Health inspection·February 26, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 resident of 17 residents (Resident #1) reviewed for quality of care. Residents Affected - Few The facility failed to assess Resident #1, who was prescribed daily anticoagulant medication, before lifting her up off the floor when she had an unwitnessed fall and sustained facial injuries and a bleeding hematoma to the back of her head. An Immediate Jeopardy (IJ) was identified on 02/22/2024. The IJ template was provided to the facility on [DATE] at 3:22 p.m. While the IJ was removed on 02/24/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective. These failures placed residents who experience falls with injuries at risk of further injury, pain and delayed medical treatment. Findings include: Record review of Resident#1 face sheet on 02/22/24 revealed that she was an [AGE] year-old white female that was originally admitted to the facility 10/01/22. She has the diagnoses of Alzheimer (A progressive disease that destroys memory and other important mental functions), Pneumothorax, unspecified (A condition when air leaks into the space between the lungs and chest wall), Acute kidney failure (A condition in which the kidneys suddenly can't filter waste from the blood), Hypokalemia (A blood level that is below normal in potassium), and bipolar disorder(A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident#1's Quarterly MDS, dated [DATE] revealed Resident #1 BIMS score was determined to be three due to cognitive impairment. MDS completed by staff, which indicated Resident#1 had memory problems and was severely impaired cognitively. Resident#1 did exhibit behavioral symptoms of wandering and required supervision and one-person physical assist for ADLs. Record review of Resident #1's care plan dated 01/10/24 indicated she had impaired communication, evidenced by: resident having difficulty making herself understood and understanding others. Also, Resident #1 was care planned for bleeding because she was prescribed Plavix. Interventions include administer medications as ordered, engage the resident in simple structured activities that avoid overly demanding tasks, watch for bleeding, blood in urine, and blood in stool. Page 1 of 6 455643 455643 02/26/2024 Avir at Bay City 700 12th St Bay City, TX 77414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident#1 physician's orders dated 10/19/22 revealed that she was prescribed blood thinner Plavix 75mg per day and she should be monitored for bleeding, blood in urine, and blood in stool. Observation of video pertaining to Resident#1's fall dated 2/5/24 revealed that she was on the floor and CNA-B came into the room and lifted Resident#1 off the floor before she had been assessed by a Nurse. In an interview with LVN-A on 02/21/24 at 6:51pm she stated CNA B notified her that Resident#1 was in the room of another resident on the floor. LVN-A stated before she was able to get to the memory care unit, Resident#1 had been lifted from the floor of the other resident's room and placed in her own bed, which was next door. LVN-A stated during the assessment of Resident#1 she discovered that Resident#1 had a bump and laceration to the back of her head and the right side of her head, and she had a bump and laceration to her right cheek and right side of her eye with bruising. LVN-A stated the facility protocol was not followed regarding this incident. She stated that CNA-B should not have lifted Resident#1 off the floor before she was assessed. LVN-A said lifting a resident off the floor before they are properly assessed puts the resident in danger of more severe injuries because you don't know the extent of their injuries due to the fall. In an interview with CNA-B on 02/22/24 at 9:58 am she stated that she was doing her rounds when she saw Resident#1 in the room of another resident. She said that Resident#1 was on the floor at the foot of a bed. She said she sent LVN A, who was also responsible for caring for resident on another hall, a text message, letting her know what happened. CNA-B stated that Resident#1 was trying to get up off the floor. She said she left the room to check on other residents and when she returned to Resident #1, she was still trying to get off the floor. She said she was afraid that Resident#1 would fall again so she lifted Resident#1 off the floor and took her back to her room and laid her in the bed. CNA-B stated she noticed that Resident#1 had blood coming from the back of her head. In an interview with the facilities' DON on 02/22/24 at 11:51am she stated that facility policy states that when there is an unwitnessed fall that a resident must be assessed before they are lifted from the floor. She said that the reason that a resident must be assessed is because the extent of their injuries is unknown and that by lifting them from the floor could cause more severe injuries. She said she was aware CNA-B lifted Resident #1 off the floor prior to a nursing assessment because she saw the incident on video. She said she conducted an in-service on falls after the incident, but CNA-B did not attend. In an interview with LVN-B on 02/22/24 at 11:45am she stated that she had reported to the Administrator and DON that more staff were needed on the Memory Care Unit, because having one staff assigned to Memory Care Unit was not safe for the residents and was not fair to staff. LVN-B also said that during the night shift there are more falls and because of that, more staff was needed. In an interview with the facilities' DON on 02/22/24 at 11:51am she stated that having one staff assigned to the Memory Care Unit during the hours of 6:00pm to 6:00am with eighteen residents was sufficient. The DON stated staff had complained that more staff was needed in the memory care unit on the night shift. The DON stated she did not go to the Memory Care Unit during the night shift to validate staff