Health inspection·August 10, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 an accurate MDS assessment was completed for 1 of 5 residents (Resident # 21) reviewed for accuracy of MDS assessments. Residents Affected - Few The facility failed to accurately code Resident # 21's antipsychotic medication usage on the MDS assessment. This failure could place residents at risk for not receiving needed care and services. Findings include: A review of Resident #21's face sheet for August 2023 indicated Resident # 21 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), Parkinson's disease, and paranoid schizophrenia. A review of Resident #21's Quarterly MDS, dated [DATE] revealed he was coded as receiving antipsychotic medication on each of the 7 days of the observation period. A review of the physician's orders noted an order on 04/11/2023 to discontinue the administration of Olanzapine, an antipsychotic drug. A review of the April 2023 Medication Administration Record (MAR) indicated the drug was discontinued as ordered. There was no record of Resident #21 receiving any antipsychotic medication after 04/11/2023. During an interview with the DON on 07/07/2023, she said the facility did not have a full time MDS Coordinator. Page 1 of 7 675289 675289 08/10/2023 Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's interdisciplinary team failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment or no more than 21 days after admission for 1 of 5 residents (Resident #74) and failed to review and revise the person-centered care plan to reflect the current condition for 1 of 5 residents (Resident #74) reviewed for care plan revisions. The facility failed to review and revise Resident #74's baseline care plan within the required timeframe with a comprehensive care plan. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of Resident #74's face sheet dated 08/09/23 indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included protein-calorie malnutrition, physical debility, diabetes, stage 4 (wound to the bone) pressure ulcer of sacral region, chronic peripheral venous insufficiency (narrowed blood vessels causing reduced blood flow in the limbs), glaucoma (eye condition that can cause blindness), high blood pressure, and osteomyelitis (inflammation of the bone caused by infection) of the vertebra, sacral and sacrococcygeal region. Review of Resident #74's quarterly MDS dated [DATE] indicated she had clear speech, could understand and be understood by others, a BIMS of 11 indicating a mild cognitive decline, required extensive assistance of 1-2 staff with ADLs, had an indwelling urinary catheter, was incontinent of bowel, had a feeding tube, and had a stage 4 pressure sore on the sacral region and a stage 4 pressure sore on the right heel. During an interview and record review on 08/09/23 at 09:30 AM the DON pulled up Resident #74's care plan in the EMR. The DON said she was responsible for care plans. She said when the 48-hour (baseline) care plans are initiated by the charge nurses on admission she reviews and signs them. She said the facility has not had an MDS coordinator for over a year and MDS reviews have been done remotely by different individuals. She said she thought they had had a care plan meeting with Resident #74 but could not remember for certain. She said the SW planned the meetings. She said because they have not had a consistent MDS coordinator there had not been any generation of the care plans. She said when the comprehensive resident assessment was done for Resident #74, no care plans were generated at that time. She reviewed the EMR and it indicated Resident #74 had an admission MDS on 04/14/23 and Quarterly MDS on 07/15/23 and 07/28/23 and no care plans were initiated or reviewed within that period. She said the resident had some care plans initiated on 08/05/23 by a corporate registered nurse. During an interview on 08/09/23 at 09:45 AM the SW said she remembered meeting with Resident #74's husband and trying to set up a formal care plan meeting with him and his wife. She said he did not really wish to attend a formal meeting and said to just have it with his wife. She said Resident #74's husband came to the facility almost daily and she and other staff may discuss things with him when he visited but none of those interactions were documented. She said she had tried to schedule the meeting after the 07/15/23 quarterly assessment and he could not attend and then she said she moved it to 07/28/23 and she said different circumstances that kept her from scheduling and meeting on that 675289 Page 2 of 7 675289 08/10/2023 Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701

