Health inspection·January 12, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs for 4 of 18 residents (Residents #5, #31, #47, and #19) reviewed for call lights. Residents Affected - Some The facility failed to ensure the call lights were within reach for Residents #5, #31, #47, and #19. This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life. Findings included: Review of Resident #5's Face sheet, dated 01/12/23, revealed the resident was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset, hypertensive heart disease without heart failure, psychotic disorder with delusions due to known physiological condition. Review of Resident #5's care plan, dated 11/11/22, revealed Resident #5 had an ADL self-performance deficit r/t Alzheimer's, Dementia, Impaired balance. The interventions included: Encourage use of bell to call for assistance. Review of Resident #5's quarterly MDS (assessment), dated 12/03/22, revealed a BIMS score of 05 which indicated the resident's cognition was severely impaired. The MDS further indicated Resident #5 limited assistance by one person for physical assistance with mobility. An observation on 01/10/23 at 11:02 AM of Resident #5 revealed the resident was seated on her bed. The call button was on top of the resident's overbed light and out of reach of the resident. An attempt was made to interview Resident #5, but Resident #5 was unable to answer any questions. Review of Resident #31's Face Sheet, dated 01/12/23, revealed the resident was an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dementia, without behavioral disturbance, cognitive communication deficits, hypertensive heart disease without heart failure. Review of Resident #31's care plan, dated 11/11/22, revealed, Resident #31 was at risk for falls r/t gait/balance problems; the resident will be free of falls through the review date; The interventions included: Be sure the resident's call light is with reach and encourage the resident to use it Page 1 of 18 676127 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0558 for assistance as needed. Level of Harm - Minimal harm or potential for actual harm Review of Resident #31's quarterly MDS, dated [DATE], revealed the BIMS score was not completed due to the resident rarely/never being understood. The MDS further indicated Resident #5 limited assistance by one person for physical assistance with mobility. Residents Affected - Some An observation on 01/10/23 at 11:05 AM of Resident #31 revealed the resident was seated on her bed. The resident's call button was on the floor, under the bed, and out of reach of the resident. An attempt was made to interview Resident #31, but Resident #31 was unable to answer any questions. Review of Resident #47's Face Sheet, dated 01/12/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, Parkinson's disease and other chronic pain. Review of Resident #47's quarterly MDS, dated [DATE], revealed the BIMS score was 11 which indicated moderate cognitive impairment. The MDS further indicated Resident #47 needed extensive assistance by two people for transfers from the bed, chair, wheelchair, and standing position. Review of Resident #47's care plan, dated 12/29/22, revealed, Resident #47 was a high risk for falls r/t weakness, Alzheimer's, Dementia. Her risk score was 18; the resident will be free of falls through the review date. The interventions included: Be sure the resident's call light is with reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. An observation on 01/10/23 at 2:33 PM of Resident #47 revealed the resident was in bed sleeping. The call button was on the floor, under the bed, and out of reach of the resident. Review of Resident #19's Face sheet, dated 01/12/23, revealed the resident was an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Alzheimer's disease with late onset, vascular dementia, unspecified severity, with anxiety. Review of Resident #19's quarterly MDS, dated [DATE], revealed the BIMS was not completed due to the resident rarely/never being understood. The MDS further indicated Resident #19 needed extensive assistance by two people for transfers from the bed, chair, wheelchair, and standing position. Review of Resident #19's care plan, dated 01/02/23, revealed, Resident #19 has a history of falling r/t diagnosis of dementia, decreased functional mobility, poor safety skill and poor endurance; resident will remain free from major injuries. The interventions included keep call light in reach at all times. An observation on 01/10/23 at 2:34 PM of Resident #19 revealed the resident was in bed sleeping. The call button was inside the resident's nightstand drawer and out of reach of the resident. During an observation and interview on 01/10/23 at 2:50 PM, CNA E revealed she was the aide for 300 Hall. She stated she completed her hall round after lunch around 1:00 PM-1:15 PM. She stated calls lights needed to be within reach of residents; even if the residents are not able to use it. She stated they usually placed the call lights in the residents' bed. CNA E stated all the residents on her hall had their call lights within reach. CNA E and the State Surveyor checked on Residents #5, #31, and #47. CNA E was observed to pick up and move the call lights closer to the residents. Observed 676127 Page 2 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #19 to have her call light clipped to the bed. CNA E stated she was not aware that the call lights were not within reach. She stated the risk of not having call lights within reach could prevent resident from calling for help during an emergency. During an interview on 01/10/23 at 2:50 PM, LVN D revealed she was the nurse for 300 Hall. She stated she completed her rounds when she came into the unit around 2:15 PM. LVN D stated call lights should be placed within reach of the resident. LVN D stated it was everyone's responsibility to ensure that the call lights were within reach. She stated she was not aware that Residents #5, #31, #47, and #19 did not have their call lights within reach. She stated the risk of not having call lights within reach could prevent residents from calling for help. During an interview on 01/12/23 at 3:44 PM, the DON revealed her expectations were for staff to keep call lights within reach of residents and for staff to answer in a timely matter. She stated anyone working in the secure unit or the facility are responsible to ensure call lights are within reach of the residents. She stated the risk of not having them within reach was the resident would not be able to call for assistance. Review of the facility's policy entitled Call Light - Use of, dated June 2022, revealed: It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use. 676127 Page 3 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

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 observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of four residents (Residents #35, and #67) reviewed for comprehensive assessments. The facility failed to ensure Resident #35 and Resident #67 had a care plan that addressed the residents' need for oxygen use. This failure could place residents at risk for incomplete assessments which could cause incorrect care and services in oxygen support and could result in a decline in health. Findings included: 1. Review of Resident #35's face sheet, dated 01/12/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, Review of Resident #35's care plan, dated 12/02/22, revealed the care plan did not address the resident's oxygen use. Review of Resident #35's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The resident's active diagnoses included asthma, chronic obstructive pulmonary disease. The MDS reflected Resident #35 received oxygen therapy. Review of Resident #35's physician orders revealed: Change and date oxygen tubing/humidifier and nebulizer plastics (if in use) every Saturday NOC shift and include dated plastic bag for storage. Order dated: 11/09/22; Time: 10:00 PM - 06:00 AM. Review of Resident #35's physician orders revealed: Change O2 tubing and date. Special Instructions: Change tubing and date every Sunday on night shift. Order date: 05/30/22; Time: 10:00 PM - 06:00 AM General: Clean O2 concentrator filters, oxygen @ (blank) l/min via nasal canula (orders did not reflect oxygen flow rate) During observation and interview on 01/10/23 at 10:30 AM, Resident #35 was lying in bed, and she stated just finished breakfast. Resident #35 had a nasal canula in her nose. Observation of the tubing was dated 12/31/22 and the water bottle was empty with a date of 12/31/22. Resident #35 stated the facility was to change out the oxygen tubing and water bottle weekly. Resident #35 stated she was not aware of when the last time staff has come to change out the tubing and water. Resident #35 stated so far, she has not had any issues with her breathing or feeling ill due to the tubing and water not being changed. During observation and interview with Resident #35 on 01/12/23 at 11:40 AM revealed the oxygen tubing and water bottle were dated 01/11/23. Resident #35 stated staff on the overnight shift changed the tubing and water due to resident water had run out. 676127 Page 4 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of Resident #67's face sheet, dated 01/12/23, revealed the resident was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included disease of upper respiratory tract, presence of automatic (implantable) cardiac defibrillator, shortness of breath, cardiac arrhythmia, congestive heart failure. Review of Resident #67's care plan, dated 08/02/22, revealed the resident had COPD, The care plan goal reflected the resident would display optimal breathing pattern daily through review date. The care plan approaches reflected to give aerosol or bronchodilators as ordered, give oxygen therapy as ordered by the physician. Head of bed elevated, monitor for difficulty breathing on exertion, monitor for acute respiratory insufficiency. Review of Resident #67's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The resident's active diagnoses included coronary artery disease and heart failure. The MDS reflected no indication of oxygen use. Review of Resident #67's physician orders revealed: Change and date oxygen tubing/humidifier and nebulizer plastics (if in use) every Saturday NOC shift and include dated