Health inspection·June 20, 2023

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm Residents Affected - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for changes in condition, in that: The facility failed to ensure Resident #1's NP was notified that she had missed doses of her prescribed Prednisone (normally prescribed for a short term in order to control acute flare-ups of Chron's disease) for eight days which exacerbated her symptoms of pain, nausea, vomiting, and diarrhea. This failure placed residents at risk of illness, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Crohn's disease (chronic inflammation of the digestive tract that leads to abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition) of both small and large intestine, fistula (abnormal connection) of intestine, and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment, dated 05/31/23, reflected a BIMS of 15, indicating she was cognitively intact. Section H (Bladder and Bowel) reflected she had an ostomy (a procedure that creates an opening in the abdomen for waste or urine to exit the body). Review of Resident #1's quarterly care plan, revised 02/07/23, reflected she had an ostomy with an intervention of reporting redness, inflammation, or draining at ostomy site. Review of a Resident #1's physician order, dated 05/10/23, reflected Prednisone oral tablet, 10 MG, 4 tablets by mouth one time a day for Chron's for 7 days. Review of Resident #1's MAR, on 06/20/23, reflected she was administered Prednisone on 05/11/23 and 05/12/23, and not again until 05/20/23. On 05/13/23 and 05/14/23, OT was documented, meaning Other/See Nurse Notes. On 05/15/23 and 05/16/23, MA A documented the medication was administered. On 05/18/23 and 05/19/23, H was documented, meaning On Hold. Review of Resident #1's progress notes in her EMR, dated 05/13/23 and 05/14/23, documented by MA B, reflected the following: Page 1 of 6 455785 455785 06/20/2023 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0580 Note Text: Prednisone Oral Tablet 10 MG, give 4 tablets by mouth one time a day for Chron's for 7 days: waiting on delivery from pharmacy. Med not in e-kit (Emergency kit). c/n aware. Level of Harm - Actual harm Review of Resident #1's physician order list in her EMR, on 06/20/23, reflected the following: Residents Affected - Some 05/11/23 - order for Prednisone given by the NP 05/13/23 - ADON made an order for Prednisone from the pharmacy 05/17/23 - the NP requested the medication be put on hold until received from pharmacy and then start over 05/18/23 - Prednisone was received from the pharmacy 05/19/23 - the administering of the Prednisone was resumed Review of a physician's order for Resident #1, dated 05/15/23, documented by LVN C, reflected the following: Lomotil Oral Tablet, 2.5 - 0.025 MG, give 2 tablets by mouth every 6 hours as needed for diarrhea. Review of Resident #1's MAR, on 06/20/23, reflected she was administered Lomotil by LVN C on 05/15/23, 05/16/23, and 05/17/23. Review of Resident #1's hospital discharge summary, on 06/20/23, reflected she had been hospitalized for a bowel obstruction from 05/25/23 - 05/29/23. During an interview on 06/20/23 at 1:15 PM, MA B stated they were out of Prednisone for Resident #1 on 05/12/23. She stated she notified the NP who instructed her to utilize the e-kit. She stated the e-kit only had enough for one dose, and she was administered the dose that day. She stated she notified the charge nurse at the time but could not remember who the nurse was. She stated she was not sure why it took so long to receive the medication, but from what she could understand, it had something to do with Resident #1's insurance. She stated Resident #1 had not seemed more nauseous or in pain more than normal during the time she went without the medication. During a telephone interview on 06/20/23 at 1:23 PM, Resident #1's NP stated she put in an order for Prednisone on 05/11/23 due to Resident #1's Chron's symptoms being exacerbated causing a flare-up. She stated this medication was used for short periods of time to help relieve the symptoms when someone was having a flare-up. She stated she was notified on 05/12/23 when the facility ran out of the prescribed Prednisone and instructed them to retrieve it from the e-kit. She stated she was never informed by the facility staff that there was only one dose in the e-kit. She stated she had believed they had been utilizing the e-kit the whole time (05/12/23 - 05/17/23) until 05/17/23 when she realized the e-kit was out of the medication. She stated it was Resident #1 who informed her she had not been receiving the Prednisone and had been having extreme bouts of nausea, vomiting, and diarrhea. She stated Resident #1 had not expressed increased pain to her that day (05/17/23). She stated she then placed the order on hold until the medication was delivered from the pharmacy so that the seven-day regimen could start over. She stated it would be her expectation that she be notified if the facility was unable to obtain a resident's medication. She stated she did not believe Resident #1 not receiving the medication caused the bowel obstruction (diagnosed in the hospital on [DATE]), but 455785 Page 2 of 6 455785 06/20/2023 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0580 definitely could have been uncomfortable for her and exacerbated her symptoms such as nausea, vomiting, and diarrhea. Level of Harm - Actual harm Residents Affected - Some Observation and interview on 06/20/23 at 1:34 PM revealed Resident #1 in her room. She stated she went almost a week without Prednisone and because of that she ended up in the hospital for four days with a bowel obstruction. She stated during that time, her pain was a 10 out of 10 and she kept telling the