Health inspection·December 21, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 one resident (Resident #2) of five residents reviewed for physician orders received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Residents Affected - Few -Resident #2 was given supplements for colonoscopy preparation but had no order for them. -The colonoscopy preparation supplement had been ordered for a different resident. The deficient practice could place residents at risk of ingesting medications not prescribed resulting in severe abdominal distress and diarrhea. Findings include: Record review of the Face Sheet (printed 11/22/2023) for Resident #2 revealed she was [AGE] years old, and was originally admitted to the facility on [DATE]. Diagnoses included, but were not limited to, unspecified psychosis, dysphagia (difficulty swallowing), and dementia. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #2 was rarely understood, and rarely understood others. The MDS reflected the resident exhibited severely impaired cognitive skills for daily living. Record review of the Care Plan (edited 10/17/2023) for Resident #2 revealed the resident was at risk for nutritional deficit and weight loss related to having severe dementia. An 'approach' read, in part, .diet and supplements as ordered by MD. In an interview via telephone on 11/21/2023 at 9:21 a.m., a family member of Resident #2 said the resident was prepped for a colonoscopy, but she did not have one scheduled. The family member said she received an email from the facility asking what time the colonoscopy appointment was. She said Resident #2 was drained and agitated. Observation on 11/21/2023 at 11:50 a.m. revealed Resident #2 was in her room. She was not interviewable. Her sitter was in the room with her. In an interview on 11/21/2023 at 11:50 a.m., Resident #2's sitter said the next morning the resident had low strength and had diarrhea. In an interview on 11/21/2023 at 2:49 p.m. LVN A said Resident #2 received a bowel prep about a Page 1 of 4 455643 455643 12/21/2023 Avir at Bay City 700 12th St Bay City, TX 77414

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few week earlier. She said Resident #2 returned from a doctor's appointment on 10/23/2023 with instructions for bowel prep. She said she taped the instructions onto the 24-hour report. She said the night nurse gave the bowel prep at midnight. She said the facility staff was not able to locate the instructions later that day. She said she looked on the computer for the time of the transport but did not see it. She then called the family member, and the family member was unaware of any colonoscopy appointment. When the hospital was called, they confirmed there was no colonoscopy appointment. Record review of the NN dated 11/10/2023 at five minutes past midnight for Resident #2 revealed LVN B administered the bowel prep. The NN dated 11/10/2023 at 1:11 a.m. for Resident #2 read in part, .Res tol [Resident tolerating] bowl [sic] prep well. cont [continue] to prep for colonoscopy. It was signed by LVN B. The NN dated 11/10/2023 at 2:00 a.m. read in part, .Bowl [sic] prep completed. Res had multiple BM. It was signed by LVN B. LVN B was not available for interview. In an interview on 11/22/2023 at 2:00 p.m., the DON said Resident #2 and Resident #3 had both went to GI doctor appointments on the same day. When they returned to the facility, the paperwork instructions got mixed up. She said there was no name and no date on the instruction sheet for bowel preparation. The DON said an order was not transcribed into the chart. She said the night nurse (LVN B) saw the paperwork in Resident #2's chart and gave the bowel prep with Resident #2's medications. The DON said the next morning Resident #2's family member called, and it was discovered Resident #2 had been given the bowel prep. The physician was notified, and the resident was provided with Pedialyte to rehydrate her. The DON said Resident #2 had diarrhea as if she was going to have the colonoscopy. Resident #3 was not given the bowel prep but did not have the colonoscopy due to waiting for cardiology clearance. As of exit, the bowel preparation instruction sheet was not provided by the facility. The facility policy entitled Medication and Treatment Orders (revised February 2014) read in part, .Orders for medications and treatments will be consistent with principals of safe and effective order writing .3. Drug and biologicals must be recorded on the Physician's Order Sheet in the resident's chart. 455643 Page 2 of 4 455643 12/21/2023 Avir at Bay City 700 12th St Bay City, TX 77414

