Health inspection·June 12, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 failed to develop a comprehensive care plan within seven days after the comprehensive MDS assessment was completed for one (Resident #1) of five residents reviewed for comprehensive care plans. The facility failed to complete a comprehensive person-centered care plan to address Resident #1's needs within seven days after the comprehensive MDS assessment was completed. This failure could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life. Findings included: Review of Resident #1's Face Sheet dated 06/12/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Intertrochanteric Fracture of Right Femur (type of hip fracture in which the femur is fractured), Malignant Neoplasm of Unspecified Ovary (primary or metastatic malignant tumor involving the ovary), and Chronic Kidney Disease (long-term condition where the kidneys do not work as well as they should). Review of Resident #1's MDS admission Assessment, dated 05/22/2024 revealed Resident #1 had a BIMS Score of 6, which indicates severe cognitive impairment. The MDS Assessment revealed that Resident #1 was a new admit from 04. Short-Term General Hospital. The MDS Assessment in Section H - Bladder and Bowel indicated C. Ostomy (including urostomy, ileostomy, and colostomy) related to Resident #1, which required additional care. Review of Resident #1's undated electronic health records revealed an initiated Care Plan date of 5/23/2024. Review of the Comprehensive Care Plan file revealed that it contained no information and indicated, No data found. Interview on 06/12/2024 at 4:00 PM, the DON stated that the facility did not have an MDS Coordinator and was utilizing an MDS Consultant to assist. The DON stated that she wanted care plans for residents to be completed immediately or within a day of their completed MDS admission Assessment. The DON stated that she is responsible for ensuring that care plans for residents are completed. The DON reviewed the electronic records for Resident #1 and stated that they had failed to complete her Comprehensive Care Plan in the required time. The DON stated that Comprehensive Care Plans are vital to ensure proper care for their residents' needs and to ensure they are met. Page 1 of 4 675885 675885 06/12/2024 Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/12/2024 at 4:17 PM, the MDS Consultant stated that she is currently assisting the facility with completion of MDS Assessments. The MDS Consultant stated that once the MDS assessment is complete it is the facility's responsibly to ensure that the Comprehensive Care Plan is completed. The MDS Consultant stated that the Comprehensive Care Plan needs to be completed within 7 days of the resident MDS admission Assessment. The MDS Consultant reviewed the electronic file of Resident #1 and stated that she did not have a completed Comprehensive Care Plan and should have. The MDS Consultant stated that the Comprehensive Care Plan must be completed to ensure that the facility as well as the resident and their families are on the same page. The MDS Consultant stated that failure to complete the Comprehensive Care Plan in a timely manner could result in uninformed / improper care of the resident. Interview on 06/12/2024 at 4:23 PM, the Interim Administrator stated that they are currently utilizing consultants to assist with MDS Assessments. The Interim Administrator stated that Care Plans are a team effort and should be completed within 24 hours of the completed MDS Assessment. The Interim Administrator stated that Comprehensive Care Plans are completed to ensure the needs of the resident are met. Interview on 06/12/2024 at 4:38 PM, Resident #1 stated that she and her responsible party have not had a meeting with the facility to discuss and approve her Comprehensive Care Plan. Review of the facility Comprehensive Care Plan Policy dated 2023 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally - competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessments Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidence in the clinical record. 675885 Page 2 of 4 675885 06/12/2024 Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure that medications were stored in a locked compartment for 2 (300 Hallway) of 4 medication carts reviewed for medication storage in the facility. The facility failed to ensure that both medication carts for the 300-hallway remained locked at all times when not in use and direct view of staff. This failure could result in harm due to unauthorized access to medications by residents and visitors. Findings included: Observation on 06/12/2024 at 9:02 AM, revealed a multi-drawer, rollable medication cart that was left unlocked in front of the nurse's station in the 300 hallway. LVN A was seated in a chair behind the nurses' station working at a computer and RN C was present viewing paperwork. Two residents were seated in a common area watching television approximately twenty feet from the cart. Observation on 06/12/2024 at 9:39 AM, revealed that the cart observed at 9:02 AM was still in the same location unlocked and now a second multi-drawer, rollable medication cart was next to it in front of the nurses' station that was also unlocked. Two staff members were present on the opposite side of the counter discussing paperwork. Observation and interview on 06/12/2024 at 10:09 AM, revealed that both medication carts observed at 9:39 AM in front of the nurses' station in the 300 hallway were still unlocked and no staff or residents were present around them. LVN A approached the original unlocked cart and looked over at the second unlocked medication cart. LVN A engaged the lock on the second cart to secure it and then obtained medication from the first cart before locking it. LVN A stated that the two carts should not have been unlocked prior to her securing them. LVN A stated that medication carts are to be always locked if not in direct view and actively being used by staff. LVN A stated that both observed carts were considered the 300 hallway medication carts. LVN A stated that they are to keep the medication carts locked at all times to ensure that residents do not gain access to medications, which could result in illness if ingested. LVN A stated that she and RN C utilized the two 300 hallways carts this morning. Interview on 06/12/2024 at 10:17 AM, the DON was notified of the unlocked medications carts for the 300 hallway. The DON stated that if staff are not directly in front of the medication cart they are to be locked at all times. The DON stated that the facility has residents with Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) as well as visitors who could gain unauthorized access to medications if the carts are not locked. The DON stated that if someone ingested medications that were not theirs it could result in medical side effects. Interview on 06/12/2024 at 10:45 AM, RN C stated that she did assist LVN A with medication pass this morning between 6:45 AM and 7:00 AM. RN C stated that she knew she locked the cart she used before turning it over to LVN A. RN C stated that medication carts were to be locked at all times when not 675885 Page 3 of 4 675885 06/12/2024 Avir at Caldwell 1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in use or their direct view. RN C stated that the medication carts are to be locked even if they are in the area of them. RN C stated that medication carts must be locked to ensure that no residents gain access to medications, which could result in an adverse reaction. Interview on 06/12/2024 at 2:40 PM, MA D stated that they are trained that medication carts are to be locked at all times if they are not directly in front of them working. MA D stated that as soon as they obtain the medications they need for a resident they are to close the computer screen and lock the medication cart. MA D stated that failure to do so could result in a resident getting into the cart and taking some medications, which could cause an adverse effect. Interview on 06/12/2024 at 2:50 PM, LVN B stated that they are trained that medication carts are to be locked at all times when not directly in front of them. LVN B stated that medication carts have to remain locked to ensure that residents do not gain access to medications that are not theirs, which could lead to an allergic reaction. Follow-up interview on 06/12/2024 at 4:00 PM, the DON stated that the facility has four medications carts, which contain medications for their residents. The DON stated that the 300 hallway does have two of the four medication carts, which she audited after notification and found no evidence of drug diversion. Interview on 06/12/2024 at 4:23 PM, the Interim Administrator stated that medication carts are to be locked immediately after use and if not directly in front of staff. The Interim Administrator stated that failure to lock medication carts could lead to a resident gaining access to medications resulting in a possible adverse reaction. Review of the facility's Drug Diversion Policy dated 2024 revealed, Policy: This facility recognizes the risks for contamination and infection associated with diversion of injectable medications and monitors staff with access to injectable controlled substances to prevent transmission of infections. Definitions: Drug diversion refers to the theft or other deviation that removes a prescription drug from its intended path from the manufacturer to the patient. Policy Explanation and Compliance Guidelines: 1. All drugs and biologicals, including controlled substances, are stored in locked compartments and only authorized personnel have access to the keys to locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). 2. Staff with access to medications are trained on their responsibilities for safe storage and administration of medications, including documentation and disposition of medications. 675885 Page 4 of 4