complaints, however, specific resident's psychotropic medications were adjusted. Record review of Resident#1's nurses note dated 02/05/2024 written by LVN A read in part, Resident#1 was found on the floor in another resident's room by CNA B. She had a bump and laceration to the 455643 Page 2 of 6 455643 02/26/2024 Avir at Bay City 700 12th St Bay City, TX 77414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few back of her head. She also had a bump and laceration to her right check and right eye. She is being sent to the ED because she is on blood thinners. The provider, responsible party and DON were notified. have sustained a small gash or laceration to her right upper brow. She was awake and alert. In an interview on 2/21/24 at 6:30pm LVN A said she was notified by CNA B that Resident #1 was in the room of another resident on the floor. LVN A said that CNA B told her that she had lifted Resident#1 off the floor and placed her in her bed and that Resident#1 had two bumps to her head that were bleeding. LVN A was asked if it was proper protocol for a resident to be lifted off the floor before being assessed by a Nurse and she said no it's not proper protocol to move a resident before they are assessed. LVN A was asked what the risk is of moving a resident before they are accurately assessed. She stated that the resident may have a fracture, dislocation, or other more serious injuries. LVN A stated that she examined Resident #1 and called the facility Doctor, DON, and Responsible party. LVN A said that she was given orders by the facility Doctor to send Resident#1 to the Hospital. This was determined to be an Immediate Jeopardy (IJ) on 02/22/2024 at 3:22 p.m. The VP of Operations, the DON, and the Regional Reimbursement Consultant were notified. The VP of Operations was provided with the IJ template on 02/22/2024 at 3:22 p.m. A Plan of Removal was requested at that time. The following Plan of Removal submitted by the facility was accepted on 02/23/2024 at 6:06 p.m.: The Plan of Removal was accepted on 02/23/24. An Immediate Jeopardy (IJ) was identified on 02/22/2024. The IJ template was provided to the facility on [DATE] at 3:22 p.m. While the IJ was removed on 02/24/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective. Facility Plan to ensure compliance: Plan to remove immediate jeopardy. The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for Resident#1 who was found in the room of another resident on the floor bleeding from her head on 02/05/24. The facility failed to assess Resident #1 before she was lifted from the floor.

F684 On 2/22/24, the director of nursing/designee completed an assessment of resident #1 for changes in condition, no concerns were identified. Resident #1 fall assessment and care plan were reviewed. The director of nursing/designee completed assessments on all residents on secure unit for any changes in condition, no concerns identified. The director of nursing/designee reviewed falls for the last thirty (30) days to determine timely notifications and that facility policy was followed, no concerns were noted. Fall assessments and care plans for residents with a previous history of falls and at risk of falls from wandering were reviewed and updated as needed. This was completed on 2/22/24. 455643 Page 3 of 6 455643 02/26/2024 Avir at Bay City 700 12th St Bay City, TX 77414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety The VP-Regional Director in-serviced C.N.A. 1:1 on fall management/changes in condition, and notification to a licensed nurse to assess a resident before moving resident. It was completed on 2/22/2024. Current nurse staffing ratios are sufficient to cover the facility and will be reviewed during the QAPI meeting to revise depending on current facility census. The current staffing ration has been determined sufficient to meet the needs of every resident in the facility and will be reviewed in QAPI meeting for any changes. Residents Affected - Few Medical Director was notified by Vice-President, Regional Director on 2/22/24 of Immediate Jeopardy and plan of removal. Starting on 2/22/24, the Director of Nursing and the Vice-President, Regional Director, initiated in-service with facility staff on adequate supervision and the policy regarding a change in condition specifically related to the fall policy. Included in the training was not moving a resident before a licensed nurse assessed the resident. Staff were also educated at this time on the facility protocol of having two (2) staff members on the Secured Unit. The staff will first call out for a licensed nurse, if no response they will call via phone, if no response, a staff member will stay with the resident while another staff member goes to notify the licensed nurse that help is needed. The in-services will be by DON/Designee, including PRN staff, agency, and weekends staff. On 2/23/24, the Regional Nurse Consultant in-serviced the Director of Nursing and nursing management on completing the post-fall observation after a resident fall in the morning clinical meeting to determine new interventions and update the care plan. The staff nurses are completing and have been trained on post fall assessment to include immediate interventions by the DON on 2/22/24. An Ad-Hoc QAPI meeting was held 2/22/24, with the Medical Director, VP and Regional Director, and the Director of Nursing to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. On 2/22/24, the Director of Nursing/Designee will interview at least 5 staff members on compliance with the education. The VP-Regional Director will be responsible for ensuring this plan is completed on 2/22/2024. Monitoring: Observation of the facility on 02/24/2024 from 12:50 a.m. until 2:45 a.m. revealed there were always two staff members inside the locked memory care unit. Before LVN E left the unit for any reason, he called another staff to go to the unit and stay until