Health inspection·March 13, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review the facility failed to ensure a resident had the right to a dignified existence and was treated with respect for 1 of 4 residents reviewed for rights. ( Resident #1) The facility failed to ensure CNA A provided Resident #1 with care when she activated her said staff often come into her room and turn the call light, CNA A entered the room turned the call light off and left the room. without providing any care or consideration due to her speech impairment and them not wanting to take the time and listen. CNA A was seen in a video turning off Resident #1's call light without providing her assistance. This failure placed residents at risk of deficient practice could cause the resident not receiving needed care and services, loss of dignity and self-worth. Findings included: Record review of Resident #1's undated face sheet indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included amyotrophic lateral sclerosis (ALS- a muscular weakness or loss with difficulty speaking and swallowing), high blood, pressure, and anxiety disorder. Record review of Resident #1's a significant change MDS dated [DATE] indicated intact cognition. The resident required substantial to maximum assist with eating toileting, and upper body dressing. The resident was occasionally incontinent of bile and bladder. Record review of a care plan for Resident #1 with a problem start date of 12/8/23 and last edited on 3/6/24 indicated a problem of behavioral symptoms. The resident exhibited depressive/maladaptive behaviors and agitation with staff as evidenced by refusing ADL care, medication's, eating, likewise, she refused to use the communication board to enable staff to meet her needs. On 2/23/24. The resident complained of nasal congestion then refused to take the prescribed medication. The resident continued to refuse other medication's that were ordered by the physician. On 2/24/24. The resident refused to allow an aid to feed her breakfast. On 2/25/24. The resident continued to refuse to allow certain staff to feed her. On 2/26/24. The resident refused her hair, face and back to be washed. On 2/28/24 the resident refused all nighttime meds. On 3/2/24 the resident screamed out when a CNA attempted to place her on the bed pan and later refused to allow the CNA to feed her dinner. Some of the approaches were when the resident became agitated, wait until a later time to approach. Have familiar staff feed resident when available. Hospice called regarding the resident not wanting to be fed by Page 1 of 6 675949 675949 03/13/2024 Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aid or allow the aid to be taught the way resident would allow staff to feed her. The staff would calmly explain the procedure prior to providing care and the staff would give the resident ample time to respond , if the resident became upset, they would ensure her safety and allow her time to calm down before care resumed. A problem for the start date of 11/22/23. The resident hads difficulty making self-understood related to a diagnosis of ALS. One of the approaches was to provide a quiet non-hurried environment, free of distractions, and repeat what the resident hads expressed to validate. Record review of Resident #1's care plan dated 2/20/24 indicated the Resident /RP had elected to use a camera/electronic monitoring device in the room. One of the approaches was to ensure residents and staff are aware they are being recorded. Review of a video dated 2/24/24 at 6:29 p.m. showed CNA A go into the Resident #1's room. He turned off the call light without asking her what she needed. Resident #1 asked him, Are you going to feed me? and he said I am sure other people have tried. He continued to exit the room and said, I have got to go and finish up. During an interview on 3/6/24 at 1:30 p.m., with Resident #1 revealed that her speech was hard to understand. She said that the staff did not respect her. She said there was video that showed a male aide coame into her room, turned the call light off. She asked to be feed and he said other people had tried. Resident #1 said it could seen by the video that the food was still covered, and no one had tried to feed her. She said that later that night a nurse came in and assisted her with eating at about 730 p.m. Resident #1 said the staff reported she had refused to eat but she was easily choked. She said she was afraid for people to feed her that had not assisted her with eating in the past. Resident #1 said they do not understand her, and they leave her alone because they do not understand but she did not refuse. She said she wanted to eat . During an interview on 3/6/24 at 4:31 p.m., the DON, ADON and Administrator said they would try to teach staff to feed the resident and sometimes she still would not allow them to assist her with eating. They said she often would not allow certain people to help her. During