staff. She stated she was constantly nauseous, was throwing up after each meal, and was experiencing diarrhea. She stated she was feeling better since she came back from the hospital. During an interview on 06/20/23 at 1:45 PM, LVN C stated she worked with Resident #1 when they were out of her prescribed Prednisone. She stated the NP was notified and she instructed them to use the e-kit. She stated the MAs did not notify her going forward that there was none left in the e-kit. She stated she could not remember how long she was off the medication. She stated she did not remember if Resident #1 had been experiencing more pain or other side effects during that time. She stated if she had put in an order for Lomotil, that would not have been out of the ordinary, as Resident #1 often had diarrhea. During an interview on 06/20/23 at 2:00 PM, the ADM stated she had not been aware Resident #1 had gone without Prednisone. She stated the DON that had worked during that timeframe was no longer working at the facility. She stated her expectation was when a medication ran out, the NP would be notified, and it would be reordered immediately. She stated if it was taking a while for the pharmacy to deliver the medication, the NP could order an alternative or put it on hold. She stated it was the nurses' responsibility to ensure medications were ordered in a timely manner. She stated there could be numerous negative outcomes if residents went without medication, but it would depend on what the medication was for. She stated she did not believe that was what caused Resident #1 to have a bowel obstruction. She stated although MA A documented the medication was given on 05/15/23 and 05/16/23, there was no way it would have been possible due to the medication not being in the facility and she must have falsified on Resident #1's MAR. She stated MA A no longer worked at the facility. The ADM stated they did not have a policy on reordering medications or physician orders. During an interview on 06/20/23 at 2:31 PM, the ADON stated no one notified him that the e-kit did not have any Prednisone or that Resident #1 had gone multiple days without it. He stated nurses and medication aides had the ability to call the pharmacy to refill medications or to follow-up on medications that had not been delivered. He stated it could be possible that Resident #1's symptoms were exacerbated due to not receiving the Prednisone. Review of the facility's undated Pharmacy Services Policy reflected the following: .The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without necessary interruptions. . Facility staff should take all measures required by Facility Policy, Applicable Law, and the State Operations Manual following administration of medications. Following resident medication administration, facility staff should appropriately document medication administration . 455785 Page 3 of 6 455785 06/20/2023 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - 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 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care, in that: Residents Affected - Some The facility failed to ensure Resident #1 received her prescribed Prednisone (normally prescribed for a short term in order to control acute flare-ups of Chron's disease) for eight days which exacerbated her symptoms of pain, nausea, vomiting, and diarrhea. This failure placed residents at risk of illness, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Crohn's disease (chronic inflammation of the digestive tract that leads to abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition) of both small and large intestine, fistula (abnormal connection) of intestine, and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment, dated 05/31/23, reflected a BIMS of 15, indicating she was cognitively intact. Section H (Bladder and Bowel) reflected she had an ostomy (a procedure that creates an opening in the abdomen for waste or urine to exit the body). Review of Resident #1's quarterly care plan, revised 02/07/23, reflected she had an ostomy with an intervention of reporting redness, inflammation, or draining at ostomy site. Review of a Resident #1's physician order, dated 05/10/23, reflected Prednisone oral tablet, 10 MG, 4 tablets by mouth one time a day for Chron's for 7 days. Review of Resident #1's MAR, on 06/20/23, reflected she was administered Prednisone on 05/11/23 and 05/12/23, and not again until 05/20/23. On 05/13/23 and 05/14/23, OT was documented, meaning Other/See Nurse Notes. On 05/15/23 and 05/16/23, MA A documented the medication was administered. On 05/18/23 and 05/19/23, H was documented, meaning On Hold. Review of Resident #1's progress notes in her EMR, dated 05/13/23 and 05/14/23, documented by MA B, reflected the following: Note Text: Prednisone Oral Tablet 10 MG, give 4 tablets by mouth one time a day for Chron's for 7 days: waiting on delivery from pharmacy. Med not in e-kit (Emergency kit). c/n aware. Review of Resident #1's physician order list in her EMR, on 06/20/23, reflected the following: 05/11/23 - order for Prednisone given by the NP 05/13/23 - ADON made an order for Prednisone from the pharmacy 455785 Page 4 of 6 455785 06/20/2023 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0684 05/17/23 - the NP requested the medication be put on hold until received from pharmacy and then start over Level of Harm - Actual harm 05/18/23 - Prednisone was received from the pharmacy Residents Affected - Some 05/19/23 - the administering of the Prednisone was resumed Review of a physician's order for Resident #1, dated 05/15/23, documented by LVN C, reflected the following: Lomotil Oral Tablet, 2.5 - 0.025 MG, give 2 tablets by mouth every 6 hours as needed for diarrhea. Review of Resident #1's