Health inspection·September 20, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility has failed to ensure the resident environment remained as free of accident hazards as possible and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Residents #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1's wheelchair brakes were functioning correctly to prevent a fall in her bathroom which resulted in a fracture. This failure could place residents at risk of injury from accidents and hazards. Findings include: Record review of Resident #1's face sheet, dated 09/19/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE], with a readmission on [DATE]. Resident #1 had diagnoses which included generalized muscle weakness, history of falling, age-related cognitive decline (experience of worsening or more frequent confusion or memory loss), age related osteoporosis (is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes) without current pathological fracture (a complete or partial break in a bone), muscle wasting and atrophy (shortening), and difficulty in walking. Record review of Resident #1's quarterly MDS assessment, dated 08/02/23, indicated Resident #1 was usually understood and usually understood others. Resident #1 had clear speech, minimal difficulty hearing, and adequate vision with corrective lenses. Resident #1 had a BIMS of 11, which indicated moderate cognitive impairment. Resident #1 required limited assistance for transfer and toilet use. Resident #1 had was not steady, but able to stabilize without staff assistance for moving from seated to standing position, moving on and off toilet, surface-to-surface transfer (transfer between bed and chair or wheelchair). Resident #1 used a wheelchair. Resident #1 had occasional urinary and bowel incontinence. Resident #1 had not experienced falls since admission/entry or reentry or prior assessment. Record review of Resident #1's care plan, dated 02/11/23, with revision on 06/22/23, indicated Resident #1 had an actual fall with a bruise to buttocks due to unsteady gait. Interventions included continue interventions on the at-risk plan. Place call don't fall sign in room for resident reminder to call. Record review of facility incident report dated 09/19/23 at 10:25 a.m., completed by LVN A, Page 1 of 6 675241 675241 09/20/2023 Avir at Jefferson 1307 Martin Luther King Dr Jefferson, TX 75657

F 0689 Level of Harm - Actual harm Residents Affected - Few indicated Resident #1 had pulled emergency light in bathroom .Resident #1 was noted to be on the bathroom floor, sitting facing the toilet with her body under the sink .Resident #1 was attempting to transfer from wheelchair to toilet .redness to left elbow, left lower back, left 2nd and 3rd knuckles, left shoulder, and red marks to front of neck .orders were received to set up an orthopedic (is the medical specialty that focuses on injuries and diseases of your body's musculoskeletal system (includes bones, muscles, tendons, ligaments and soft tissues)) consult .MRI (scan uses a strong magnetic field and radio waves to create detailed images of the organs and tissues within the body) to determine if this is new fracture, and pain medications was adjusted .physical therapy made aware and would like MRI results to decide treatment . Record review of Resident #1's x-ray report, dated 09/19/23, indicated compression fracture of the L2 (is the second lumbar spinal vertebra in the human body) vertebral body (is a type of break in the bones in your back that stack up to form your spine) is of indetermined age. During an interview and observation on 09/19/23 at 11:30 a.m. revealed Resident #1 was sitting in her recliner with her legs elevated by the footrest. Resident #1 had a grimace of face and slight bouncing of her legs. Resident #1 had a moderate area of redness noted to the chest underneath her chin. Resident #1 said she was in pain. Encouraged Resident #1 to call for assistance. Resident #1 pushed the call light and LVN A arrived. LVN A said she had just given her some pain medication and then told Resident #1 to give it some time to work. Resident #1 said my arms, shoulders, back, and pelvis hurts. I fell in the bathroom. LVN A said Resident #1 fell in the bathroom not too long ago and said the doctor ordered an x-ray. Resident #1 said my left wheelchair brake is loose and when I was trying to get my feet set to transfer, it moved. Resident #1 said she had told someone recently about her brakes being loose and no one had done anything about it. Resident #1 said she did not remember who, but she thought it was a male. LVN A and the State Surveyor set both brakes on the wheelchair and the wheelchair was able to be pushed back. During an interview and observation on 09/19/23 at 2:15 p.m., the Maintenance Supervisor said he was responsible for the maintenance of resident's wheelchairs. He said he did not have a process or schedule of checking resident's wheelchairs. The MS said he only knew if a wheelchair had issues if therapy or the resident told him. He said he had tightened Resident #1's wheelchair brake about 3 months ago. The MS said he had not recently received a maintenance order about Resident #1's wheelchair but he had worked on it because Resident #1 was particular about things. He said after the incident today (09/19/23) with Resident #1, he went to tighten the left brake but did not feel like it was loose beforehand. The MS went to Resident #1 room and moved the hardware on Resident #1's wheelchair that held the left brake lever to its former position, locked both brakes, and the wheelchair moved. He said, I guess the brake was a little loose. He said he had been the only maintenance work for a while, and it was hard to keep up with everything. The MS said it was important to provide maintenance to resident's wheelchair to prevent accidents. During an interview on 09/19/23 at 2:20 p.m., CNA B said she was Resident #1's aide today from 6am-2pm. She said she was in another room when Resident #1 fell in the bathroom. CNA B said LVN A came and got her to help her get Resident #1 off the floor. She said Resident #1 told her she fell because her wheelchair moved when she tried to stand up. CNA B said she had not touched Resident #1's wheelchair this morning so she did not know the brakes were loose. CNA B said after the incident before the MS tightened the brake, she pushed both brakes on Resident #1's wheelchair and it still moved. During an interview on 09/19/23 at 3:05 p.m., LVN A said she went to Resident #1's room because her emergency call light came on. She said when she arrived Resident #1's wheelchair was in the 675241 Page 2 of 6 675241 09/20/2023 Avir at Jefferson 1307 Martin Luther King Dr Jefferson, TX 75657

