Health inspection·September 8, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, and Resident #3) of 3 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address type of transfer assistance was required for Resident #1. 2. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of medroxyprogesterone (female hormone used to lower sex drive in men) as an intervention for inappropriate sexual behaviors for Resident #2. 3. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the behavior of Resident #3 holding up her dress and wandering about the unit. These failures could affect the residents by placing them at risk for not receiving care and services to meet their needs. Findings included: Resident #1 Review of Resident #1's electronic face sheet revealed resident was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include: paralysis of left side, weakness, and lack of coordination. Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score (08) indicated moderate cognitive impairment. Section G: Transfer: Extensive assistance with two-person physical assist. Review of Resident's #1's electronic comprehensive care plan initiated 05/18/2023, revealed: Problem: Self-care deficit: requires assistance. Extensive/Weight Bearing. Goal: Will maintain ability to participate with self-care at current level as evidenced by ADL score. Will anticipate and meet needs while giving cues/direction to preform ADL at their ability. Approach: Explain all procedures before starting. Praise attempts/performance. Explain plan of care. Promote dignity by ensuring privacy, conversing with resident while providing care. Further review of comprehensive care plan revealed Page 1 of 8 675001 675001 09/08/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some no evidence of a focus, objective, or interventions related to the type of transfer assistance required for Resident #1. Review of Resident #1's electronic nurse progress note dated 07/08/2023 at 12:58 pm, signed by LVN D, revealed: NA reported to this nurse that she had assisted in a controlled fall involving the Hoyer lift. Per the NA, the resident leaned backwards, and the Hoyer lift arm tilted backward and caused the Hoyer to tip over. The NA was able to control the fall and stated the resident maintained his position in the sling and did not hit his head on the floor. The resident landed softly onto his back. The resident was lifted with the Hoyer lift and placed into his wheelchair. This nurse evaluated the resident and there were no visible injuries. The resident denies pain or injury. The family present described the event in much the same way as the NA. They praised the NA for how she handled the situation. DON and PCP notified. Resident #2 Review of Resident #2's electronic face sheet revealed resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis to include: Sexual dysfunction, brain damage, and Psychotic disorder with delusions. Review of Resident #2's Quarterly MDS dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score section blank. Section E: Behavior: Behavioral Symptoms: Physical behavioral symptoms directed toward others occurred 1 to 3 days. Verbal behavioral symptoms directed toward others occurred 1 to 3 days. Other behavioral symptoms not directed toward others occurred 1 to 3 days. Review of Resident's #2's electronic comprehensive care plan initiated 07/05/2023, revealed: Problem: Resident has displayed inappropriate sexual behaviors towards young ladies in the unit. Goal: Prevent any further inappropriate behaviors. Approach: Redirect resident away from ladies in the unit. Discuss with resident about the inappropriate behaviors and educate on appropriate behaviors. Further review of comprehensive care plan revealed no evidence of a focus, objective, or interventions related to the use of medroxyprogesterone as an intervention for inappropriate sexual behaviors. Review of Resident #2's electronic physicians orders revealed: Medroxyprogesterone suspension 150 mg/ml intramuscular once a day on Monday every 2 weeks with a start date of 04/06/2023. Resident #3 Review of Resident #3's electronic face sheet revealed resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include: dementia and depression. Review of Resident #3's Quarterly MDS dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score left blank. Section E: Behavior: Behavioral Symptoms: Wandering occurred daily. Review of Resident's #3's electronic comprehensive care plan edited on 08/23/2023, revealed: Problem: Resident resides in secure unit and is at risk for injury from wandering in an unsafe environment. Resident is at risk for injury from others while residing in secure unit. Goal: Dignity will be maintained, and resident will wander about unit without the occurrence of any injury over the next quarter. Approach: Resident will be redirected if wonders into another resident's room. Allow resident to choose activities inside and