Health inspection·May 8, 2025

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interviews the facility failed to ensure the daily nurse staffing information, including the facility name, current date, total number and actual hours worked by Registered Nurses, Licensed Practical Nurses or Licensed Vocational Nurses, Certified Nurse Aides, and the resident census, was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors for one of one facility reviewed for posted nurse staffing. Residents Affected - Many The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings included: Observation on 05/06/2025 at 7:30 AM, revealed the daily staffing schedule dated 4/30/2025 was posted on the right side of the hallway, around the right corner from the reception area. During an interview on 5/7/2025 at 5:15 PM, the ADM stated the Human Resource Coordinator was responsible to post the nurse staffing data each day. She was out of the facility unexpectedly and there should have been a back-up to assume the responsibility. He stated the facility did not have a policy which addressed the posting of nurse staffing, and they follow CMS guidelines. During an interview on 5/8/2025 at 2:20 PM, the DON and the RNC both stated the facility does not have a specific policy which addresses the posting of nurse staffing and census. Page 1 of 8 455785 455785 05/08/2025 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerance's, and preferences for 2 of 3 residents (Resident #13 and Resident #46) reviewed for food allergies. The facility failed to honor Resident #13 and Resident #46's food preference of an alternative meal according to their meal ticket. This failure could place the residents at risk of not having their preference honored and a diminished quality of life. Findings included: Review of Resident # 13's face sheet, dated, 05/08/2025, reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses which included need for assistance with personal care (helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), anemia in chronic kidney disease (a common complication where the body has a deficiency of red blood cells or hemoglobin, which can lead to a reduced ability to carry oxygen throughout the body), type 2 diabetes mellitus without complications (chronic metabolic disorder characterized by consistently high blood glucose (sugar) levels, where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce), end stage renal disease (the most severe stage of kidney failure, where the kidneys are no longer able to filter waste and excess fluid from the blood.) Review of Resident #13's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 7, which indicated her cognition was severely impaired. Resident #13 did not have a weight loss or a weight gain. Resident #13 had a potential nutritional problem related to diabetes mellitus. Resident #13 diet was on a liberalized renal regular texture, regular consistency, with no added salt packets on the tray. Resident #13 requested large portions. Intervention: Provide and serve diet as ordered. Review of Resident #13's Physician Orders, initiated on 11/07/2023, reflected Resident #13 was ordered regular diet, regular texture, and regular consistency (did not specify fluids). Review Resident #13's meal ticket on 05/07/2025 at 12:45 PM reflected Resident #13 was on a liberalized renal regular texture large portion diet. Resident #13's beverage texture was regular. Resident #13's entrée was one serving regular portion of spaghetti and meatballs. She dislikes spaghetti. Her meal ticket specifies to have an entrée of a hamburger on bun. Also, it noted to limit tomatoes. Observation and Interview on 05/07/2025 at 12:45 PM Resident #13 meal was not double or large portion. The meal served did not reflect what was on her meal ticket. She had normal portion size, and she did not have the meal she preferred. When Resident #13 was asked why she was not eating, she responded she does not like spaghetti. The meal ticket stated hamburger and she was asked would she like 455785 Page 2 of 8 455785 05/08/2025 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0806 to have a hamburger and she stated she would. Level of Harm - Minimal harm or potential for actual harm Review of Resident # 46's face sheet, dated, 05/08/2025, reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #46 had diagnoses which included need for assistance with personal care (helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), acute kidney failure unspecified (a sudden loss of kidney function that can happen within hours or days), type 2 diabetes mellitus without complications (chronic metabolic disorder characterized by consistently high blood glucose (sugar) levels, where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce), unspecified systolic (congestive) heart failure (a condition where the heart's left ventricle struggles to pump blood efficiently.) Residents Affected - Few Review of Resident #46's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 12, which indicated her cognition was cognitively intact. Resident #46 did not have a weight loss or a weight gain. Resident #46 had a potential nutritional problem related to diabetes mellitus. Resident #46 diet was on a liberalized renal regular texture, regular consistency, with no added salt packets on the tray. Intervention: Provide and serve diet as ordered. Observation and Interview on 05/07/2025 at 12:55 PM Resident #46 meal served did not reflect what was on her meal ticket. She did not have the meal she preferred. When Resident #46 was asked why she was not eating, and she responded she did not order spaghetti and she wanted a hamburger. The meal ticket stated hamburger and she was asked would she like to have a hamburger and she stated it was alright, and she ate the meatballs, and she would be fine until dinner. She denied wanting to receive the hamburger as ordered. Interview on 05/08/25 at 9:23 AM the DM stated all residents' meals was to reflect