plastic bag for storage. Order date: 11/09/22; Time: 10:00 PM - 06:00 AM Review of Resident #67's physician order revealed: May have oxygen as needed due to anxiousness; Order date: 08/13/22. The orders did not reflect an oxygen flow rate. During observation and interview on 01/10/23 at 1:53 PM revealed Resident #67 lying in bed. Resident #67 was with oxygen tube in his nose. Observation of the tubing was dated on tape 01/10/23. Resident #67 stated staff ran in the room just prior to surveyor returning and placed tape around the tubing. Resident #67 stated staff are supposed to change out the tubing every weekend and that he does recall staff changing the tubing. Resident #67 stated the oxygen level is supposed to be set at 5, however when he was told the lever was set at 3.5, he stated he has to constantly ask them to increase. Resident #67 stated he was not having a hard time breathing currently but would like the oxygen to be where it was supposed to be set. During interview on 01/12/23 at 12:17 PM with LVN G revealed the night nursing staff are to change out resident's oxygen tubing and water bottles with labeling and dates on both. LVN G stated he did check Resident #35's portable oxygen before she left for a visit yesterday and noted it was dated 12/31/22. LVN G stated he was not aware that her oxygen in her room was also dated for 12/31/22. According to LVN G the ADON or DON would be responsible to check to ensure the tubing are getting changed out on a weekly basis. When asked who was responsible for updating resident care plans with oxygen use, LVN G stated he did not know who updates the care plans but he would ask the DON. LVN G stated not having oxygen therapy on the care plans puts residents at risk of not getting proper care. During interview on 01/12/23 02:30 PM with MDS Coordinator, revealed she was new to the facility and is working to review all resident files to include care plans. MDS Coordinator stated oxygen treatment was a service that should be care planned. She stated during stand-up meetings was when she was notified of new treatments ordered for residents and she updated their care plan at that time. MDS Coordinator stated not having resident care plans updated puts residents at risk by staff not being aware of any changes to resident care. During interview on 01/12/23 at 3:44 PM DON revealed the facility has a new MDS Coordinator who was responsible for completing and updating care plans. The DON stated residents' oxygen orders should 676127 Page 5 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be in the system obtained from the physician, the best practice was to have the exact variance of the order to best serve the resident. The DON stated residents that use oxygen should have their care plans updated within days of receiving the order and use. The DON stated she was not aware that there were some care plans that were not updated with resident oxygen orders. The DON stated she does not see any risk to residents by not having their care plans updated because they are in fact still receiving the oxygen as ordered. A Care Plan policy was requested; however, it was not provided prior to exit. 676127 Page 6 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

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 residents were provided with respiratory care consistent with professional standards for 4 of 18 residents (Residents #21, #35, #6 and #67) reviewed for respiratory care in that: Residents Affected - Some 1. Residents #21, #35, #6 and #67's oxygen tube and concentrator bottles were not dated per physician orders. 2. Resident #6's humidifier attached to the oxygen concentrator was empty. 3. Resident #35 oxygen tube and concentrator bottle had not been changed since 12/31/22. 4. Residents #21, #35, and #67 were receiving oxygen without any physician orders. These deficient practices could affect residents who received oxygen with inadequate oxygen support, infections and could result in a decline in health. Findings included: 1. Review of Resident #21's face sheet, dated 01/12/23, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included 2019-nCoV acute respiratory disease (Coronavirus disease 2019 (COVID-19), chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure, cellulitis (bacterial skin infection) of left lower limb, muscle wasting and atrophy, and atherosclerosis of native arteries of left leg with ulceration of other part of lower leg. Review of Resident #21's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The resident's active diagnoses included: asthma, chronic obstructive pulmonary disease, and respiratory failure. The MDS reflected Resident #21 received oxygen therapy and hospice care. Review of Resident #21's care plan, dated 12/19/22, edited on 01/10/23 revealed the resident had oxygen therapy related to shortness of breath. The care plan goals were that the resident would not have signs or symptoms of poor oxygen absorption through the review date. The care plan approaches included: monitoring the resident for respiratory distress and reporting to the doctor. The care plan also reflected Resident #21 required hospice due to the terminal illness of COPD. The care plan reflected for hospice reflected in the approaches that the facility would communicate with hospice when there were any changes indicated in the resident's plan of care and to ensure the facility and hospice agency were aware of the other's responsibilities. 