Health inspection·March 10, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #205) of 5 residents reviewed for care plans. The facility failed to provide Resident #205 with a diabetic care plan. This failure could place residents at risk for not receiving care based on their care plans. Findings included: 1. Review of Resident #205's MDS assessment, dated 02/15/23, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included diabetes . Review of Resident #205's Order Summary Report for March 2023 reflected: 1. Regular Diet 2. Lantus Subcutaneous Solution100 UNIT/ML (Insulin Glargine) Inject 10 units at bedtime. 3. Novolin R Injection Solution100 UNIT/ML (Insulin Regular) Inject as per sliding scale 4. Tradjenta tablet 5 mg daily. 5. Page 1 of 9 675902 675902 03/10/2023 Avir at Pilot Point 208 N Prairie St Pilot Point, TX 76258

F 0656 Metformin 500 mg two times a day. Level of Harm - Minimal harm or potential for actual harm 6. Registered Dietitian to evaluate and treat. Residents Affected - Few Review of Nutrition/Dietary Note for Resident #205, dated 03/07/23 at 11:04 AM, reflected: Dietician Nutrition Note: Met with resident to discuss healthy eating for diabetes. Diet education provided; resident reported she does not want to eat any carbs. Discussed importance of carbohydrates and how to incorporate carbohydrates in diet for glucose control. Will continue to monitor education needs. Review of Resident #205's Current Comprehensive Care Plans revealed no care plan for diabetes or diet until Surveyor intervention. An observation and interview on 03/08/23 at 12:26 PM with Resident #25 revealed she was in her room, awake, tired, and oriented. She said she had concerns about nutrition because she was diabetic, and the facility did not serve her a diabetic diet. The resident had her lunch tray in front of her. It contained apple turnovers, a yeast roll, and cottage cheese with canned peaches. She said the only thing she could eat was the cottage cheese. An interview with Resident #205 on 03/10/23 at 10:56 AM revealed she was upset. She said her blood sugar was 237 and she was required to take insulin. She said she did not eat what the kitchen served unless it did not contain carbohydrates. She said she only ate scrambled eggs and bacon for breakfast. She said the Dietician spoke to her and said she had to eat. She said she told them she needed a diabetic diet. She said she always received cookies and cake with icing that she should not eat. An interview with Resident #205 on 03/10/23 at 12:41 PM revealed she was happy with her lunch of nachos without the chips. She said staff would offer her alternative meals when she did not want to eat what was served, but they were always full of carbohydrates. She said the alternatives offered were, cottage cheese with canned fruit, loaded with sugar, or a grilled cheese with tomato soup, also full of sugar. An interview on 03/10/23 at 12:48 PM with MDS Nurse revealed Resident #205 did not have a care plan for diabetes. She said the DON was supposed to do the initial care plan. The MDS Nurse said she was responsible for care plans. She said she did not think the resident's health would be affected due to a lack of care plan . An interview on 03/10/23 at 1:36 PM with the Dietician revealed Resident #205 was on a regular diet and the facility did not offer a diabetic diet. The Dietician said the meals served were well-balanced and usually contained 3-4 carbohydrate servings. She said the resident had requested a no carbohydrate diet. She said she did not change the resident's diet order because the facility only offered a regular, liberalized diet. An interview on 03/10/23 at 1:16 PM with the DON for Resident #205 revealed she put in a care plan for diabetes after Surveyor intervention. She said the MDS Nurse was responsible for care plans and she did not know why one was not entered. She said she did not think there was a risk to the 675902 Page 2 of 9 675902 03/10/2023 Avir at Pilot Point 208 N Prairie St Pilot Point, TX 76258

F 0656 resident if she did not have the care plan . Level of Harm - Minimal harm or potential for actual harm Review of the Facility Policy, Care Plans dated 2022, reflected: Residents Affected - Few It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . 675902 Page 3 of 9 675902 03/10/2023 Avir at Pilot Point 208 N Prairie St Pilot Point, TX 76258

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences for one (Resident #205) of 5 residents reviewed for food preferences. The facility failed to provide Resident #205 with her preferred diet to address her diabetes. This failure could place residents at risk for malnutrition and poor quality of life. Findings included: 1. Review of Resident #205's MDS assessment, dated 02/15/23, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included diabetes. Review of Resident #205's Order Summary Report for March 2023 reflected: 1. Regular Diet 2. Lantus Subcutaneous Solution100 UNIT/Milliliter (Insulin Glargine) Inject 10 units at bedtime. 3. Novolin R Injection Solution100 UNIT/Milliliter (Insulin Regular) Inject as per sliding scale 4. Tradjenta tablet 5 mg daily. 5. Metformin 500 mg two times a day. 6. Registered Dietitian to evaluate and treat. Review of Resident #205's lab work on admit, dated 11/11/22, reflected: HGB A1C (lab that shows average blood sugar level over the last 2-3 months) 8.0 High (normal range 4.5-5.7) 675902 Page 4 of 9 675902 03/10/2023 Avir at Pilot Point 208 N Prairie St Pilot Point, TX 76258

