Health inspection·April 12, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure residents were free from physical restraint for 4 Residents Affected - Some (Residents # 7, #13, #27 and #47) of 77 residents reviewed for restraints. The facility failed to ensure Residents #7, #13, #27, and #47 were free from wheelchair seat belt restraints. This failure could place residents at risk for entrapment with serious injury or death. Findings include: Record review of Resident # 7's face sheet dated 4/10/2024 revealed a [AGE] year-old female admitted on [DATE] with diagnosis that include other Cerebral Palsy ( a congenital disorder of movement, muscle tone or posture), Aphasia ( inability to communicate as a result of a damage to the language areas of the brain), Epilepsy ( a disorder in which nerve cell activity in the brains is disturbed, causing seizures.), Spastic Quadriplegic Cerebral Palsy (paralysis of both arms and both legs, with muscle stiffness.) Record Review of Resident # 7's Quarterly MDS assessment dated [DATE] revealed a staff assessment for mental status revealed that resident was severely impaired for making decisions. Resident # 7's functional status revealed she is wheelchair bound with substantial/ maximal assistance with activities of daily living. No documentation of trunk restraint was noted. Record review of Resident # 7's Care Plan revised 12/2023 revealed no problem or interventions regarding seatbelt use while in wheelchair. Record review of Resident # 7's assessments between October 2023 and April 2024 revealed there were no seatbelt/ restraint assessments. Record Review of Resident' # 7's medical record showed no consent present for seatbelt use while in wheelchair. Record Review of Resident # 7 's physician orders dated 4/10/2024 revealed Order for release seat Page 1 of 10 675797 675797 04/12/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0604 belt Q 2 hours x 10 minutes, every shift written on 4/1/2024. Level of Harm - Minimal harm or potential for actual harm Record review of Resident# 13's face sheet dated 4/10/2024 revealed a [AGE] year-old male admitted [DATE] with readmission on [DATE] with diagnosis that include Spastic diplegic cerebral palsy ( a congenital disorder of movement, muscle tone or posture), neuromuscular scoliosis, thoracolumbar region ( the presence of one or more abnormal curvatures of the spine that causes the spine to bend to the left or the right in the shape S or a C) and Quadriplegia ( a paralysis of all four limbs) Residents Affected - Some Record review of Resident # 13's 5-day MDS assessment dated [DATE] revealed Resident had a BIMS score of 15 which indicated he was cognitively intact. Resident assessment revealed use of a motorized wheelchair, and dependent in all activities of daily living. There was no documentation of trunk restraint. Record review of Resident # 13's care plan revised 3/26/2024 revealed no problem or interventions for seatbelt. Record review of Resident #13's assessments from March 2023 to April 2024 revealed there was no seatbelt/restraint assessment. Record review of Resident # 13's physician orders dated 4/10/2024 at 11:37 am revealed an order for Resident uses seatbelt and shoulder strap when up in his wheelchair D/T Cerebral Palsy. Release q 2 hours for 10 minutes every shift written 4/10/2024. Record Review of Resident's 13's medical records revealed no consent for use of seatbelt and shoulder strap present. Record Review of Resident # 27's face sheet dated 4/10/2024 revealed a [AGE] year-old female admitted on [DATE] with a readmission date of 3/31/2024 with diagnosis that include Spastic Hemiplegia (A form of cerebral palsy a congenital disorder of movement, that affects both arms and legs and often the torso and face.) and Aphasia (inability to communicate as a result of a damage to the language areas of the brain) Record review of Resident # 27's Quarterly MDS dated [DATE] revealed a staff assessment for mental status revealed that resident was severely impaired for making decisions. Resident #27's functional status revealed she is wheelchair bound with substantial/ maximal assistance with activities of daily living. No documentation of trunk restraint was noted. Record review of Resident# 27's care Rev plan revised 4/9/2024 revealed uses a seatbelt r/t spastic Hemiplegia affecting right dominant side, unspecified intellectual disabilities seated in her wheelchair per RP choice to prevent sliding/falling out of wheelchair interventions include Ensure the resident is positioned correctly with proper body alignment while restrained. Record Review of Resident # 27's assessments from March 2023 through April 2024 revealed no assessment for seatbelt/restraint. Record review of Resident # 27's physician orders revealed order for seat belt in use related to blindness, release seat belt q 2 hours x 10 minutes written 3/28/2024. Record review of Resident # 27's medical records revealed no consent for the use of seat belt/ 675797 Page 2 of 10 675797 04/12/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0604 restraint present. Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 47's face sheet revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with the diagnosis that include Spastic Quadriplegic Cerebral Palsy (A congenital disorder of movement the affects both arms and legs and often the torso and face), and Cognitive Communication Deficit (Difficulty with thinking and how someone uses language). Residents Affected - Some Record review of Resident # 47's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive impairment. Resident is wheelchair bound and is dependent for all activities of daily living. Assessment does not indicate trunk support device. Record review of Resident # 47's care plan revised 4/9/2024 revealed a problem with uses a seatbelt while seated in his wheelchair r/t spastic quadriplegic cerebral palsy .per RP choice to prevent sliding/falling out of wheelchair. Initiated 4/9/2024 with an intervention of ensure the resident is positioned correctly with proper body alignment while restrained. Record review of Resident # 47's physician orders revealed When up in Wheelchair use safety belt to prevent resident from sliding out of wheelchair r/t blindness. Release q 2-hour x 10 minutes every shift. Written 3/28/2024. Record review of Resident # 47's assessments from March 2023 through April 2024 revealed no seatbelt/restraint assessment. Record Review of Resident #47's medical record revealed no consent for seatbelt/restraint present. Observation of Residents # 7, #27, and #47 on 4/10/2024 at 10:45 am revealed residents reclining in wheelchair with seatbelt in place, Resident # 13 had both a seat belt and a shoulder strap in place. Observation of Resident # 13 on 4/11/2024 at 020:30 pm revealed resident laying in bed. Observation of Resident #7 and # 27 on 4/11/2024 at 02:30 pm revealed residents up in wheelchair in the common are with seat belt in place. Interview with Resident # 13 on 4/10/2024 at 11:00 am, resident communicates with a computer and stated he could not remove his seatbelt or shoulder strap, but like them as they make me feel safe from sliding out of the chair. Interview with Resident # 47's RP per phone on 4/10/2024 at 3:30 pm where she stated that the resident is able to remove the seatbelt if he chooses to and she would prefer his to wear it because it lowers the risk of him falling out of the chair. Interview with DON on 4/10/2024 at 12:04 pm she stated that they do not have a restraint policy as they do not have restraints in the building. She stated the seat belts on the 4 residents that have them are all safety devices. She stated that they do need a physician's order for them, but they did not have an assessment or consent for them as they are used for safety not restraint. She stated that the family members insist that the residents wear the seat belts. Interview per phone with Dr. on 4/10/2024 at 02:21 pm when asked about the orders for seatbelt he 675797 Page 3 of 10 675797 04/12/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0604 Level of Harm - Minimal harm or potential for actual harm was not sure what kind of seatbelt it was. He stated all four residents have a medical diagnosis that requires the use of the seatbelt for safety. He stated he believe it's better for their quality of life to have the seatbelts and be out of the bed. Residents Affected - Some 675797 Page 4 of 10 675797 04/12/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observations, interviews, and record review, the facility failed to post the nurse staffing data, including the total number and the actual hours worked by registered nurses, licensed practical or vocational nurses, and certified nurse aides, daily for 1 of 1 staffing log reviewed. Residents Affected - Many -The facility failed to ensure the Daily Staffing log was posted for 04/06/24, 04/07/24, 04/08/24, and 04/09/24. -The facility failed to ensure the Daily Staffing log contained the total number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift for registered nurses, licensed practical or vocational nurses, and certified nurse aides. These deficient practices could place resident at risk by not providing adequate staffing information for the staff, residents, and general public to know how many staff are providing care on all shifts. Findings included: An observation on 04/09/24 at 8:27 AM revealed Daily Staffing dated 04/05/24 posted near the receptionist's desk. Review of the Daily Staffing form dated 04/05/24, revealed a census of 79, RN: AM an illegible number, PM 1, LVN: AM 3 PM 1, CNA: AM 8 PM 4, MA: AM 2 PM 2. The posting did not reflect the total number and actual hours worked. During an interview on 04/11/24 at 9:28 AM, the receptionist stated the CNA Scheduler was responsible for the staffing hours. She stated he brought her the form and she placed the form in the plastic frame. During an interview on 04/11/24 at 9:41 AM, the CNA Scheduler stated he was responsible for posting the daily staffing information. He stated that either the DON or the HR person was responsible for monitoring the posting. The CNA Scheduler stated the charge nurse was responsible for posting the staffing log on the days he did not work. He stated he did not work the weekend of 04/06/24 through 04/07/24 because something came up. He was not sure why the posting was not updated. He stated if someone called in sick, he marked it on the staff schedule at the nurses' station but did not put that information on the daily staffing form posted near the reception desk. He stated he had received some training on completing the form, but he was not aware that he was supposed to post the actual hours worked. He stated he did not know what affect it would have if the required information was not posted on a daily basis. 