2. Review of Resident #35's face sheet, dated 01/12/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease. Review of Resident #35's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The resident's active diagnoses included asthma and chronic obstructive pulmonary disease. The MDS reflected Resident #35 received oxygen therapy. 676127 Page 7 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #35's care plan, dated 12/2/22, revealed the care plan did not address the resident's oxygen use. Review of Resident #35's physician orders revealed: Change and date oxygen tubing/humidifier and nebulizer plastics (if in use) every Saturday NOC shift and include dated plastic bag for storage. Order date - 11/09/22 times: 10:00 PM - 06:00 AM. Review of Resident #35's physician order revealed: Change O2 tubing and date. Special Instructions: Change tubing and date every Sunday on night shift. Order date: 05/30/22 times: 10:00 PM - 06:00 AM General: Clean O2 concentrator filters, oxygen @ (blank) l/min via nasal canula The physician orders did not reflect a respiratory order for oxygen, and there was no order for how many liters per minute the resident was to receive. During observation and interview on 01/10/23 at 10:30 AM revealed Resident #35 lying in bed. Resident #35 stated she just finished breakfast. Resident #35 had with an oxygen nasal canula in her nose. Observation of the tubing revealed it was dated 12/31/22 and the water bottle was empty with a date of 12/31/22. Resident #35 stated the facility was supposed to change out the oxygen tubing and water bottle weekly. Resident #35 stated she was not aware of when the last time staff had come to change out the tubing and water. Resident #35 stated so far, she has not had any issues with her breathing or feeling ill due to the tubing and water not being changed. 3. Review of Resident #6's face sheet, dated 01/12/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, acute bronchitis and Alzheimer's disease with late onset. Review of Resident #6's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 01, which indicated the resident's cognition was severely impaired. The resident's active diagnoses included chronic obstructive pulmonary disease. The MDS reflected Resident #6 received oxygen therapy. Review of Resident #6's care plan, dated 11/09/22, revealed Resident #6 had oxygen therapy related to congestive heart failure and respiratory illness. The care plan reflected the resident would have no signs or symptoms of poor oxygen absorption through the review date. The care plan interventions reflected the resident's would received oxygen via nasal canula at 2 liters per minute as needed for shortness of breath and low oxygen saturation. Review of Resident #6's physician orders revealed: Change and date oxygen tubing/humidifier and clean filters on concentrator once a day on Sunday. Order date - 06/01/22 times: 10:00 PM - 06:00 AM. Review of Resident #6's physician orders revealed: O2 at 2 lpm continuous for SOB, Every Shift; Days 6:00AM - 2:00PM, Evenings 2:00 PM - 10:00 PM, Nights 10:00 PM - 6:00 AM. Order date: 06/01/22 Observation on 01/10/23 at 2:16 PM of Resident #6 revealed the resident was in bed sleeping, observed resident to be on oxygen. Resident #6 oxygen tube and concentrator bottles were not dated. 4. Review of Resident #67's face sheet, dated 01/12/23, revealed the resident was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included disease of upper respiratory tract, presence of automatic (implantable) cardiac defibrillator, shortness of breath, cardiac arrhythmia, congestive heart failure. 676127 Page 8 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #67's care plan, dated 08/02/22, revealed resident had COPD, Goal indicated Resident will display optimal breathing pattern daily through review date. Approach indicated to give aerosol or bronchodilators as ordered, give oxygen therapy as ordered by the physician. Head of bed elevated, monitor for difficulty breathing on exertion, monitor for acute respiratory insufficiency. Review of Resident #67's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The resident's active diagnoses included coronary artery disease and heart railure. The MDS did not reflect the resident used oxygen. Review of Resident #67's physician order revealed: Change and date oxygen tubing/humidifier and nebulizer plastics (if in use) every Saturday NOC shift and include dated plastic bag for storage. 