Health inspection·March 29, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 2 of 4 (Resident #16, Resident #20) residents reviewed for resident's rights. The facility failed to ensure Resident #16 and #20 had privacy covers for their urinary catheter bags. This failure could place residents at risk of low self-esteem resulting in a diminished quality of life. Findings included: Record review of the MDS dated [DATE] revealed Resident #16 was a [AGE] year-old male admitted [DATE], with a BIMS score of 13 indicating intact cognitive impairment. Medical Diagnoses include Dementia (cognitive decline), Cirrhosis (impaired liver function). Record review of Residents #16 Care Plan dated 12/5/23, Category Indwelling Catheter, stated, observe my indwelling catheter, provide catheter care Q shift, and change my catheter, drainage bag and privacy bag Q month and PRN. Observation and interview on 3/21/24 at 10:10 a.m., revealed Resident #16 sitting up reading, the urinary catheter bag was placed on the left side, down by the foot of the bed, no privacy cover and urinary catheter bag can be seen from hallway. Resident #16 stated he would like the catheter bag to have a privacy cover and stated he did not recall catheter bag ever being covered. Record review of MDS dated [DATE] revealed Resident #20 was [AGE] year-old male, admitted [DATE], with BIMS 00 (severely Page 1 of 28 675932 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cognitively impaired). Medical diagnoses include Paroxysmal atrial fibrillation (irregular heartbeat that stops and starts suddenly), Dementia (cognitive decline). Record review of Resident #20 Care Plan dated 02/13/24, Category Indwelling Catheter did not address privacy cover for catheter. Observation on 03/21/24 at 11:15am, Resident #20 lying in bed sleeping, observed catheter bag positioned left side at foot of bed, catheter bag did not have a privacy cover and could be seen from hallway. Resident #20 was not interview able. In an interview with the DON on 03/22/24 at 10:18 a.m., the DON D stated she expected that all catheter collection bags on beds and wheelchairs be covered by a privacy pouch. The DON stated the failure of not placing catheter collection bags in privacy pouches could compromise a residents' dignity. Record review of facility policy for catheter care. The Compliance Store, Indwelling Catheter Use and Removal, dated 2022. Policy did not address catheter privacy bags. Record review of the facility Resident Rights Guidelines for All Nursing Procedures dated 10/2010, revealed, Purpose - To provide general guidelines for resident rights while caring for the residents. Prior to having direct care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: Resident dignity and respect. 675932 Page 2 of 28 675932 03/29/2024 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 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 maintain a safe, clean, and homelike environment for 1 of 4 resident rooms (Resident #1's room) reviewed for environment. 1. The facility failed to ensure Resident #1's room was cleaned of vomit that was on the wall, blinds, bedrails, floors, and mattress. 2. For Resident #3, the facility failed to ensure the room was free of smeared feces on the window blinds, oxygen machine, and wall. This failure could place residents at risk for a diminished clean and homelike environment. Findings included: Record review of Resident #1's Face Sheet, dated 03/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Unspecified sequelae (consequence of a previous disease) of cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area), Hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #1's MDS dated [DATE], revealed, a cognitively intact BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 14, to be able to recall information and make daily decisions. Resident #1 was able to eat independently. Resident #1 has no swallowing issues noted. Record review of Resident #1's care plan dated 10/08/22, revealed, a nutritional status diet. It does not indicate that Resident #1, does not eat bacon because it no longer agrees with his stomach. Resident #1 has no restrictions on nutritional approaches (what type of texture the food will be). Record review of Resident #3's Face Sheet, dated 03/14/2024, revealed a [AGE] year-old female who was admitted to the facility 01/16/2024, with diagnoses of Displaced bimalleolar fracture (type of ankle fracture that involves both the distal [point of attachment] ends of the fibula [outer, smaller bone of the lower leg] and tibia [inner, larger bone of the lower legs] bones) of left lower leg, subsequent encounter (after treatment) for open fracture I or II with routine healing (Admission), Encounter for other orthopedic aftercare (critical phase that follows orthopedic surgeries or treatment), Schizophrenia (mental disorder that involves delusions, hallucinations, unusual physical behavior, and disorganized thinking and speech), Epilepsy (disorder of the brain characterized by repeated seizures), Moderate intellectual disabilities (observable developmental delays, which may be accompanied by physical impairments), and Cognitive communication deficit (difficulty with thinking and how someone uses language that may occur after a stroke, brain injury, or other neurological damage). 675932 Page 3 of 28 675932 03/29/2024 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 Record review of Resident #3's admission MDS Assessment, dated 01/22/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 08, which indicated a moderate impairment. Section H Bladder and Bowel under H0100 revealed Resident #3 had an Ostomy appliance (attached to the skin around the stoma to collect bodily waste). During an interview on 03/06/2024 at 6:45 p.m., Resident #1 said he had been ill several months ago and threw up his dinner on the side of his bed that was against the wall. Resident #1 said he told the aide and the aide responded that cleaning the vomit up was not her job. Resident #1 could not remember the name of the employee he talked to. Resident #1 could not remember when he vomited but said it had been a few months. Resident #1 was said he did not care who cleaned it up, Resident #1 said having the vomit under his bed was nasty. During an observation on 03/06/2024 at 6:52 p.m., when Resident #1's bed was pulled away from the wall, observed a dark brown stain that was dry and streaked down the surface of the wall approximately the height of the bed that covered the cove base and went onto the floor. The stain was approximately three (3) feet in height and one and half (1 ½ ) feet wide on the wall. Observed a large round stain on the floor approximately two (2) feet in diameter that contained black pieces of an unknown substance that caked on the floor. Observed an area where the vinyl floor had broken and exposed the material underneath that was covered in the dry, black substance. Observed the vinyl floor was wrinkled and showed water damage. During an observation on 03/12/2024 at 11:22 a.m., while interviewing Resident #3 in her room, observed a dark brown smudge, approximately three (3) inches in length on a slate of the window blind and three (3) smaller smudges near the large one. Observed a smaller dark brown smudge on the slate underneath. Observed Resident #3's bed was pushed up against the wall and window and the slates with the brown stain were approximately 6 inches above Resident #3's sheets. Observed a small dark brown smudge on the wall next to Resident #3's headboard and nightstand, approximately ½ inch in size. Observed a brown circle smudge on right front side of Resident #3's oxygen machine that was also brown in color and a smudge on the top left side of the machine brown in color. During an interview on 03/12/2024 at 11:25 a.m., Resident #3 said the substance on the window blind was poop. During an interview on 03/14/2024 at 10:47 a.m., Housekeeper Supervisor J entered Resident #3's room and looked at the dark brown smear on the blinds and the dark brown stain on the wall and said both looked like poop. Housekeeper Supervisor J said the substance on the oxygen machine looked like coffee and feces. Housekeeper Supervisor J said the housekeepers would not clean a medical device but should have notified the nursing staff. Housekeeper Supervisor J said this was an infection control issue and bad practice. Housekeeper Supervisor J at times the housekeepers would get busy and would miss cleaning up. Housekeeper Supervisor J said the housekeepers were supposed to clean behind the residents' beds daily. Housekeeper Supervisor J said not cleaning up the vomit behind Resident #1's and the dark brown residue on Resident #3's blinds and wall could cause a negative outcome. Housekeeper Supervisor J said the resident or his/her room could have gotten sick from the germs. Housekeeper Supervisor J said the house keepers need to monitor the walls and under the bed closer. During an observation on 03/14/2024 at 11:05 a.m., entered the Room of Resident #3 and observed the same stains observed on 03/12/2024 at 11:22 a.m. Review of photo evidence, dated 02/06/2024, sent in by complainant with complaint intake that fecal 675932 Page 4 of 28 675932 03/29/2024 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 matter was suspected to be located on the oxygen machine in Resident #3's room was compared to the actual oxygen machine and photo evidence by investigator taken on 03/12/2024 and 03/14/2024. During an interview on 03/14/2024 at 11:36 a.m., Administrator F said the housekeeping department was responsible for cleaning residents' rooms. Administrator F said feces on any item in a resident's room would be a concern and would be an infection control issue and a big deal. During an interview on 03/14/2024 at 11:40 a.m., ADON B said the nursing staff would be responsible for wiping down the oxygen machine every time the tubing was changed. ADON B said tubing was changed once a week. ADON B said feces on the oxygen machine was unsanitary and could cause illness to the residents. During an interview on 03/14/2024 at 11:45 a.m., Human Resource Staff K said she was the Housekeeping Supervisor until 03/04/2024. Human Resource