Health inspection·December 15, 2023

F 0679 Provide activities to meet all resident's needs. 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 provide an ongoing program of activities designed to meet Residents Affected - Some the interests and the physical, mental, and psychosocial well-being for 4 of 13 residents (#6, #7, #8, #9) on the Secure Unit reviewed for activities, in that 1. Resident #6, #7, #8, #9 did not have an ongoing activity program designed to meet her interests. This deficient practice placed residents on the Secure unit at risk for isolation, low self-esteem, and decline in mental status. Finding Include: 1. Review Resident #6 face sheet dated 12/15/23 revealed an [AGE] year-old female, admitted to facility on 1/7/21 with diagnoses that included Gastrointestinal hemorrhage (bleeding in the gastrointestinal tract), Alzheimer's disease (neurodegenerative disease). Review of Resident #6's MDS assessment dated [DATE], BIMS score 4 (severe cognitive impairment) revealed under preferences for activities was not coded. Review of Resident 6's Care Plan dated 10/14/23 for Psychosocial Well-Being Provide opportunity for me to build relationships with others residing in the facility through activity programming. For Behavioral Symptoms Offer in-room activities such as favorite TV, music, reading, and provide a program of activities that is of interest and accommodates residents' status. Observation on 12/12/23 at 3:00 pm, revealed 3 residents were sitting in the tv room watching old black/white western shows. 5 Page 1 of 10 455744 455744 12/15/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0679 Level of Harm - Minimal harm or potential for actual harm residents were sitting at dining tables doing nothing. 2 residents were in their rooms sleeping in bed. 3 residents were sitting in their rooms in wheelchairs; 1 was watching tv and 2 were doing nothing. No Activity calendar was found in any resident's rooms or in the Residents Affected - Some Secure unit common areas. Observation on 12/12/23 at 3:08 pm, revealed Resident #6 was sitting at a dining table staring out the window. Interview on 12/12/23 at 3:20 pm, CNA A stated that residents in the Secure unit does not have many activities. CNA A stated that sometimes she will hand out coloring books or play music, but nothing is scheduled. CNA A stated the Activity Director will sometimes supply them with puzzles or coloring books. CNA A stated there has never been any Activity calendar posted for residents and residents do not leave the hall to participate in activities in the main unit. CNA A stated the residents only get activities if staff has enough time. Interview on 12/12/23 at 3:40 pm, CNA B stated that the Activity Director sometimes brings supplies for activities, but nothing is scheduled or planned for the residents in the Secure unit. Sometimes if residents get bored, staff will play music. CNA B stated the Activity Director does not lead any activities for Secure unit, aides initiate activities when possible. CNA B stated she never seen any calendars for the residents in the Secure unit. 2. Review of Resident #7's face sheet dated 12/15/23 revealed [AGE] year-old female, admitted to the facility on [DATE] with diagnosis that included Pulmonary embolism (blockage of an artery in the lungs). Review of Resident #7's annual MDS dated [DATE] revealed a BIMS score 3 (severely cognitive impaired), under preferences for activities that were somewhat important to her was music, groups of people, pets, keeping up with the news. Review of Resident #7's Care Plan dated 10/14/23 for Behavioral Symptoms revealed Provide activity calendar and encourage 455744 Page 2 of 10 455744 12/15/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0679 Level of Harm - Minimal harm or potential for actual harm participation in the unit, provide a program of activities that is of interest and accommodates residents' status. Observation and interview on 12/12/23 at 3:00 pm revealed Resident #7 was sitting in her wheelchair in her room doing nothing. Residents Affected - Some Resident #7 stated she did nothing all day. Resident #7 stated she likes reading and doing crosswords. Observed some reading materials in her room but found no crossword puzzle books. 