11/09/22 10:00 PM - 06:00 AM Review of Resident #67 physician order revealed: May have oxygen as needed due to anxiousness 08/13/22. (Orders did not reflect a respiratory order for oxygen, and was with no liters per minute identified) During observation and interview on 01/10/23 at 1:53 PM revealed Resident #67 lying in bed. Resident #67 was with oxygen tube in his nose. Observation of the tubing was dated on tape 01/10/23. Resident #67 stated staff ran in the room just prior to surveyor returning and placed tape around the tubing for us both (Resident #21 and Resident #67). Resident #67 stated staff are supposed to change out the tubing every weekend and that he does recall staff changing the tubing. Resident #67 stated the oxygen level is supposed to be set at 5, however when he was told the lever was set at 3.5, he stated he has to constantly ask them to increase. Resident #67 stated he was not having a hard time breathing currently but would like the oxygen to be where it was supposed to be set. During interview and observation on 01/12/23 at 12:17 PM with LVN G revealed the night nursing staff are to change out resident's oxygen tubing and water bottles with labeling and dates on both. LVN G stated he did check Resident #35's portable oxygen before she left for a visit yesterday and noted it was dated 12/31/22. LVN G stated he was not aware that her oxygen in her room was also dated for 12/31/22. While viewing Resident #35's orders it was revealed there was no order to indicate liters per minute identified and the nurse entered #3 in the order. When asked why he entered #3 in the blank, he responded that Resident #35 had been on 3 liters since he began employment back in September 2022. When asked to see the original order LVN G stated he could not access the order. While reviewing Resident #35's care plan it did not reveal a focus area for Resident #35 being on oxygen therapy. LVN G was asked to review orders for Resident #67, upon review LVN G stated he could not find an order for Resident #67's oxygen. After looking at Resident #67's care plan, LVN G stated he would not be able to know or identify if Resident #67 was on any oxygen. According to LVN G the ADON or DON would be responsible to check to ensure the tubing are getting changed out on a weekly basis. When asked who is responsible for updating resident care plans with oxygen use, LVN G stated he did not know who updates the care plans but will ask the DON. LVN G stated not having clear orders on oxygen therapy can harm residents if they are not getting adequate amounts of oxygen. LVN G stated if a resident is receiving oxygen, it should be clear on the care plans if not it puts residents at risk of not getting proper care. During observation on 01/12/23 at 12:45 PM revealed humidifier attached to Resident #6's oxygen concentrator was empty. Resident #6 oxygen tube and concentrator bottles were not dated. During observation on 01/12/2023 at 3:00 PM of Resident #6 revealed the resident was in bed 676127 Page 9 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sleeping, she had her oxygen on. Observed humidifier to be empty. Resident #6 oxygen tube and concentrator bottles were not dated . During interview on 01/12/23 at 3:10 PM with LVN D revealed Resident #6 had an oxygen order and for oxygen tube to be change every Sunday. LVN D stated it is changed by the night nurse. LVN D stated any time an oxygen tube is changed it has to be labeled with the date of when it was changed. LVN D and State Surveyor entered Resident #6 room and LVN D stated Resident #6 did not have a date on her oxygen tubing and noticed that her humidifier had no water. LVN D stated she was not aware that Resident #6 oxygen tubing was not labeled. LVN D stated she was also not aware that Resident #6 humidifier had no water. LVN D stated they have other ways to ensure that the tubing had been changed; however, by labeling they can know that it had been changed. LVN D stated the risk of not labeling could cause bacteria and also not getting the proper care. During an interview on 01/12/23 at 3:48 PM, the DON stated MDS Coordinator was responsible for completing and updating care plans. The DON stated residents' oxygen orders should be in the system obtained from the physician, the best practice is to have the exact variance of the order to best serve the resident. The DON stated residents have a standing order for oxygen therapy at 3.5, when asked to see the original order from the physician The DON stated if LVN G could not provide it then she would not be able to and would need to complete an investigation. The DON stated she would need to investigate whether LVN G altered Resident #67's physician order by entering #3 in the blank which would indicate how much oxygen Resident #67 was to receive. The DON stated she was not aware that residents receiving oxygen their oxygen tubes were not dated, she stated she was also not aware that Resident #6 humidifier was empty. The DON stated she needed to talk to her staff regarding Resident #6 oxygen. A policy for Oxygen Storage and Assembly, Respiratory Care policy was requested; however, it was not provided prior to exit. 676127 Page 10 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 safety in the facility's only kitchen. Residents Affected - Many The facility failed to ensure food items were labeled and dated. These failures could place residents at risk for food-borne illness. Findings included: During an observation of the kitchen on 01/10/23 at 8:48 AM, revealed the following: - 4 blocks of cheese in a plastic zip bag - unlabeled