Staff K said she remembered Resident #1 threw up and told her but could not remember when. Human Resource Staff K said she told Resident #1 she would get an aide to clean up the vomit and then she would sanitize the area. Human Resource Staff K said she failed to follow up to ensure the aide cleaned up the vomit. Human Resource Staff K said she did not know the vomit was cleaned up or not. Human Resource Staff K said if the staff failed to clean up vomit, the room would smell, be unsanitary, smell bad, and could make the resident, his roommate, or anyone who entered the room sick. During an interview on 03/15/2024 at 12:57 p.m., Administrator F said the environmental issues and uncleaned areas of the Resident #1 and Resident #3's room did not meet her expectations. Administrator F said she had identified specific training needs and areas that needed to be changed. Administrator F said she had already identified where employee changes needed to be made. Administrator F said the unclean environment and failure put the residents at risk for illness and unsanitary living conditions. Observation and interview on 03/27/24 at 8:43 AM, Resident #1 stated sometime last week on Wednesday (03/13/24) or Thursday (03/14/24) he threw up on the right side of the bed. Resident #1's bed was moved revealing vomit on the window blinds, bottom side of the wall, the floor, on linen on the floor, bed rails, and mattress. Resident #1 stated he had eaten bacon that morning because he was hungry. Resident #1 stated normally he would eat sausage for breakfast, but the staff bought him bacon. Resident #1 stated he could not remember who the staff was that delivered his breakfast. Resident #1 stated he did not usually eat bacon because since his body became sick. Resident #1 said at times, he was unable to keep bacon down. Resident #1 stated the bacon was not greasy, the temperature was good, and tasted good. Resident #1 stated he had told the CNA and nurse but could not remember who he reported he had thrown up to. Resident #1 stated he was told by the nursing staff that they were not responsible for cleaning it up. Resident #1 stated the CNA, nor the nurse came to clean it up and has been there ever since. Observation and interview on 03/27/24 at 8:50 AM, with Administrator F, Resident #1, and DON D. Administrator F observed the wall, blinds, floor, bed rails and inquired if Resident #1 had reported to nursing staff that he vomited. Resident #1 stated he had told a CNA and a nurse last week on either Wednesday or Thursday and was told by them that they do not clean up the vomit. Administrator F stated nursing staff should have cleaned it up. The DON D was observed picking up the linen and wipes that had vomit on them and placed them into the clear plastic bag. A foul odor was observed as the linen and wipes were being moved. The odor was perforating out into the hallway. DON D stated the nursing staff should have cleaned up the vomit. DON D stated it was expected for the nursing staff to 675932 Page 5 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0584 clean up any bio fluids from the residents and then housekeeping comes in and sanitizes everything. Level of Harm - Minimal harm or potential for actual harm Record review of the facility Resident Rights Guidelines for All Nursing Procedures policy dated 10/2010, revealed, To provide general guidelines for resident rights while caring for the resident. Residents Affected - Some Prior to having direct care responsibilities for residents, staff must have appropriate in-services training on resident rights, including: Resident dignity and respect. Resident notification of rights, service, and health/medical condition Record review of the facility's introduction policy dated 03/03/23, revealed, Environmental Services - A standard, systematic approach to environmental services was the key to the success of the Environmental Services Department. The performance of Senior Living Properties and its subsidiaries was based upon our ability to teach and implement the methods outlined in this manual. Areas positively impacted by having standardized environmental services methods include: Quality of Service - Quality service can only be delivered and maintained through use of proper environmental services methods, which are outlined herein. Infection Control - Standardized infection control procedures are used in thoroughly cleaning and disinfecting the facilities we serve. Record review of the facility's policy, Environmental Services, dated 03/03/2023, revealed residents' room were cleaned daily with the goal of infection control. The instructions in the policy stated to wipe and disinfect all flat surfaces, wipe, clean, and disinfect all vertical surfaces, dust mop all trash, debris, and dust on floor, and damp mop floor with germicide solution. Every room must be deep cleaned at least monthly including moving furniture and removing any food items and turning over to nursing. 675932 Page 6 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0637 Assess the resident when there is a significant change in condition 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 complete a significant change of condition assessment within 14 days of determining or should have determined that there had been a significant change in a resident physical or mental condition for 1 (Resident #1) of 9 residents reviewed for significant change in condition. Residents Affected - Few The facility failed to recognize and complete a comprehensive significant change MDS assessment after Resident #1 began refusing medication, wound care, and showering. This failure placed residents at risk of not developing interventions to meet their needs for care assistance and services and possible deterioration in their condition. Findings included: Record review of Resident #1's Face Sheet, dated 03/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Unspecified sequelae (consequence of a previous disease) of cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area), Hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin diminishes and is defined as insulin resistance), and surgical amputation of both legs below the knees. Record review of Resident #1's Quarterly MDS Assessment, dated 01/26/2024, Section C- Cognitive Response Patterns revealed a BIMs score of 14, which identified an intact cognitive response. Review of Section E - Behavior, E0800 revealed Resident #1 had not exhibited rejection of care during the time the assessment was completed. Record review of Resident #1's Care Plan, dated 12/18/2023, revealed Resident #1 had a Problem/Category area of - Pressure Sores/Skin Care and a goal to prevent/heal pressure sores and skin breakdown. Review revealed Resident #1 had a Problem/Category area of - ADL Function/Rehab Potential and a goal to achieve maximum functional mobility with the approach of bathing with extensive 2+ plus staff. Review revealed the Care Plan did not reflect Resident #1 had a pattern of refusal of care. There was no goal or interventions to address refusal of care. Record review of Resident #1's progress notes revealed no significant change MDS was completeted. 01/27/2024 at 10:14 a.m., revealed Resident #1 refused to stay in prone position (on his stomach) in bed to be assisted with wound care on left leg and right buttocks. 01/29/2024 at 1:44 p.m., revealed LVN C tried several times to complete Resident #1's wound care and Resident #1 kept saying later not right now and also refused to have hospice aides to assist him with a bath; stated he had to go outside and smoke as that was the only time could breathe right. 02/27/2024 at 6:06 a.m., revealed Resident #1 refused his medication and refused assistance from nurse to change his wound care bandage. 675932 Page 7 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0637 03/03/2024 at 6:12 a.m., revealed Resident #1 refused wound care to buttock and stump despite multiple attempts and encouragement. Level of Harm - Minimal harm or potential for actual harm 03/05/2024 at 4:41 a.m., revealed Resident #1 refused to have his wound dressing changed on the shift. Residents Affected - Few 03/07/2024 at 1:51 a.m., revealed Resident #1 refused to have his wound dressing changed on the shift. 03/10/2024 at 3:34 a.m., revealed Resident #1 refused to have his wound dressing changed on the shift even with multiple encouragement. Record review of Resident #1's MAR for February 2024, revealed Resident #1 refused to take blood glucose level during the hours of 6:00 a.m. and 8:30 a.m. on 2/01/2024, 02/02/2024, 02/04/2024, 02/05/2024, 02/06/2024, 02/27/2024. Review revealed Resident #1 refused to take medication, Novolin 70/30 U-100 Insulin suspension; 100 unit/ML, during the hours 11:00 a.m. and 12:30 p.m., on 02/03/2024, 02/05/2024, 02/06/2024, 02/09/2024, 02/10/2024, 02/11/2024, 02/13/2024, 02/14/2024, 02/15/2024, 02/17/2024, and 02/23/2024. During the hours of 6:00 p.m. and 10:00 p.m., Resident #1 was documented as refused on 02/08/2024, 02/09/2024, 02/10/2024, 02/11/2024, 02/13/2024, 02/14/2024, and 02/23/2024. Record review of Resident #1's MAR for March 2024, revealed Resident #1 refused to take blood glucose level during the hours of 6:00 a.m. and 8:30 a.m. on 03/05/2024 and Novolin 70/30 U-100 Insulin suspension; 100 unit/ML, during the hours 11:00 a.m. and 12:30 p.m., on 03/05/2024. During an interview on 03/06/2024 at 6:45 p.m., Resident #1 said he did not like changing his bandaging on his legs because he did not have time. Resident #1 said the nurses took too long to take him out of and put him back into his wheelchair and he needed to smoke. Resident #1 said if he was not in his electric wheelchair, he would not be able to go outside. Resident #1 said he did not like to shower for the same reason and the hospice gals knew he wanted to take a bed bathe. Resident #1 said he had to lay down to get a bed bathe and if the bathe took too long, he would not be able to smoke when he needed to. Resident #1 said he could not go more than 30 minutes without a cigarette. Resident #1 said he told the nurses his concerns. Resident #1 said he refused to take his medication sometimes. Resident #1 said the nurse would come by