675797 Page 5 of 10 675797 04/12/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0732 Level of Harm - Potential for minimal harm Residents Affected - Many During an interview on 04/11/24 at 1:06 PM, the DON stated they did not have a policy on the posted staffing hours, We just follow the guidelines. During an interview on 04/11/24 at 4:05 PM, the DON stated the staffing should have been posted daily. She stated the department heads were responsible for posting the log when the CNA Scheduler was not working. She stated the daily posting was just missed over the weekend. She stated there was no negative outcome from not posting the required information. 675797 Page 6 of 10 675797 04/12/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #48) reviewed for unnecessary medications. Residents Affected - Few The facility failed to ensure Resident #48 had behavior monitoring for her prescribed Quetiapine (an antipsychotic medication used to treat schizophrenia), Sertraline (an antidepressant used to treat depression and anxiety), Trazodone (an antidepressant used to treat major depression), and hydroxyzine (an antianxiety/anticholinergic medication used to treat anxiety). The facility failed to ensure Resident #48 had side effect monitoring for her prescribed Sertraline, Trazodone, and hydroxyzine. These failures could place president at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #48's face sheet printed 04/11/24, reflected a [AGE] year-old female initially admitted to the facility 07/26/21. Her diagnoses included hemiplegia (paralysis of one side of the body), Type 2 diabetes (a condition that affects the way the body processes blood sugar), insomnia (trouble falling and/or staying asleep), psychotic disorder with hallucinations due to known physiological condition (altered thinking, perceptions, and behavior), anxiety disorder (intense and excessive worry and fear), and major depressive disorder - recurrent - severe with psychotic symptoms (severe, persistent feeling of sadness and loss of interest with delusions (false beliefs) and/or hallucinations (an experience of seeing, hearing, feeling, or smelling something that does not exist) with themes of guilt and worthlessness). Review of Resident #48's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section D (Mood) reflected no mood indicators and no feelings of social isolation. Section E (Behavior) reflected no hallucinations or delusions and no other behavioral symptoms. Section N (Medications) reflected the use of antipsychotic and antidepressant medications. Section N did not indicate the use of antianxiety medications. Review of Resident #48's Physician's Order Listing Report reflected the following orders: 04/01/24 Hydroxyzine HCl oral tablet 25 mg - give 1 tablet by mouth two times a day for anxiety. 02/18/24 Quetiapine Fumarate oral tablet 50 mg - give 1 tablet by mouth at bedtime related to anxiety disorder, psychotic disorder. 04/01/24 Sertraline HCl oral tablet 50 mg - give 1 tablet by mouth one time a day related to major depressive disorder. 04/09/24 Trazodone HCl oral tablet 100 mg - give 1 tablet by mouth at bedtime for insomnia. 675797 Page 7 of 10 675797 04/12/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0757 Level of Harm - Minimal harm or potential for actual harm 04/05/24 Side Effects - Antipsychotic: chart all appropriate codes - 0-none, 1-sedation/drowsiness, 2-increased falls/dizziness, 3-hypotension, 4- anxiety/agitation . 22-other every shift. Review of Resident #48's Physician's Order Listing Report did not reflect any orders for monitoring side effects of the antidepressant or antianxiety medications. Residents Affected - Few Review of Resident #48's Physician's Order Listing Report did not reflect any orders for monitoring effectiveness or behaviors related to the use of the antipsychotic, antidepressant, or antianxiety medications. Review of Resident #48's MAR for April 2024 reflected she had received the Hydroxyzine, Quetiapine, Sertraline, and Trazodone as ordered. Further review of the MAR reflected the resident was monitored each shift for side effects of the antipsychotic medication. A check mark and initials indicated the task was completed but the number for the corresponding code (0-none, 1-sedation/drowsiness, 2-increased falls/dizziness, 3-hypotension, 4- anxiety/agitation . 