he returned. Record review of facility document, Quality Assessment and Performance Improvement Plan dated 02/22/2024 at 5:14 p.m. revealed the facility's management team met with their medical director regarding in-services, assessments, and audits necessary to remove immediacy. Record review of 'In-service Training Report dated 02/22/2024 revealed CNA B was educated by the VP of Operations regarding falls, the locked unit, and changes in resident conditions. The document 455643 Page 4 of 6 455643 02/26/2024 Avir at Bay City 700 12th St Bay City, TX 77414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few read in part, When a resident is found on the floor (fallen), go to the resident, stay with the resident. Do not move the resident. Activate the call light (if in the room), call (yell) for help; use your cellular phone to call the facility or 911. Once the LVN/RN arrives at the scene, she takes charge. Wait for further directions. The secure unit will be always staffed with two staff members. If one staff comes off the unit, that staff must be replaced until they return to the unit . Record review of 'In-service Training Report dated 02/22/2024 revealed LVN A was educated by the VP of Operations regarding falls, the locked unit, and changes in resident conditions. The document read in part, When a resident is found on the floor (fallen), go to the resident, stay with the resident. Do not move the resident. Activate the call light (if in the room), call (yell) for help; use your cellular phone to call the facility or 911. Once the LVN/RN arrives at the scene, they take charge. Wait for further directions. Do not move the resident until the nurse gives direction. Record review of 'In-service Training Report dated 02/22/2024 revealed all facility staff were educated by the DON regarding falls management and changes in resident conditions. Record review of 'In-service Training Report dated 02/22/2024 revealed all facility staff were educated by the Regional Reimbursement Consultant regarding secure unit staffing. The document read in part, The secure unit will be always staffed with two staff members. If one staff member needs to exit the unit, they must have another staff member relieve them, until they return to the unit. Record review of 'In-service Training Report dated 02/23/2024 revealed all facility nurses were educated by the DON regarding post fall assessments. The documents read in part, The charge nurse is to complete the Post Fall Assessment as soon as practical, by the end of shift, along with progress note. The charge nurse is to implement the doctor recommendations and to include the immediate intervention with the DON. Record review of 'In-service Training Report dated 02/23/2024 revealed all facility nurses were educated by the DON regarding post fall assessments. The documents read in part, The events will be reviewed in the morning meeting every business day of the week to identify a fall. The director of nursing or nurse management will then open the post fall observation and complete the fall history, validate doctor and responsible party notifications, and develop an intervention for the fall and update the care plan. The IDT should participate in developing new interventions. The care plan will be updated during the meetings by nursing management. Record review of -service: Post-Fall Assessment to Director of Nursing and Nursing Management dated 02/23/2024 revealed the nursing managers, including the DON, ADON, and the MDS LVN were educated by the Regional Nurse Consultant regarding post-fall assessments. Record review of facility documents titled; Wound Location Chart dated 02/22/2024 revealed all memory care residents (18), including Resident #1, were assessed from head to toe with all skin injuries/variances noted. There were no necessary changes to any of the residents' care plans. Record review of an audit of all recent facility falls (01/23/2024 - 02/23/2024) revealed 7 of the 18 falls during the that time occurred in the locked memory care unit on varied shifts (4 were during the night shift). There were no necessary changes to any of the residents' care plans. Record review of Compliance Interviews F-684 dated 02/22/2024 revealed the DON tested five staff regarding recent in-services. All five staff answered the questions correctly with no concerns. 455643 Page 5 of 6 455643 02/26/2024 Avir at Bay City 700 12th St Bay City, TX 77414

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interviews were conducted on 02/24/2024 from 12:50 a.m. until 1:00 p.m. with staff on both shifts (6:00 a.m. - 6:00 p.m. and 6:00 p.m. - 6:00 a.m.) including the VP of Operations, the Regional Reimbursement Consultant, DON, LVN A (night shift), CNA B (night shift), LVN C (day shift), LVN D (night shift), LVN E (night shift), CNA F (night shift), LVN G (night shift), CNA H (night shift), CNA I (night shift), CNA J (day shift), CNA K (day shift), CNA L (day shift), Housekeeper M (day shift), and LVN N (day shift) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. The VP of Operations, the Regional Reimbursement Consultant, DON, LVN A, CNA B, LVN C, LVN D, LVN E, CNA F, LVN G, CNA H, CNA I, CNA J, CNA K , CNA L, Housekeeper M, and LVN N were able to explain the importance of assessing residents for injuries and other complications before moving them after they experience falls, staying with the resident after they experience falls, requesting assistance from a nurse or other staff by utilizing the call light system, yelling for help, or using personal cellular phone devices, and ensuring there is adequate staffing (at least two staff) in the locked memory care unit at all times during the night shift. The VP of Operations and the Regional Reimbursement Consultant were informed the Immediate Jeopardy was removed on 02/24/2024 at 1:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 455643 Page 6 of 6