Health inspection·June 8, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand for 2 (Resident #16 and Resident #27) of 4 residents reviewed for discharge. The facility failed to notify Resident #16 or her representative of her transfer in writing. The facility failed to notify Resident #27 or his representative of his transfer in writing. These failures place residents and/or their resident representatives at risk of understanding the reasons and/or location of transfers. Findings included: Resident #16 Record review of Resident #16's Face sheet dated 06/07/23 revealed a [AGE] year-old female with an admission date of 02/27/23. She had a diagnosis list that included: cardiomyopathy (Primary), anxiety disorder, ankylosing spondylitis, generalized edema, adverse effect of stimulant laxative, rheumatoid arthritis, idiopathic progressive neuropathy, hypertension, hyperkalemia, CHF, heart disease, COPD, type 2 diabetes without complication, anorexia. Record review of Resident #16's Census dated 06/07/23 revealed a discharge with an expected return on 05/23/23 and 06/02/23. Record review of Resident #16's Progress Notes revealed: 05/23/2023 08:45 AM called Dr office at 0810 explained resident's current condition and MD stated to send her to (hospital) to be checked out. Called @ 0820 (emergency contact) and notified him of his mother's condition. Called dispatch at 0825 for transportation to hospital. EMT's arrived at facility at 0830. Printed ccd and gave EMT's a copy and a copy of resident's vital signs from this morning. Resident left facility at 0835 via stretcher. 06/02/2023 05:36 PM. Was called to resident's room by resident's daughter . Resident's V/S T: 97.7 P:79 R:24 B/P: 120/79 SPO2: 95% via NC. Resident is difficult to arouse, disoriented, and lethargic. Called Dr. and MD stated to send resident out to the emergency room. Dispatch called at 1735. Family with resident at this time and are aware of change in condition. Notified DON of resident being sent out. Resident #27 Page 1 of 11 675259 675259 06/08/2023 Avir at Cisco 1404 Front St Cisco, TX 76437

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #27's Face sheet dated 06/07/23 revealed a [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included Acute respiratory failure with hypoxia (Primary), stage 2 pressure ulcer of sacral region, pneumonia, neuromuscular dysfunction of bladder, dementia, Record review of Resident #27's Census dated 06/07/23 revealed a discharge with an expected return on 05/05/23. During an interview on 06/07/23 at 2:30pm with ADM and DON, they said they did not provide Resident #16 or Resident #27 or their representatives written notice of their transfers. DON said both residents were transferred to the hospital and had to be admitted to the hospital for a period of time. ADM said he was not aware that the facility needed to provide them with a written notice of their transfers when they went to the hospital. Record review of facility policy labeled Transfer or Discharge; Emergency last revised September 2012 revealed: Prepare a transfer form to send with the resident. 675259 Page 2 of 11 675259 06/08/2023 Avir at Cisco 1404 Front St Cisco, TX 76437

F 0625 Level of Harm - Potential for minimal harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interviews and record reviews, the facility failed to provide a written bed hold policy for 1 of 1 facility reviewed for transfers and discharges. Residents Affected - Many The facility failed to have a written bed hold policy. This failure placed residents at risk of returning to their room in the facility upon return from emergent transfers. Findings included: During an interview on 06/07/23 at 11:31AM with ADM, he said he was not sure if the facility notified residents or their representatives with a written bed hold form during transfers. During an interview on 06/07/23 at 11:38AM with BOM, she said the facility did not notify residents or their representatives with a written bed hold form during transfers. She said she was unaware of the need to inform the resident or their representatives with a written form. During an interview on 06/07/23 at 1:07PM with ADM, he said he understood that regarding a bed hold, upon transfer of a resident he does not always tell the families during each transfer but he has in the past had families ask, so it is that the resident room will be closed upon transfer, no personal belongings will be moved and the resident has the right to come back to their room when they transfer back to the facility. He said he did not know that there was any type of a form or that the facility needed to inform the resident and their family in writing about the bed hold. He said that they did not have a written policy that he could find regarding bed hold. Record review did not reveal a written policy to notify residents or their representatives in writing of a bed hold to allow them to return to the facility to their room after transfers. 675259 Page 3 of 11 675259 06/08/2023 Avir at Cisco 1404 Front St Cisco, TX 76437