with no open date or use by date; - 1 bag of cut lettuce inside a bag wrapped in a clear wrap - unlabeled with no prepared date or use by date; - 3 bags of frozen fried chicken inside a clear bag- unlabeled with no open date or use by date; - 1 bag of frozen chicken legs in a plastic bag - unlabeled with no open date or use by date; - 1 bag of frozen hushpuppy in a plastic bag - unlabeled with no open date or use by date; - 1 bag of frozen biscuits in a plastic bag - unlabeled with no open date or use by date; - 1 bag of frozen okra - unlabeled with no open date or use by date; and - 2 bags of pasta - unlabeled with no open date or use by date. Interview on 01/10/23 at 8:56 AM with [NAME] F revealed today was her first day back from being off, and she was not sure when some of the food items were opened. [NAME] F stated any item that was open needed to have an open date. [NAME] F stated it was the kitchen staff's responsibility to make sure food items were labeled and dated. She stated the risk of not labeling could cause resident to get sick. Interview on 01/10/23 at 9:38 AM with the Dietary Manager revealed her staff and herself were responsible for labeling and dating all food items. The Dietary Manager stated she was the one who oversaw all food items were being labeled and dated. She stated every Tuesday and Thursday she did her rounds to make sure everything was labeled and mad sure to order any items that they did not have. She stated she just came in to her shift and had not completed her rounds today. She stated today was truck day so she would be completing her rounds when the truck arrived. She stated this failure would cause food borne illness. Review of the facility's Food Storage policy revised July 2019, reflected: Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 676127 Page 11 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, revealed (A) .food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold or discarded when held at a temperature 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 (B) .refrigerated, ready-to-eat time/temperature controlled for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24-hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations (2) The day or date marked by the food establishment ay not exceed a manufacturer's used-by date if the manufacturer determined the use-by date based on food safety. 676127 Page 12 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to arrange for the provision of hospice care under a written agreement to coordinate care provided by the LTC facility and hospice staff for 2 of 2 residents (Resident #15 and Resident #21) reviewed for hospice services, in that: The facility did not have Resident #15 or Resident #21's hospice plan of care, Hospice Consent and Election Form, Physician Certification of Terminal Illness, documentation of specific interdisciplinary hospice staff providing services to resident, specific to the resident in a location accessible and available to nursing staff for review and coordination of services. These failures could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: 1. Record review of Resident #15's face sheet, dated 01/12/23, revealed the resident was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, metabolic encephalopathy, bronchopneumonia, chronic kidney disease Stage 3, heart failure. Record review of Resident #15's admission MDS, dated [DATE], revealed the resident had a BIMS score of 08, which indicated the resident had moderately impaired cognition. The resident's active diagnoses included atrial fibrillation, coronary artery disease, renal insufficiency, renal failure, or end-stage renal The MDS did not indicate in Section O Special Treatments, Procedures, and Programs that the resident received hospice care. Record review of Resident #15's care plan, dated 09/22/22, edited on 01/10/23 revealed Resident #15 required hospice as evidenced by terminal illness of (enter diagnosis) and used [name of hospice company] Hospice. The care plan goal reflected: Dignity will be maintained, and the resident will be kept comfortable and pain free with meds as ordered or other interventions. The care plan approaches reflected: Ensure facility and hospice agency are aware of the others' responsibilities, Assist with activities of daily living and provide comfort measures as indicated, communicate with Hospice when any changes are indicated in residents plan of care, Ensure representative and resident are aware decreased appetite, weight loss, skin breakdowns are expected. Monitor for these and notify Hospice/doctor and representative as they occur. Monitor for increased pain and give medication as ordered for relief. Notify Hospice for any medication refills as needed. Record review of Resident #15's order summary report dated 01/12/23 revealed an order to admit to hospice services, with order date 10/04/22 and no end date. Record review of Resident #15's hospice medical record binder revealed there was no current documentation of Resident #15's hospice Plan of Care, Hospice Consent and Election Form, Physician Certification of Terminal Illness, or documentation of specific interdisciplinary hospice staff providing services to the resident. 