outside that don't pose a safety risk. Further review of comprehensive care plan revealed no evidence of a focus, objective, or interventions related to Resident #3's 675001 Page 2 of 8 675001 09/08/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0656 behavior of holding up her dress. Level of Harm - Minimal harm or potential for actual harm Review of Resident #3's nurses notes dated 08/22/2023 at 8:36 pm, signed by DON, revealed: CNA walked in to find female Resident #3 in male Residents #2's room holding her dress up. CNA found male Resident #2 standing behind Resident #3 with his penis in his hand. He was not touching female Resident #2 during this time. Residents Affected - Some During an interview on 09/08/2023 at 2:30 PM, DON stated Resident #3 held her dress up all the time. She stated it was part of her behaviors. DON stated the facility had been working on improvement of the care plan process. She stated the MDS nurse was responsible for the development and updating of the care plans. She stated the MDS nurse was not available for interview because she was on vacation. DON stated it was ultimately her responsibility to monitor the accuracy of care plans. She stated Resident #1's required assistance for 2 person transfers, and Resident #2's medroxyprogesterone and Resident #3's behavior should have been in the care plan. DON stated the possible risk to residents could be major injuries or incidents. DON stated the failure occurred because the facility was working on updating all care plans and had not reviewed those care plans yet. Record review of the facility's policy Care Plans, Comprehensive Person-Centered, dated as revised December 2016, revealed the following [in part]: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 12. The comprehensive, person-centered care plan is developed withing seven (7) days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significate change in the resident's condition. b. When the desired outcome in not met. c. When the resident has been readmitted to the facility from and hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. 675001 Page 3 of 8 675001 09/08/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was free of accidents which resulted in him being dropped due to inappropriate use of assistance devices by NA A. This failure could place residents at risk of injuries. Findings include: Review of Resident #1's electronic face sheet revealed resident was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include: paralysis of left side, weakness, and lack of coordination. Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score (08) indicating moderate cognitive impairment. Section G: Transfer: Extensive assistance with two-person physical assist. Review of Resident's #1's electronic comprehensive care plan initiated 05/18/2023, revealed: Problem: Self-care deficit: requires assistance. Extensive/Weight Bearing. Goal: Will maintain ability to participate with self-care at current level as evidenced by ADL score. Will anticipate and meet needs while giving cues/direction to preform ADL at their ability. Approach: Explain all procedures before starting. Praise attempts/performance. Explain plan of care. Promote dignity by ensuring privacy, conversing with resident while providing care. Further review of comprehensive care plan revealed no evidence of a focus, objective, or interventions related to the type of transfer assistance was required for Resident #1. During an interview on 09/06/2023 at 12:15 PM, Resident #1 stated he had been dropped multiple times during transfers. He stated that he did not know the exact dates or staff involved in the other alleged falls. He stated the staff always transferred him using the mechanical lift with only one staff member present, and he had been dropped at least twice. Resident #1 stated the staff had recently began transferring him with a two person stand pivot transfer with two very little girls who were not strong enough to transfer him and he had been dropped multiple times. Resident #1 stated he had not received any injuries. During an interview on 09/06/2023 at 1:00 PM, Resident #1's family member stated Resident #1 had been dropped during transfers multiple times. She stated he had been dropped twice using the mechanical lift. Resident #1's family member stated the staff always used only one person when performing mechanical transfers with Resident #1. She stated the staff sometimes performed two persons stand pivot transfers with Resident #1. She stated she was unclear as to whether the staff should be using the mechanical lift or using two person transfers. She stated Resident #1 always felt very unsafe during transfers. Review of Resident #1's electronic nurse progress note dated 07/08/2023 at 12:58 pm, signed by LVN 675001 Page 4 of 8 675001 09/08/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few D, revealed: NA A reported to this nurse that