Health inspection·November 20, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on interviews and records reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #2) of 3 residents reviewed for baseline care plans. The facility failed to ensure Resident #2 had a baseline care plan developed within 48-hours after admission with goals, services, and interventions. This failure could place newly admitted residents at risk of not receiving the care and services needed to promote good health and continuity of services. The findings included: Record review of Resident #2's Face sheet, dated 11/20/2024, revealed Resident #2 was a 62 -year-old male, with an admission date of 11/08/2024. Diagnoses included Myopathy (disease of muscle tissue), Insomnia (inability to sleep peacefully), hypertension (high blood pressure), esophageal varices with bleeding (cancer arising from the esophagus), alcoholic liver disease, Type 2 diabetes (adult-onset diabetes). Record review of Resident #2's admission MDS assessment, dated 11/14/2024, revealed Resident #2's BIMS score was N/A, Section A of MDS was only section completed at time of investigation on 11/20/24. Record review of Resident #2's clinical records revealed there was no Baseline Care Plan or Comprehensive Care Plan in the facility's electronic health record system. During an interview on 11/20/2024 at 2:50 p.m., the DON said the DON, weekend RN on duty should have completed the baseline care plan. DON stated it was her expectation that a baseline Care Plan be completed within 48 hours of resident's admission so staff can care for resident's needs. During an interview on 11/20/2024 at 3:00 p.m., the Administrator said her expectation was for baseline care plans to be completed upon admission with the first 48 hours. The Administrator said the development of a Baseline Care Plan was the responsibility of the nursing staff and should be monitored by the DON. The Administrator said the negative outcome of not having a Baseline Care Plan would be improper care. Page 1 of 4 675932 675932 11/20/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0655 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy, Care Plans - Baseline, dated 07/2024, revealed a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The DON, RN Weekend Supervisor or a registered nurse on duty will complete the baseline care plan. The interdisciplinary Team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate needs. Residents Affected - Few 675932 Page 2 of 4 675932 11/20/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident #2) of one resident observed for infection control practices in that: Residents Affected - Few The facility failed to ensure the WCN performed adequate hand hygiene by scrubbing hands with soap for at least 20 seconds or greater before and after performing wound care on Resident # 2. This failure could place residents that require wound care at risk for healthcare associated cross-contamination and infections. The findings included: Record review of Resident #2's Face sheet, dated 11/20/2024, revealed Resident #2 was a 62 -year-old male, with an admission date of 11/08/2024. Diagnoses included Myopathy (disease of muscle tissue), Insomnia (inability to sleep peacefully), hypertension (high blood pressure), esophageal varices with bleeding (cancer arising from the esophagus), alcoholic liver disease, Type 2 diabetes (adult-onset diabetes). Record review of Resident #2's Quarterly MDS assessment, dated 11/14/2024, revealed Resident #2's BIMS score was N/A, Section A of MDS was only section completed at time of investigation on 11/20/24. Record review of Resident #2's clinical records revealed there was no Baseline Care Plan or Comprehensive Care Plan in the facility's electronic health record system. Record review of physician's orders revealed Resident #2 had wound on calf on right leg. Orders were clean wound with wound cleaner, pat dry, apply calcium alginate, apply dressing, 3 times per week. During observation on 11/20/2024 at 1:52pm of wound care, the WCN applied calcium alginate, new dressing applied, did not use a no-touch technique, WCN did not use tongues while applying clean wound, use just gloves. WCN did not perform hand hygiene or don clean gloves before applying wound medication and clean dressing. In an interview on 11/20/2024 at 2:05pm WCN stated she forgot to perform hand hygiene between cleaning and applying new dressing. The WCN stated not washing hands and changing gloves at the appropriate intervals could put residents at risk of getting their wounds infected or slow the healing process. The WCN stated she was nervous and did not realize she had skipped a step. The WCN could not state when the last in-service on performing hand hygiene was. In an interview on 11/20/2024 at 2:50pm the DON stated all staff are expected to wash hands for at least 20 seconds or greater to maintain infection control measures and stop the spread of germs. The DON stated not performing hand hygiene and wearing gloves as recommended could cause the resident's wounds to get infected. The DON stated she was going to conduct a one-on-one training with the WCN 675932 Page 3 of 4 675932 11/20/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0880 and in-service all staff on hand washing and changing gloves. DON stated the nurses are to follow Wound Care procedure with regards to infection control. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Wound Care program dated 6/2024 stated: Residents Affected - Few Steps in procedure: 2. Perform hand hygiene, 4. Put on clean gloves, remove dressing, 5. remove gloves, perform hand hygiene, 6. Put clean gloves on, 7. Use no-touch technique, use sterile tongue blades and applicators to remove ointments and creams from containers. 675932 Page 4 of 4