F 0657 date. She said a care plan meeting was not currently scheduled. Level of Harm - Minimal harm or potential for actual harm A review of Resident #74's electronic record indicated there was no comprehensive care plans initiated and reviewed during the two quarterly MDS assessments on 07/15/23 and 07/28/23. The record indicated only a baseline care plan initiated by the charge nurse on admission [DATE]. Residents Affected - Some 675289 Page 3 of 7 675289 08/10/2023 Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #15) reviewed for gastrostomy tube management. The facility failed to ensure Resident #15's head of bed was elevated at a minimum of 30-degree angle during medication administration via gastrostomy tube (G-tube) (a tube directly inserted through the skin to the stomach to deliver nutrition). This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health. Findings include: Record review of Resident #15's face sheet dated 08/08/23, indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including Rett's syndrome (genetic condition that affects brain development and causes severe impairments in movement, communication and cognition), aphasia (disorder that affects how you communicate), dysphagia (difficulty in swallowing food or liquid), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food and medication). Record review of Resident #15's MDS, dated [DATE] revealed she had severely impaired cognition was not able to answer questions. She had a feeding tube used for nutrition. Record review of Resident #15's care plan dated 05/03/23 and last reviewed on 06/21/23 indicated she required a feeding tube related to dysphagia and interventions included the head of bed should be elevated when in bed, avoid flat while feeding is on/pump running. Record review of Resident #15's physician order dated 05/04/23 revealed an order for Phenobarbital 60mg (prevent and control seizures) tablet and to give one tablet via G-Tube (a tube directly inserted through the skin to the stomach to deliver nutrition and medications) two times a day. During an observation and interview on 08/08/23 at 8:19 a.m., LVN C prepared Resident #15's medication then entered her room. Resident #15 was in bed with the head of bed elevated. Resident #15 was slouched downwards with her torso in the middle of the bed lying flat on her back. LVN C did not reposition Resident #15 and administered her medication. Resident #15 was not elevated at least 30 degrees when LVN C administered her medication. LVN C said a resident with a G-Tube should be elevated at least 30-degrees when administering medications to prevent them from aspirating (fluid or food enter the lungs accidently). LVN C said she did not have Resident #15 elevated at 30-degrees when she administered her medication. LVN C said Resident #15 was at risk for aspirating and she should have repositioned her before she administered her medication. During an interview on 08/08/23 at 9:06 a.m., the DON said LVN C notified her she did not have Resident #15 elevated at 30-degrees when she administered her medication. The DON said a resident with a G-Tube should be elevated at least 30-degrees when administering medications to prevent them from 675289 Page 4 of 7 675289 08/10/2023 Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aspirating and expected the staff to do so. The DON said Resident #15 was at risk for aspirating when LVN C administered her medication without elevating her first. Record review of the facility's Medication Administration via Enteral Tube policy dated 03/15/19 indicated, .To administer medication through an enteral tube in an accurate, safe, timely and sanitary manner .Guidelines: .6. Elevate head of bed to Fowler's position (elevating the head and upper body at a 30 to 45-degree angle to reduce the risk of aspiration) . 675289 Page 5 of 7 675289 08/10/2023 Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701

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 observations, interviews, and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 of 2 residents (Resident #29) reviewed for oxygen therapy, in that: Residents Affected - Some Resident #29's oxygen was set to 3 LPM on 3 consecutive days instead of 2 LPM as ordered by the physician. This failure could place residents who receive oxygen therapy at risk for respiratory distress. The findings were: Review of Resident #29's electronic face sheet for August 2023 indicated she was admitted to the facility on [DATE] with diagnoses including cerebral palsy and hypertension. Review of Resident #29's MDS assessment dated [DATE] indicated she scored a 15/15 on her BIMS which indicated she was cognitively intact. A review of Resident #29's s physician orders for August 2023 indicated she was to receive oxygen via nasal canula at 2 LPM (liters per minute) as needed. During observations Resident #29 was receiving oxygen at 3 LPM on the following dates and times: - 08/07/2023 at 03:50 PM, -08/08/2023 at 07:50 AM, -08/08/2023 at 03:30 PM, and - 08/09/2023 at 11:01 AM. During an interview on 08/09/2023 at 11:20 AM with LVN D, she said Resident #29's oxygen rate was ordered for 3 LPM. When asked to clarify, LVN D reviewed the physician's orders and said the oxygen rate was ordered for 2 LPM. LVN D went to Resident # 29's room, inspected the oxygen setting, and said it was set at 3 LPM. The nurse lowered the setting to 2 LPM. LVN D could not identify any risks for a resident receiving oxygen at a rate higher than what is ordered by the physician. LVN B said Resident #29 had been receiving oxygen therapy since she was admitted . During interviews with ADON A and ADON B on 08/09/2023 at 10:05 AM, they both said the charge nurses were responsible for monitoring oxygen administration. During an interview on 08/09/2023 at 10:30 AM, charge nurse, LVN C, said the charge nurses were responsible for monitoring oxygen therapy to ensure flow rates are set as ordered by the physician. A review of the facility's Oxygen Administration Policy dated 03/14/2019 indicated the following: 3. Obtain physician orders for oxygen administration. Orders should include the following: 675289 Page 6 of 7 675289 08/10/2023 Avir at Azalea Heights 3505 Old Jacksonville Rd Tyler, TX 75701

F 0695 c. flow rate delivery . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675289 Page 7 of 7