Health inspection·November 26, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 7 of 12 residents reviewed for environment. 1. The facility failed to ensure the secure unit was a comfortable temperature on 11/26/24, and Residents #1, 2, 3, 4, 5, and 6 felt uncomfortably cold. 2. The facility failed to ensure Resident #7's room was free of holes, paint scuffs, and had a well-fitting screen for the window. These failures placed residents at risk of discomfort and diminished quality of life. Findings included: Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included hypertension, anemia, underweight, osteoarthritis of hip, pain in right lower leg, and dementia. Review of the quarterly MDS assessment for Resident #1 dated 08/23/24 reflected a BIMS score of 03, indicating severe cognitive impairment. It also reflected she required supervision/touching assistance in the activity of dressing. Review of the undated face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included hypertension, muscle wasting and atrophy, lack of coordination, dementia, and major depressive disorder. Review of the admission MDS assessment for Resident #2 dated 11/17/24 reflected a BIMS score of 03, indicating severe cognitive impairment. It also reflected she required supervision and touching assistance in the activity of dressing. Review of the undated face sheet for Resident #3 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, vascular dementia, urinary incontinence, facial pain, difficulty in walking, weakness, adjustment disorder with depressed mood, unspecified head injury, muscle wasting and atrophy, chronic obstructive pulmonary disease, and depressive episodes. Review of the quarterly MDS assessment for Resident #3 dated 11/07/24 reflected a BIMS score of 06, Page 1 of 4 675712 675712 11/26/2024 Avir at Itasca 409 S Files St Itasca, TX 76055

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicating severe cognitive impairment. It also reflected he required supervision or touching assistance in the activity of dressing. Review of the undated face sheet for Resident #4 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included mild malnutrition, vascular dementia, peripheral vascular disease, muscle wasting and atrophy, hypothyroidism, and vitamin D deficiency. Review of the quarterly MDS assessment for Resident #4 dated 11/06/24 reflected a BIMS score of 01, indicating severe cognitive impairment. It also reflected he was independent in the activity of dressing. Review of the undated face sheet for Resident #5 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included muscle wasting and atrophy, abnormal weight loss, atherosclerotic heart disease, malnutrition, anxiety disorder, and Alzheimer's disease. Review of the quarterly MDS assessment for Resident #5 dated 10/22/24 reflected a BIMS score of 01, indicating severe cognitive impairment. It also reflected he required substantial/maximal in the activity of dressing. Review of the undated face sheet for Resident #6 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, muscle wasting and atrophy, difficulty in walking, vitamin D deficiency, and unspecified pain. Review of the annual MDS assessment for Resident #6 dated 11/05/24 reflected a BIMS score of 01, indicating severe cognitive impairment. It also reflected he required substantial/maximal in the activity of dressing. Review on 11/29/24 of a web page found at the address www.timeanddate.com/weather/@4700235/historic reflected the outside temperature in the facility town was 46 degrees Fahrenheit at 09:30 AM on 11/26/24. Observation and interview on 11/26/24 at 09:39 AM revealed the thermostat in the secure unit of the facility was reading 67 degrees Fahrenheit. Residents #1 and #2 were sitting in a television room on chairs, both in their pajamas with shoes and socks on. The room was dark, due to a large entertainment center blocking the window. It felt cold in the room. Resident #1 stated it was very cold in there, and she would love some hot coffee. Resident #2 did not use words, but when asked if she was cold, nodded her head vigorously. The ADM adjusted the desired heat from 76 to 79 degrees Fahrenheit. Within five minutes, the thermostat read 70 degrees Fahrenheit. Observation and interview on 11/26/24 at 11:26 AM revealed the thermostat in the hall for the secure unit read 68 degrees Fahrenheit. Residents #1 and #2 were walking around the common areas talking about how cold it was. Resident #1 was wearing a robe over her pajamas, and Resident #2 had on a sweater. Resident #1 said to Resident #2 Even the chairs feel too cold to sit in. Resident #1 held out her hands, and they were very cold to touch. Resident #6 was walking up and down the halls in a t-shirt, pajama pants, and non-skid socks, and his hands were also cold to touch. He did not respond verbally when asked if he was cold. A call light came on in Resident #598's room, and he stated he needed another blanket. When asked if he was cold, he stated, Hell yeah! Resident #3 was lying in his bed and stated he was trying to take a nap but was cold. Resident #4 was lying in his bed with a coat on and several blankets over him. He did not respond verbally to any questions. The MAINT used a 675712 Page 2 of 4 675712 11/26/2024 Avir at Itasca 409 S Files St Itasca, TX 76055