his room when he was outside and on his way to smoke and he did not have time to stop and take his medication. During an interview on 03/07/2024 at 10:33 a.m., LVN A said Resident #1 was non-complaint with showering and wound care often and most of the time he would not allow the assigned nurse to change his bandage on his left leg. LVN A described often as more than 50% of the time. LVN A said Resident #1 refused to take his medication more often and would become verbally aggressive when prompted. During an interview on 03/07/2024 at 12:05 p.m., ADON B said Resident #1 had a history of refusing to shower and wound carer. ADON B said multiple staff would prompt him and if he did not let the nurses change his bandage on one shift, the next shift would attempt to complete the task. ADON B said he agreed that the information should be in his care plan because Resident #1 had been refusing showers and wound care for several months and interventions were needed so all nursing staff would know how to handle the situation. During an interview on 03/08/2024 at 2:15 p.m., Hospice CNA G said Resident #1 was very non-compliant with showering. Hospice CNA G said Resident #1 would refuse to shower or have a bed bathe at 675932 Page 8 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few least two (2) or three (3) times a week even though she prompted him several times during the time Hospice CNA G was in the facility. Hospice CNA G said Resident #1's shower schedule was Monday, Wednesday, and Friday in the afternoon because Resident #1 requested the days and time. Hospice CNA G said she and another hospice aide would ask Resident #1 if he wanted to take a shower and Resident #1 would tell them to come back. Hospice CNA G said she would wait about 30 minutes and ask again and most of the time he would refuse. During an interview on 03/13/2024 at 9:18 a.m., Clinical Case Manager H said she was responsible for completing the MDS assessment. Clinical Case Manager H said when she considered a change of condition, she would look at progress notes, observations or clinical assessments, or any additional assessments. Clinical Case Manager H said she followed the guidelines of the timeframe referenced in the state rule. Clinical Case Manager H said during the nurses' meeting, they would discuss documentation and observation to determine if a change in condition assessment was needed. Clinical Case Manager H said Resident #1's behaviors of refusal were not discussed. Clinical Case Manager H said when Resident #1 refused to shower, it was not a refusal but a personal choice. Clinical Case Manager H said if the refusal was not documented in the records then she would not be aware of the behavior. Clinical Case Manager H said if Resident #1 refused wound care, the refusal would need to be documented in the record. Clinical Case Manager H said they would monitor Resident #1's behaviors for two weeks but by the time the two weeks were up, his wound would be healed. Clinical Case Manager H said she agreed that interventions were needed to address Resident #1's non-compliance. During an interview on 03/14/2024 at 9:04 a.m., Hospice LVN M said Resident #1 was non-complaint with his showers when the hospice CNAs went to the facility to assist Resident #1 with the task. Hospice LVN M said the hospice staff would change his time from the morning to the evening at Resident #1's request and Resident #1 would still refuse at least once or twice a week. Hospice LVN M said Resident #1 would refuse to let the facility nursing staff change his bandage on his left amputated site and facility nursing staff would have to ask him several times. Hospice LVN M said at times, the hospice aides would provide Resident #1 a bed bath, but he was non-complaint with most of the time due to the need to smoke. Record review of facility policy, SLP Operations Care Plan/Delegation of Responsibilities, not dated, revealed the Comprehensive Care Plan was completed by multiple members of the IDT. The Clinical Case Manager was responsible for CAAs, Comprehensive, and Quarterly Reviews. Regarding unwanted or unacceptable behaviors: it is the responsibility of ALL staff to identify and report to the DON/designee new behaviors or changes from the resident's baseline and what, if any, interventions have been employed so these may be added to the care plan and communicated to the resident's direct care staff. 675932 Page 9 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 (Resident #1 and Resident #10) of 12 resident reviewed for care plans in that: 1. For Resident #1, the comprehensive care plan did not reflect the resident refused wound care and showers. 2. For Resident #10, the comprehensive care plan did not reflect the resident was on dialysis. These failures could result in residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Record review of Resident #1's Face Sheet, dated 03/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Unspecified sequelae (consequence of a previous disease) of cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area), Hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance), and surgical amputation of both legs below the knees. Record review of Resident #1's Quarterly MDS Assessment, dated 01/26/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 14, which identified an intact cognitive response. Review of Section E - Behavior, E0800 revealed Resident #1 had not exhibited rejection of care during the time the assessment was completed. Record review of Resident #1's Care Plan, dated 12/18/2023, revealed Resident #1 had a Problem/Category area of - Pressure Sores/Skin Care and a goal to prevent/heal pressure sores and skin breakdown. Review revealed Resident #1 had a Problem/Category area of - ADL Function/Rehab Potential and a goal to achieve maximum functional mobility with the approach of bathing with extensive 2+ plus staff. Review revealed the Care Plan did not reflect Resident #1 had a pattern of refusal of care. There was no goal or interventions to address refusal of care. Record review of Resident #10's Face Sheet, 03/08/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Osteomyelitis (serious infection of the bone) of vertebra (spine), thoracic (middle section of your spine) region, End stage renal (kidney) disease, Unspecified dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to an extent that it interferes with a person's daily life and activities) , Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance), Dependence on renal dialysis (treatment for people whose kidneys are failing), and Chronic kidney disease, Stage 5 (last stage). 675932 Page 10 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #10's Quarterly MDS Assessment, dated 12/10/2023, Section C- Cognitive Response Patterns revealed a BIMs score of 08, which identified moderate impairment. Section I - Active Diagnoses revealed in I8000 Resident #10 had the diagnosis of Dependence on renal dialysis. Section O Special Treatments revealed in Section O0110 J1, Resident #10 received the treatment of Dialysis upon admission and while a resident. Residents Affected - Few Record review of Resident #10's Care Plan, daed 02/02/2024, revealed the plan did not include was on dialysis and attended three days a week. During an interview on 03/06/2024 at 6:45 p.m., Resident #1 said he did not like the nurses to change his bandage on his left leg because he did not have time. Resident #1 said the nurses took too long to take him out of and put him back into his wheelchair and he needed to smoke. Resident #1 said he did not like to shower for the same reason and the hospice gals knew he wanted to take a bed bath. Resident #1 said he had to lay down to get a bed bathe and if the bathe took too long, he would not be able to smoke when he needed to. During an interview on 03/07/2024 at 10:33 a.m., LVN A said Resident #1 refused to let the nurse assigned to his hall complete his wound care. LVN A said she and other nurses would ask Resident #1 several times, but Resident #1 was non-complaint with wound care often and most of the time he would not let the assigned nurse change his bandage. During an interview on 03/08/2024 at 2:15 p.m., Hospice CNA G said she had assisted Resident #1 since he began working with her agency 01/01/2024 and she assisted with showering. Hospice CNA G said Resident #1 was very non-compliant with showering and was often verbally aggressive. Hospice CNA G said Resident #1 would refuse to shower or have a bed bathe most of time. Hospice CNA G said the provider had attempted to work with Resident #1 and changed his shower time to the afternoons from mornings upon Resident #1's request, but Resident #1 would still refuse. Hospice CNA G said she and another the other hospice aide would ask Resident #1 if he wanted to take shower and Resident #1 would tell them to come back. Hospice CNA G said she would wait about 30 minutes and ask again and most of the time he would refuse. Hospice CNA G said Resident #1 told her he did not want to get out of his wheelchair because he wanted to smoke. Hospice CNA G said at the times, Resident #1 would take a shower, Resident #1 would demand to go smoke and refuse wound care with facility nursing staff. During an interview on 03/14/2024 at 9:04 a.m., Hospice LVN M said Resident #1 was non-complaint with his showers when the hospice CNAs went to the facility to assist Resident #1 with the task. Hospice LVN M said Resident #1 would be verbally aggressive and wanted to shower on his time. Hospice LVN M said the hospice staff would change his time from the morning to the evening and Resident #1 would still refuse. Hospice LVN M said Resident #1 would refuse to let the facility nursing staff change his bandage on his left amputated site and facility nursing staff would have to ask him several times. During an interview on 03/13/2024 at 9:18 a.m., Clinical Case Manager H said if Resident #1 refused wound care, the refusal would need to be documented in the record and a change in condition could be considered. Clinical Case Manager H said Resident #1's care plan should have been updated to include interventions to assist the nursing staff to meet Resident #1's needs. During an interview on 03/08/2024 at 9:00 a.m., Resident #10 said he had problems with his kidneys that made him feel bad some days. Resident #10 said he went to the clinic a few days a week and had dialysis treatment. 