Health inspection·April 28, 2023

F 0610 Respond appropriately to all alleged violations. 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 thoroughly investigate an allegation of abuse for 2 (Resident # 57 and Resident # 35) of 18 residents reviewed for abuse. Residents Affected - Few The facility failed to complete a thorough investigation and maintain documentation that an allegation of abuse for Resident #57 and Resident #35 were thoroughly investigated. This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated. Findings include: Review of Resident #35's face sheet dated 04/28/2023 revealed a [AGE] year-old female admitted on [DATE], with the following diagnosis Dementia, Alzheimer's disease, and need for assistance with personal care. Review of Resident # 35's Quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 0 (Severe cognitive impairment Review of Resident #35's progress notes, written by LVN B , written on 11/20/2022 at 12:18 AM revealed nurse was called to unit by CNA. CNA said she heard grunting and went to where it was coming from and found this resident on her back on the bed another resident was on top of her in a sexually aggressive manner, both residents were fully clothed. CNA asked the other resident to get off this resident and that resident replied no. CNA rolled the other resident off this resident and removed her from the room and came and got this nurse. Review of Resident #35's progress notes, written by LVN A, written on 11/25/2022 at 6:30 PM revealed this resident was located in room [ROOM NUMBER] lying at the foot of the bed underneath the male resident that resides in that room . Male resident was on top of this resident with his brief and pants down to his ankles. This resident's shirt was pulled up exposing her breast. Her pants were pulled down mid-thigh and her brief was partially down but still covering vaginal area. Male resident was immediately redirected and moved off the resident. The resident was immediately taken out of the room and to her room for assessment. Resident is not displaying any emotional distress at this time. Resident noted with slight red area to top of right breast and slight small red area to top of left breast. Skin intact. Resident is not able to recall incident poor cognitive ability. Review of Resident #57's face sheet dated 04/27/2023 revealed a [AGE] year-old male admitted on [DATE], with the following diagnoses: Dementia with behavioral disturbance, Alzheimer's disease, Page 1 of 12 455744 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0610 antisocial personality disorder, , and conduct disorder. Level of Harm - Minimal harm or potential for actual harm Review of Resident # 57's Annual MDS assessment dated [DATE] revealed, Section C - Cognitive Behavior revealed a BIMS score of 5 (Severe cognitive impairment) and Section E- Behavior Resident revealed Resident #57 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing other sexually). Residents Affected - Few Review of Resident #57's physician orders dated 11/19/2023 revealed Provera tablet 5mg: amount one tablet; oral once a day 9:00 AM. Review of Resident #57's physician orders dated 11/26/2023 revealed Provera tablet 10mg: amount one tablet; oral once a day 9:00 AM. Review of The Sexual Abuse Clinic accessed https://www.sacpd.com on 04/28/2023 revealed: depo-Provera is the trade name for a medication whose chemical name is medroyxprogesterone acetate. It is a female hormone which, when given to a man, inhibits the production of testosterone, thus reducing sexual drive. When taking depo-Provera, men are still able to engage in sexual relations, but they do not think about sex as often and their sexual thoughts are not as strong as before. Hence there is less risk that a man will act out sexual impulses in ways that might get him into trouble. Review of Resident #57's progress notes, written by LVN B, on 11/19/2022 at 8:30 PM revealed; this nurse was called back to unit by CNA. CNA stated she had just separated this resident and other resident. CNA stated she had heard grunting noises and went to this residence room to find him on top of female resident and stated this resident had other resident in a sexual vulnerable position. CNA stated that both residents were fully clothed. CNA stated she told this resident to get off the other resident and this resident replied no. CNA at this time rolled this resident off the resident and removed female resident from the room. The female resident had been urinated on by this resident. Review of Resident #57's progress notes, written by LVN A, on 11/25/2023 at 6:30 PM revealed, Resident was discovered on top of a female resident at the foot of his bed. Upon discovery of resident, it was noted that residents brief and pants were pulled down to his ankles. Female resident's shirt was pulled up exposing her breast. Female resident's pants were pulled down mid-thigh and brief was partially pulled down but still covering vaginal area. This resident was immediately redirected and removed off the female resident. Female resident immediately removed from the room and taken to her room. Residents brief and pants were pulled back up to proper placement. During an observation on 04/25/023 at 11:10 AM Resident # 35 was on secure