Health inspection·November 20, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 3 (Resident #135, #79 and 72) 8 residents reviewed for comprehensive care plans. The facility failed to ensure Residents #135, #79, and #72's comprehensive care plans reflected the residents were at a high risk for wandering and them residing in the memory care unit. This deficient practice could place residents at risk for receiving improper care and services due to inaccurate care plans. Findings included: 1. Review of Resident # 135's face sheet dated 11/19/2024 revealed an [AGE] year-old female admitted on [DATE] with a readmission on [DATE]. Her diagnosis included Dementia in other Diseases classified elsewhere, moderate, with other behavioral disturbance (long-term brain disorder causing personality changes and impaired memory, reasoning, and social function), Arteriosclerotic heart disease (abnormal called lesions in the walls of arteries), and anxiety disorder (a group for mental disorders characterized by significant and uncontrollable feelings of anxiety). Review of Resident # 135's admission MDS assessment dated [DATE] revealed a BIMS score of 10 which can indicate she had moderate cognitive impairment. Section E - Behavior revealed the resident had verbal behavior occurred 1 to 3 days, and other behavioral symptoms not directed at others occurred 1 to 3 days, these behavioral symptoms did not put the resident or others are risk. The resident had wandering behavior that occurred 1 to 3 days with no impact of risk to resident or the privacy of others during the seven day look back period. Review of Resident # 135's Care plan dated 10/4/2024 revealed no indication of wandering behavior or interventions present. No indication in care plan for need for memory care unit or any interventions. Review of Resident #135's physician orders dated 10/08/2024 revealed admit to memory care unit. Review of Resident # 135's Memory Care Unit admission screening for placement dated 10/08/2024 revealed the resident has Alzheimer's of related dementia diagnosis; a habit of wandering, and was able to ambulate independently, and less restrictive alternative have been unsuccessful and will benefit Page 1 of 6 675946 675946 11/20/2024 Avir at Temple East 1511 Marlandwood Rd Temple, TX 76502

F 0656 from a structured environment with specialized activities therefore met criteria. Level of Harm - Minimal harm or potential for actual harm Review of Resident # 135's Wandering assessment dated [DATE] revealed a wandering score of 11 (Above high risk to wander) Residents Affected - Some Review of Resident # 135's Consent for Memory care unit dated 10/7/2024 revealed it was signed by resident's responsible party. 2. Review of Resident # 79's Face sheet dated 11/19/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Congestive Heart Failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), and bipolar disorder (a mental disorder characterized by period of depression and periods of abnormally elevated mood that each last from days to weeks.) Review of Resident # 79's review of admission MDS dated [DATE] revealed a BIMS score of 15 (cognitively intact). Behavior section revealed Physical behavioral symptoms towards others occurred 1-3 days during the look back period, verbal behavioral symptoms towards others occurred 1-3 days 1 to 3 days during the 7-day look back period and other behavioral symptoms not directed toward others occurred 1 to 3 days during the same look back period. Behaviors did not have an impact on the resident or others. Wandering occurred 1 to 3 days during the 7-day look back period with no impact on the resident or invasion of others privacy. Behavior symptoms remained the same. Review of Resident # 79's care plan dated 10/8/2024 revealed no problem or interventions for wandering behavior and no problem of interventions for need to be in the memory care unit. Review of Resident # 79's physician order dated 9/19/2024 revealed admit to Memory care unit. Review of Resident # 79's memory care unit admission screening dated 9/18/2024 revealed the resident had a habit of wandering and less restrictive alternatives had been unsuccessful. The resident was able to ambulate independently and would benefit from a structured environment with specialized activities. Review of Resident # 79's wandering risk scale dated 9/18/2024 revealed a score of 11 which placed the resident at high risk to wander. Review of Resident # 79's memory care unit consent for placement dated 9/18/2024 revealed it was signed by Resident # 79. 3. Review of Resident #72's face sheet dated 11/19/2024 revealed an [AGE] year-old female admitted on [DATE] with diagnoses that include Alzheimer's disease (a biological process that begins with the appearance of buildup of proteins in the brain), and schizoaffective disorder (a mental disorder characterized by symptoms of schizophrenia (a mental disorder characterized by hallucinations, delusions, disorganized thought process, a flat or inappropriate affect, and a mood disorder.) Review of Resident # 72's Quarterly MDS dated [DATE] revealed the resident has a BIMS score of 4 (severe cognitive impairment). Behavioral symptoms include verbal behavioral symptoms directed toward others and other behavioral symptoms not directed at others occurred 1 to 3 days during the 7-day 675946 Page 2 of 6 675946 11/20/2024 Avir at Temple East 1511 Marlandwood Rd Temple, TX 76502