675932 Page 11 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/14/2024 at 12:20 p.m., Clinical Case Manager H said she was responsible for the care area assessment. Clinical Case Manager H said dialysis should be in Resident #10's Care Plan. Clinical Case Manager H said based on the current MDS coded for yes for urinary incontinence and indwelling catheter, dialysis would have been a triggered area. Clinical Case Manager H said Resident #10's MDS Section H - frequency of incontinence and Section GG - coded maximum assistance for toilet hygiene were coded correctly to trigger the correct area and she was not sure why dialysis did not make it into Resident #10's Care Plan. Clinical Case Manager H said the IDT process between nursing and herself was to make sure dialysis was in the care plan. Clinical Case Manager H said Resident #10's diagnosis of End stage renal disease was a part of him, and dialysis was the service and goal. During an interview on 03/15/2024 at 12:28 p.m., DON D said Resident #1's refusal of showers and wound care should be addressed in his Care Plan document. DON D said the information not in his plan could cause lack of communication between staff. DON D said Resident #10's dialysis service should be in the care plan. Not being in the care plan would cause a lack of communication. Administrator F said the area of Resident #1 refusal to do wound care and assistance with showers should had been reflected in his care plan. Administrator F said Resident #10's dialysis service should had been in his care plan and addressed with a goal and approaches. Administrator F said both were identified the area of concern that needed to be care planned. Administrator F said dialysis was an approach to Resident #10's diagnosis of End stage renal failure. Administrator F said the information not in the care plans would limit the nursing staff's knowledge of residents' services and prevent follow up or no services delivered entirely. Record review of the facility policy, Comprehensive Care Plan, dated 01/26/2024, revealed the comprehensive care plan include measurable objective and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives would be utilized to monitor the resident's progress. Alternative interventions would be documented as needed. The facility would attempt to alternate methods for refusal of treatment and services and document such attempts in the clinical record as the care plan will be reviewed and revised by the IDT at least quarterly or more often as needed. 675932 Page 12 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure the environment remained free of accidents hazards and provided adequate supervision to prevent accidents for 5 of 9 (Resident #1, #8, #9, #10 and #11) residents reviewed. 1. The facility failed to ensure Resident #1, #8, #9, and #10 were provided direct supervision of staff when smoking. Residents #1, #8, #9, and #10 were allowed to sign out and go outside to smoke in an undesignated smoking area unsupervised in an area with flammable objects of dry grass and dry wood. Residents #1 and #8 were observed to cross the street in front of the facility to the picnic table at the park and smoke in their wheelchairs unsupervised near a creek with an 8-foot drop off. 2. The facility failed to ensure Resident #1 was safe when smoking with no supervision as evidence by a burn on his clothing, fanny pack and blanket. 3. The facility failed to ensure Residents #1,#8, #9, and #10 complied with the facility's smoking policy that required all smoking paraphernalia to be checked in and out by the nursing staff and stored in a secure location upon return from pass. 4. The facility failed to follow their Nursing Guideline: Out on Pass/Leave Procedure Policy, dated 03/2024, by failing to abide by: - ensure smoking actions were implemented in Residents #1 and #8's Care Plan per policy to correctly identify the residents' smoking safety needs. - obtain physician orders prior to Residents #1, #8, #9, and #10 physically signing out of the facility on pass to smoke. - ensure proper documentation on the Out of Pass Release of Responsibility Form for Resident #1, #8, and #10 was completed accurately and entirely, to include what time the residents left the building, and what time the residents planned to return. - ensure Resident #1, #8, #9, and #10 were assessed by a nurse prior to signing out and leaving the facility and upon return to the facility from pass. 5. The facility failed to ensure a smoking assessment was conducted for Resident #9's to determine his smoking risk when admitted on [DATE]. 6. The facility failed to ensure Resident #11's cigarettes were not stored on his person and kept in a secure area during other times than scheduled, supervised smoking breaks. An IJ was identified on 03/28/2024. The IJ template was provided to the facility on [DATE] at 1:15 p.m. While the IJ was removed on 03/29/2024, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to 675932 Page 13 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0689 residents who require supervision while smoking. Level of Harm - Immediate jeopardy to resident health or safety Findings included: Residents Affected - Some Record review on 03/07/2024 at 11:30 a.m. of Resident #1's Face Sheet, dated 03/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Unspecified sequelae (consequence of a previous disease) of cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area), Hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance), and surgical amputation of both legs below the knees. Resident #1 Record review on 03/07/2024 at 11:31 a.m. of Resident #1's Doctor's Orders, dated 01/24/2024, revealed Resident #1 had a general order of Nasal Cannula (prn for comfort): o2@ (2-4) L/Min, Every shift - PRN Shift, Shift1, Shift2, Shift3. Record review on 03/07/2024 at 11:32 a.m. of Resident #1's Doctor's Orders, dated 03/07/2024, revealed Resident #1 did not have physician orders that identified Resident #1 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/07/2024 at 11:33 a.m. of Resident #1's Quarterly MDS Assessment, dated 01/26/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 14, which identified an intact cognitive response. Section GG0115 - Functional Limitation in Range of Motion revealed Resident #1 had impairment on both sides of his lower extremity and Section GG0120 revealed Resident #1 ambulated by use of a wheelchair. Review of Section E - Behavior, E0800 revealed Resident #1 had no behaviors or refusals of care. Record review on 03/07/2024 at 11:34 a.m. of Resident #1's Smoking Risk Assessment, dated 09/29/2023, revealed Resident #1 scored high and was deemed an unsafe smoker. The assessment revealed Resident #1 was assessed as a chain smoker, severe problem with smoking in unauthorized area, severe problem with careless with smoking materials, such as drops cigarette on floor or burns fingertips, severe problem smoking used cigarettes butts from ash trays, severe problem giving cigarettes to others, and severe problem with begging or stealing cigarettes. The assessment recommended Resident #1 continue current plan of care and follow facility policy. Record review on 03/07/2024 at 11:36 a.m. of Resident #1's SLP Smoking Risk Assessment, dated 02/13/2024, revealed a paper copy of an Observation Detail List Report with the identifying information marked out with a black marker. Under the Section - Smoking, Assessment - Observation Information, Resident #1's name was hand-written in. Review revealed the questions on the assessment were blank and the form was unsigned and not dated. The summary and rating of Resident #1's smoking ability was blank and undetermined. Record review on 03/07/2024 at 11:38 a.m. of Resident #1's Care Plan, dated 12/18/2023, revealed Resident #1 had a Problem/Category area of - Smoking: I am a smoker. I am not always compliant with the smoking policies. I have been found smoking outside of the designated smoking area and I have been 675932 Page 14 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some known for not returning all of my smoking materials. Review revealed Resident #1's goal was to comply with smoking policies and would smoke in designated area(s) at scheduled times through the next review period. Record review on 03/07/2024 at 11:39 a.m. of Resident #1's Progress Note, dated 2/08/2024 at 8:07 a.m., revealed Resident #1 was observed smoking outside in the smoking area even though he was reminded not to go. Resident #1 said to the staff, stay out of my business and I am not a f__cking child. Resident #1 remained outside and refused to extinguish his cigarette. Record review on 03/07/2024 at 11:40 a.m. of Resident #1's Progress Note, dated 2/10/2024 at 12:35 a.m., revealed Resident #1 was observed going outside with another male resident who pushed Resident #1 in his wheelchair to the smoking area even though he was reminded not to go but he went anyway and smoked. During an observation on 03/07/2024 at 8:30 a.m., Resident #1 was observed outside sitting in his wheelchair and smoking on the east side of the facility unsupervised in an undesignated smoking area. Observed the area where Resident #1 was smoking was located by a side street that intersected with the road that ran in front of the facility. Resident #1 was observed as he smoked by a telephone phone surrounded by yellow, dried weeds approximately two (2) feet in height and a grey wooden pallet, or a flat wooden platform on which goods are stored so that they can be lifted and moved using a forklift truck, was observed lying flat on top of the weeds. During an interview on 03/07/2024 at 9:32 a.m., LVN L said he had observed Resident #1 exit the facility through the front entrance and go to the east side of the facility and smoke unsupervised on multiple occasions. LVN L said he did not know which residents who smoked were assessed as safe or unsafe. LVN L said he had observed Resident #1 across the street at the park at the picnic table smoking on several occasions. LVN L said Resident #1 was independent and he assumed Resident #1 could smoke as long as he was off the property. On 03/27/2024 @8:33 a.m., Resident #1 was observed with a small hole in his fanny packet he wore around his waist, approximately ¼ inch in diameter, singed and melted around the edges. Observed two small black spots on the blanket Resident #1 had draped over his lap. Resident #1 said he was sitting outside smoking a week prior and the wind blew his blanket up and knock his cigarette out of his hand. Resident #8 Record review on 03/07/2024 at 6:45 p.m. of Resident #8's Face Sheet, dated 03/07/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Atherosclerotic (thickening or hardening of the arteries) heart disease of native coronary artery with unspecified angina pectoris (occurs when arteries that carry blood to your heart become narrowed and blocked because of thickening or hardening of the arteries or a blood clot); Alcohol dependence; History of methamphetamine dependence, Chronic obstructive pulmonary disease, and Acquired absence of other specified parts of digestive tract-Partial colectomy (surgeon removes the diseased portion of the colon and a small portion of surrounding of heathy tissue). Record review on 03/07/2024 at 6:46 p.m. of Resident #8's Doctor's Orders, dated 09/23/2023, revealed Resident #8 had a general order of Oxygen 2-4 L/Minute PRN As Needed, PRN1, PRN2, PRN3. 