an interview 3/6/24 at 3:45 p.m., CNA A said he had worked at the facility about a month. He first said he did not remember going into Resident #1's room turninged off the call light and did not providing her care. After looking at the video he said he did remember, it was a weekend 2/24/24 and he was told by several aides Resident #1 had refused to allow them to feed her. He said he had gone in the room and asked the resident what she needed. She asked him if he was going to feed her. He turned off the call light and told her other people had trired and left. He said he told her he would tell the nurse. He said he did not assist residents on the hall with eating. He assisted residents in the dining room. During a telephone interview on 3/13/24 at 10:44 a.m., LVN B said she did come in that Sunday, 2/24/24 at 6:00 p.m. and the staff said Resident #1 had refused to allow several staff to feed her dinner. She said she did not know the exact time she had gone in the room around 6:30 p.m. or so after she had completed getting report. She said she did not remember an aide telling her Resident #1 wanted to be feed. She had just received the information in report and decided she would give it a try. She said she had gone in and assisted Resident #1 with eating with no problems. During an interview on 3/13/24 at 8:39 a.m., Resident #1's friend said she came to the facility most days. The friend replayed the video when CNA A came into the room and turned off the call light. CNA A could clearly be heard saying I have to go finish up as he left the room. The friend said the biggest problem was that staff would come in and turn off the call light and without care being 675949 Page 2 of 6 675949 03/13/2024 Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503

F 0550 provided. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675949 Page 3 of 6 675949 03/13/2024 Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident receives and the facility provides food prepared in a form that meet the resident needs for 1 of 4 residents reviewed for puree food. (Resident #1) The facility failed to ensure Resident #1's pureed breakfast meal was the correct consistency and not bland. This deficient practice could place residents at risk for weight loss. Findings included. Record review of Resident #1's significant change MDS dated [DATE] indicated intact cognition. The resident required substantial to maximum assist with eating toileting, and upper body dressing. The resident was occasionally incontinent of bowel and bladder. Record review of a care plan with a problem start date of 12/8/23 and last edited on 3/6/24 indicated the resident exhibited depressive/maladaptive behaviors and agitation with staff as evidenced by refusing ADL care, medication's, eating, likewise, she refused to use the communication board to enable staff to meet her needs. On 2/23/24. The resident complained of nasal congestion then refused to take the prescribed medication. The resident continued to refuse other medication's that were ordered by the physician. On 2/24/24. The resident refused to allow an aid to feed her breakfast. On 2/25/24. The resident continued to refuse to allow certain staff to feed her. On 2/26/24. The resident refused her hair, face and back to be washed. On 2/28/24 the resident refused all nighttime meds. On 3/2/24 the resident screamed out when a CNA attempted to place her on the bed pan and later refused to allow the CNA to feed her dinner. Some of the approaches were when the resident became agitated, wait until a later time to approach. Have familiar staff feed resident when available. Hospice called regarding the resident not wanting to be fed by aid or allow the aid to be taught the way resident would allow staff to feed her. The staff would calmly explain the procedure prior to providing care and the staff would give the resident ample time to respond, if the resident became upset, they would ensure her safety and allow her time to calm down before care resumed. A problem for the start date of 11/22/23. The resident has difficulty making self-understood related to a diagnosis of ALS. One of the approaches was to provide a quiet non-hurried environment, free of distractions, and repeat what the resident has expressed to validate. Record review of Resident #1's care plan dated 2/20/24 indicated the Resident /RP had elected to use a camera/electronic monitoring device in the room. One of the approaches was to ensure residents and staff are aware they are being recorded. During an observation and interview on 3/6/24 at 12:50 p.m., Resident #1 received her tray and the ADON was there to assist her with eating. On the tray was a meal slip that read regular pureed diet mildly thick Nectar like with the word waiver written on top. Offer and encourage nectar fluids with and between meals. Food in large bowls assisted with meals, large pureed portions of food at all meals. The resident had pureed