F 0806 Review of Resident #205's lab work after being in the facility, dated 02/07/23 reflected: Level of Harm - Minimal harm or potential for actual harm HGB A1C 12.2 Very High (normal range 4.5-5.7) Review of Resident #205's Nurse Note, dated 03/02/23 at 2:12 PM, reflected: Residents Affected - Few LVN B Resident with increased anxiety. Resident verbally c/o anxiety and body language appears anxious. Resident states I can't live like this, the blood sugars and insulin. Attempt to give reassurance resident inconsolable. Resident husband at bedside. Resident refused to eat lunch d/t sugars. New order for Klonopin 0.5mg BID routine. Xanax 0.25mg x 1 now. Resident then states good maybe it will let me sleep through the rest of my life. Review of Resident #205's Nurse Note, dated 03/03/23 at 2:09 PM, reflected: LVN C . Remains shakey. States she is not eating for only a few days to bring blood sugar down. Explained need to eat but resident refuses. Review of Physician Progress Note for Resident #205 by FNP, dated 03/03/23 reflected: She is also concerned about her blood sugar--explained about cortisol release and stress. She is not optimized on oral medications yet, as she had medications discontinued in hospital. She is now fixated on her blood sugars and is refusing blood sugar sticks and insulin. Instead, she states she will not eat. Informed resident that this would weaken her and she would lose all progress she had made in physical therapy and would be too weak to go home but she is still refusing to eat and states she has an extreme needle phobia. She is taking Lantus and Tradjenta. 4. Noncompliance Resident noncompliant with care and refuses to eat or allow blood sugar sticks. Encourage resident to comply so that we can manage glucose levels. Review of Nutrition/Dietary Note for Resident #205, dated 03/07/23 at 11:04 AM, reflected: Dietician Nutrition Note: Met with resident to discuss healthy eating for diabetes. Diet education provided; resident reported she does not want to eat any carbs. Discussed importance of carbohydrates and how to incorporate carbohydrates in diet for glucose control. Will continue to monitor education needs. Review of Resident #205's Current Comprehensive Care Plans revealed no care plan for diabetes or diet until Surveyor intervention. An observation and interview on 03/08/23 at 12:26 PM with Resident #25 revealed she was in her room, awake, tired, and oriented. She said she had concerns about nutrition because she was diabetic, 675902 Page 5 of 9 675902 03/10/2023 Avir at Pilot Point 208 N Prairie St Pilot Point, TX 76258

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and the facility did not serve her a diabetic diet. The resident had her lunch tray in front of her. It contained apple turnovers, a yeast roll, and cottage cheese with canned peaches. She said the only thing she could eat was the cottage cheese. An interview with Resident #205 on 03/10/23 at 10:56 AM revealed she was upset. She said her blood sugar was 237 and she was required to take insulin. She said she did not eat what the kitchen served unless it did not contain carbohydrates. She said she only ate scrambled eggs and bacon for breakfast. She said the Dietician spoke to her and said she had to eat. She said she told them she needed a diabetic diet. She said she always received cookies and cake with icing that she should not eat. An interview with Resident #205 on 03/10/23 at 12:41 PM revealed she was happy with her lunch of nachos without the chips. She said staff would offer her alternative meals when she did not want to eat what was served, but they were always full of carbohydrates. She said the alternatives offered were, cottage cheese with canned fruit, loaded with sugar, or a grilled cheese with tomato soup, also full of sugar. An interview with the LVN B on 03/10/23 at 2:11 PM regarding the nurse note she wrote for Resident #205 on 03/02/23 at 2:12 PM revealed the resident was very anxious and did not want to eat lunch. LVN B said she could not remember what was served to the resident, but the resident told her she was not going to eat for a couple of days to bring her blood sugar down. She said the family would bring in food, but she did not know what was in the containers. An interview on 03/10/23 at 2:16 PM with LVN C regarding her nurse note for Resident #205 on 03/03/23 at 2:09 PM revealed the resident was afraid to eat. LVN C said she explained to the resident that she needed to eat. LVN C said the resident would be offered what was served and she did not eat it. LVN C said the resident did not request anything different to eat. And interview on 03/10/23 at 12:51 PM with the FNP revealed on admit the resident's HGBA1C was lower than after being in the facility because the resident took steroids. (Resident was not currently on steroids.) She said when the resident admitted her diabetes was controlled with diet and metformin. She said the increased HGBA1C occurred because the resident had taken steroids and was non-compliant with her diet. She said the resident would eat food brought in by the resident's spouse. The FNP said she was having to use insulin to control the resident's blood sugars and that the resident had stopped eating. She said the resident was needle-phobic. She said she did not know why the resident was not on a diabetic diet even though the resident requested one, but that the Dietician spoke with the resident. An interview on 03/10/23 at 1:36 PM with the Dietician revealed Resident #205 was on a regular diet and the facility did not offer a diabetic diet. The Dietician said the meals served were well-balanced and usually contained 3-4 carbohydrate servings. She said the resident had requested a no carbohydrate diet. She said she did not change the resident's diet order because the facility only offered a regular, liberalized diet. An interview with the DON on 03/10/23 at 11:05 AM for Resident #205 revealed to address her diabetes the resident was followed by the FNP, had sliding scale insulin, and diet management. The DON said the resident's diet was a regular diet and that her family would bring food and she had alternate meals available to her. She said the facility did not offer a diabetic diet or a low concentrated sweets diet. She said the only diet served in the facility was a liberated, regular diet. 675902 Page 6 of 9 675902 03/10/2023 Avir at Pilot Point 208 N Prairie St Pilot Point, TX 76258