675932 Page 15 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review on 03/07/2024 at 6:47 p.m. of Resident #8's Doctor's Orders, dated 03/07/2024, revealed Resident #8 did not have physician orders that identified Resident #8 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/07/2024 at 6:48 p.m. of Resident #8's MDS Quarterly Assessment, dated 02/22/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 12, which indicates moderate impairment. Section - GG0120 - Mobility Devices, revealed Resident #8 ambulated with the use of a wheelchair. Review of Section E - Behavior, E0800 revealed Resident #1 had no behaviors or refusals of care. Record review on 03/07/2024 at 6:49 p.m. of Resident #8's SLP Smoking Risk Assessment, dated 02/13/2024, revealed a paper copy of an Observation Detail List Report with the identifying information marked out with a black marker. Under the Section - Smoking Assessment - Observation Information, Resident #8's name was hand-written in. Under the Section - Observation Detail List Report - the question, Is the resident physically capable of smoking? was blank as well as Section - Evaluation, Smoking Risk, Referral, and Plan of Care. Review revealed the assessment was not signed or dated and was incomplete. The summary and rating of Resident #8's smoking ability was blank and undetermined. Record review on 03/07/2024 at 6:51 p.m. of Resident #8's Smoking Risk Assessment, dated 09/28/2023, revealed Resident #8 had a score that identified her as Potentially Unsafe Smoker and deemed Resident #8 with the need for care plan intervention. The assessment revealed Resident #8 was assessed as a chain smoker, minimum problem with smoking in unauthorized area, moderate problem with careless with smoking materials, such as drops cigarette on floor or burns fingertips, moderate giving cigarettes to others, and moderate problem with begging or stealing cigarettes. The assessment recommended Resident #8continue current plan of care and follow facility policy. Record review on 03/07/2024 at 6:54 p.m. of Resident #8's Care Plan, dated 01/08/2024, revealed Resident #8 had a Problem area of - Res is a smoker; Review revealed Resident #8's goal was to maintain safety while smoking, which included nursing staff to assist and assure Resident #8 removed oxygen before smoking and reviewed/discussed the facility's smoking policy with Resident #8 quarterly. Resident #9 Record review on 03/08/2024 at 9:25 a.m. of Resident #9's Face Sheet, dated 03/08/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Other psychoactive (affecting the mind) substance abuse with substance-induced persisting dementia (loss of cognitive functioning - thinking, remembering, and reasoning- to such an extent that it interferes with a person's daily life and activities), Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance) with hyperglycemia (high blood glucose), Osteomyelitis (infection in the bone) of vertebra (spine), thoracic region (middle of spine), and Paraplegia, incomplete (the injury has not completely severed the spinal cord and some degree of sensation and movement control would be present). Record review on 03/08/2024 at 9:26 a.m. of Resident #9's Doctor's Orders, dated 03/08/2024, revealed Resident #9 did not have physician orders that identified Resident #9 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). 675932 Page 16 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review on 03/08/2024 at 9:27 a.m. of Resident #9's Other Payment MDS Assessment, dated 12/06/2023, Section C- Cognitive Response Patterns revealed a BIMS score of 14, which identified an intact cognitive response. Section G revealed Resident #9 required extensive assistance with two or more persons with toileting and transferring to his wheelchair. Review of Section E - Behavior, E0800 revealed Resident #9 had no behaviors of rejection of care to meet his goals for health and well-being. Record review on 03/08/2024 at 9:30 a.m. of Resident #9's clinical record progress notes, dated 09/18/2023 through 02/13/2024 revealed Resident #9 did not have a Smoking Risk Assessment. Record review on 03/08/2024 at 9:33 a.m. of Resident #9's SLP Smoking Risk Assessment, dated 02/13/2024, revealed a paper copy of an Observation Detail List Report with the identifying information marked out with a black marker. Under the Section - Smoking Assessment - Observation Information, Resident #9's name was hand-written in. Under the Section - Observation Detail List Report - the question, Is the resident physically capable of smoking? was blank as well as Section - Evaluation, Smoking Risk, Referral, and Plan of Care. Review revealed the assessment was not signed or dated and was incomplete. The summary and rating of Resident #9's smoking ability was blank and undetermined. Resident #10 Record review on 03/08/2024 at 10:20 a.m. of Resident #10's Face Sheet, dated 03/08/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Osteomyelitis (serious infection of the bone) of vertebra (spine), thoracic (middle section of your spine) region, End stage renal (kidney) disease, Unspecified dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to an extent that it interferes with a person's daily life and activities) , Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance), Dependence on renal dialysis (treatment for people whose kidneys are failing), and Chronic kidney disease, Stage 5 (last stage). Record review on 03/07/2024 at 10:22 a.m. of Resident #10's Doctor's Orders, dated 02/16/2023, revealed Resident #10 had a general order of Nasal Cannula (PRN): O2@ 2L/Min, As Needed, PRN 1, PRN 2, PRN 3. Record review on 03/08/2024 at 10:24 a.m. of Resident #10's Doctor's Orders, dated 03/08/2024, revealed Resident #10 did not have physician orders that identified Resident #10 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/08/2024 at 10:25 a.m. of Resident #10's Quarterly MDS Assessment, dated 12/10/2023, Section C- Cognitive Response Patterns revealed a BIMS score of 08, which identified moderate impairment. Section I - Active Diagnoses revealed in I8000 Resident #10 had the diagnosis of Dependence on renal dialysis. Section O - Special Treatments revealed in Section O0110 J1, Resident #10 received the treatment of Dialysis upon admission and while a resident. Section E - Behavior, E0800 revealed Resident #10 had no behaviors of rejection of care. Record review on 03/08/2024 at 10:28 a.m. of Resident 10's Smoking Assessment, dated 12/20/2023, was incomplete as the questions were not answered and the assessment was not dated and signed. Review of the Resident #10's Smoking Assessment, dated 10/06/2023, revealed Resident #10 had a minimal problem of understanding the facility policy and a minimal problem of general behavior and interpersonal 675932 Page 17 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0689 interaction. Resident #10's score was a 5, which in the middle of the range of the safe smoker category. Review revealed Plan of Care section recommended to continue current care plan. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident 10's Care Plan dated 02/02/2024, revealed the plan did not include a goal or interventions to address smoking. Residents Affected - Some Resident #11 Record review on 03/14/2024 at 5:50 p.m. of Resident #11's Face Sheet, dated 03/14/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] , with diagnoses of Cerebral infarction, unspecified (stroke or not enough blood was getting through certain blood vessels in your brain and the tissue had not received enough blood causing damage); Bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Gout (happens when urate, a substance in your body, builds up and forms needle-shaped crystals in your joints), Morbid obesity (have a high body mass index and experience negative health effects due to excessive body weight), and Hypertension (when the pressure in your blood vessels is too high). Record review on 03/14/2024 at 5:53 p.m. of Resident #11's MDS Optional State Assessment, dated 12/06/2023, Section C- Cognitive Response Patterns revealed a BIMs score 15, which identified an intact cognitive response. Review of Section E - Behavior, E0800 revealed Resident #11 had no behaviors or refusals of care. Record review on 03/14/2024 at 5:55 p.m. of Resident #11's Smoking Risk Assessment, dated 09/29/2023, revealed Resident #11 had a score that identified him as Potentially Unsafe Smoker and deemed Resident #11 had the need for care plan intervention. The assessment revealed Resident #11 was assessed as a chain smoker, severe problem with providing smoking material to other residents, severe problems with begging and stealing smoking materials from other residents, and severe problem with behavior and interpersonal interaction. The