676127 Page 13 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of Resident #21's face sheet, dated 01/12/23, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of 2019-nCoV acute respiratory disease (Coronavirus disease 2019 (COVID-19), chronic obstructive pulmonary disease with (acute) exacerbation (sustained increase in cough), and chronic respiratory failure. Record review of Resident #21's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The resident's active diagnoses included asthma, chronic obstructive pulmonary disease, and respiratory failure. The MDS reflected the resident received hospice care. Record review of Resident #21's care plan, dated 12/19/22, edited on 01/10/23 revealed the resident required hospice as evidence by terminal illness of: COPD. The care plan goals reflected: Dignity will be maintained and the resident will be kept comfortable and pain free with meds as ordered. The care plan approaches reflected: communicate with Hospice when any changes are indicated in residents plan of care, ensure facility and hospice agency are aware of the other's responsibilities, assist with activity of daily living skills and provide comfort measures as indicated, Ensure representative and resident are aware decreased appetite, weight loss, skin breakdowns are expected. Monitor for these and notify Hospice/doctor and representative as they occur. Monitor for increased pain and give medication as ordered for relief. Notify Hospice for any medication refills as needed. Record review of Resident #21's order summary report dated 01/12/23 revealed an order to admit to hospice services, with order date 07/13/22 and no end date. Record review of Resident #21's hospice medical record binder revealed there was no current documentation of Resident #21's hospice Plan of Care, Hospice Consent and Election Form, Physician Certification of Terminal Illness, or documentation of specific interdisciplinary hospice staff providing services to the resident. During observation and interview on 01/11/23 at 1:50 PM with CNA G revealed Resident #21 was on hospice services; however, he would generally refuse assistance from staff for his activities of daily living. CNA G was asked how many times will Resident #21 refuse before completing the activity of daily living services, CNA G stated she had worked with Resident #21 a couple of times and Resident #21 had allowed her to complete his bed baths, wash his face, and attempt to brush his teeth but not that often. CNA G stated she did notify the floor nurse or whoever was on duty when Resident #21 was non-complaint. When asked if this information was being relayed to the hospice service, she replied there was a book located at the nursing station that would have documentation between hospice and the facility on when the resident refused services. CNA G was asked to retrieve Resident #21's hospice book from the nursing station, when surveyor and CNA G approached the nursing station CNA G stated she was not able to locate the hospice binder. The DON was present and was observed looking for the binder and stated she will have to locate the binder and deliver it soon after. During an observation and interview on 01/12/23 at 3:44 PM, with the DON revealed, the Administrator was in charge of handling the hospice agreements, The DON stated she was not sure why the agreement was not in the Hospice Book and would have to confer with the Administrator on the expectations and agreements with hospice agencies. The DON stated each hospice entity has a community liaison to help facilitate the care for their residents in the facility. The DON stated, typically, my floor nurses are responsible for communicating with hospice case managers when they enter, sign off on hospice iPad (which shows that hospice was visiting) and schedule care plan meetings. The DON stated hospice writes their own plan of care and they will fax it to us, or hospice will come in to put in the 676127 Page 14 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some binders during their visit. The DON stated the facility did not have any documentation or information regarding Resident #21's hospice status either in the hospice binder or in the electronic medical record. The DON stated she called the hospice agency when records were requested by the surveyor and pulled what she could from the computer fax. The DON stated Resident #21 was on hospice, per his request was removed and then per his request went back on hospice. Resident #21 has discontinued the aides from coming because he was constantly refusing their service with assisting him with bathing. The DON stated now he only sees the nurse, and the facility was managing Resident #21's comfort and pain through hospice. The DON stated they were looking into the hospice service because they were needing to have better documentation, be notified of changes, and when they were being implemented. The DON further stated when it came to Resident #15's hospice binder, it was empty, and she contacted the hospice agency upon request of his hospice book so that there would be something