Health inspection·June 21, 2023

F 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews the facility failed to ensure total privacy for residents in 14 (Rooms 1, 2, 3, 5, 6, 8, 9, 10, 11, 29, 30, 34, 35, and 36) of 25 resident rooms reviewed for privacy. Residents Affected - Some The facility failed to provide privacy curtains to ensure resident privacy in Rooms 1, 2, 3, 5, 6, 8, 9, 10, 11, 29, 30, 34, 35, and 36. This failure placed residents at risk of decreased self-worth by being exposed during resident care. Findings included: Observation on 06/21/23 starting at 9:10 AM of Rooms 1, 2, 3, 5, 6, 8, 9, 10, 11, 29, 30, 34, 35, and 36 revealed privacy curtains were hung from the ceiling to provide residents of the A bed with total privacy, there was no curtain hung at the end of the B bed to provide that resident with total privacy. Observations of the rooms revealed there was no track on the ceiling to enable a curtain to be hung at the end of the B bed. Interview on 06/21/23 at 1:00 PM, Resident #1 stated he used a bedside commode, and he did not like that he was visible from the hallway, and it was embarrassing to him. Interview on 06/21/23 at 1:10 PM, Resident #2 stated there had never been a curtain at the end of her bed and she did worry sometimes that someone could walk in and see her exposed. Interview on 06/21/23 at 1:20 PM, LVN A stated double occupied rooms could not provide complete privacy for the resident in the B bed because the room lacked a curtain at the end of the B bed. She stated there had never been a curtain in place for as long as she knew. She stated staff would close the door and pull the middle curtain to provide some privacy. Interview on 06/21/23 at 1:24 PM, the Housekeeping Supervisor stated he was responsible for changing out privacy curtains when they were dirty. He stated he had never seen a curtain at the end of the B bed of the rooms. Interview on 06/21/23 at 1:30 PM, the Administrator stated he was aware that each resident required total privacy when care was being provided but he did not know that there needed to be a curtain at the end of the B bed. Interview on 06/21/23 at 1:40 PM, the DON stated total privacy to her meant that the resident could Page 1 of 2 675374 675374 06/21/2023 Avir at Irving 619 N Britain Rd Irving, TX 75061

F 0914 not be viewed while they were exposed during cares, especially during peri care. Level of Harm - Minimal harm or potential for actual harm Interview on 06/21/23 at 1:45 PM, LVN B stated residents should have total privacy when care was being provided. LVN B stated privacy included closing the door and closing off the bed with a curtain. Residents Affected - Some 675374 Page 2 of 2