assessment revealed Resident #11 continue current plan of care and follow facility policy. Record review on 03/14/2024 at 5:58 p.m. Resident #11's Care Plan, dated 03/11/2024, revealed a Problem Area included in Resident #11's Care Plan in the category of smoking, which was started 09/18/2023. The Care Plan revealed under the Category: Smoking: I am a smoker, and I am not always compliant with smoking policies. I have been found smoking in areas that are not designated smoking areas and I do not always comply with returning smoking materials. Review revealed the goal was to comply with smoking policies through the next review period. During an interview on 03/06/2024 at 6:45 p.m., Resident #1 said he could not go more than 30 minutes without smoking a cigarette. Resident #1 said the facility's smoking policy was unfair and he did not agree with the policy that he could not smoke without being supervised. Resident #1 said he signed himself out at the nurses' station, signed his name on the sign book and smoked on the east side of the building. Resident #1 said the staff that was at the nurses' station at the time he signed out would hand him a bag that contained his cigarettes and lighter and he went outside without staff to smoke. During an interview on 03/06/2024 at 7:31 p.m., Administrator F said the nursing home followed facility policy and provided supervision to the residents who were assessed as unsafe smokers. Administrator F said if a resident had a high BIMS score and was assessed as a safe smoker, the resident could sign-out on pass at the nurses' station and smoke outside unsupervised. Administrator F said the 675932 Page 18 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0689 facility did not have policy that covered when residents signed out on pass to specifically smoke. Level of Harm - Immediate jeopardy to resident health or safety During an observation on 03/07/2024 at 11:45 a.m., observed the smoking schedule posted on the door that exited out into the designated smoking area revealed smoking breaks were scheduled for 6:30 a.m., 8:30 a.m., 11:00 a.m., 1:00 p.m., 4:00 p.m., and 7:00 p.m., and were 15 minutes in length or two (2) cigarettes each time. Observed the facility's designated smoking area was located outside a door accessible from the dining room. Observed the door had opened into a secure gated area that contained a table, chairs, ashtrays, and smoking vests that hung on the wall. Residents Affected - Some During an interview on 03/07/2024 at 12:05 p.m., ADON B said the facility had one designated smoking area and the designated smoking space was the area located off the dining room through a non-exit door into the secure fenced area. ADON B said the residents did not smoke outside the facility and there was not a designated smoking area on the East side of the building on the outside of the fenced in location. ADON B said the residents were provided cigarettes during designated smoking times from the staff who provided supervision and when the break was over, the residents returned the cigarettes and lighters to the staff to be secured in a plastic tote that was stored under the nurses' station. ADON B said residents who were assessed as safe smokers signed out on pass and requested cigarettes from the nurses who would get them from the plastic storage box located under the desk area in the nurses' station. ADON B said the nurse would give the resident what the resident had in the box even if it was 2 cigarettes or a pack of cigarettes. During an observation on 03/07/2024 at 12:47 p.m., observed a clear plastic storage tote under the nurses' station that was not locked or secure. Observed the storage tote was under the desk area at the front of nurses' station where the sign out book was located. Observed ADON B open the tote and remove a small tackle box that contained a vape device with three (3) bottles labeled nicotine. Observed approximately 30 large zip lock bags with residents' name written on the side that contained lighters and cigarettes or cigarette packs. During an interview on 03/07/2024 at 12:50 p.m., ADON B said the employee of the facility or person who let the resident in the door was responsible to ensure he/she returned his/her plastic bag including the lighter. ADON B said the reason Resident #1 could sign out and smoke was because Resident #1 had a high BIMS Score and was his own responsible party. During an observation on 03/07/2024 at 12:53 p.m., observed Resident #8 at the front desk, sign out on the facility sign out book, and take her cigarette and lighter from the staff behind the counter. Observed Resident #8 exit the facility and ambulate by use of her wheelchair to the east side of the facility and light her cigarette and smoke unsupervised by the telephone phone and side street. During an interview on 03/07/2024 at 1:15 p.m., DON D said the residents had a right to sign out if they had a high BIMS score and a safe smoking assessment. DON D said once a resident signed out, the facility could not stop them from smoking on the east side of the building unsupervised. DON D said the east side of the building was not a designated smoking area and was not set up to meet the facility's policy as a designated smoking area During an interview on 03/07/2024 at 1:30 p.m., Resident #8 said she knew the facility had a designated smoking area by the dining room and designated smoking break times, but she would rather sign herself out on pass and smoke. Resident #8 said she could not wait for each facility break time to smoke because she needed to smoke more often. 675932 Page 19 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 03/07/2024 at 1:37 p.m., Resident #9 said he would sign himself out on pass and smoke outside the facility. Resident #9 said he did not need supervision and could push himself outside to the side of the facility because he needed to smoke several cigarettes at a time during his smoke break. During an interview on 03/07/2024 at 1:41 p.m., Hospitality Aide E said the residents that were able to independently sign out would sign out on pass and she would give them their cigarettes and lighters that were stored in a zip lock bag inside the plastic tote container. Hospitality Aide E said the residents would go outside to the east side of the building by the telephone pole and side road curb and smoke. Hospitality Aide E said the residents had to have a high BIMS score and be assessed as a safe smoker. Hospitality Aide E said she did not have a list of which residents were safe smokers and were able to sign out on pass independently. Hospitality Aide E said she had not read the smoking policy or out on pass/leave policy. During an observation on 03/07/2024 beginning at 1:48 p.m., observed Resident #1 and Resident #8 sign out on pass, receive their cigarettes from staff at nurses' station, exit the facility, and go outside to the east side of the building to smoke unsupervised in an undesignated smoking area. Observed Resident #1 was in an electric wheelchair and Resident #8 was in a manual. After smoking, observed both cross the parking lot and observed Resident #1 as he rode his chair on the side of the road next to the sidewalk and Resident #8 as she went up on the sidewalk and enter the handicap low curb. Resident #1 and Resident #8 were observed crossing the road to the sidewalk on the other side of the road at the park. Observed Resident #8 take several minutes to maneuver her wheelchair down the sidewalk as there was a sharp slope down to the picnic table. Observed Resident #9 with his family member sitting at the picnic table ahead of Resident #1 and Resident #8. Resident #9's family member was observed walking up the hill and pushed Resident #8 down to the picnic table. Observed the picnic table was approximately 30 yards from the river that had an 8 foot drop off to the water below. During a group interview on 03/07/2024 at 1:59 a.m., at the picnic table at the park across from the facility, Resident #9's family member said Residents #1, #8, and #9 came to the park just about every day. Resident #1 said prior to the first of February, Residents #1, #8, and #9 smoked whenever they wanted to in the designated facility smoking area. Resident #1 said he was assessed by the fact that if he could get out the door, he did not need supervision. Resident #9 said he had never been assessed for smoking. Resident #1 said prior to the first of February, the group could smoke whenever they wanted to in the facility's designated smoking area unsupervised. Resident #9 said he came to park when his family member could push him over because Resident #9 said he was not strong enough to push himself in his wheelchair by himself all the way across the street, down the hill, and to the picnic tables. Resident #9 said he would sign himself out on pass and smoke on the side of the facility when his family member was not at the facility. Resident #1 said prior to first of February, he kept his cigarettes and lighter with him in his room. Resident #8 said she kept her cigarettes and lighter in her room as well and no one asked Resident #8 to turn her lighter in when Resident #8 came in from pass. Resident #8 said she could not go two (2) or three (3) hours without smoking a cigarette and Resident #8 said the smoking policy should only apply to residents who were unsafe smokers. During an interview on 03/07/2024 at 3:27 p.m., Administrator F said residents were deemed able to sign out of the facility and smoke based on a high BIMs score and if a smoking assessment revealed the resident was a safe smoker. Administrator F said the east side of the building was not a designated smoking area, but the residents smoked in the space when signed out on pass from the facility. During an interview on 03/07/2024 at 4:06 p.m., Social Worker I said she attempted to complete a 675932 Page 20 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some smoking assessment with Resident #1 on 02/13/20/24. Social Worker I said Resident #1 told her he did not smoke so she did not complete the assessment. Social Worker I said she had not assessed or attempted to assess Resident #9 after learning he was a smoker. During an observation on 