Health inspection·July 21, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 16 resident (Resident #61) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #61 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings include: Record review of Resident #61's face sheet dated 07/21/2023, revealed an admission date of 06/21/2023, Record review of Resident #61's medical record revealed that as of 07/18/2023, no admission assessment MDS had been completed. Section A of the MDS assessment was still showing as incompleted. Interview with MDS Coordinator B on 07/21/23 at 11:40 a.m. revealed the time frame for an initial MDS to be completed was 14 days from admission. He stated he was not the only MDS nurse for the facility and had not done the assessment for Resident #61. He did no know why the other MDS had not completed the assessment on time. He revealed they used the RAI manual as reference and they had electronic access to the manual. He revealed an incomplete admission assessment was putting the resident at risk for improper care. Interview with the Administrator on 07/21/2023 at 11:45 a.m. revealed the Administrator was not aware the assessment was late. Record review of the mds-3.0-rai-manual-v1.17.1_October_2019 revealed The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the endn of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident' s first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. Page 1 of 3 676099 676099 07/21/2023 The Arbour at Westminster Manor 4200 Jackson Ave Austin, TX 78731

F 0641 Ensure each resident receives an accurate assessment. 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 an assessment which accurately reflected the resident's status for 1 of 18 (Resident #33) residents reviewed, in that: Residents Affected - Few Resident #33's quarterly MDS assessment inaccurately documented 2 administrations of insulin which did not occur. This failure could result in inadequate care due to an inaccurate assessment of his medication administrations. The findings were: Record review of Resident #33's face sheet, dated 07/19/2023, revealed the male resident, aged [AGE] year, was admitted to the facility on [DATE] with diagnoses including: type 2 diabetes mellitus with hyperglycemia (a condition that occurs with elevated blood sugar levels), anxiety disorder unspecified (a condition in which feelings of worry and fear interfere with daily activities), and peripheral vascular disease unspecified (a condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #33's Quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. Record review of Resident #33's physician order summary dated 7/19/23 revealed an order, initiated 02/05/2021, for Trulicity Solution (an active substance which is not insulin and is used to lower blood sugar) Pen-injector .75mg, inject 0.5 ml subcutaneously once a week. The physician order summary revealed no orders for insulin for the time frame of 05/06/2023 or for a look back period of 7 days. Record review of Resident #33's quarterly MDS assessment dated [DATE] Section N revealed documentation of two insulin administrations. During an interview with the MDS Manager and the DON on 07/20/2023 at 08:15a.m. both staff stated that the MDS document dated 05/06/2023 for Resident #33 inaccurately noted that Resident #33 was given 2 insulin administrations during a 7 day look back period. The MDS Manager stated that the medication administrations were for the medication Trulicity and not for the medication insulin. She stated that Resident #33 does not take insulin. She stated that the MDS assessments need to accurately reflect what was going on with the resident. The DON stated the MDS assessment needs contain accurate information to be reported to the government. Record review of the facility policy for Comprehensive Assessments dated 02/2022 stated that the comprehensive assessments are to be conducted in accordance with the criteria and time frames established in the Resident Assessment Instrument User Manual. 676099 Page 2 of 3 676099 07/21/2023 The Arbour at Westminster Manor 4200 Jackson Ave Austin, TX 78731

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 designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 wings (East wing) on the second floor of the facility reviewed for infection control, in that: Residents Affected - Some Laundry staff C did not sanitize her hands between residents' room. This deficient practice could place residents at-risk for infection due to improper care practices. The findings include: Observation on 07/18/2023 at 1:12 p.m. revealed Laundry staff C, on the second Eastside wing was passing clean clothing to the residents' room. Laundry staff C was observed going to 3 different rooms, placing clothing in closets and drawers, without practicing hand hygiene. Interview with Laundry staff C, on 07/18/2023 at 1:18 p.m., Laundry staff C confirmed she did not sanitize her hands. Laundry staff C stated she had received infection control and hand hygiene training. Interview with the DON, on 07/20/2023 on 2:34 p.m., the DON confirmed the laundry staff should practice hand hygiene between rooms and residents. The DON stated Laundry staff was trained on infection control like the rest of the staff. Audit and spot check were done by the ADON during the week and the RN supervisor during the weekend to insure procedures were followed. Review of the facility policy titled, Handwashing/hand hygiene, dated August 2019, revealed use an alcohol-based hand rub containing at least 62% alcohol [ .] for the following situations: [ .] after contact with objects in the immediate vicinity of the resident. 676099 Page 3 of 3