she had assisted in a controlled fall involving the mechanical lift. Per the NA A, the resident leaned backwards, and the mechanical lift arm tilted backward and caused the mechanical lift to tip over. The NA A was able to control the fall and stated the resident maintained his position in the sling and did not hit his head on the floor. The resident landed softly onto his back. The resident was lifted with the mechanical lift and placed into his wheelchair. This nurse evaluated the resident and there were no visible injuries. The resident denies pain or injury. The family present described the event in much the same way as the NA A. They praised the NA A for how she handled the situation. DON and PCP notified. Review of Resident #1's electronic nurse progress note dated 05/24/2023 at 3:21 PM, signed by LVN E, revealed in part: Resident required mechanical lift and Geri chair due to resident not being able to hold himself up. Resident does complain off pain in left shoulder and in groin area. This nurse informed doctor. Received new order for Geri chair, use of Hoyer lift to get resident out of bed and in bed . Review of Resident #1's electronic physicians orders revealed no evidence of an order to use mechanical lift for transfers. Review of Resident #1's physical therapy notes revealed no evidence of what type of transfer assistance was required or suggested for Resident #1. During an observation on 09/08/2023 at 11:30 AM, NA B and NA C performed a mechanical lift transfer with Resident #1. Two staff performed the transfer appropriately and safely. During an interview on 09/08/2023 at 12:00 PM, NA B stated Resident #1 was a two person stand pivot transfer. She stated she had always used two people but had never used a mechanical lift to transfer Resident #1. She stated she had been trained on the proper use of the mechanical lift. She stated information on how to transfer residents could be found in the computer, but Resident #1's transfer information was not in his records. During an interview on 09/08/2023 at 12:15 PM, NA C stated she had performed a skills competency check off on mechanical lift transfers. She stated two people must always be present during a mechanical lift transfer. She stated she transferred Resident #1 with a two person stand pivot. She stated she had never dropped Resident #1 and had never heard of Resident #1 being dropped. She stated she was not aware of how to find a residents transfer status in the computer. She stated she would just ask another employee if she had not known what assistance was required to transfer a resident. Attempted interview on 09/08/2023 at 1:30 PM with NA A via phone call with no answer. Message left with no return call. Review of NA A's Skills Competency Check Off dated 04/25/2023, revealed she had been trained and checked off on two person transfers and transfers using the mechanical lift. During an interview on 09/08/2023 at 2:30 PM, DON stated two people were always required when transferring a resident with a mechanical lift. She stated she was aware that NA A had performed a one-person transfer using mechanical lift and had dropped Resident #1, but she was not aware of Resident #1 being dropped any other times. She stated NA A had been trained that mechanical lifts required two people. DON stated she had in-serviced NA A again after the incident on 07/09/2023. DON stated she had interviewed NA A and NA A stated she had a stressful day and was in a hurry when transferring 675001 Page 5 of 8 675001 09/08/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0689 Level of Harm - Minimal harm or potential for actual harm Resident #1 and was not thinking. DON stated NA A no longer worked for the facility; she had resigned about a week ago. DON stated Resident #1 initially required a Hoyer lift transfer, but now only required a two person stand pivot transfer. DON stated not having an order or anything in the care plan stating how to transfer Resident #1 could have been what led the failure of the inappropriate transfer. [NAME] stated the possible risk to the resident could have been a major injury. Residents Affected - Few Review of Inservice titled 2 person Lift Transfers, dated 07/09/2023, revealed NA A and other NAs were in serviced stating 2 people must always be present during a Hoyer lift transfer. Review of facility policy titled, Lifting Machine, Using a Portable, revised December 2013, revealed: Purpose: The purpose of this procedure is to help lift residents using a manual lifting device. Preparation: 1. Review the residents care plan to assess for any special needs of the resident. 2. assemble the equipment and supplies as needed. General guidelines: Two nursing assistants are required to perform this procedure. 