03/08/2024 at 8:55 a.m., observed Resident #1 and Resident #10 outside smoking on the east side of the facility unsupervised in an undesignated smoking area. Observed Resident #1 and #10 ambulated by wheelchairs and sat next to a side street by a telephone pole. During an observation on 03/13/2024 at 8:29 a.m., Resident #1 was observed outside sitting in his wheelchair and smoking on the east side of the facility unsupervised in an undesignated smoking area. Observed Resident #1 sitting by a telephone pole and dry grass next to the pole. No ashtrays present. During an observation on 03/13/2024 at 9:15 a.m., observed Resident #11 walk by the nurses' station with the assistance of a rolling walker with a cigarette tucked behind his left ear. During an interview and observation on 03/13/2024 at 9:52 a.m., Resident #11 said he was a smoker and smoked outside in the designated smoking area. Resident #11 said he would rather not answer the question of where he kept his cigarettes or where he was supposed to keep his smoking supplies. Observed a cigarette behind his left ear. During an interview on 03/13/2024 at 10:10 a.m., Administrator F said all resident smoking materials had to be kept stored in a central place and none was allowed in the residents' rooms or on their person. Administrator F said she was not sure why Resident #11 had cigarettes in his room, but she went down and talked to Resident #11, and he gave her three (3) cigarettes he had in his room. Observed Administrator F with three (3) cigarettes in her hand. During an interview and observation on 03/13/2024 at 2:15 p.m., observed Resident #1 and Resident #9 outside sitting in their wheelchairs and smoking on the east side of the facility unsupervised in an undesignated smoking area. During an interview on 03/15/2024 at 12:57 p.m., Administrator F said the facility smoking policy was necessary and should be enforced for the residents' safety. Administrator F said she realized changes to the process were needed in the smoking assessments and how they were completed did not meet her expectations. During an interview on 03/25/2024 at 8:02 a.m., DON D said the residents who were smokers and who checked out on pass to smoke at the side of the building were violating the facility smoking policy. DON D said the residents were at risk smoking near the building if the cigarette was not extinguished properly. DON D said the residents who smoke had be in-serviced and educated on 03/14/2024 on the dos and don'ts of the smoking policy and had been informed that the only designated area for smoking was the facility patio. During an observation on 03/25/2024 at 10:42 p.m., revealed Resident #1 smoking outside unsupervised approximately 10 feet from a parked car. Resident #1 turned his wheelchair with his back facing the building near the exit of Hall A and was observed with a lit cigarette in his hand. Observed Residents #8 and #9 come out of the facility and join Resident #1 to form a circle and smoke. On 03/27/2024 @8:33 a.m., Resident #1 was [TRUNCATED] 675932 Page 21 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 a resident who needs respiratory care, is Residents Affected - Some provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents goals, and preferences for 3 of 4 residents (Resident #14, Resident #17, Resident #3) reviewed for respiratory care. 1. The facility failed to ensure Resident #14 and #17's nebulizer tubing was kept in bag while not in use. 2. The facility failed to ensure Resident #3's room was free of smeared feces on the oxygen machine These failures could place residents at risk for respiratory infections. The findings include: Record review of Resident #14's MDS admission assessment dated [DATE], revealed Resident #14 was admitted to the facility on 09/29/22, with a BIMS score of 99 (severely cognitively impaired). Medical diagnoses Hemiplegia & hemiparesis (severe form of paralysis), Cerebral infraction (stroke). Resident is non interview able. Record review of Resident #14's prescription order start date 10/14/22, Resident #14 was to receive, ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; amt: 1; inhalation every 4 hours-PRN. Record review of Resident #14's Care Plan dated 3/11/24, revealed terminal care and on hospice. In an observation on 3/21/24 at 9:00am, Resident #14 was lying in bed sleeping, the nebulizer was sitting on the nightstand on the right-side of the bed, the nebulizer tube was hanging down touching the floor, and the cup was not in a plastic bag for storage when not in use. Record review of Resident #17 MDS dated [DATE] revealed 68-yer-old female admitted on [DATE] with BIMS of 13 (cognitively 675932 Page 22 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0695 intact). Medical diagnosis include schizoaffective disorder (abnormal thought process). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #17's prescription order start date 01/16/24, Resident #17 was to receive, ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; amt: 1; inhalation Residents Affected - Some every 4 hours-PRN. In an observation and interview dated 3/21/24 at 10:45am, Resident #17 was seated in a wheelchair watching tv, observed nebulizer on nightstand not bagged. Resident #17 stated she used the nebulizer last night; Resident #17 does not recall that nebulizer has ever been in a bag between uses. In an interview with the DON on 03/22/24 at 10:20 a.m., DON D stated she expected the nebulizer cup and tubing be changed once per week, dated, and stored in baggie when not in use. DON D stated the failure to store the nebulizer cup and tubing properly could result in infection. DON D provided facility policy and procedure. Record review of the policy titled Respiratory Therapy- Prevention of Infection, 2001 MED-PASS, Inc. (Revised November 2011) Indicated: Section: Infection Control Consideration Related to Medication Nebulizer/Continuous Aerosol: Step 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. Resident #3 Record review of Resident #3's Face Sheet, dated 03/14/2024, revealed a [AGE] year-old female who was admitted to the facility 01/16/2024, with diagnoses of Displaced bimalleolar fracture (type of ankle fracture that involves both the distal [point of attachment] ends of the fibula [outer, smaller bone of the lower leg] and tibia [inner, larger bone of the lower legs] bones) of left lower leg, subsequent encounter (after treatment) for open fracture I or II with routine healing (Admission), Encounter for other orthopedic aftercare (critical phase that follows orthopedic surgeries or treatment), Schizophrenia (mental disorder that involves delusions, hallucinations, unusual physical behavior, and disorganized thinking and speech), Epilepsy (disorder of the brain characterized by repeated seizures), Moderate intellectual disabilities (observable developmental delays, which may be accompanied by physical impairments), and Cognitive communication deficit (difficulty with thinking and how someone uses language that may occur after a stroke, brain injury, or other neurological damage). Record review of Resident #3's admission MDS Assessment, dated 01/22/2024, Section C- Cognitive 675932 Page 23 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Response Patterns revealed a BIMS score of 08, which indicated a moderate impairment. Section H Bladder and Bowel under H0100 revealed Resident #3 had an Ostomy appliance (attached to the skin around the stoma to collect bodily waste). During an observation on 03/12/2024 at 11:22 a.m., while interviewing Resident #3 in her room, observed a dark brown smudge, approximately three (3) inches in length on a slate of the window blind and three (3) smaller smudges near the large one. Observed a smaller dark brown smudge on the slate underneath. Observed Resident #3's bed was pushed up against the wall and window and the slates with the brown stain were approximately 6 inches above Resident #3's sheets. Observed a small dark brown smudge on the wall next to Resident #3's headboard and nightstand, approximately ½ inch in size. Observed a brown circle smudge on right front side of Resident #3's oxygen machine that was also brown in color and a smudge on the top left side of the machine brown in color. During an interview on 03/12/2024 at 11:25 a.m., Resident #3 said the substance on the window blind was poop. During an interview on 03/14/2024 at 10:47 a.m., Housekeeper Supervisor J entered Resident #3s room and looked at the dark brown smear on the blinds and the dark brown stain on the wall and said both looked like poop. Housekeeper Supervisor J said the substance on the oxygen machine looked like coffee and feces. Housekeeper Supervisor J said the housekeepers would not clean a medical device but should have notified the nursing staff. Housekeeper Supervisor J said this was an infection control issue and bad practice. Housekeeper Supervisor J at times the housekeepers would get busy and would miss cleaning up. Housekeeper Supervisor J said the housekeepers were supposed to clean behind the residents' beds daily. Housekeeper Supervisor J said not cleaning up the vomit behind Resident #1's and the dark brown residue on Resident #3's blinds and wall could cause a negative outcome. Housekeeper Supervisor J said the resident or his/her room could have gotten sick from the germs. Housekeeper Supervisor J said the house keepers need to monitor the walls and under the bed closer. During an observation on 03/14/2024 at 11:05 a.m., entered the Room of Resident #3 and observed the same stains observed on 03/12/2024 at 11:22 a.m. Review of photo evidence, dated 02/06/2024, sent in by complainant with complaint intake that fecal matter was suspected to be located on the oxygen machine in Resident #3's room was compared to the actual oxygen machine and photo evidence by investigator taken on 03/12/2024 and 03/14/2024. During an interview on 03/14/2024 at 11:36 a.m., Administrator F said the housekeeping department was responsible for cleaning residents' rooms. Administrator F said feces on any item in a resident's room would be a concern and would be an infection control issue and a big deal. During an interview on 03/14/2024 at 11:40 a.m., ADON B said the