Health inspection·October 16, 2024

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 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 three residents reviewed for quality of care. Residents Affected - Few The facility failed to complete an accurate skin assessment on Resident #1 upon readmission from the hospital on [DATE] in which six insect bites were not noted to his right hip. These failures could place residents at risk of not receiving necessary medical care, skin breakdown, and pain. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type II diabetes, end-stage renal disease, paraplegia (a form of paralysis that mainly affects the lower body), and muscle weakness. Review of Resident #1's admission MDS assessment, dated 09/09/24, reflected a BIMS score of 15, indicating he was cognitively intact. Review of Resident #1's initial care plan, dated 10/03/24, reflected he had a skin impairment to the top of his right foot with an intervention of keeping the skin clean and dry. Review of Resident #1's readmission assessment, dated 10/14/24 and locked by the DON, reflected dryness to his feet. During an observation and interview on 10/16/24 at 12:12 PM, Resident #1 stated he had been bitten by ants. He stated when he was admitted to the hospital (on 10/09/24) he had ants falling out of his pants. He pulled down the sheet covering him which revealed six round insect bites on his right hip. He stated they were not causing him pain nor were they causing him to itch. During an observation and interview on 10/16/24 at 12:25 PM, the DON stated she only locked Resident #1's readmission assessment and she believed LVN A had completed the assessment. The DON and Surveyor went to Resident #1's room and she observed his right hip. She confirmed the insect bites and stated it would be her expectation that they would have been addressed in the readmission skin assessment. Page 1 of 2 455785 455785 10/16/2024 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0684 Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 10/16/24 at 12:33 PM, LVN A stated she did not conduct Resident #1's readmission assessment. She stated they had three residents being readmitted that night (on 10/14/24) and the ADON stated she would conduct his assessment. She stated if a resident had any kind of skin impairment, including insect bites, she would absolutely address it on the skin assessment upon readmission. Residents Affected - Few During an interview on 10/16/24 at 12:37 PM, the ADON stated she did conduct Resident #1's readmission skin assessment on 10/14/24. She stated she did not notice any bites, blisters, or anything of that nature. She stated her main concern was the dryness to his feet. She stated if she had observed insect bites on him, she would have 100% document them on the assessment. During an interview on 10/16/24 at 1:51 PM, the DON stated accurate skin assessments were important so that any skin issues could be identified and treated immediately. She stated skin integrity issues could be indicative of an underlying problem. She stated not documenting all skin issues could lead to something going untreated and worsening. Review of the facility's admission Assessment and Follow Up: Role of the Nurse Policy, revised September 2012, reflected the following: . 8. Conduct a physical assessment, including the following systems: . j. Skin. Review of the facility's Charting and Documentation Policy, Revised July 2017, reflected the following: . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 455785 Page 2 of 2