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for two (Resident #21, Resident #33) of eight residents reviewed for care plans, in that: The facility failed to address the care and monitoring of Resident #21's left lower leg prosthetic and the risk for skin breakdown on the comprehensive care plan. The facility failed to address the care and monitoring of Resident #33's indwelling urinary catheter and colostomy These failures could place residents at risk for not having their needs met. Findings included: Review of Resident #21's face sheet revealed a [AGE] year-old female initially admitted [DATE] with most recent admission on [DATE]. Resident #21's diagnoses included peripheral vascular disease (problems with the circulation of blood in the arms and/or legs), heart failure, kidney failure, lower left leg amputation, and type 2 diabetes. Review of Resident #21's 1 - 5-day Scheduled Assessment MDS dated [DATE], Section C: Cognitive Patterns, C0500. BIMS Summary Score revealed a BIMS score of 15 on a 1- 15 scale indicating intact cognition. Observation and interview on 06/05/23 at 11:09 AM, Resident #21 was propelling self in wheelchair down the hall. Right lower leg prosthetic was in place. Resident #21 denied issues with the prosthetic. Record review of Resident #21's care plan edited 06/01/2023 revealed a problem of Resident is at risk for pressure ulcer due to activity and chairfast. Interventions included Consider postural alignment, weight distribution, balance stability, and pressure relief when positioning in chair or wheelchair, Consider PT consult for conditioning and W/C assessment, and Teach or do frequent small shifts of body weight. Record review of Resident #21's MDS 1-5 day Scheduled assessment dated [DATE] revealed in section GG0110 Prior Device Use, choice E. Orthotics/Prosthetics was checked. Record review of Resident #33 face sheet dated 06/08/23 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. Resident was diagnosed with constipation but did not have a diagnosis that would relate to the need for a urinary catheter. Record review of Resident #33 admission MDS dated [DATE] revealed a BIMS of 11 meaning mild cognitive decline, resident had an indwelling urinary catheter and a colostomy. Record review of Resident #33 care plan last revised 06/01/23 revealed no care areas addressing an 675259 Page 4 of 11 675259 06/08/2023 Avir at Cisco 1404 Front St Cisco, TX 76437

F 0656 indwelling urinary catheter or the use of a colostomy. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #33 Physician orders dated 06/08/23 revealed no orders for indwelling urinary catheter care, monitoring, changing, or discontinuing. Further review also revealed no orders for colostomy care, monitoring the stoma site, changing the wafer and fecal collection bag or Residents Affected - Few During an observation and interview with Resident #33 on 06/05/23 at 3:30 PM revealed an indwelling urinary catheter draining to gravity with 1000 mLs of amber colored urine. He also had a colostomy on his left lower quadrant of his abdomen. Resident said he had the catheter and colostomy before he came into the facility however, he could not remember why he had either. During an interview with the DON on 06/07/23 at 3:40 PM, she said resident's that have indwelling catheters should have a diagnosis relating to the catheter. She said they should have physician's orders for the catheter that would include changing the catheter PRN, what size catheter to use when changing it, recording output each shift, and monitoring for any issues. She said evidence-based practices no longer indicated that Foley catheters should be routinely changed on a monthly basis, but that they would be changed as needed when residents were having difficulties, bladder pain, obvious sediment in the bag, leaking of the catheters, or when a resident would pull it out accidentally. DON also said that if a resident had an indwelling catheter, then the catheter would be addressed on a resident's care plan. She said resident's that had colostomies should have had a diagnosis relating to the colostomy. She said they should have physician's orders for the colostomy that would include changing the wafer and feces collection bag PRN, recording output each shift, and monitoring for any issues. DON also said that if a resident had a colostomy, then it would be addressed on a resident's care plan. DON stated there was no reason as to why the prosthetic use and skin issues were not care planned. Review of the facility policy titled Care Plans - Comprehensive revised September 2010 revealed under Policy Interpretation and Implementation item 1. Our facility's Care Planning Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Item 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem area, b. Incorporate risk factors associated with identified problems, c. Build on the resident's strengths, d. Reflect the resident's expressed wishes regarding care and treatment goals, e. Reflect treatment goals, timetables and objectives in measurable outcomes, f. Identify the professional services that are responsible for each element of care, g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program, and i. Reflect currently recognized standards of practice for problem areas and conditions. Item 7. The resident's comprehensive care plan is developed withing seven (7) days of the completion of the resident's comprehensive assessment (MDS). Item 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 675259 Page 5 of 11 675259 06/08/2023 Avir at Cisco 1404 Front St Cisco, TX 76437