nursing staff would be responsible for wiping down the oxygen machine every time the tubing was changed. ADON B said tubing was changed once a week. ADON B said feces on the oxygen machine was unsanitary and could cause illness to the residents. During an interview on 03/14/2024 at 11:45 a.m., Human Resource Staff K said she was the Housekeeping Supervisor until 03/04/2024. Human Resource Staff K said she remembered Resident #1 threw up and told her but could not remember when. Human Resource Staff K said she told Resident #1 she would get an aide to clean up the vomit and then she would sanitize the area. Human Resource Staff K said she failed to follow up to ensure the aide cleaned up the vomit. Human Resource Staff K said she did 675932 Page 24 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not know the vomit was cleaned up or not. Human Resource Staff K said if the staff failed to clean up vomit, the room would smell, be unsanitary, smell bad, and could make the resident, his roommate, or anyone who entered the room sick. During an interview on 03/15/2024 at 12:57 p.m., Administrator F said the environmental issues and uncleaned areas of the Resident #1 and Resident #3's room did not meet her expectations. Administrator F said she had identified specific training needs and areas that needed to be changed. Administrator F said she had already identified where employee changes needed to be made. Administrator F said the unclean environment and failure put the residents at risk for illness and unsanitary living conditions. Record review of the facility Resident Rights Guidelines for All Nursing Procedures policy dated 10/2010, revealed, To provide general guidelines for resident rights while caring for the resident. Prior to having direct care responsibilities for residents, staff must have appropriate in-services training on resident rights, including: Resident dignity and respect. Resident notification of rights, service, and health/medical condition Record review of the facility Introduction to Senior Living Properties, LLC policy dated 03/03/23, revealed, Environmental Services - A standard, systematic approach to environmental services was the key to the success of the Environmental Services Department. The performance of Senior Living Properties and its subsidiaries was based upon our ability to teach and implement the methods outlined in this manual. Areas positively impacted by having standardized environmental services methods include: Quality of Service - Quality service can only be delivered and maintained through use of proper environmental services methods, which are outlined herein. Infection Control - Standardized infection control procedures are used in thoroughly cleaning and disinfecting the facilities we serve. Record review of the facility's policy, Environmental Services, dated 03/03/2023, revealed residents' room were cleaned daily with the goal of infection control. The instructions in the policy stated to wipe and disinfect all flat surfaces, wipe, clean, and disinfect all vertical surfaces, dust mop all trash, debris, and dust on floor, and damp mop floor with germicide solution. Every room must be deep cleaned at least monthly including moving furniture and removing any food items and turning over to nursing. 675932 Page 25 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviewed the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for 1 of 4 residents (Resident #1) reviewed for pharmacy services as the facility failed to ensure Resident #1 received ordered glucose readings and insulin when Resident #1 signed out on pass to exit the facility to smoke. The failure placed residents at risk of not receiving the daily therapeutic dosage of medication prescribed by the physician. Findings included: Record review of Resident #1's Face Sheet, dated 03/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Unspecified sequelae (consequence of a previous disease) of cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area), Hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin diminishes and is defined as insulin resistance), and surgical amputation of both legs below the knees. Record review of Resident #1's Quarterly MDS Assessment, dated 01/26/2024, Section C- Cognitive Response Patterns revealed a BIMs score of 14, which identified an intact cognitive response. Review of Section E - Behavior, E0800 revealed Resident #1 had not exhibited rejection of care during the time the assessment was completed. Record review of Resident #1's Care Plan, dated 12/18/2023, revealed Resident #1 had a Problem/Category area of - Smoking: I am a smoker. I am not always compliant with the smoking policies. I have been found smoking outside of the designated smoking area and I have been known for not returning all of my smoking materials. Review revealed Resident #1's goal was to comply with smoking policies and would smoke in designated area(s) at scheduled times through the next review period. Record review of the care plan revealed there was no information documented that resident #1 signed himself out on pass to smoke multiple times a day. Record review of Resident #1's MAR for February 2024, revealed Resident #1 was unavailable to take blood glucose level during the hours of 6:00 a.m. and 8:30 a.m. on 2/04/2024 because he was signed out of the facility. Review revealed Resident #1 was unavailable to take blood glucose level during the hours of 11:00 a.m. and 12:30 p.m. on 02/08/2024 and 02/12/2024, during the hours of 4:00 p.m. and 5:30 p.m. on 02/11/2024 and 02/28/2024, and during the hours of 6:00 p.m. and 10:00 p.m. on 02/01/2024, 02/02/2024, 02/03/2024, 02/04/2024, and 02/05/2024 because he was unavailable. Review revealed Resident #1 did not receive Novolin 70/30 U-100 Insulin suspension; 100 unit/ML, during the hours 11:00 a.m. and 12:30 p.m., on 02/04/2024, 02/075/2024, and 02/12/2024 because he was signed out on pass. Record review of MAR revealed physician was notified. Record review of Resident #1's MAR for March 2024, revealed Resident #1 was not available to have his blood glucose level taken during the hours of 6:00 a.m. and 8:30 a.m. on 03/06/2024, 03/07/2024, 675932 Page 26 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 03/10/2024, 03/12/2024 and 03/15/2024 and Novolin 70/30 U-100 Insulin suspension; 100 unit/ML, during the hours 11:00 a.m. and 12:30 p.m., on 03/12/2024 due to being unavailable. Record review of MAR revealed physician was notified. During an interview on 03/25/2024 at 1:26 p.m., ADON B said the residents who sign out on pass to exit the facility and smoke have not requested to sign out their medications. ADON B said he was unaware of policy that addressed medication when a resident signed out on pass specifically to smoke. ADON B said if a resident missed a dosage of medication due to be out on pass, the physician should be notified. ADON B said the fact that Resident #1 missed his insulin and measuring of glucose was unacceptable and could cause Resident #1 to have elevated blood sugar. During an interview on 03/26/2024 at 3:50 p.m., Resident #1 said he did not take his medication with him when he signed out on pass to smoke. Resident #1 said when he signed out, he did not know how long he would be gone so he did not write down a time that Resident #1 would return. Resident #1 said the nurses had not told him he should take his medication and Resident #1 said he had not asked. During an interview on 03/27/2024 at 9:32 a.m., LVN L said he had observed Resident #1 exit the facility through the front entrance and go to the east side of the facility and smoke unsupervised on numerous occasions. LVN L said Resident #1 signed himself out on pass and LVN L was unsure how long Resident #1 would be away from the facility. LVN L said he did not know if Resident #1 took his medication with him or not. LVN L said he was unaware if the residents who signed out on pass to smoke signed out their medications. LVN L said he was unaware of the policy that covered residents who signed out on pass to smoke regarding medication and had never been in-serviced or trained. During an interview on 03/27/2024 at 2:06 p.m., LVN C said she had observed Resident #1 sign out on pass and go outside to the East side of the building to smoke on numerous occasions. LVN C said she had been assigned to administered medication to Resident #1 on several occasions in February 2024 and if he was not in the building and signed out on pass, LVN C said she would document on the MAR that Resident #1 was unavailable. LVN C said she was unaware of the policy that covered residents who signed out on pass to smoke regarding medication and had never been in-serviced or trained. During an interview on 03/28/2024 at 3:22 p.m., DON D said when a resident went out on pass for days, the resident took his/her medication with them. DON D said the residents who went out on pass to smoke and returned within a short time period and missed their medication did not take their medication with them. DON D said the facility had no process to address missed medications for the residents who went on pass to smoke. DON D said the residents do not ask to take their medication with them when they sign out on pass to smoke. DON D said when the resident comes back and missed the dose, the nurse should contact the doctor. DON D said the risk could be elevated glucose for Resident #1. DON D said she was responsible for ensuring the nurses administered meds and followed procedure. Record review of Resident #1's MAR, dated 02/08/2024, 11:00 a.m. and 12:30 p.m., revealed LVN C did not take Resident #1's glucose level due Resident Unavailable. Record review of facility policy, Administering Medication, dated 04/2019, revealed the policy did not address actions to take if a resident was out on pass. Record review of the facility's policy, Out on Pass/Leave Procedures Policy, dated 01/24/2018, 675932 Page 27 of 28 675932 03/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0755 revealed medications that the resident will need while OOP will be recorded on the medication release form and released by the nurse to the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675932 Page 28 of 28