F 0584 Level of Harm - Minimal harm or potential for actual harm laser thermometer to take the temperatures in the resident rooms. Resident #3 and #4's room was 66 degrees Fahrenheit by the door and 63 degrees Fahrenheit by the window. Resident #5's room was 66 degrees by the door and 64 degrees by the window. The MAINT stated he was going to take apart the heater and figure out what was going on. The ADM was passing out warm hats, and a medication aide brought warm coffee in to serve the residents. Residents Affected - Some Observation and interview on 11/26/24 at 01:13 PM revealed the temperature in the secure unit was no longer cold. The thermostat read 74 degrees. Resident #1 stated she was comfortable now, and she was warm enough. 2. Review of the undated face sheet for Resident #7 reflected a [AGE] year-old female admitted to the facility on [DATE]. Review of the quarterly MDS assessment for Resident #7 dated 08/13/24 reflected a BIMS score of 12, indicating intact cognition. Observation and interview on 11/26/24 at 10:41 AM revealed two holes in the drywall in Resident #7's room, scratches in the wall paint behind her bed, and many scratches in the paint on her dresser. Observation also revealed the window screen was bent and no longer fit in the window. Resident #7 stated the holes in the drywall scared her, because she was worried rats and bugs would come into her room. She stated she did not know if any bugs or rats had come inside. She stated the scratches in the paint were ugly, but the facility had said they were going to fix it. She stated she would really like to open her window sometimes and get fresh air. She stated she could not open her window, because the screen was broken. During an interview on 11/26/24 at 03:00 PM, the MAINT stated the company had just been in the building to fix the heater a couple of weeks prior. He stated the problem was the sensor that went from the thermostat to trigger the fan to start blowing out warm air became disconnected. He stated that was what had happened that morning, and he was able to go into the machine and adjust it, and it was now working. He stated the HVAC company would still be coming out, because they thought they had fixed it permanently but obviously had not. The MAINT stated the holes in drywall and paint scratches in the rooms were on the back burner, as there were so many other things that needed fixing in the building. He stated it was an old building, and he had worked there a little over a year, but problems came up every day. He stated he wanted to take all the doors and handrails off, sand them, and repaint them, but the facility owner had told him to wait until they do a complete renovation. He stated he did not know exactly when that would happen, but it was supposed to be coming up soon. He stated Resident #7 had not complained to him about the holes and scratched paint in her room or the window screen. He stated he did not know what the potential negative impact on a resident might be if they had no working window screen or damaged areas of their rooms. During an interview on 11/26/24 at 03:43 PM, the ADM stated the MAINT was the responsible person for ensuring the temperatures in the facility were compliant. She stated she looked at the thermostats each day. She stated she had already turned up the thermostat early that morning, but then when she walked back through, it was still cold, so she had turned it up again. The ADM stated she always did a morning round of the whole facility when she arrived for the day, and she made rounds throughout the day but could not say at what interval she did so. She stated she perceived it was cold in the secure unit that morning, turned the thermostat up to 76 degrees F, and then when she walked through 675712 Page 3 of 4 675712 11/26/2024 Avir at Itasca 409 S Files St Itasca, TX 76055

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with the surveyor, and it was still cold, so she turned the thermostat up to 79 degrees F. She stated she had put a call out to their HVAC company to come look at it, but the HVAC company had only just been there to ensure everything was working well, and they fixed the exact thing that was not working well that morning. She stated she was not sure of the exact date but would produce the invoice. The ADM stated they generally made all repairs as they came up. She stated the Owner recently visited the building, and they made a list of things that needed to be done. She stated a potential negative outcome of the secure unit being colder than required was it could make the residents sick. She stated a potential negative impact of the holes and scratched paint in resident rooms was it might mess with their minds a little bit. Review of an invoice provided by the ADM on 11/26/24 reflected the service performed by the HVAC company on 11/19/24 was the following: Checked unit operation: flame sensor was unplugged, removed and cleaned the flame sensor, and checked heating operations. No other mechanical issues at this time. Review of the maintenance log from September 2024-November 2024 reflected no mention of any issues with the heater in the facility and no issues related to damage to Resident #7's room. Review of facility policy dated February 2021 and titled, Homelike Environment reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment, and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, home setting. These characteristics include: A. clean, sanitary, and orderly environment; H. Comfortable and safe temperatures (71°F to 81°F). 675712 Page 4 of 4