carrots, potatoes, chicken fried steak and gravy and dessert. The bowel with the chicken fried steak looked like cottage cheese, it was very lumpy. The ADON tried to smooth some of the lumps but was unable to do so. She said it was lumpy. Resident #1 said she did not want any meat. 675949 Page 4 of 6 675949 03/13/2024 Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 3/13/24 at 6:40 a.m. of a sign posted in the kitchen indicated the census wase 72 residents. There were 56 regular diets, 9 mechanical soft diets, and 7 puréed diets. During an observation and interview on 3/13/24 at 6:50 a.m., the cook prepared pureed sausage, she said she eyeballed it and to see how many sausages she needed. She said there were 7 residents on pureed diets, so she doubled the amount because they were supposed to get two sausages apiece. She placed 10 sausages into the blender and about half of an 8-ounce carton of whole milk. The cook ran the [NAME] for about 4 minutes, the mixture was pasty and thick. She removed the mixture from the blender and put it on the serving table. At 7:02 a.m., a sample of the sausage with the cook had small particles of meat. The cook said she had to chew to swallow the mixture. She placed the mixture back in the blender and added more milk and blended it for about 4 more minutes. A sample of the mixture was taken, and it still had meat particles. The cook added more milk and blended the mixture for about 4 more minutes, a sample was then smooth, and it could be swallowed without having to chew. The cook said if there was a recipe for the purée sausage, she was not made aware and had never used a recipe to puree food by. She said she just eyeballed it to determine if it looked right. She said she had never tried the puree food before. Observation and interview on 3/13/24 at 7:20 a.m., the cook prepared puree eggs she put several scoops of scrambled eggs into the blender. She did not measure them out. She added a little milk about a half an 8-ounce carton and blended it. A sample of the eggs was taken they were without taste but smooth. She said that she was not aware of a recipe for pureed eggs. During an interview on 3/13/24 at 7: 57 a.m., the dietary manager said that there was a recipe for pureed food. She said the cook was relatively new and she had not shown her the recipe for the puree foods yet. She said that she had had issues with Resident #1 before. The dietary manager said if the food was a smooth enough, she would take it back to the kitchen. She would sometimes have to blend the food some more because Resident #1 required her food be at baby food consistency. Record review of the pureed diet food guide indicated for meat 1ounce of cooked meat was equal to 1 ounce of protein. One egg cooked was equal to 1 ounce of protein. Record review of the recipe for pureed breakfast sausage indicated Ingredients beef base- 4th teaspoon, water- 2/3 cup breakfast sausage seven each. Dissolve base in water to make broth placed prepared, sausage and broth in a sanitize food processor and blend until smooth. Note any liquid specified in the recipe is a suggested amount of fluid some recipe items will require no fluid, added to achieve the desired consistency. If the product needs thinning gradually add an appropriate amount of liquid, not water to achieve a smooth pudding or mashed potato consistency. If the product needs sticking gradually add a combined and natural water thicker, such as potato flakes, or baby rice to achieve a smooth, putting soft mashed potato consistency. Record review of the recipe for puréed scrambled eggs indicated scrambled eggs, seven each and 5 tablespoons and 2 teaspoons of milk. Place prepared scramble, eggs, and milk in a sanitize processor for at least 15 seconds. Note any liquid specified in the recipe was a suggested amount of fluid some recipe items will require no fluid, added to achieve the desired consistency. If the product needs thinning gradually add an appropriate amount of liquid, not water to achieve a smooth pudding or mashed potato consistency. If the product needs sticking gradually add a combined and natural water thicker, such as potato flakes, or baby rice to achieve a smooth, putting soft mashed potato consistency. 675949 Page 5 of 6 675949 03/13/2024 Avir at Cowhorn Creek 5524 Cowhorn Creek Texarkana, TX 75503

F 0805 Level of Harm - Minimal harm or potential for actual harm Record review of the Puree Diet policy (Manual 2022) indicated the pureed diet is designed for individuals who cannot chew foods or have difficulty swallowing. The puree diet followed the regular diet with alterations in the consist of food to puree consistency as needed. Additional liquid is added in the form of broth, gravy, vegetable or fruit juices, or milk to achieve the appropriate consist of pudding, smooth mash potatoes. Weigh or measure the number of drained portions required for the standardized recipe. Residents Affected - Few 675949 Page 6 of 6