F 0689 Level of Harm - Actual harm Residents Affected - Few doorway, and she was on her left side on the floor between the sink and toilet. LVN A said Resident #1 scratched her chest on the raised seat handle. She said Resident #1 told her she slid trying to get her feet underneath her, but the wheelchair moved. LVN A said she had not noticed Resident #1's left brake being loose, and Resident #1 had not reported it to her. She said Resident #1's wheelchair did move even though the brakes were locked early when her and I [State Surveyor] tested it. LVN A said maintenance took care of resident's wheelchairs. She said the facility used a special computer system to report maintenance issues, but it was currently not working. LVN A said they also directly told the MS about maintenance issues too. LVN A said it was important to report maintenance issues and for wheelchair brakes to work properly to prevent falls and accidents. During an interview on 09/20/23 at 1:20 p.m., the DON said the MS was responsible for the upkeep and maintenance of resident's wheelchairs. She said the facility had just hired a maintenance assistant. The DON said when as issue was reported the MS, he immediately fixed it. The DON said staff reported maintenance issues by a computer program or verbally. She said she did not know his schedule for equipment maintenance. The DON said Resident #1 was able to safely transfer herself. She said when wheelchair brakes did not function correctly, it could lead to incidents. During an interview on 09/20/23 at 2:25 p.m., the ADM said the MS was responsible for resident's wheelchairs. He said it would be impossible to have a maintenance schedule for resident's wheelchairs. The ADM said therapy, staff or the resident had to inform them if their wheelchair had issues. He said he just had an in-service today over reporting maintenance issues timely. The ADM said a loose brake on a wheelchair could cause the resident to have an accident. Record review of a Fall and Fall Risk, Managing policy, dated 03/18, indicated .environmental factors that contribute to the risk of falls included .improperly fitted or maintained wheelchairs Record review of a facility Maintenance Service policy, dated 12/09, indicated .maintenance service shall be provided to .an equipment .the maintenance department is responsible for .and equipment in a safe and operable manner .the maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable condition Record review of a Safety and Supervision of Residents policy, dated 07/17, indicated .our facility strives to make the environment as free from accident hazard as possible .resident safety and supervision and assistance to prevent accidents are facility-wide priorities 675241 Page 3 of 6 675241 09/20/2023 Avir at Jefferson 1307 Martin Luther King Dr Jefferson, TX 75657

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 1 of 2 resident (Resident#1) reviewed safe, functional equipment. Residents Affected - Few The facility failed to ensure Resident #1's wheelchair brakes were functioning correctly. This failure could place residents at risk of injuries and falls. Findings included: Record review of Resident #1's face sheet, dated 09/19/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE], with a readmission on [DATE]. Resident #1 had diagnoses which included generalized muscle weakness, history of falling, age-related cognitive decline (experience of worsening or more frequent confusion or memory loss), age related osteoporosis (is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes) without current pathological fracture (a complete or partial break in a bone), muscle wasting and atrophy (shortening), and difficulty in walking. Record review of Resident #1's quarterly MDS assessment, dated 08/02/23, indicated Resident #1 was usually understood and usually understood others. Resident #1 had clear speech, minimal difficulty hearing, and adequate vision with corrective lenses. Resident #1 had a BIMS of 11, which indicated moderate cognitive impairment. Resident #1 required limited assistance for transfer and toilet use. Resident #1 had was not steady, but able to stabilize without staff assistance for moving from seated to standing position, moving on and off toilet, surface-to-surface transfer (transfer between bed and chair or wheelchair). Resident #1 used a wheelchair. Resident #1 had occasional urinary and bowel incontinence. Resident #1 had not experienced falls since admission/entry or reentry or prior assessment. Record review of Resident #1's care plan, dated 02/11/23, with revision on 06/22/23, indicated Resident #1 had an actual fall with a bruise to buttocks due to unsteady gait. Interventions included continue interventions on the at-risk plan. Place call don't fall sign in room for resident reminder to call. Record review of the facility incident report, dated 09/19/23 at 10:25 a.m., completed by LVN A, indicated [Resident #1] had pulled emergency light in bathroom .[Resident #1] was noted to be on the bathroom floor, sitting facing the toilet with her body under the sink .[Resident #1] was attempting to transfer from wheelchair to toilet .redness to left elbow, left lower back, left 2nd and 3rd knuckles, left shoulder, and red marks to front of neck During an interview and observation on 09/19/23 at 11:30 a.m., Resident #1 said my arms, shoulders, back, and pelvis hurts. I fell in the bathroom. LVN A said Resident #1 fell in the bathroom not too long ago and said the doctor ordered an x-ray. Resident #1 said my left wheelchair brake is loose and when I was trying to get my feet set to transfer, it moved. Resident #1 said she had told someone recently about her brakes being loose and no one had done anything about it. Resident #1 said she did not remember who, but she thought it was a male. LVN A and the State Surveyor set both brakes on the wheelchair and the wheelchair was able to be pushed back. 675241 Page 4 of 6 675241 09/20/2023 Avir at Jefferson 1307 Martin Luther King Dr Jefferson, TX 75657