3. Review of Resident #8's face sheet dated 12/12/23 revealed [AGE] year-old female, admitted to the facility on [DATE], with diagnosis that included Schizophrenia (mental disorder characterized by continuous or relapsing episodes of psychosis). Review of Resident #8's MDS dated [DATE], BIMS score 10(moderate cognitive impairment) under preferences for activities somewhat important to resident. Review of Resident #8's Care Plan dated 11/17/23 for Activities, Provide activity program that is satisfying for resident. Observation on 12/13/23 at 10:15 am, no activities being conducted, 2 residents were sitting in common area watching tv, 3 residents were sitting at dining table. Resident #8 was sleeping in bed, lights out, call light within reach. Found no activity calendar in room. 4. Review of Resident #9's face sheet dated 12/13/23 revealed [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included Major depressive disorder (clinical depression), insomnia (sleeplessness) Review of Resident #9's MDS dated [DATE], BIMS score 8 (cognitive impaired) under preferences for activities no response. Review of Resident #9's Care Plan dated 11/10/23 for Psychosocial Well-Being stated, Provide opportunity for me to build relationships with others residing in the facility through activity programming and provide activity program that is satisfying for resident. Observation and interview on 12/13/23 at 10:22 am, revealed Resident #9 was sitting in her room in her wheelchair. Resident #9 455744 Page 3 of 10 455744 12/15/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0679 stated she was bored. When asking what her interests were, Resident #9 could not stay on topic. Level of Harm - Minimal harm or potential for actual harm Activity Director had turned in (his/her) notice of termination and was not available for an interview during the time of survey. Residents Affected - Some Attempts to contact (him/her) by phone failed. Interview on 12/14/23 at 10:40 am with Assistant Activity Director C revealed she tries to get supplies, coloring books, puzzles for the activities in the Secure unit. Assistant Activity Director C stated she usually supplies aides with activities to do. Assistant Activity Director C stated they did not supply the Secure unit with activity calendars or setting up more structured activities for residents in the secure unit. Interview on 12/14/23 10:48 am, The Administrator stated the Activity Director is responsible for providing activities for the whole facility, not providing activities for the residents in the secure unit could cause emotional harm. Interview on 12/14/23 10:50 am, The DON stated not having structured activities for residents in the secure unit could cause emotional harm. Record review of Activity Policy: Med-Pass, revised dated April 2009 revealed, Group Programs and Activities Calendar Policy Statement Group activities are available in this facility and an activities calendar is completed to inform residents, families, and staff of the activity opportunities available. Policy Interpretation and Implementation I. Both large and small group activities are part of our activity programs. 2. The activities calendar states all activities available for the entire month, which may also include scheduled room visitation. 455744 Page 4 of 10 455744 12/15/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0679 3. Level of Harm - Minimal harm or potential for actual harm Residents are encouraged to participate in all group activities, especially those that are best suited for their interests and Residents Affected - Some physical, mental, and emotional needs. 4. Activities professionals plan scheduled activities for the month and post the activities on a large bulletin board in a prominent location in the facility. 5. Activities calendars are posted in high-visibility and high-traffic areas in the facility at a height that is readable from a wheelchair. The number of posted calendars is determined by the size and physical layout of the overall facility. 6. Smaller monthly activity calendars are placed in each resident room at a height and location that is acces [NAME] to the resident. 7. Activities are also advertised through announcements over the public address system and [NAME] invitations to join an activity on an individual basis. If public address announcements are appropriate for the facility the following format is recommended: Orientation (i.e., Today is Monday, April 27, 2009); brief description of the activity; location of the activity; time activity will begin. 8. Modifications, time changes, cancellations or substitutions are reflected on all large posted calendars. It is recommended that final versions of the monthly calendar be kept on file for three years. 455744 Page 5 of 10 455744 12/15/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0679 9. Level of Harm - Minimal harm or potential for actual harm Calendar development and changes are discussed with the Resident Council to keep them informed. The Activity Residents Affected - Some Director/Coordinator periodically reviews the current types of activity programs in terms of the current facility population and changes are made based on this analysis with input from the Resident Council. 