unit (Hall 2). During Observation on 04/26/2023 at 10:00 AM Resident #57 was in his room on Hall 3 laying in his bed sleeping. Review of the facility incident report, completed by LVN A, dated 11/19/2022 revealed Resident #57 had aggressive sexual behavior toward another resident . Review of the facility incident report, completed by LVN A, dated 11/20/2022 revealed Resident #35 was found in sexually vulnerable position under other resident. Review of the facility incident report, completed by LVN B, dated 11/26/2022 revealed Resident #35 was discovered in room [ROOM NUMBER] laying at the foot of the bed underneath the male resident that 455744 Page 2 of 12 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resides in that room. Male resident was on top of this resident with his brief and pants down to his ankles. This resident shirt was pulled up exposing her breast, her Pants were pulled down mid-thigh and her brief was partially down but still covering vaginal area. Male resident was immediately redirected and removed off this resident. The resident was immediately taken out the room and to her room for assessment. Review of the facility incident report, completed by LVN B, dated 11/26/2022 revealed Resident #57 was on top of the female resident at the foot of his bed in room [ROOM NUMBER]. Upon discovering a resident., it was noted that residents brief and pants were pulled down to his ankles. Female resident shirt was pulled up exposing her breast. Female resident's pants were pulled down mid-thigh and brief was partially pulled down but still covering vaginal area. This resident was immediately redirected and moved off of the female resident. Female resident immediately removed from the room and taken to her room. During an interview on 04/27/23 at 3:04 PM Resident #35's family member stated he had been notified of the incidents with Resident #35 on 11/ 19/2022 and 11/25/2022. Resident #35's family member stated the male resident was moved off Hall 2(secure unit) on to another hall. Resident #35's family member stated he did not think Resident #35 suffered physical or psychological injury. Resident #35's family member stated he feels that the facility is taking good care of Resident #35. During an interview on 04/27/2023 at 3:32 PM, the DON stated Resident #57 had been placed on the secure unit (Hall2) due to his exit seeking behaviors. The DON stated prior to the incident on 11/19/2023 Resident #57 had not had any inappropriate sexual behaviors. The DON stated physician was contacted after the incident on 11/19/2023 and he ordered Provera to reduce sexually inappropriate behaviors and was put on 15-minute checks and referred to psych services. The DON stated Resident remained on secure unit, and staff were told to maintain close supervision of Resident #57. The DON stated after the incident on 11/25/2022 the physician increased Resident #57's Provera, MHMR was contacted, and he was placed on 15-minute checks until they were able to move him from the secure unit, back to Hall 3. The DON stated Resident #57 primarily stays to himself and did not leave his room and there has not been any other incidents with this resident During an interview on 04/28/23 at 11:35 AM, LVN B stated she was the nurse who worked the night of 11/25/2022. LVN B stated she was under the assumption the incident between Resident #35 and Resident #57 had been reported. LVN B stated she completed a head-to-toe assessment of Resident #35 and that she had red area to both of her breasts and did not note any other red marks or bruising. LVN B stated the red marks faded within 24 hours. LVN B stated she had not seen or heard of Resident #57 having any other inappropriate sexual behaviors besides the incident on 11/19/2022 and 11/25/2022, and that he rarely left his room. LVN B stated neither resident had the mental capacity to consent. LVN B stated that Resident #35 wandered around the unit, and that Resident #57 resided in Resident #35's old room. LVN B stated she contacted Resident #57's physician who increased Resident # 57's Provera, which had been prescribed to prevent inappropriate sexual behavior. During an interview on 04/28/23 at 11:53 AM, the ADMN stated he was the Abuse Coordinator and was responsible for completing investigations of Abuse and Neglect. The ADMN stated his expectation was that allegations of abuse and neglect be investigated thoroughly. The ADMN stated the determination for not investigating was due to neither resident was able to consent, and there was no physical harm . The ADMN stated 15-minute checks were conducted on Resident #57 to assess for behaviors. The ADMN stated after the incident on 11/19/2022 the physician was notified and Resdient #57 was restarted on Provera 5mg. The ADMN stated the Physician was notified on 11/25/2022 and Provera was increased 455744 Page 3 of 12 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from 5mg to 10 mg. The ADMN stated Resident #35 was monitored closely and she did not have any signs of pain, discomfort, or emotional distress. The ADMN stated he talked with staff but did not document any interviews with staff and he did not conduct any resident or resident family safe interviews . The ADMN stated he did not have any documentation to support