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and observation on 09/19/23 at 2:15 p.m., the Maintenance Supervisor said he was responsible for the maintenance of resident's wheelchairs. He said he did not have a process or schedule of checking resident's wheelchairs. The MS said he only knew if a wheelchair had issues if therapy or the resident told him. He said he had tightened Resident #1's wheelchair brake about 3 months ago. The MS said he had not recently received a maintenance order about Resident #1's wheelchair but he had worked on it because Resident #1 was particular about things. He said after the incident today (09/19/23) with Resident #1, he went to tighten the left brake but did not feel like it was loose beforehand. The MS went to Resident #1 room and moved the hardware on Resident #1's wheelchair that held the left brake lever to its former position, locked both brakes, and the wheelchair moved. He said, I guess the brake was a little loose. He said he had been the only maintenance work for a while, and it was hard to keep up with everything. The MS said it was important to provide maintenance to resident's wheelchair to prevent accidents. During an interview on 09/19/23 at 2:20 p.m., CNA B said she was Resident #1's aide today from 6am-2pm. She said she was in another room when Resident #1 fell in the bathroom. CNA B said LVN A came and got her to help her get Resident #1 off the floor. She said Resident #1 told her she fell because her wheelchair moved when she tried to stand up. CNA B said she had not touched Resident #1's wheelchair this morning so she did not know the brakes were loose. CNA B said after the incident before the MS tightened the brake, she pushed both brakes on Resident #1's wheelchair and it still moved. During an interview on 09/19/23 at 3:05 p.m., LVN A said she went to Resident #1's room because her emergency call light came on. She said when she arrived Resident #1's wheelchair was in the doorway, and she was on her left side on the floor between the sink and toilet. LVN A said Resident #1 scratched her chest on the raised seat handle. She said Resident #1 told her she slid trying to get her feet underneath her, but the wheelchair moved. LVN A said she had not noticed Resident #1's left brake being loose, and Resident #1 had not reported it to her. She said Resident #1's wheelchair did move even though the brakes were locked early when her and I [State Surveyor] tested it. LVN A said maintenance took care of resident's wheelchairs. She said the facility used a special computer system to report maintenance issues, but it was currently not working. LVN A said they also directly told the MS about maintenance issues too. LVN A said it was important to report maintenance issues and for wheelchair brakes to work properly to prevent falls and accidents. During an interview on 09/20/23 at 1:20 p.m., the DON said the MS was responsible for the upkeep and maintenance of resident's wheelchairs. She said the facility had just hired a maintenance assistant. The DON said when as issue was reported the MS, he immediately fixed it. The DON said staff reported maintenance issues by a computer program or verbally. She said she did not know his schedule for equipment maintenance. The DON said Resident #1 was able to safely transfer herself. She said when wheelchair brakes did not function correctly, it could lead to incidents. During an interview on 09/20/23 at 2:25 p.m., the ADM said the MS was responsible for resident's wheelchairs. He said it would be impossible to have a maintenance schedule for resident's wheelchairs. The ADM said therapy, staff or the resident had to inform them if their wheelchair had issues. He said he just had an in-service today over reporting maintenance issues timely. The ADM said a loose brake on a wheelchair could cause the resident to have an accident. Record review of a Fall and Fall Risk, Managing policy, dated 03/18, indicated .environmental factors that contribute to the risk of falls included .improperly fitted or maintained wheelchairs Record review of a facility Maintenance Service policy, dated 12/09, indicated .maintenance service 675241 Page 5 of 6 675241 09/20/2023 Avir at Jefferson 1307 Martin Luther King Dr Jefferson, TX 75657

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shall be provided to .an equipment .the maintenance department is responsible for .and equipment in a safe and operable manner .the maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable condition Record review of a Safety and Supervision of Residents policy, dated 07/17, indicated .our facility strives to make the environment as free from accident hazard as possible .resident safety and supervision and assistance to prevent accidents are facility-wide priorities 675241 Page 6 of 6