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 (Resident #33) of 3 residents reviewed for indwelling catheters. The facility failed to have a diagnosis, physician orders and care plan interventions for Resident # 33's indwelling urinary catheter. These findings place resident at risk of complications related to urinary catheterization. Findings included Record review of Resident # 33 Face sheet dated 06/08/23 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. Resident did not have any diagnosis that would relate to the need for a urinary catheter. Record review of Resident #33 admission MDS 05/12/23 reveal a BIMS of 11 meaning mild cognitive decline and resident had an indwelling urinary catheter. Record review of Resident #33 care plan last revised 06/01/23 revealed no care areas addressing indwelling urinary catheter. Record review of Resident #33 Physician orders dated 06/08/23 revealed no orders for indwelling urinary catheter care, monitoring, changing or discontinuing. During an observation and interview on 06/05/23 at 3:30 PM with Resident #33, he had an indwelling urinary catheter draining to gravity with 1000CC's of amber colored urine. Resident said he had the catheter before he came into the facility however, he could not remember why he had the catheter. During an interview with the DON on 06/07/23 At 3:40 PM. She said resident's that had indwelling catheters should have a diagnosis relating to the catheter. She said they should have physician's orders for the catheter that would include changing the catheter PRN, what size catheter to use when changing it, recording output each shift, and monitoring for any issues. She said evidence-based practices no longer indicated that Foley catheters should be routinely changed on a monthly basis, but that they would be changed as needed when residents were having difficulties, bladder pain, obvious sediment in the bag, leaking of the catheters, or when a resident would pull it out accidentally. DON also said that if a resident had an indwelling catheter, then the catheter would be addressed on a resident's care plan. Record review of facility policy labeled Catheter Care, Urinary last revised October 2010 revealed: review the Resident observe the resident urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. Maintain an accurate record of the resident daily output, per facility policy and procedure. Check the resident frequently to be sure he or she is not laying on the catheter and to keep the catheter and tubing free of kink. Unless specifically ordered, do not apply clamp to the catheter. The urinary drainage bag 675259 Page 6 of 11 675259 06/08/2023 Avir at Cisco 1404 Front St Cisco, TX 76437

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Routine hygiene is appropriate. Empty the drainage bag regularly using a separate, clean collection container for each resident. Empty the collection bag at least every eight hours. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when they close system is compromised. Care plan to assess for any special needs of the resident. 675259 Page 7 of 11 675259 06/08/2023 Avir at Cisco 1404 Front St Cisco, TX 76437

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who enters the facility with a colostomy receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident ' s goals and preferences for 1 (Resident #33) of 2 residents reviewed for colostomies. The facility failed to have a diagnosis, physician orders, and care plan for Resident # 33's colostomy. These findings place resident at risk of complications related to a colostomy. Findings included Record review of Resident # 33 Face sheet dated 06/08/23 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. He had a diagnosis list that included constipation. Record review of Resident #33 admission MDS 05/12/23 reveal a BIMS of 11 meaning mild cognitive decline and resident had a colostomy. Record review of Resident #33 care plan last revised 06/01/23 revealed no care areas addressing his colostomy. Record review of Resident #33 Physician orders dated 06/08/23 revealed no orders for colostomy care, monitoring the stoma site, changing the wafer and fecal collection bag or. During an interview with resident #33 on 06/05/23 at 3:30 PM revealed a colostomy on his left lower quadrant of his abdomen. He said he had the colostomy before he came into the facility for the past year, however he could not remember what happened that caused him to get it. During an interview with the DON on 06/07/23 At 3:40 PM. She said resident's that had colostomies should have had a diagnosis relating to the colostomy. She said they should have physician's orders for the colostomy that would include changing the wafer and feces collection bag PRN, recording output each shift, and monitoring for any issues. DON also said that if a resident had a colostomy, then it would be addressed on a resident's care plan. Record review of facility policy labeled colostomy/ileostomy care last revised October 2010 revealed: review the resident's care plan to assess for any special needs of the resident . documentation. the following information should be recorded in the resident's medical record. the date and time the colostomy/ileostomy care was provided. The name and title of the individual who provided the colostomy/ileostomy care. Any breaks in the resident's skin, signs of infection, or excoriation of the skin. How the resident tolerated the procedure. If the resident refused the procedure, the reason why and the intervention taken. The signature and title of the person recording the data. 675259 Page 8 of 11 675259 06/08/2023 Avir at Cisco 1404 Front St Cisco, TX 76437

