Health inspection·January 9, 2024

F 0675 Honor each resident's preferences, choices, values and beliefs. 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 provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1 (Residents #1) of 4 residents reviewed for quality of life. Residents Affected - Few The facility did not ensure Residents #1 received a shower upon and after being admitted on [DATE]. Resident was not showered until 12/17/23. Resident #1 was not showered on his scheduled day of 12/15/23. This deficient practice had the potential to affect residents by placing them at an increased risk of poor self-esteem, infections, socialization, and a poor quality of life. Findings included: Record review of Resident #1's face sheet dated 12/24/23 reflected the resident was a [AGE] year-old male that was admitted on [DATE] and discharged on 12/20/23. His diagnosis included: hepatic encephalopathy (liver failure), altered mental status, unspecified, pain, cognitive communication deficit (difficulty communicating), alcoholic cirrhosis of liver without ascites (decline in liver functioning), muscle weakness (generalized), and unsteadiness on feet. Review of Resident Pain Management plan revealed no pain regimen necessary. Review of Resident #1's physician orders reflected an order dated 12/20/23 for tramadol 50 mg tablet BID (8:00 AM and 8:00 PM) ICD-10 Diagnosis: R52: Pain, unspecified. Verbal order by MD S, Created By: LVN K on 12/20/2023 14:45 [2:45 PM]. Record review of Resident #1's skilled nursing chart dated 12/20/23 reflected .impaired decision making .mood of overeating, decreased concentration. Cognition alert to person place and time, speech clear, unlabored breathing and regular heart rate call light in reach. Record review of Resident #1's BIMS dated 12/19/23 reflected a score of 3, indicating he had severe cognitive impairment. In an interview on 01/08/24 at 1:10 PM with Resident #1's family member (FM C) revealed upon arrival to the facility on [DATE], she observed Resident #1 with the same clothing on, not showered, and unshaven. She had brought clothing to the facility and hygiene products on 12/15/23. FM C approached the nurse, and the nurse said Resident #1 missed his shower. FM C asked a staff (name unknown) about Page 1 of 6 676127 676127 01/09/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0675 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the shower and then gave FM B towels to shower the resident. FM C said FM B, who was present, then showered and shaved Resident #1. FM C stated the staff (name unknown) did not offer a reason why he was not showered and would not shower the resident when requested. The staff member was later identified as CNA H. In an interview on 01/08/24 at 1:30 PM with CNA D, she stated she worked the 6:00 AM-2:00 PM shift on 12/17/23 with Resident #1. She denied having a conversation with FM B and FM C about showers; however, she observed FM B in the shower room with Resident #1 giving him a shower. She did not offer to assist. She said it was common for family to shower the residents. She said FM C nor FM B complained to her about Resident #1 not receiving shower. She did not know who provided the towels to FM B to shower Resident #1 on 12/17/23 nor who provided the location of the shower room to the FM B. In an interview on 01/08/24 at 2:30 PM with CNA J, she stated she was assigned to Resident #1 on 12/17/23, and Resident #1 was showered by the family member prior to her arriving to work at 2:00 PM. She said the family did not report any concerns about missing showers, and she conducted rounds in Resident #1's room every two hours throughout the shift. In an interview on 01/08/24 at 2:45 PM with CNA H, she stated FM B asked for the location of the shower room, so she showed FM B the shower room. CNA H told FM B that she would return and shower Resident #1 once she completed care task with another resident. CNA H said FM B replied he would shower Resident #1. CNA H provided towels and the location of the shower room to FM B on 12/17/23. In an interview on 01/8/24 at 4:27 PM, LVN M stated she was asked by FM C on 12/17/23 about Resident #1 not receiving a shower at approximately 1:51 PM. LVN M told FM C that Resident #1 missed his shower day. LVN M could not recall Resident #1's shower day when interviewed nor when Resident #1 was admitted . LVN M did not recall offering Resident #1 a shower, nor facility staff that were working on 12/17/23. LVN M said FM B gave Resident #1 a shower on 12/17/23. LVN M stated she expected aides to offer and administer showers according to the day assigned and as needed. A telephone interview was attempted with CNA I for an interview on 01/08/24 at 3:58 PM. A message was left for CNA I to contact the surveyor. On 01/09/24, a review of the surveyor's call log revealed CNA I had called on 01/08/24 at 7:01 PM and 7:02 PM. A message was left to return call. In an interview on 01/09/24 at 9:00 AM with FM B, the family member stated upon arrival to the facility with FM C for a visit with Resident #1, the resident smelled of urine and had not been shaved and showered. FM B did not recall if FM C asked the staff to shower Resident #1; however, the staff working (LVN M, CNA D, CNA H) did not offer to shower Resident #1, so FM B asked CNA H for the location of the shower room and FM B showered and shaved Resident #1. Resident #1 said he felt much better. In an interview on 01/09/24 at 11:10 AM with the DON, she stated upon further investigation CNA J stated Resident #1 refused a shower on 12/15/23. The DON provided the shower sheet for 12/15/23, 12/18/23, and 12/20/23 for review. The DON said it was her expectation for the charge nurse to ensure residents were offered a shower on their scheduled days. The DON stated she expected the aides to report to the charge nurse immediately when residents refused care and showers, and document on the