in his binder. The DON stated it was the responsibility of the hospice agency to provide documentation for the hospice binder, set up care plan meetings, and notify the facility of any changes in care. The DON stated there were no risk for the residents because the facility was following physician's orders for their care. The surveyor requested to see the facility policy on their hospice care. A Hospice Care and Agreement policy was requested; however, it was not provided prior to exit. 676127 Page 15 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Residents #79, #80, and #130) of 18 residents and 4 (100 & 400 Nurses carts and 2 rooms on 100 Hall) of 8 sharps containers reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure LVN A disinfected the blood pressure cuff in between blood pressure checks for Residents #78, #80, and #130. 2. The facility failed to ensure sharps containers were monitored and emptied when they were filled. These failures placed residents at-risk of cross contamination which could result in infections or illness. Findings included: Observation on 01/10/23 from 10:21 AM to 11:50 AM revealed the sharps containers (a rigid puncture-resistant container used for collection of discarded needles/sharps) for three rooms on the 400 Hall were overfilled. The sharps container for the shower room of 400 Hall was overfilled. Two rooms on 400 Hall had no sharps containers in the sharps box. Two rooms of the 400 Hall had sharps deposited on top of the sharps containers. Observation on 01/10/23 at 12:15 PM, the sharps container on the nurse medication cart for 100 and 400 Halls was overfilled. Observation on 01/10/23 at 12:18 PM revealed two rooms on 100 Hall that had sharps containers that were overfilled. Interview on 01/10/23 at 1:35 PM the DON stated nurses were responsible for changing out sharps containers when they were filled, and before they were overfilled. Failing to do so puts residents at risk of being exposed to bloodborne pathogens that might be present on used sharps. Observation on 01/11/23 from 7:50 AM to 8:28 AM. LVN A used the same blood pressure cuff to check the blood pressure on Residents #79, #80 and #130 without disinfecting the cuff between each resident. Interview on 01/11/23 at 8:50 AM LVN A stated it was her second day working as a nurse, and she was not aware she should disinfect the cuff between residents. Interview and observation on 01/11/23 at 8:54 AM LVN B stated she was training LVN A and had not noticed she did not disinfect the cuff between residents. LVN B stated it was important to sanitize the cuff between residents to prevent spreading any infections. LVN B checked her cart for disinfecting wipes and none were found. Observation on 01/11/23 at 9:10 AM the DON was placing disinfecting wipes on all medication carts. 676127 Page 16 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0880 Level of Harm - Minimal harm or potential for actual harm Interview on 01/11/23 at 9:15 AM. the DON stated failing to disinfect equipment between residents placed residents at risk of being cross contaminated from another resident. Interview on 01/11/23 at 1:29 PM, LVN C stated not disinfecting equipment between resident uses exposed residents to any infections the other residents may have. Residents Affected - Some Review of facility's Infection Control-Cleaning and Disinfecting Resident Care Items and Equipment policy, dated 12/01/18, reflected: It is the policy of this home to clean and disinfect resident-care equipment, including reusable items and durable medical equipment per current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Reuseble items are cleaned and disinfected or sterilized between residents. Per CDC guidelines posted at CDC.gov reflected: Cleaning of Patient-Care Devices should include: Cleaning medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Review of OSHA standards on sharps, as described on their website osha.gov, reflected: .1910.1030(c)(1)(i) Each employer having employees with occupational exposure to bloodborne pathogens shall establish an Exposure Control Plan designed to eliminate or minimize employee exposure .1910.1030(d)(1) General Universal precautions shall be observed to prevent contact with blood or other potentially infectious material. .1910.1030(d)(2)(i) Engineering and work practice controls shall be used to eliminate of minimize employee exposure to bloodborne pathogens .1910.1030(d)(2)(viii) Immediately, or as soon as possible after use, contaminated sharps shall be placed in appropriate containers. These containers shall be: . Puncture resistant . Labeled or color-coded . Leakproof .1910.1030(d)(4)(iii)(A)(2) During use containers for sharps shall be: . Easily accessible to personnel . Maintained upright throughout use 676127 Page 17 of 18 676127 01/12/2023 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0880 . Replaced routinely and not be allowed to overfill Level of Harm - Minimal harm or potential for actual harm . Containers should be closed immediately to prevent spillage or protrusions of contents during handling, storage, transport, or shipping. Residents Affected - Some 676127 Page 18 of 18