the physician order and the residents' preferences. She stated Resident #13 did have a preference of double portions. The DM stated if it was on Resident meal ticket it was expected to be served. She stated that if something that a resident requested was not on the menu then the resident must be notified three days in advance. She stated that if a resident requested an alternate meal, the kitchen staff was responsible for ensuring the resident gets the proper meal requested, and it must be signed off by a dietary aide. When asked what the purpose was of asking the resident if they were ok with the meal being served, she said so they know that they are satisfied and are aware of their likes and dislikes. If served a meal they did not ask for, she said the resident will complain and be dissatisfied, she that the resident may not finish the food, loss weight, and not eat until the next meal. She said that a liberal renal diet means you are limited to tomatoes, potatoes, and oranges. Interview on 05/08/25 at 9:36 AM the CK stated it was the DM responsibility to make sure the residents were aware what will be served at the menu times. She stated if a resident requested an alternate meal, it was the CNA on that resident's hallway will mark it in their meal ticket. She stated that the purpose of asking the resident if they were ok with the meal being served, was to make sure they get what they want to eat. She said that if the resident was served a meal they did not ask for, then the resident may not eat the food, or they may come to the kitchen staff and ask for something different. Interview on 05/08/25 at 9:41 AM the DA A stated the supervisor was responsible to make sure the 455785 Page 3 of 8 455785 05/08/2025 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0806 Level of Harm - Minimal harm or potential for actual harm residents were aware what will be served at the menu times. She said that if a resident requested an alternate meal, the supervisor and the aide were responsible for ensuring the resident gets the proper meal requested. She said that the purpose of asking the resident if they were ok with the meal being served, was to ensure that the resident gets to eat what they like. If the resident was served a meal they did not ask for, DA A said that they may complain. Residents Affected - Few Interview on 05/08/25 at 9:48 AM the DA B stated the night staff prints out the menus sent to them from PFG. She stated if a resident requested an alternate meal, it was the DM responsibility to double check the trays. She stated the purpose of asking the resident if they were ok with the meal being served was to ensure that the resident gets what they want because the residents have preferences. She stated if a resident was served a meal, they did not ask for, the residents may complain to staff. Interview on 05/08/25 at 2:10 PM the ADM stated the CNA's typically goes around and see if the residents were aware of what was being served and if they would like that or an alternate meal. He stated if a requested an alternate meal, it was the collaboration of dietary to make sure the meal was made and the nurse to make sure the meal reflects the meal on the tray reflects what is on the meal ticket. He stated the purpose of asking the resident if they want the meal being served was because they have the right to have the food they want within their limitations. If they were served a meal they did not want, it could lead into malnourishment, and weight loss. It was the responsibility of everyone to make sure the residents have a full belly. Interview on 05/08/25 at 2:29 PM the DON stated it was the CNA's responsibility to make sure the residents were aware what will be served at mealtimes. She stated if the resident requested an alternate meal, it was both the nurses and dietary aids to make sure the resident gets the proper meal requested. Dietary was responsible for making sure the proper meal was on the tray and the nurses were to make sure the meal matched the meal ticket. She stated the purpose of asking a resident if they wanted the meal being severed was to ensure the resident received quality of life because food is important. They want to have a good meal and to be able to enjoy what they were eating. She stated this was their home and they should be able to have their diet within their limits. She stated they should be able to accommodate the residents. She stated if residents received a meal they did not asked for, it could result in them receiving the wrong texture and choke, not be able to chew and digested it. Some residents have fewer teeth and not able to chew it and the food consistency can be a little tougher than they can handle. She stated if they have food allergies, they can have an allergic reaction to the food. She stated all residents had a right to voice their meal preferences. Record review of the facility's Resident Right Policy, not dated, reflected a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Resident had a right to receive services and /or items included in the plan of care. 455785 Page 4 of 8 455785 05/08/2025 Avir at Western Hills 512 Draper Dr Temple, TX 76504