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (Resident #1) of five residents reviewed on the secured unit for adequate supervision to prevent accidents. The facility failed to ensure resident safety, as evidenced by: -The door of the nurses' office on the secured unit was open and accessible to residents. -Resident #1, a confused resident, was in close proximity to a bag of medications on the nurses' desk, with no staff within line of sight of the nurses' office. The deficient practice placed residents at risk for ingesting medications that could be detrimental to his or her health, resulting in illness or hospitalization. Findings included: Record review of the Face Sheet for Resident #1 (printed 11/22/23) revealed she was [AGE] years old,and was originally admitted to the facility on [DATE]. She resided on the secured unit. Diagnoses included, but were not limited to, paranoid schizophrenia, bipolar disorder, and mood disorder. Record review of the annual MDS assessment dated [DATE] revealed Resident #1 scored 1 of 15 on the BIMS, indicative of severe cognitive impairment. The MDS reflected the resident exhibited inattention and disorganized thinking. The MDS reflected Resident #1 was able to propel her wheelchair with limited assist from one person. Resident #1 did not have functional limited range of motion of any extremities. Record review of the Care Plan for Resident #1 (edited 10/17/2023) revealed the resident could propel her wheelchair short distances without the assist of staff. The Care Plan reflected Resident #1 had a memory/recall deficit, and was disoriented to date/time, and had short-term memory loss. The 'Goal' read, in part, .Resident will non sustain serious injury due to memory/recall deficit. The 'Approach' read, in part, .Ensure resident's areas are free of hazards. Observation on 11/21/2023 at 2:31 p.m., revealed the door of the nurses' station on the 300 Hall (secured unit) was open. A plastic bag of medications was observed to be on the chair just inside the doorway. Resident #1 was observed in the hallway in her wheelchair. She was independently propelling her wheelchair. There was no staff within visibility of the nurses' station or Resident #1. The surveyor monitored the medications and resident. Observation on 11/21/2023 at 2:39 p.m., revealed staff was visible in the dining room, at the opposite end of the hallway from the nurses' station. Observation on 11/21/2023 at 2:41 p.m., revealed the Administrator was in the main area of the facility, visible through the window of the door of the secured unit. The surveyor asked him to come to the unit. The Administrator entered the secured unit. He acknowledged the bag of medications was unattended in the nurses' station. He locked the door and exited the unit. 455643 Page 3 of 4 455643 12/21/2023 Avir at Bay City 700 12th St Bay City, TX 77414

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 11/21/2023 at 2:42 p.m. revealed the Administrator returned to the secured unit with LVN A. LVN A said she usually kept the nurses' station door closed, but she had been called to a meeting. When asked what could have happened, LVN A replied that the resident may or may not have entered the room and may or may not have ingested the medications. Observation on 11/21/2023 at 2:43 p.m. revealed LVN A took inventory of the medications, which were not prescribed for Resident #1 included the following: Resident #1 included the following: -19 Hydrochlorothiozide (HCTZ) 25 mg (diuretic) tablets, -24 Gabapentin 400 mg (anticonvulsant) tablets, -18 Zoloft 50 mg (antidepressant) tabs, -10 Losartan Potassium 10 mg (for treating high blood pressure) tablets, -21 Risperdal 1 mg (antipsychotic) tablets, -30 Atorvastatin 10 mg (reduces Cholesterol) tablets, -13 Amlodipine 10 mg (to treat chest pain) tablets, -13 Protonix 40 mg (to treat reflux) tablets, -28 Latuda 40 mg (antipsychotic) tablets, -19 Topiramate 50 mg (anticonvulsant) tablets, -21 Naproxen 250 mg (treats pain and inflammation) tablets, -27 Depakote 250 mg (preventative medication for seizures) tablets, and -1 Fluconazole spray (antifungal). Interview on 11/22/2023 at 2:00 p.m., the DON revealed she said the door of the secured unit nurses' station should have been locked. She said the resident could have ingested the medications and had side effects. The facility policy entitled Storage of Medications (revised April 2007) read, in part, .The facility shall store all drugs and biologicals in a safe, secure and orderly manner .2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use . 455643 Page 4 of 4