455744 Page 6 of 10 455744 12/15/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that the residents who need respiratory care, is Residents Affected - Few provided such care, consistent with professional standards of practice, the comprehensive person-center care plan, the residents' goals, and preferences for 2 of 4 residents (Resident #11, Resident #13) reviewed for quality of care. The facility failed to ensure Resident #11 and Resident #13's nebulizer cup and tubing was kept in bag while not in use. This failure could place residents at risk for respiratory infections. The findings include: 1. Record review of Resident #11's MDS, [AGE] year-old male, admission assessment, dated 10/5/23 revealed Resident #11 was admitted to the facility on [DATE]. Cognitive patterns revealed a BIMS score of 10 (moderate cognitive impairment). Medical diagnosis revealed Cerebral infarction (stroke). Record review of Resident #11's Care Plan dated 11/7/23 revealed it did not include the use of nebulizer. Record review of Resident #11's Order summary report accessed 12/13/23 revealed an order on 10/2/23 for Albuterol sulfate solution for nebulization: 2.5mg/3ml (0.083%) amount 1 UD via nebulizer inhalation. In an observation and interview on 12/13/23 at 10:30 am, Resident #11 was sitting in wheelchair in room watching tv. Resident #11's nebulizer cup and tubing was sitting on the nightstand not stored in bag while not in use. Resident #11 stated he had treatment last night. Resident #11 stated sometimes he will have several treatments per day if needed. Resident #11 did not recall if or when nebulizer cup and tubing have been cleaned or replaced. 2. Record review of Resident #13, [AGE] year-old female admitted [DATE], MDS dated [DATE], revealed Cognitive patterns indicated a BIMS score of 15 (cognitively intact). Section I: Medical diagnosis revealed Acute respiratory failure. In an observation and interview on 12/13/23 at 11:02 am, Resident #13 was lying in bed. Nebulizer cup and tubing was laying on nightstand not stored in bag while not in use. Resident #13 stated she had her last breathing treatment at 9:00 am. 455744 Page 7 of 10 455744 12/15/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0695 Record review of Resident #13's Care Plan dated 10/13/23 revealed it did not include the use of nebulizer. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #13 Order summary report accessed 12/13/23 revealed an order on 7/24/23. Residents Affected - Few Albuterol-Ipratropium 0.5mg-3mg (2.5mg base)/3ml suspension; 0.5mg-3mg (2.5mg base)/3ml; amt: ONE inhalation. In an interview with DON on 12/13/23 at 2:05 pm, The DON stated she expected the nebulizer cup and tubing to be bagged by the nurse when not in use and changed each Sunday as per policy. DON stated the failure to store nebulizer equipment properly could result in infection. Record review Respiratory Policies and Procedures Dated 6/2012 Subject: Handheld Nebulizer Procedure-23; Disassemble device and rinse the mouthpiece and nebulizer cup with water and dry. Place entire unit in a bag to be maintained in the patient's/resident's room. 455744 Page 8 of 10 455744 12/15/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 6 (room [ROOM NUMBER], #204 and #206) rooms in the secure unit observed for environment. The window blind blades (white 2-inch vinyl blades) were broken or missing in residents' rooms #202, #204 and #206. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment . Findings include: Observation on 12/12 23 at 3:40 pm, revealed that Resident #6's room [ROOM NUMBER], Resident #8 room [ROOM NUMBER], and Resident #9 room [ROOM NUMBER]'s windows blinds (white 2-inch vinyl blades) were broken or missing blades. Resident's #6, #8 and #9's cognition was severely impaired and were not interview able. Record review of the Maintenance repair log for October 2023 through December 13, 2023, revealed no repair request was found for the damaged blinds in rooms #202, #204 and #206. Interview on 12/14/23 at 9:45 am, the Administrator stated he knew about damaged blinds in rooms #202, #204 and #206. Administrator stated the maintenance man had been home ill for several weeks and Administrator was trying to fill-in as he could. Interview on 12/14/23 at 11:00 am, The Administrator stated that new blinds were purchased, and Administrator replaced damaged blinds in rooms #202, #204, and #206. Observation on 12/14/23 at 11:34 am revealed the damaged blinds were replaced with new blinds in rooms #202, #204 and #206. Record review of 2001 MED-PASS, Inc, dated December 2009 revealed. 455744 Page 9 of 10 455744 12/15/2023 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0921 Maintenance Service Policy Statement: Level of Harm - Minimal harm or potential for actual harm Maintenance services shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. Residents Affected - Some 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 455744 Page 10 of 10