a thorough investigation. a reportable incident . The ADMN stated a thorough investigation should have included documentation of interviews with staff, residents, families, and other related documentation to the incident. The ADMN stated the effect on residents for not completing a thorough investigation would have been residents could have felt unsafe. The ADMN stated LVN A no longer worked for the facility. During an interview on 05/01/2023 at 10:30 AM with CNA D she stated she had worked the night of 11/19/2022. CNA D stated she was shocked to find Resident #57 and Resident #35 together. CNA D stated she was not aware of Resident #57 previously having any issues of inappropriate sexual behaviors, and has not had any incidents since the 11/25/22 incident. Review of facility policy titled, Abuse, Neglect, and Misappropriation of Property dated April 26, 2012, revealed: The facility maintains that all allegations of abuse, neglect, and misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken . The facility conducts an internal investigation to the legal department, if applicable, and reports the results to enforcement agencies within five working days . Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusion Written summaries of interviews with individuals having firsthand knowledge of the incidents. NOTE: employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer Unless otherwise directed by the legal department, all Ms. situations are to be in writing and kept on file in the Administrator's office. The facility collects, retains and safeguards all information and evidentiary material pertinent to the investigation of the alleged abuse or neglect. 455744 Page 4 of 12 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that: Residents Affected - Some The facility had no RN coverage on 03/20/2022, 06/18/2022, 06/19/2022, 08/21/2022, 01/01/2023, 01/29/2023, and 03/25/2023. The facility had less than 8 consecutive hours of RN coverage on 04/30/2022, 05/22/2022, 08/28/2022, 10/30/2022, 04/14/2023, and 04/22/2023. This failure could affect residents at the facility by placing them at risk for not having their nursing and medical needs met. Findings Included: Record review of nursing staff schedules, daily staffing sheets, and RN time records between 03/10/2022 and 04/28/2023 revealed that the facility did not provide 8 hours of RN coverage on 7 days (03/20/22, 06/18/22, 06/19/22, 08/26/22, 01/01/23, 01/29/23, and 03/25/23) of the 118 days reviewed and did not provide RN services for a full 8 hours on 6 (04/30/22, 05/22/22, 08/28/22, 10/30/22, 01/14/23, and 04/22/23) of the 118 days reviewed. There was no scheduled RN coverage on January 1, 2023, and January 29, 2023. During an interview with the Director of Nurses on 04/28/23 at 11:24 AM, she stated could only speak to why the failure occurred since she was hired in August 2022. The DON explained the missing RN hours were due to call ins and no one would cover the shift. As for no RN scheduled for 2 weekend days in January 2023, she stated making sure the days were covered was overlooked on the schedule. The DON stated the ADON was responsible for developing schedules for nursing staff and the DON looks over the schedule before it was posted. She stated she was much more involved in scheduling now. The DON explained the ADON was already doing the scheduling when she was hired so she could not comment on training the ADON received on scheduling. The DON stated she was responsible for monitoring schedules. She stated the consequences to residents of not having an RN available every day was related to the scope of practice differences between LVN and RN. The DON explained that an RN could assess a resident whereas an LVN could only evaluate. She stated an RN may notice things an LVN may not, due to an RN's larger knowledge base. During an interview with the ADON on 04/28/23 at 11:40 AM, the ADON stated she did not receive training when she accepted the ADON position and responsibilities of an ADON. The ADON explained not having an RN in the facility every day could affect the residents because if something goes wrong, having a nurse with the extra training RNs receive was beneficial. She stated having an RN to utilize as a resource to ask questions or verify findings was a benefit for the nursing staff. During an interview on 04/28/23 at 11:55 AM, the ADMN explained the reason for the failure of having an RN in the facility for 8 consecutive hours every day was he had a night RN who refuses to change her schedule or fill in shifts. He explained in several situations on the time sheets, an RN was in the building for 12 hours, but the hours were not consecutive. He stated he had hired an RN to work weekends but due to personal circumstances she has not been able to start working yet. The ADMN stated the new DON had made improvements by hiring RN's that were willing to help fill the schedule. The ADMN verified the ADON was responsible for scheduling and coordinated with the DON. The ADMN stated he did not feel missing RN coverage would have much of an impact on the residents. 455744 Page 5 of 12 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0727 During an interview on 04/28/23 at 11:55 AM, the ADMN was not able to provide a policy on RN coverage. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 455744 Page 6 of 12 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the menu was followed, for 3 (Resident # 11, Resident #14 and Resident #53) of 13 residents observed during lunch meal on 04/25/2023. The facility failed to ensure Resident # 11, Resident #14 and Resident #53 received a garlic bread stick or an approved alternative during the lunch meal. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. The findings include: Review of Resident #11's Quarterly MDS assessment dated [DATE] revealed, Section A- Identification Section revealed a [AGE] year-old female. C- Cognitive Behavior revealed a BIMS score of 5 (severely impaired cognitive); Section I - Active Diagnoses revealed Anemia, Diabetes, Dementia, and Malnutrition. Review of Resident #14's Annual MDS assessment dated [DATE] revealed, Section A- Identification Section revealed a [AGE] year-old female. C- Cognitive Behavior revealed a BIMS score of 2 (severely impaired cognitive); Section I - Active Diagnoses revealed Dementia, and Malnutrition. Review of Resident #53's Quarterly MDS assessment dated [DATE] revealed, Section A- Identification Section revealed a [AGE] year-old female. C- Cognitive Behavior revealed a BIMS score of 3 (severely impaired cognitive); Section I - Active Diagnoses revealed Renal Insufficiency and Malnutrition. Observation and review of posted daily facility menu for Tuesday 04/25/2023 revealed, Lasagna w/meat sauce, Winter Mixed Vegetables, and Garlic Bread Stick Observation of the meal on 04/25/2023 at 11:30 AM revealed Resident # 11, Resident #14 and Resident #53 were served Lasagna w/meat sauce, and Winter Mixed Vegetables. Residents' trays were served without a garlic bread stick or an approved alternative. During an interview on 04/28/23 at 10:52 AM, the DM stated her expectation was the menu was followed and residents received all items on menu or given a substitution. The DM stated the effect on residents not receiving all their food was residents would not have gotten all nutritional value they were supposed to have received in their daily calorie intake. The DM stated the cook, and the DM were responsible to ensure residents' meal trays were correct . The DM stated the cook and DM were supposed to ensure the food on the tray matched the resident's meal ticket. The DM stated staff were nervous, because state surveyors were in the building, and that was what led to failure of items being missed. During an interview on 04/28/23 at 12:19 PM, the ADMN stated his expectation was that residents received a meal that was hot, balanced, appealing and residents enjoyed eating. The ADMN stated residents not receiving an item on the menu could have caused residents to have had weight loss or had not received a balanced meal they needed. The ADMN stated the cook, cook aide, DM, and nurses were responsible to look at each tray and ensure residents received all items on menu. The ADMN stated staff 455744 Page 7 of 12 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0803 were nervous which led to failure of items being missed on tray. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled, Menus dated October 2008 revealed: Menus shall a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed. Menus will be planned that meet the nutritional needs of residents in accordance with the recommended dietary allowanced of the Food and Nutrition Board Residents Affected - Some 455744 Page 8 of 12 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerator. The facility failed to ensure foods were sealed and/or labeled properly in dry storage. The facility failed to ensure all food was not past expiration date. These failures could place residents that eat from the kitchen at risk for food borne illnesses. Findings included: Observation of the kitchen on 04/25/23 between 9:35AM and 10:00 AM revealed the following: Refrigerator 1. Container of Beef Soup with a use by date of 4/19. 2. One container of cottage cheese with a use by date of 4/15. 3. One bag of shredded lettuce frozen. 4. One plastic bag with a seal of grated cheese with no use by date. Dry Storage 1. One plastic bag with a seal of tortilla chips with no use by date or label of food item. 2. One plastic bag with a seal of potato chips with no use by date or label of food item. 3. 455744 Page 9 of 12 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0812 One container of open pickles with a manufacturer label stating, refrigerate after opening. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/28/23 at 10:52 AM, the DM stated her expectation was that food items were labeled with an open date, use by date and an item description. The DM stated food items were supposed to be discarded after 72 hours. The DM stated the facility policy does not give a time frame, but she was trained that food should be discarded after 72 hours and that was her expectation. The DM stated cooks, aides and herself were responsible to ensure items were labeled and discarded. The DM stated staff were given verbal training on storage, labeling, and discarding items by herself when hired. The DM stated the effect on residents could have been food lost flavor, lost nutritional value, or could have made residents sick. The DM stated what led to failure of items not being discarded or labeled was due to the weekend person was brand new. Residents Affected - Some During an interview on 04/28/23 at 12:19 PM, the ADMN stated his expectation was that residents received fresh and good food. The ADMN stated what led to failure of items not being labeled or discarded was the large fridge was broken and staff were having to use the small fridge and things were unorganized. The ADMN stated this failure could have affect residents by causing them to get sick. Review of CMS Form 672 titled, Resident Census & Conditions of Resident dated 04/25/2023 revealed 69 of 69 resident eat out of the kitchen. Review of facility policy titled, Food Receiving and Storage dated December 2008 revealed: Dry foods that are stored in bins will be roved from original packaging labeled and dated (use by date). All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 455744 Page 10 of 12 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 8 staff reviewed for infection control procedures. Residents Affected - Some Facility staff failed to wear facemasks that covered the nose and mouth at all times when in the presence of residents. These failures could place residents at risk for the transmission of communicable diseases. Findings included: During an observation and interview on 04/25/23 at 09:25 AM, there was a nurse sitting at a central nurses' station with her mask hanging off her ear. ADM came to greet surveyors, and said the transmission was medium and they preferred for staff to wear masks if doing direct patient care or within 6 ft of residents. During an observation on 04/25/23 at 09:56 AM, a housekeeping staff on hall 4 was wearing a mask that was not covering the nose. A shower aide was wearing a mask that did not cover her nose. Residents were ambulating in the hallway near both staff. During an observation on 04/25/23 at 09:59 AM, 2 staff came from outside and walked into dining room with their mask below their chin while residents were sitting at tables throughout the dining room. Another housekeeper was observed cleaning rooms on hall 4 with her mask below her nose. Staff took medicine to a resident in the dining room with her mask below nose. During an observation on 04/25/23 at 10:08 AM, a nurse aide gave resident a hug at nurses' station and began talking with resident, while her mask was below her nose. DON was talking with a resident at nurses' station and her mask had gone below her nose. Staff walked from hall 4 to nurses' station, then down hall 3 with mask barely covering mouth, not covering nose at all. Shower aide walked down hall 4 with mask below chin. Dietary staff came out of dining room to the nurses' station, passing residents with her mask below her chin. During an observation on 04/25/23 at 10:15 AM, again noted that DON mask has fallen below nose while talking with a resident. Nurse aide on hall 1 was pushing a resident in a Geri chair from their room with her face leaned over the resident and the aide's mask was not covering her nose. During an interview on 04/25/23 at 10:17 AM with DON, she said the facility was in the yellow, meaning transmission rates for the county were medium. She said that meant that staff were to wear masks throughout the facility in resident care areas working with residents. She said those areas included the dining room, nurses' station or hallways. She said the masks were expected to be pulled up to cover the nose and the mouth when staff were in those areas. During an interview on 04/27/23 at 5:45PM, ADM provided facility policy for Masks in the facility. He said the facility was in the yellow range meaning medium level transmissibility for Covid-19 in the county. He said with the facility being yellow, that meant that staff was to wear a mask covering the nose and the mouth in all areas that were frequented by residents. ADM said the hallways, 455744 Page 11 of 12 455744 04/28/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0880 Level of Harm - Minimal harm or potential for actual harm resident rooms, and dining room were areas that were frequented by residents and masks should be worn properly in those locations. He said that talking to a resident, hugging a resident, and pushing a resident in a Geri chair would constitute being within 6 feet of a resident and providing some type of direct care. ADM said that would require that the staff wear their facemask properly and ensure that the mask covered the nose and the mouth. Residents Affected - Some Record review of facility policy labeled Coronavirus Source Control Requirements and Policy undated revealed: When community transmission rate is high or substantial the facility staff will be required to wear surgical masks. For the week of 4/21/2023 the facilities transmissibility rate was medium (substantial). Record review of CDC website accessed on 05/01/23 at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html#masks last updated 01/26/23, revealed: When wearing a mask or respirator (for example, N95), it is most important to choose one that you can wear correctly, that fits closely to your face over your mouth and nose, that provides good protection, and that is comfortable for you. 455744 Page 12 of 12