Health inspection·January 10, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #1, Resident #2) of 10 residents reviewed for call lights. Residents Affected - Few Staff failed to ensure Resident #1 and Resident #2, call buttons were within reach. This failure could place resident at risk for decreased quality of life, self-worth, and dignity. Findings included: Review of Resident #1's face sheet dated 01/10/2024 reflected a [AGE] year-old female admitted to the facility on 10/30/2023 with diagnosis of Other Specified Sepsis (A life-threatening reaction to an infection that damages tissues and organs); Cerebral Infarction, Unspecified (Disrupted blood flow to the brain due to problems with blood vessels that supply it); Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus (Seizures that can't be completely controlled by medicine). Review of Resident #1's Comprehensive Care Plan revised 10/31/20233 reflected Resident #1 is a risk for falls related to CVA (Cerebral Vascular Accident) and cognitive deficits with poor safety awareness. No interventions in place for call light placement within reach. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] reflected the resident was moderately cognitively impaired. Resident #1 required supervised assistance with ADLs. BIMS Score (Brief Interview for Mental Status) was 08/15. Observation on 01/10/2024 at 12:30 pm revealed Resident #1 was in her recliner and her call light was across from her out of reach laying on her bed to the left of her. Resident #1 could not reach the call light if she needed to push the button. On 01/10/2024 at 12:30 pm interview with Resident #1 revealed that she would have to call out for help if she could not reach the call light to push for help. Page 1 of 3 675374 675374 01/10/2024 Avir at Irving 619 N Britain Rd Irving, TX 75061

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #2's face sheet dated 01/10/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Parkinsonism, unspecified (A motor syndrome that manifests as rigidity, tremors and bradykinesia); Chronic obstructive pulmonary disease, unspecified (A condition involving constriction of the airways and difficulty or discomfort in breathing); Difficulty in walking, not elsewhere specified (Gait disorders are an abnormal walking pattern with many possible causes like an injury, sore, and inner ear (balance) issue or nerve damage). Review of Resident #2's Comprehensive Care Plan revised 11/02/2023 reflected Resident #2 has history of falling related to impaired mobility and unsteady gait. She has poor safety awareness and is very impulsive. Care Plan did not address call lights. Review of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] reflected the resident moderately cognitively impaired. Resident #2 required supervised to extensive assistance with ADLs. BIMS Score (Brief Interview for Mental Status) was 09/15. Observation on 01/10/2024 at 12:45 PM revealed Resident #2 was in her bed and her call light was under her bed. Interview with Resident #2 revealed that she was doing fine and did not need anything. Resident was not aware her call cord was in the floor. In an interview on 01/11/2024 at 1:30 PM with ADM revealed he was not aware of the call lights were not within reach of the residents. The ADM stated that not having the call light within reach would cause several issues for the resident may try and get up and fall. In an interview on 01/11/2024 at 1:45 PM with CNA A revealed that she did not know the call lights were not within reach for Resident #1 or Resident #2. Revealed to CNA that there were 2 residents out of 10 residents that did not have call light within reach. CNA A revealed that Resident #1 does get up and walk around. Ask CNA A what could happen if call light was not within reach of resident who needed assistance? CNA A revealed resident could try and get up and fall, may be sick and need assistance, or may just need water. CNA A revealed she would make sure all call lights were within reach. Review of the facility's policy Answering the Call Light. implemented on September 21, 2022, indicated When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 675374 Page 2 of 3 675374 01/10/2024 Avir at Irving 619 N Britain Rd Irving, TX 75061

F 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #3) of 5 residents observed for infection control. Residents Affected - Few Resident #3's urinal with urine was left on top of Resident #3's bedside tray table which the resident used to eat meals on every day. This failure could place residents at risk of cross-contamination and the spread of infection. Findings included: Review of Resident #3's face sheet dated 01/11/2024 reflected a [AGE] year-old male admitted on [DATE] with the diagnoses of Chronic kidney disease, stage 3 unspecified (Longstanding disease of the kidneys leading to renal failure); Acquired absence of left leg below knee (below the knee amputation that involves removing the foot, ankle joint, distal tibia, fibula, and corresponding soft issue structures. Review of Resident #3's Comprehensive Care Plan revised 11/02/2023 reflected Resident #3 was at risk for activity intolerance related to imbalance between supply oxygenation needs. Interventions: included to provide assistance in self-care activities as needed. Resident would need assistance in moving items from bedside table. Review of Resident #3's MDS Assessment (Minimum Data Set) dated 12/24/23 reflected the resident's cognition was intact. BIMS Score (Brief Interview for Mental Status) was 15/15. Observation on 01/11/2024 at 12:00 PM, revealed Resident #3 in his room eating lunch, using his tray table with urinal on overbed table with urine in urinal. In an interview on 01/11/2024 at 12:00 PM with Resident #3 revealed that he did not like the urinal on the overbed table while he was eating his meals. Resident #3 expressed his frustration by commenting that there was nothing that could be done about it. In an interview on 01/11/2024 at 2:00 PM with ADM revealed he was not aware that the CNAs were not removing the urinals from the overbed tables before meals were served to male residents. The ADM will inform the DON to provide proper infection control training to all nursing staff. ADM agreed that the CNA should have removed the urinal and placed in another location before placing the lunch tray on the overbed table. Review of the facility's Infection Control policy Implemented January 2020 indicated this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. 675374 Page 3 of 3