675001 Page 6 of 8 675001 09/08/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident # 2) of 3 residents reviewed for medications. Residents Affected - Some The facility failed to administer 10 doses of medroxyprogesterone (female hormone used to lower sex drive in men) to Resident #2 due to medication not being available, but MAR indicated 4 of those doses were administered when they were not. The deficient practice placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings Included: Review of Resident #2's electronic face sheet revealed resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis to include: Sexual dysfunction, brain damage, and Psychotic disorder with delusions. Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed: Section C: Cognitive Patterns: BIMS score section blank. Section E: Behavior: Behavioral Symptoms: Physical behavioral symptoms directed toward others occurred 1 to 3 days. Verbal behavioral symptoms directed toward others occurred 1 to 3 days. Other behavioral symptoms not directed toward others occurred 1 to 3 days. Review of Resident's #2's electronic comprehensive care plan initiated 07/05/2023, revealed: Problem: Resident has displayed inappropriate sexual behaviors towards young ladies in the unit. Resident has displayed inappropriate sexual behaviors towards young ladies in the unit. Goal: Prevent any further inappropriate behaviors. Approach: Redirect resident away from ladies in the unit. Discuss with resident about the inappropriate behaviors and educate on appropriate behaviors. Further review of comprehensive care plan revealed no evidence of a focus, objective, or interventions related to the use of medroxyprogesterone as an intervention for inappropriate sexual behaviors. Review of Resident #2's electronic physicians orders revealed: Medroxyprogesterone suspension 150 mg/ml intramuscular once a day on Monday every 2 weeks with a start date of 04/06/2023. Review of Resident #2's MAR revealed Resident #2 had not received medroxyprogesterone on 04/10/23, 05/08/23, 05/22/23, 07/03/23, 07/17/23, and 08/14/23. Further review of the MAR revealed medroxyprogesterone was administered on 04/24/23 by LVN D, on 06/05/23 by RN F, on 06/19/23 by LVN G, and on 07/31/23 by RN H. During an interview on 09/06/23 at 3:50 PM, DON stated Resident #2 was involved in a sexual incident, which prompted her to do a chart audit. She discovered that Resident #2 had not received his Medroxyprogesterone Injection on 08/14/23. She stated that she instructed for his injection to be given immediately. DON stated Resident #2 had a profound change after receiving his injection which prompted her to look into his previous administration of this medication. DON stated after researching Resident #2's chart, calling the pharmacy, and interviewing nurses, it was discovered that his medication had not been given until 08/23/23. DON stated she verified that the pharmacy had only sent 1 dose of Medroxyprogesterone on 07/30/23 which was the dose given on 08/24/23. DON stated there was no way Medroxyprogesterone was adminsitered on 04/24/23 by LVN D, on 06/05/23 by RN F, on 06/19/23 by LVN 675001 Page 7 of 8 675001 09/08/2023 Avir at Woodlands 125 Inspiration Blvd Eastland, TX 76448

F 0760 G, and on 07/31/23 by RN H. Level of Harm - Minimal harm or potential for actual harm During an interview attempt on 09/08/23 at 2:40 PM, LVN D, RN F, LVN G, and RN H did not answer the phone. Voice mails were left with no return call. Residents Affected - Some During an interview on 09/08/23 at 2:50 PM, Residents #2's family member stated she was notified Resident #2 had not received his medication when it was discovered in August. During an interview on 09/08/2023 at 2:30 PM, DON stated it was the nurse's responsibility to contact the pharmacy when a medication was not available and to notify her. She stated nurses should never document a medication as given when it was not. DON stated she interviewed and in-serviced the nurses about false documentation on 08/28/2023. She stated she did not know what lead to the failure other than nurses not paying attention. DON stated this failure caused Resident #2 to continue to have sexual behaviors. Review of in service dated 08/28/2023 regarding documentation, following physicians' orders, and following the 7 rights of medication administration was signed by LVN D, RN F, LVN G, and RN H. Review of the facility's policy titled, Medication Administration Procedures dated 2023, revealed, .5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration. Initials are to be used. Check marks are not acceptable All nurses administering medication must sign and initial the designated area of each resident's medication/treatment administration record or resident specific master signature log for identification of all initials used in charting. 6. If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record. In the presence of individual facility policies concerning refused and held documentation, the facility policy supersedes this policy .15. Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence. 675001 Page 8 of 8