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 47 days out of 154 days reviewed. Residents Affected - Many The facility failed to have an RN for 8 consecutive hours 7 days a week for 47 days out of 154 days reviewed from January 1, 2023, through June 4, 2023. These failures could place all residents at risk for their clinical needs not being met. Findings included: Review of Daily Staffing Data revealed the facility did not have the services of an RN on the following dates: January 1-2, 7 - 9, 14 - 15 and 28 - 29, 2023; February 4- 5, 11 - 12, 19 and 26, 2023; March 11 - 12, 18 19 and 25 - 26, 2023; April 1 - 2, 7 - 9, 15 - 16, 22 - 24 and 29 - 30; 2023. May 4, 6 - 8, 13 - 14, 20 - 21 and 28 - 31, 2023; June 1 - 3, 2023. During an interview on 06/06/23 at 12:31 PM, the DON stated the facility had been having a hard time finding registered nurses to cover weekend shifts. The facility was advertising and had a Now Hiring banner in front of the building. The DON stated she would cover weekend shifts when she was able. During an interview on 06/07/23 at 2:03 PM, the Admin agreed with the DON that finding RN's was difficult in a small town. The Admin was not able to recall how long the facility had only the DON for RN coverage. Review of facility policy labeled Departmental Supervision revised August 2006 revealed: The nursing services department shall be under the direct supervision of a RN or LVN at all times. 1. A Registered or Licensed Practical/Vocational Nurse (RN/LPN, LVN) is on duty twenty-four hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A Registered Nurse (RN) is employed as the Director of Nursing Services (DNS). The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a Nurse Supervisor/Charge Nurse is responsible for the supervision of all nursing department activities including the supervision of direct care staff. 675259 Page 9 of 11 675259 06/08/2023 Avir at Cisco 1404 Front St Cisco, TX 76437

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 observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food service safety. Residents Affected - Some The facility failed to label items in refrigerators and freezers. The facility failed to discard items in a timely manner that were stored in refrigerators and freezers. The facility failed to seal items that were stored in the refrigerators and freezers. These failures placed all residents at risk of complications of foodborne illnesses. Findings included: During an observation and interview on 06/05/23 at 08:45AM of the kitchen and food storage areas with the DM Refrigerator 1 (Near Door) 1 package of tortillas with an opened date of 4/3/23. DM said they were supposed to be thrown out after 7 days. 1 package of mozzarella shredded cheese with an opened date of 5/24/23. DM said the cheese should have been thrown out after 7 days. 1 package of sliced cheese with an opened date of 5/20/23. DM said it should have been thrown out after 7 days. 1-1-gallon container of bar-b-que sauce that was 1/2 empty with an illegible date opened on the bottle. 1 container of pimento cheese that was 3/4 empty that had no opened date on the container. DM said she did not know when it was opened. Refrigerator 2 (Near Sink) 1 carton of Thickened Orange Juice with an opened date of 5/23/23. The carton instructions state to use by 7 days after opening. DM was unaware how long the juice lasted. 1-32oz jug of Almond Milk that was 1/2 full had an opened date of 3/25/23. DM said that it should have been thrown out within 7 days. 1 Hamburger meat roll, wrapped in foil with top open and exposed to elements, which was hanging over top of pan. The hamburger meat was next to cabbage on the bottom of the icebox. DM said there was the potential for the hamburger meat to drip onto the cabbage. 675259 Page 10 of 11 675259 06/08/2023 Avir at Cisco 1404 Front St Cisco, TX 76437

F 0812 Chest Freezer Level of Harm - Minimal harm or potential for actual harm 1 large bag of yeast rolls that was unsealed. As DM picked up the bag, several of the frozen yeast rolls fell out of bag. DM had staff go out and get a new bag and placed the torn bag inside and used a twist tie to close the bag. Residents Affected - Some Stand up Freezer #1 1 clear zipper sealed bag labeled turkey was dated 5/31/23 that was stored in the door, and it had noticeable ice crystals throughout the bag, touching the meat, edges of some of the fillets were noted to be white and yellow. 1 clear plastic bag labeled Pork Riblets that was unsealed had an illegible date on the bag. DM took the bag out then got a twist tie and wrapped the bag to seal it. 1 clear zipper sealed bag labeled Pork Chops that was dated 1/18/23 was stored in the door and the bag had noted ice crystals throughout the bag touching the meat. DM said that the items in the door of the stand-up freezer were not freezer burned with ice crystals in the bags. She said they had ice crystals in the bag because of times when the freezer door was open too long. DM said that it was not that the items would briefly thaw out but that the freezer door would be left open. During an interview on 06/05/23 at 09:49 AM- DM said she checked the refrigerators daily for items that needed to be thrown out and looked in the freezers weekly on Wednesdays before the food supply trucks came in. Facility policy labeled Food Receiving and Storage last revised December 2008 revealed: Food should be received and stored in a manner that complies with safe food handling practices . All foods must be stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date) . Uncooked and raw animal products and fish will be stored separately in a drip=proof containers and below fruits, vegetables and other ready-to-eat foods. 675259 Page 11 of 11