MAR, on 06/20/23, reflected she was administered Lomotil by LVN C on 05/15/23, 05/16/23, and 05/17/23. Review of Resident #1's hospital discharge summary, on 06/20/23, reflected she had been hospitalized for a bowel obstruction from 05/25/23 - 05/29/23. During an interview on 06/20/23 at 1:15 PM, MA B stated they were out of Prednisone for Resident #1 on 05/12/23. She stated she notified the NP who instructed her to utilize the e-kit. She stated the e-kit only had enough for one dose, and she was administered the dose that day. She stated she notified the charge nurse at the time but could not remember who the nurse was. She stated she was not sure why it took so long to receive the medication, but from what she could understand, it had something to do with Resident #1's insurance. She stated Resident #1 had not seemed more nauseous or in pain more than normal during the time she went without the medication. During a telephone interview on 06/20/23 at 1:23 PM, Resident #1's NP stated she put in an order for Prednisone on 05/11/23 due to Resident #1's Chron's symptoms being exacerbated causing a flare-up. She stated this medication was used for short periods of time to help relieve the symptoms when someone was having a flare-up. She stated she was notified on 05/12/23 when the facility ran out of the prescribed Prednisone and instructed them to retrieve it from the e-kit. She stated she was never informed by the facility staff that there was only one dose in the e-kit. She stated she had believed they had been utilizing the e-kit the whole time (05/12/23 - 05/17/23) until 05/17/23 when she realized the e-kit was out of the medication. She stated it was Resident #1 who informed her she had not been receiving the Prednisone and had been having extreme bouts of nausea, vomiting, and diarrhea. She stated Resident #1 had not expressed increased pain to her that day (05/17/23). She stated she then placed the order on hold until the medication was delivered from the pharmacy so that the seven-day regimen could start over. She stated it would be her expectation that she be notified if the facility was unable to obtain a resident's medication. She stated she did not believe Resident #1 not receiving the medication caused the bowel obstruction (diagnosed in the hospital on [DATE]), but definitely could have been uncomfortable for her and exacerbated her symptoms such as nausea, vomiting, and diarrhea. Observation and interview on 06/20/23 at 1:34 PM revealed Resident #1 in her room. She stated she went almost a week without Prednisone and because of that she ended up in the hospital for four days with a bowel obstruction. She stated during that time, her pain was a 10 out of 10 and she kept telling the staff. She stated she was constantly nauseous, was throwing up after each meal, and was experiencing diarrhea. She stated she was feeling better since she came back from the hospital. 455785 Page 5 of 6 455785 06/20/2023 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0684 Level of Harm - Actual harm Residents Affected - Some During an interview on 06/20/23 at 1:45 PM, LVN C stated she worked with Resident #1 when they were out of her prescribed Prednisone. She stated the NP was notified and she instructed them to use the e-kit. She stated the MAs did not notify her going forward that there was none left in the e-kit. She stated she could not remember how long she was off the medication. She stated she did not remember if Resident #1 had been experiencing more pain or other side effects during that time. She stated if she had put in an order for Lomotil, that would not have been out of the ordinary, as Resident #1 often had diarrhea. During an interview on 06/20/23 at 2:00 PM, the ADM stated she had not been aware Resident #1 had gone without Prednisone. She stated the DON that had worked during that timeframe was no longer working at the facility. She stated her expectation was when a medication ran out, the NP would be notified, and it would be reordered immediately. She stated if it was taking a while for the pharmacy to deliver the medication, the NP could order an alternative or put it on hold. She stated it was the nurses' responsibility to ensure medications were ordered in a timely manner. She stated there could be numerous negative outcomes if residents went without medication, but it would depend on what the medication was for. She stated she did not believe that was what caused Resident #1 to have a bowel obstruction. She stated although MA A documented the medication was given on 05/15/23 and 05/16/23, there was no way it would have been possible due to the medication not being in the facility and she must have falsified on Resident #1's MAR. She stated MA A no longer worked at the facility. The ADM stated they did not have a policy on reordering medications or physician orders. During an interview on 06/20/23 at 2:31 PM, the ADON stated no one notified him that the e-kit did not have any Prednisone or that Resident #1 had gone multiple days without it. He stated nurses and medication aides had the ability to call the pharmacy to refill medications or to follow-up on medications that had not been delivered. He stated it could be possible that Resident #1's symptoms were exacerbated due to not receiving the Prednisone. Review of the facility's undated Pharmacy Services Policy reflected the following: .The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without necessary interruptions. . Facility staff should take all measures required by Facility Policy, Applicable Law, and the State Operations Manual following administration of medications. Following resident medication administration, facility staff should appropriately document medication administration . 455785 Page 6 of 6