's quarterly MDS dated [DATE] revealed she does not have a swallow even though she has a diagnosis of dysphasia, honey thicken liquid diet order and swallow study recommending honey thicken drinks they said they would look into it. List of Resident receiving thickened liquids provided by the Dietary Manager on 07/03/2023 at 11:20 AM revealed Resident #1 should receive thicken liquids. Resident #2 receive honey thicken liquids and Resident #3 receive honey thicken liquids. Review of facility undated policy titled; Thickened Liquids revealed the following: The facility will serve thickened liquids to all residents as ordered by the physician. .2. The Nutrition and Food Manager will record the ordered consistency on the resident's tray card. 3. The following consistency may be ordered. Thin - includes water, coffee 4. The speech therapist may order modified consistencies based on the resident's needs. Review of the website: https://intermountainhealthcare.org accessed on 07/10/23 at 7:00 PM revealed the description of thicken and honey thicken are as follows: Dysphagia - Liquid Consistency Thick Liquids Purpose of Diet: Thickened liquids are needed for people with swallowing problems to prevent breathing in liquids. Indications for Use: Thickened liquids are used to protect people who have had a stroke, head injury, cancer, etc. from pneumonia. Description of Diet: There are 3 levels of thickened liquids. These are nectar thick, honey thick, and spoon thick. o Nectar thick liquids are the consistency of apricot nectar. o Honey thick liquids are the consistency of honey. 455574 Page 7 of 7