22-other) was not documented. The MAR did not reflect any monitoring of effectiveness or behaviors related to the antipsychotic medication. The MAR did not reflect any monitoring for side effects, effectiveness, or behaviors for the antidepressants or antianxiety medications. Review of Resident #48's pharmacist medical record review, dated 03/25/24, reflected, The resident takes psychoactive medications. Please add behavior/side effect monitoring for: Hydroxyzine, Quetiapine, Sertraline, and Trazodone. An observation on 04/09/24 at 1:16 PM, revealed Resident #48 sitting up in her room in no acute distress. During an interview on 04/11/24 at 1:06 PM, the DON stated Resident #48 should have had monitoring for her psychotropic medications because, She has been on the medication forever. She stated everyone on psychotropic medications was supposed to be monitored for side effects and behaviors related to each psychotropic medication. During an interview on 04/11/24 at 4:05 PM, the DON stated she and the ADON were responsible for following up on pharmacy recommendations. She stated it was her expectation that recommendation follow ups were completed within seven days. The DON stated not following up on recommendations such as monitoring behaviors or side effects could cause adverse outcomes. Review of the facility policy, Psychotropic Medication Use dated July 2022, reflected in part, 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. anti-psychotics; b. anti-depressants; c. anti-anxiety medications; and d. hypnotics. 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes d. adequate monitoring for efficacy and adverse consequences. 7. Categories of medications which affect brain activity such as antihistamines, anticholinergic medications and central nervous system medications that are prescribed as a substitute for or an adjunct to a psychotropic medication are monitored and managed as psychotropic medications. 13. Residents receiving psychotropic medications are monitored for adverse consequences, including: a. anticholinergic effects . b. cardiovascular effects . c. metabolic effects . d. neurologic effects . e. psychosocial effects . 675797 Page 8 of 10 675797 04/12/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0759 Ensure medication error rates are not 5 percent or greater. 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 that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.72 percent based on 2 errors out of 32 opportunities. Which involved 2 of 4 residents (Resident # 54 and Resident # 75) reviewed for medication administration. Residents Affected - Some 1. The facility failed to ensure MA A administered medication as ordered to Resident # 54 by not having Vitamin D 100 mg to administer as ordered. 2. The facility failed to ensure MA A administered medication as ordered to Resident # 75 by not having Terazosin 1 mg available to administer as ordered. Theses failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medications and or adverse outcomes. Findings included: Resident # 54 Review of face sheet for Resident #54 printed 4/11/2024 revealed a male admitted on [DATE] with diagnosis that include vitamin deficiencies. Review of admission MDS assessment for Resident # 54 dated 2/14/2024 revealed a BIMS score of 09 which indicated a moderate cognitive impairment. Record review of Resident # 54's physician orders revealed Vitamin D 100 mg po daily ordered on 2/1/2024. Observation of MA A on 4/11/2024 at 08:46 am revealed she prepared for administration of medication for Resident # 54. Vitamin D 100 mg capsule was not available. Other medications were administered. Resident # 75 Review of face sheet for Resident # 75 printed 4/11/2024 revealed a female admitted on [DATE] with diagnosis that include Hypertension (elevated blood pressure on more than 3 times in a row) Review of admission MDS assessment for Resident # 75 dated 1/24/2024 revealed a BIMS score of 15 that indicates no cognitive impairment. Record Review of Resident # 75's physician orders revealed Terazosin 1 mg tablet po daily ordered on 1/19/2024. Observation of MA A on 4/11/2024 at 07:55 am revealed she prepared medication for Resident # 75. 675797 Page 9 of 10 675797 04/12/2024 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0759 Terazosin 1 mg was not available. Other medications were administered. Level of Harm - Minimal harm or potential for actual harm Interview with MA A on 4/11/2024 at 8:50 am she stated that usually the medication aides reorder the medications on the computer when there is only 5 days of medication left and then when it comes in, it is put in the overflow drawer. When she looked Resident # 75's medication was not there. Resident # 54's medication was over the counter, and it was usually in the medication room. She said she was running behind and did not go look. She stated she usually reorders the medications, let the DON know if they are out of OTC and stocks the overflow drawer with medications as they come in, but she was off for 2 days and she did not have time before medication pass to resupply the cart. She was unable to tell me when the medications were reordered or if they were. Normally if it was not in the medication room, she would notify the DON and she would get it. She stated residents not getting their medication can cause potential for medical conditioning worsening. Residents Affected - Some Interview with DON on 4/11/2024 at 12:30 pm she stated her expectation was the medication would be passed as ordered and if not available, notification of the charge nurse and herself is expected. She stated the medication aides are responsible for reordering prescription medications and notifying her for over-the-counter medication that need to be ordered. She stated that resident not getting their medication can put the resident at risk for uncontrolled medical condition. Record review of medication administration policy updated July 2022 reflected medication should be delivered one hour before and one hour after scheduled times per physician order. 675797 Page 10 of 10