Health inspection·August 17, 2022

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 a resident who needs respiratory care is provided care consistent with standards of practice and the care plan for one resident (Resident #16) of 4 reviewed for respiratory care, in that: Residents Affected - Few Resident #16's nebulizer and mask were lying on Resident #16's bed exposed (without being secured in a bag to prevent contamination) with medication in the medication delivery nebulizer. This failure could place residents who used small volume nebulizers at risk for exposure to communicable diseases and infections. The findings include: Review of Resident #16's undated Face Sheet revealed she was a [AGE] year-old female re-admitted on [DATE] with the following diagnoses: Dysphagia (difficulty swallowing) pneumonitis (pulmonary infection as a result of aspiration of food) sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) and Gastro-esopheal reflux (A digestive disease in which stomach acid or bile irritates the food pipe lining). Review of Resident #16's re-admission MDS assessment, dated 06/28/22 revealed she had a BIMS score of 12, indicating she was cognitively intact and able to make his needs known. Review of Resident #16's care plan dated 6/28/22 revealed: She had problems with infections and the facility was to monitor signs and symptoms of infections. The care plan did not include the process of changing the nebulizer cups or sanitary storage. Review of Resident #16's physician's orders dated 06/21/21 revealed the following: Proprium-Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% every four hours as needed for shortness of breath. During an observation and interview on 08/15/22 at 8:53 AM, revealed Resident #16 was resting in bed awake and alert, finishing her breakfast. Resident #16 had a nebulizer with a mask attached lying on her bed, which contained a small amount of medication and was uncovered and exposed to potential contamination. Further observation revealed the nebulizer was also not dated. Loose oxygen tubing was lying on her bed which was attached to the power unit that pumped air to the nebulizer creating a mist of medication. Page 1 of 5 675035 675035 08/17/2022 Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354

F 0695 Level of Harm - Minimal harm or potential for actual harm During an interview on 08/15/22 at 8:53 AM with Resident #16 she said she never noticed a bag for the nebulizer why it is just laying around During an interview on 08/15/22 at 9:00 AM, CNA A confirmed the nebulizer was not covered and should have been in a bag, to protect the device from being contaminated. Residents Affected - Few Review of website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086084 on 07/22/22 revealed the following: Problem: Although many improvements in patient safety have been made in the nation's health care system, medication errors and health care-associated infections (HAIs) still top the list of problems . 675035 Page 2 of 5 675035 08/17/2022 Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to ensure the daily nursing staffing was posted as required for 1 of 1 day. Residents Affected - Many The facility failed to post the total number and the actual hours worked by licensed and unlicensed nursing staff and did not identify the resident census. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. Findings included: Observation on 08/17/2022 at 8:10 a.m., revealed the daily nursing staffing schedule was posted but was not filled out and was blank. Interview on 08/17/22 at 8:30 a.m., the DON said she should have filled the daily nursing staffing schedule out but was busy this morning and failed to get it done. Interview on 08/17/22 at 3:08 p.m., the Administrator said it was usually the ADON's responsibility to post the nursing schedule, but she had been working the night shift. The Administrator said the DON had been filling in and should have completed it this morning. Record Review of the facility's policy Staffing, revised July 2021, revealed the following [in part]: Policy Statement: Our center provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the center assessment. 6. Staff levels for direct care staffing is updated each shift and posted in a public area. 675035 Page 3 of 5 675035 08/17/2022 Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen. Residents Affected - Many The facility failed to date and label food stored in the refrigerator. The facility failed to ensure a kitchen staff wore a hair net during the food temperature check. This failure could place residents at increased risk of exposure to food-borne illnesses. Findings included: During initial tour observation on 08/15/2022 at 7:10 AM revealed a zip top bag with two elongated sausage sticks that were not labeled or dated; and uncovered sandwich was lying exposed on a box without being in a bag or dated; and one sandwich used for snacks was not dated but only had a M labeled (marked in black ink) in the refrigerator located in the food preparation area of the kitchen. During meal service observation 08/16/2022 at 11:45 AM revealed the Dietary Aide was observed taking food temperatures prior to serving the residents in the facility. After completion of the food temperature checks the Dietary Consultant was present and surveyor indicated to the Dietary Consultant the Dietary Aide was not wearing a hair net. During an interview with Dietary Aide on 08/16/2022 at 12:00 PM, she said she did not realize she was not wearing her hair net and it must have fallen off. She said she looked on the floor but did not find it. During an interview with the Dietary Consultant on 08/16/2022 at 12:12 PM she said her expectations were for kitchen staff to wear hair nets. During an interview with the Dietary Manager on 08/16/2022 at 12:30 PM she said her expectations were for kitchen staff to wear hair nets. Dietary manager also said her expectations were, food should be dated and in a container. Provide policy and procedure regarding food storage was not available or locatable. Review of facility's undated policy and procedure titled, Authorized Kitchen Personnel revealed, It is the policy of this center that only authorized individuals will have access through food preparation, storage, and service areas to minimize the potential for cross contamination. .2. All authorized personnel must wear appropriate head covering while in the kitchen or production area. 675035 Page 4 of 5 675035 08/17/2022 Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that 1 of 31 resident rooms (room [ROOM NUMBER]) met minimum required square footage for each resident. The facility's failure could affect residents by not affording them appropriate living space which could adversely affect residents from attaining his or her highest practicable wellbeing. The findings included: An interview with the Administrator, on 08/17/2022 at 12:25 PM, revealed the facility did have a room size waiver, in place, for resident room [ROOM NUMBER]. This interview revealed the facility would like to continue with the room size waiver. An observation of the East wing, room [ROOM NUMBER], on 08/17/2022 at 12:32 PM, revealed the room measured at 218.8 square feet. room [ROOM NUMBER] was being utilized as the physical therapy room, with therapy equipment in the area. No residents were housed in the room. The room was certified to have 3 beds, which required at least 240 square feet. Review of the facility's floor plan, updated 08/17/2022 revealed room [ROOM NUMBER] was being utilized for residents physical, occupational, and speech therapy. Review of the Form 3740 Bed Classifications, dated 08/17/2022, completed by the Administrator, revealed room [ROOM NUMBER] had 3 Title 18 beds. 675035 Page 5 of 5