Health inspection·January 4, 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, interviews and record review the facility failed to provide a homelike environment and comfortable and safe temperature levels withing a range of 71 degrees to 81 degrees Fahrenheit for 2 of 10 rooms (F7 and F10) reviewed for environment. In Resident #54's room F7 the ambient temperature was 69.0 degrees Fahrenheit In Residents #32's room F10 the ambient temperature was 68.5 degrees Fahrenheit This failure could place residents at risk of an uncomfortable environment and diminish their quality of life. Findings included: Record review of Resident #54's face sheet dated 01/03/2024 indicated he was admitted to the facility on [DATE] with diagnoses of stiffness of left hand, pain and muscle weakness. He was [AGE] years of age. Record review of Resident #54's MDS dated [DATE] indicated in part: BIMS summary score was 13 indicating he was cognitively intact. During an observation and interview on 01/02/24 at 10:52 AM Resident #54 said his room was cold and that he had reported it to the Maintenance Supervisor before but did not recall when that was. Resident #54 said the Maintenance Supervisor told him that they could only set the thermostat up to 72 degrees Fahrenheit. The resident was seen wearing 3 shirts and a jacket. Resident #54 said he had to wear all that clothes so that he could keep warm in his room. The resident showed the surveyor a couple of new men's underalls he had purchased to wear so he could be comfortable in his room. His room ambient temperature was taken by the surveyor and it was 69.0 degrees Fahrenheit. Record review of Resident #32's face sheet dated 01/03/2024 indicated she was admitted to the facility on [DATE] with diagnoses of stiffness of left shoulder, pain and muscle weakness. She was [AGE] years of age. Record review of Resident #32's MDS dated [DATE] indicated in part: BIMS summary score was 15 indicating she was cognitively intact. During an observation and interview on 01/02/24 at 11:08 AM Resident #32 said she was cold in her Page 1 of 7 675932 675932 01/04/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room. The ambient temperature was taken by surveyor and it was 68.5 degrees Fahrenheit. Resident #32 said there was also gap in the window which let the cold air in. Resident #32 said she had told the Maintenance Supervisor about her room being cold and he would say that he would check on it but would not come back and let her know what was done. During an interview on 01/04/24 at 12:12 PM The Maintenance Supervisor said he had been working at the facility for one year. The Maintenance Supervisor said he would check the ambient temperature as needed but would not document it. He said the accepted temperature for the summertime was about 80 degrees Fahrenheit but was not sure what the low temperature allowed was for wintertime. The Maintenance Supervisor said some residents would complain at times that their rooms were cold and he would adjust the thermostat that was located in the hallway. The Maintenance Supervisor said he was not aware of 2 resident rooms being cold and one of the rooms having a draft in their window. The Maintenance Supervisor was made aware of the rooms temperatures being at 69 and 68 degrees Fahrenheit. He said he would check on the rooms and repair the draft on the window. During an interview on 01/04/24 at 01:22 PM the Administrator said she had been the new Administrator at the facility for a few weeks now. The Administrator said the Maintenance Supervisor kept up with the ambient temperatures as far as she knew. The Administrator was made aware of the 2 resident rooms with low ambient temperatures. The Administrator said she would get with the Maintenance Supervisor and do a temperature log and bring this issue to their QAPI (Quality Assurance and Performance Improvement) meeting to get it resolved. The Administrator said they would also check the 2 rooms and repair the window draft. Record review of the facility's policy dated February 2021 and titled Homelike environment indicated in part: Residents are provided with a safe, clean, comfortable and home like environment and encouraged to use their personal belongings to the extent possible. Comfortable and safe temperatures (71 degrees F-81 degrees F). 675932 Page 2 of 7 675932 01/04/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interview the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that: Residents Affected - Some The facility had no Registered Nurse coverage on 08/06/2023, 08/12/2023, 09/10/2023 and 09/17/ 2023. This failure could affect residents and put them at risk of improper care. The findings were: Record Review of the facility's time sheets revealed there was no Registered Nurse coverage on 08/06/2023, 08/12/2023, 09/10/2023 and 09/17/ 2023. During an interview on 01/04/2023 at 2:24 PM with the Director of Nurses confirmed there was no proof of RN coverage for 08/06/2023, 08/12/2023, 09/10/2023 and 09/17/ 2023. 675932 Page 3 of 7 675932 01/04/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 Ensure that residents are free from significant medication errors. 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 residents were free of significan medication errors for 1 of 10 residents (Residents #33) reviewed for pharmacy services and medication administration in that: Residents Affected - Some The facility failed to administer medications as prescribed for Residents #33. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: Record review of Resident #33's face sheet indicated a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses which included essential hypertension (persistently raised blood pressure), chronic venous hypertension (abnormal capillaries in leg tissue that cause fluid to leak into leg tissue), acute diastolic heart failure (left ventricle muscle becomes stiff), acute respiratory failure (disease that affects breathing). Record review of Resident #33's physician's orders, dated 11/16/23, indicated he was prescribed: Propranolol 20mg, give 1 tab by mouth, three times a daily. Hold if Systolic Blood Pressure is less than 110, Diastolic Blood Pressure is less than 60, or pulse is less than 60. Spironolactone 50mg tab by mouth daily. Hold if systolic blood pressure is less than 110. Record review of Resident #33's Quarterly MDS, dated [DATE], indicated Resident BIMS score was 15 which indicated he was cognitively intact. Record review of the MAR for Resident #33 from 11/16/2023 to 01/04/2024, reflected the following medications were administered outside of parameters: Propranolol 20mg, give 1 tab by mouth, three times a daily. Hold if Systolic Blood Pressure is less than110, Diastolic Blood Pressure is less than 60, or pulse is less than 60. *01/02/2024 0900: [SBP/DBP: 105/60 and HR: 67] *01/02/2024 1240: [SBP/DBP: 105/67 and HR: 68] Spironolactone 50mg tab by mouth daily. Hold if systolic blood pressure is less than 110. *11/27/2023 0730: [SBP/DBP: 108/66 and HR: 66] *01/02/2024 0730: [SBP/DBP: 105/60 and HR: 67] During interview on 01/02/2024 at 12:40PM, MA C confirmed that she administered Spironolactone 50mg tab by mouth to Resident #33 in the morning. MA C verified that order stated: Hold if systolic blood pressure is less than 110. MA C stated she was in a hurry and failed to double check the order. MA C stated that she was aware that she should hold medications per orders as it could cause residents 675932 Page 4 of 7 675932 01/04/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 blood pressure to drop. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/03/24 at 10:30 AM the DON stated that all orders should be followed as written. The DON stated that if order stated, hold propranolol if Systolic Blood Pressure is less than110, Diastolic Blood Pressure is less than 60, or pulse is less than 60, the propranolol should not have been given as it could have dropped the residents blood pressure to low levels. The DON stated that all staff would be re-educated on following orders. The DON stated that the physician was contacted and those medications were discontinued. Residents Affected - Some During interview on 01/03/24 at 01:55 PM Charge nurse LVN B stated that when medication aides were administering medications, they should check for parameters prior to medication administration and notify the charge nurse of any vitals outside of normal limits and follow the orders to hold medication. During an interview on 01/04/24 at 10:00AM the ADON stated that all orders should be followed as written. If order stated to hold propranolol, then the propranolol should not have been given as it could have dropped the residents blood pressure to low levels. The ADON stated that they would ensure medication aides were re-educated on reviewing orders. Record review of the facility's policy titled, Administering Medications, revised April 2019 indicated in part: Medications are administered in accordance with prescriber's orders, including any required time frame. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 675932 Page 5 of 7 675932 01/04/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for kitchen sanitation. The facility failed to: Ensure the handheld multi juice dispenser spigot was cleaned; Ensure the ice machine filter was free from lint and dirt build-up; Ensure proper hand washing to prevent re-contamination. these failures could place residents who receive food prepared in the facility kitchen at increased risk of exposure to food-borne illnesses. Findings included: During an observation and interview on 01/02/24 at 10:05 AM during the initial tour of the kitchen the DM was asked to undo the spout from juice dispenser spigot. On the inside of spigot was some slime dark deposit in it. The DM said it should have been cleaned but it had not been and that they would usually clean it at least every other day. The ice machine was inspected and the filter had lint build up in. The DM said they usually cleaned it every 2 weeks and would have it cleaned right now. The DM said she had just come back from vacation today and perhaps the reason the spigot and filter had not been done. During an observation on 01/03/24 at 11:46 AM, DA A entered the kitchen and went to wash her hands. The aide washed her hands for approximately 7 seconds, turned off the faucet with her bare hands and then dried them. Dietary Aide A then took a cup of sherbet from the refrigerator and gave it to another dietary aide to place on a resident meal tray to be served. During an interview on 01/03/24 at 11:48 AM DA A said she had been in the restroom prior to arriving in the kitchen. DA A said when she washed her hands, she was supposed to wash them for at least 30 seconds and then turn the faucet off with a paper towel. DA A was made aware that surveyor had witnessed her wash her hands after she had entered the kitchen. DA A said she should have taken more time to wash her hands and then used a paper towel to turn the faucet off. DA A said if she did not wash her hands correctly it could lead to contamination and germs getting spread. During an interview on 01/04/24 at 12:54 PM the DM said staff are expected to wash their hands for at 20 seconds, rinse, dry their hands with the paper towels and then shut the faucet off with the paper towel. The DM said she felt the failure occurred because the aide got nervous and did not do it correctly. The DM said if the ice machine filter and the juice spigot was not cleaned properly and if staff did not wash their hands correctly that could lead to cross contamination and the spread germs. During an interview on 01/04/24 01:12 PM the Administrator said she had been the new Administrator at the facility for a few weeks now. The Administrator said her expectations was for staff to keep 675932 Page 6 of 7 675932 01/04/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the kitchen clean and sanitary. The Administrator said the kitchen staff received training on hand washing and cleaning the kitchen. The Administrator said the DM was responsible for monitoring kitchen staff. The Administrator said they would be doing more training. Record review of the facility's policy titled Nutrition and food services policies and procedures manual dated 2018 indicated in part: Hand washing steps - wet hands and exposed arms with hot water at least 100 degrees Fahrenheit, apply soap, scrub hands exposed arms and fingernails for a minimum of 20 seconds being sure to apply a vigorous friction, rinse hands and exposed arms thoroughly under hot running water, dry hands and arms with a paper towel, turn of the faucet with the paper towel to avoid contaminating hands and discard towel. General kitchen sanitation: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US food codes in order to minimize the risk of infection and food borne illness. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. Clean non-food contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt and food particles and otherwise in a clean and sanitary condition. Ice machines: The facility will maintain the ice machine, scoop and storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often than needed. The scoop and storage container will be cleaned once each day. 675932 Page 7 of 7