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 03/10/23 at 11:19 AM with the Administrator for Resident #205 revealed the FNP was seeing the resident and mentioned the resident was not eating. The Administrator said the Dietician spoke to the resident and that the facility offered a liberalized diet, which were good, balanced diets. The Administrator said the facility did not have a diabetic or a low concentrated sweets diet, but the resident could get a sugar substitute, sweet and low. The Administrator said every resident had the same liberated, regular diet. Review of the Facility Policy, Liberalized Diets dated 2022, reflected: It is the policy of this facility to incorporate individualized, liberated diets for residents in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' specific goals, needs, and preferences . 2. Diet consideration is determined with the resident and in accordance with their informed choices, goals and preferences, rather than exclusively by diagnosis. 675902 Page 7 of 9 675902 03/10/2023 Avir at Pilot Point 208 N Prairie St Pilot Point, TX 76258

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 maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Residents #8, #11) of five residents reviewed for infection control. Residents Affected - Few LVN A failed to disinfect the blood pressure cuff in between blood pressure checks for Resident #8 and Resident #11. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1. Review of Resident #8's Face Sheet, not dated, reflected she was a [AGE] year-old-female with a diagnosis of hypotension (low blood pressure). Review of Resident #8's Physician Orders dated March 2023, reflected she took Midodrine (treats low blood pressure) 10 milligrams three times a day. 2. Review of Resident #11's Face Sheet, not dated, reflected he was a [AGE] year-old male with a diagnosis of hypertension (high blood pressure). Review of Resident #11's Physician Orders dated March 2023, reflected he took Coreg (blood pressure medication) 3.125 milligrams two times a day. An observation of medication administration with LVN A on 03/09/23 at 8:40 AM revealed he was wearing a wrist blood pressure cuff on his left wrist. LVN A removed the blood pressure cuff from his wrist, he did not sanitize the blood pressure cuff, and placed it on Resident #8's right wrist. He took the resident's blood pressure, removed the blood pressure cuff from Resident #8 and placed it back on his left wrist. LVN A sanitized his hands but did not sanitize the blood pressure cuff. LVN A then went to Resident #11's room, removed the blood pressure cuff from his wrist, he did not sanitize the blood pressure cuff, and placed it on Resident #11's right wrist. He took the resident's blood pressure, removed the blood pressure cuff from Resident #11 and placed it back on his left wrist. An interview on 03/09/23 at 9:00 AM with LVN A revealed staff did not need to sanitize the blood pressure cuff between residents. He said he had not received training to clean the blood pressure cuff. He did say failure to sanitize the blood pressure cuff between uses could spread germs. An interview on 03/09/23 at 11:57 AM with LVN B revealed it was not necessary to sanitize the blood pressure between resident uses. An interview on 03/09/23 at 11:05 AM with the DON revealed it was not necessary for staff to 675902 Page 8 of 9 675902 03/10/2023 Avir at Pilot Point 208 N Prairie St Pilot Point, TX 76258

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sanitize the blood pressure cuff between uses. She said if a resident was on contact precautions, then they would use a disposable blood pressure cuff. She said she had not read anything that said failure to sanitize a blood pressure cuff could cause infection. An interview on 03/09/23 2:20 PM with the Administrator revealed she provided the facility policy which reflected that blood pressure cuffs were supposed to be sanitized between uses. Review of website: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html on 03/09/23 reflected: Disinfection of Healthcare Equipment Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) Surface Disinfection Medical equipment surfaces (e.g., blood pressure cuffs, stethoscopes, hemodialysis machines, and X-ray machines) can become contaminated with infectious agents and contribute to the spread of health-care-associated infections . For this reason, noncritical medical equipment surfaces should be disinfected with an EPA-registered low- or intermediate-level disinfectant. Review of website: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/recommendations.html#rec5g on 03/09/23 reflected: Recommendations for Disinfection and Sterilization in Healthcare Facilities Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions . Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient . Record review of the facility policy and procedure , Cleaning and Disinfection of Resident-Care Equipment, dated March 2023, reflected: Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include .blood pressure cuffs . d. Multiple-resident use equipment shall be clean and disinfected after each use . 675902 Page 9 of 9