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 observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen that was reviewed for kitchen sanitation in that: Food items were not labeled and/or dated. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness. Findings include: Observation on 5/06/2025 at 7:50 am in the refrigerator reflected the following: o Sliced ham in a container with water in it dated 4-28-2025 with no discard date. o Sliced bread in a serving pan with no date. o 2-boiled eggs in a zip lock bag dated 4-25-2025 with no discard date. o 2-side serving bowls with appeared to be pureed chicken dated 4-30-2025 with no discard date. o A container of what appeared to be grits with no date and was still warmed. Observation on 5/06/2025 at 8:15 am in the pantry reflected the following: o An open bag of potato chips not wrapped up with no discard date. o An open bag of grits not wrapped up with no discard date. Interview on 05/08/25 at 9:23 AM the DM stated that it was the entire team's job to oversee making sure the food placed in the refrigerator was properly closed, and dated to reflect when it was open and used by dates. She stated that the shelf life of food cooked and placed in the refrigerator was 455785 Page 5 of 8 455785 05/08/2025 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some three days, and that the shelf life of cold cut meat placed in a container and put in the refrigerator was 'a week. DM stated the dates were not placed on the container and another staff comes in and began to make sandwiches with the meat and it is bad, someone could get sick. When asked what could happen if a resident eats the sandwich, she said that the risk is high that they could have a reaction and become sick. Interview on 05/08/25 at 9:36 AM the CK stated it was everyone's responsibility to make sure the food placed in the refrigerator was properly closed, and dated to reflect when it was opened and used by date. She stated that the shelf life of food cooked and placed in the refrigerator was three days and the shelf life on cold cut meat placed in the refrigerator in a container was a week. The [NAME] stated that if the date was not placed on the container and another staff comes in and began to make sandwiches with the meat and it was bad, then the other staff won't know that the meat was bad if it's not dated properly. When asked what can happen if the resident eats that sandwich, she said the resident could get sick. Interview on 05/08/25 at 9:41 AM DA A stated it was the last person that used the product that was responsible for making sure the food placed in the refrigerator was properly closed, and dated to reflect when it was open and used by date. DA A stated the shelf life of cooked food placed in the refrigerator and cold cut meat placed in the refrigerator in a container was three days. She said that if the date was not placed on the container and another staff comes in and began to make sandwiches with the meat and it was bad, then the meat could be spoiled and become slimy. She said that if the resident eats that sandwich then the resident could get sick. Interview on 05/08/25 at 9:48 AM the DA B stated it was everyone's responsibility to make sure the food was dated to reflect when it was opened and to place a used by date on the food. She stated the shelf life of food cooked and placed in the refrigerator was three days and a week for cold cut meat placed in the refrigerator in a container. DA B stated that if the date was not placed on the container and another staff comes in and began to make sandwiches with the meat and it was bad, then someone can get sick, someone can also get sick if a resident eats the sandwich. Record Review Food Storage Policies dated October 1, 2018, and revised on June 1, 2019, stated: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guideline. 1. Dry Storage Rooms: D. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators: D. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 3. Refrigerators: E. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 455785 Page 6 of 8 455785 05/08/2025 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #73) observed for infection prevention. Residents Affected - Few The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when LVN A provided gastric tube feeding for Resident #73. This failure could place residents at-risk for spread of infection. Findings included: Record review of Resident #73's face sheet dated 07/10/2024 revealed she was a [AGE] year-old woman, with an initial admission date of 07/10/2024, with re-admission on [DATE] and with diagnoses of Nontraumatic Intracerebral Hemorrhage, Unspecified (bleeding within the brain tissue that is not caused by head trauma). Record review of Resident #73's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, indicating the interview was not successfully completed. Further review revealed Resident #73 was assessed as having a PEG tube (a type of feeding tube that is placed through the skin and into the stomach, allowing for direct delivery of nutrition). Record review of Resident #73's Active Orders dated 05/07/2025 revealed orders which included: o Enhanced Barrier Precautions start date 02/24/2025. Observation on 05/07/2025 at 01:15 p.m., revealed there was a sign indicating Enhanced Barrier Precautions outside the door to Resident #73's room, and there was no supply of PPE available outside the door/room. Further observation revealed LVN A put on gloves but did not put on or wear a gown while performing PEG tube feeding for Resident #73. During an interview with LVNA on 05/07/2025 at 1:30 p.m., when asked to describe EBPs, she stated EBPs were to give you a warning to use gloves. Gowns were only used if there was an active infection. During an interview with the DON on 05/08/2025 at 11:01 a.m., the DON stated EBPs should be implemented when a resident has any type of implanted medical device or has wounds. The DON stated a negative outcome of failure to abide by EBPs would be the spread of infection. Record review of facility policy titled Enhanced Barrier Precautions reviewed March 2025 revealed: o Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to 455785 Page 7 of 8 455785 05/08/2025 Avir at Western Hills 512 Draper Dr Temple, TX 76504

F 0880 reduce the spread of multi-drug resistant organisms (MDROs) to residents. Level of Harm - Minimal harm or potential for actual harm o Residents Affected - Few EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: 1. dressing. 2. bathing/showering. 3. transferring. 4. providing hygiene. 5. changing linens. 6. changing briefs or assisting with toileting. 7. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and 8. wound care (any skin opening requiring a dressing). 455785 Page 8 of 8