F 0656 Level of Harm - Minimal harm or potential for actual harm look back period. Wandering behavior occurred 4-6 days but less than daily during the 7-day look back period. Review of Resident # 72's care plan dated 10/8/2024 revealed no problem or interventions for wandering or placement on the memory care unit. Residents Affected - Some Review of Resident # 72's order listing report dated 11/19/2024 revealed an order to admit to memory care unit dated 3/14/2024. Review of Resident # 72's Memory care unit admission for screening for placement dated 9/17/2024 revealed the resident had a diagnosis of Alzheimer's, habitually wandered, less restrictive measures had been unsuccessful, resident was able to ambulate independently, and would benefit from a structured environment with specialized activities. Review of Resident # 72's Wandering risk scale dated 10/17/2024 revealed a score of 11 which indicated the resident was high risk for wandering. Review of Resident # 72's Memory care unit consent for placement dated 10/17/2024 revealed the consent was signed by resident's responsible party. Observation 11-19-24 at 11:30 am . Resident # 135 was sitting at a table drinking some water ready for lunch clean dry and odor free. Resident # 79 was sitting in the common room in her wheelchair Resident # 72 was roaming around the unit interacting with other resident and staff clean dry and odor free. Interview with SW on 11/20/2024 at 10:00 am stated that the IDT were responsible for updating the care plan. She stated she does the assessment to determine if a resident needs memory care and get with the nurse to get the order. She stated she was not aware of care planning behaviors and the need to be on the locked unit. Interview with the Corporate MDS nurse,11/20/2024 at 11:00 am revealed she came to the facility about once a week, and the remote MDS coder is responsible for updating the care plan for the care items that triggered on the MDS, nursing and the social worker could have updated the care plan for behaviors and the need for memory care. Interview with the DON on 11/20/2024 at 12:30 PM revealed that her expectation was the care plans are up to date and show an accurate picture of the resident's actual needs. She stated, I currently do not have a MDS nurse and that the IDT team were trying to fill in and make sure care plans are accurate. She stated they have a stand-up meeting daily to discuss current issues and a pre-admission meeting for new residents. She stated she is not sure how the behaviors and the need for the memory care unit did not get placed on the care plans. She stated if a care plan is not current it can place the resident at risk to get inappropriate care. She stated, at the least, her expectation is that the care plan is accurate when the quarterly assessment is completed. Interview on 11/202/2024 at 2:30 PM with the ADM revealed his expectation are that care plans are updated at least 24 hours after a need is identified. He stated the team has a daily meeting Monday through Friday, and any issues raised in this meeting, should be addressed on the care plan if needed. An undated care plan is essential for the resident to receive the care they need and deserve. 675946 Page 3 of 6 675946 11/20/2024 Avir at Temple East 1511 Marlandwood Rd Temple, TX 76502

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Care Plan; Comprehensive Person-Centered revised December 2016 reflected the following: .13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. Residents Affected - Some 14. The Interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident condition, B. when the desired outcome is not met, d. At least quarterly, in conjunction with the required quarterly MDS Assessment . 675946 Page 4 of 6 675946 11/20/2024 Avir at Temple East 1511 Marlandwood Rd Temple, TX 76502

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure food items in both refrigerators, in the kitchen, were dated and labeled. The facility failed to ensure personnel items were not stored in facility refrigerator with resident food. This failure could place the residents at risk for food borne illness and cross contamination. Findings included: Observation of the kitchen on 11/18/2024 at 7:25 am of refrigerator #1 revealed two opaque plastic pitchers with covers of unknown substance with no label as to contents or use by date. Observation of the kitchen on 11/18/2024 at 7:28 am of refrigerator # 2 revealed a personnel water bottle, A Ziploc bag containing a bag of yellow slivers not identified or labeled with a use by date. A Ziploc bag containing large brown and white objects, not labeled with an identifier or a use by date. A Ziploc bag containing oval shaped pink with brown on the outside objects with no identifier or use by date noted. Interview with the DC on 11/18/2024 at 11:30 am revealed that all foods placed in the refrigerators ere to be labeled with the identification of the product, the date it was opened, and the use by date. She stated that she would not use any food not labeled as it may pose a risk to the residents for food borne illnesses. She stated it was the responsibility of the staff member to have labeled correctly and food items placed in the refrigerators. Interview on 11/18/202 at 12:30 PM with the RD revealed that all opened items should be labeled with what they are, when they were opened, and when the use by date is; no matter where they are stored. The risk of using undated and unlabeled food products, is a food borne illness for the residents. Interview on 11/20/2024 at 8:30 am with the DM revealed his expectation was any product opened and placed in another container should be labeled with its name, date of when open and when used by placed on the outside of the new container. He had instructed his staff not to use items not labeled correctly. He said the use of food items not labeled correctly could put the residents at risk for foodborne illnesses. Interview on 11/20/2024 at 2:30 PM with the ADM who stated all food in the kitchen should be safely stored which includes labeling and dating. The ADM stated his expectation is that any food not labeled correctly, not be served to the residents due to the risk of foodborne illnesses. Record review on 11/20/2024 of the facility's policy entitled Food Storage updated 2018 reflected: .2. Refrigerators d. Date, label and tightly seal all refrigerated food using clean, nonabsorbent 675946 Page 5 of 6 675946 11/20/2024 Avir at Temple East 1511 Marlandwood Rd Temple, TX 76502

F 0812 covered containers that are approved for food storage. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675946 Page 6 of 6