shower sheets. In an interview on 01/09/24 at 11:15 AM with the Administrator, he stated Resident #1 refused showers on 12/15/23 and 12/18/23. The Administrator provided the shower sheets to the surveyor for the 676127 Page 2 of 6 676127 01/09/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0675 Level of Harm - Minimal harm or potential for actual harm above dates. The Administrator was notified by the surveyor that staff (LVN M, CNA J, CNA H, and CNA D) working on 12/15/23 denied offering a shower to the Resident #1, and LVN M reported Resident #1 missed his shower on date. The Administrator said CNA I was working on 12/15/23. He was notified of the surveyor's attempts to reach CNA I by phone on 01/8/24 at 3:58 PM and that the surveyor had not received a response. Residents Affected - Few A telephone interview was attempted with CNA I on 01/09/24 at 10:16 AM, and a message was left for CNA I to return the surveyor's call regarding the investigation. On 01/09/24 at 12:01 PM, 12:02 PM, 12:13 PM, and 12:21 PM, CNA I attempted to return surveyor calls. An attempted call to CNA I for an interview on 01/09/24 at 1:15 PM, with a message to return surveyor call regarding an investigation. In an interview on 01/09/224 at 4:33 PM CNA I stated upon arriving for work, she observed Resident #1 sitting in his wheelchair in the hallway dressed, in no distress. CNA, I did not shower Resident #1 on 12/15/23, 12/17/23, 12/18/23 or 12/20/23. CNA, I stated she did not remove his linen from his bed. CNA, I stated she does not know who was assigned prior to her arrival on 12/17/23 for the 6AM-2P shift . CNA, I stated she has not observed Resident #1 soiled or saturated with urine and denied that LVN M or family requested her to shower Resident #1 on 12/15/23, 12/17/23, 12/18/23 or 12/20/23. Record review of shower sheets dated 12/15/23, 12/18/23, and 12/20/23 reflected Resident #1 refused showers. This was the only resident who was reported to miss showers. Record review of facility's Nursing Policy and Procedure manual, Section A, effective date September 2022, reflected: POLICY: It is the policy of this home to assure residents have their activities of daily living needs met. EQUIPMENT: Grooming Supplies . GROOMING TASKS When doing grooming tasks, the following procedure should be followed: 1. It is preferable to do grooming tasks in front of the mirror in the bathroom. If not, then a small standing mirror should be provided on the bedside tray table. 2. Have resident collect grooming articles from nightstand and place in walker bag or lap to carry to sink. 3. Place all articles within reach, including towel and washcloth. 676127 Page 3 of 6 676127 01/09/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0675 4. Level of Harm - Minimal harm or potential for actual harm Position in good sitting or standing posture -- resident should stand at sink side if able. 5. Residents Affected - Few Encourage use of affected upper extremity to hold containers or to assist with other grooming tasks such as smoothing on moisturizer or shave cream. 676127 Page 4 of 6 676127 01/09/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide a sanitary environment for 1 (Residents #1) of 4 residents reviewed for environmental conditions. The facility failed to ensure Resident #1 bed was made with linen, leaving the bed bare and resident lying directly on the mattress. The failure placed residents, who had their mattresses placed directly on the floor , at risk for unsanitary living conditions. Findings included : Record review of Resident #1's face sheet dated 12/24/23 reflected the resident was a [AGE] year-old male admitted on [DATE] and discharged on 12/20/23. His diagnosis included: hepatic encephalopathy (liver failure), altered mental status, unspecified, pain, cognitive communication deficit, (difficulty communicating), Alcoholic cirrhosis of liver without ascites (decline in liver functioning), muscle weakness (generalized), and unsteadiness on feet. Review of Resident Pain Management plan revealed no pain regimen necessary. Record review of Resident #1's skilled nursing chart dated 12/20/23 reflected impaired decision making Record review of Resident #1's BIMS dated 12/19/23 reflected a score of 3 indicating the resident had severe cognitive impairment. In an interview on 01/08/24 at 1:10 PM FM C she stated that upon arrival to the facility on [DATE], she observed Resident #1 bed with no sheets and lying on mattress. She asked LVN M, who removed Resident #1's. FM C was very upset and stated that LVN M could not provide a satisfying response. She said she was very angry that a suitable answer was not provided. In an interview on 01/08/24 at 1:30 PM CNA D worked the shift on 12/20/23 6:00 AM-2:00 PM, with Resident #1. CNA D observed Resident #1 bed not having linen. CNA D does not know who removed the linen. She observed Resident #1 lying on the mattress. CNA D said FM C complained that Resident #1 not having linen on the bed, and she was very upset. CNA D said all residents have the right to clean linen on their bed, and it was the facility protocol for clean environment. In an interview on 01/8/24 at 4:27 PM, LVN M was asked by FM C on 12/207/23, inquired about Resident #1 not having linen on his bed. LVN M told FM C that one of the aides had removed the sheets and was in the process of changing the linen. FM C was very upset that the LVN M was not responsive and followed up to resolve the issues. In an interview on 01/09/24 at 11:10 AM DON stated she did not know why Resident #1 did not have linen on the bed, and all staff are trained to remove linen, disinfect mattress, then return to put the linen back on the bed. It is her expectation for aides and nursing staff to ensure all resident beds have clean linen. 676127 Page 5 of 6 676127 01/09/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 01/09/24 at 11:15 AM Administrator stated Resident #1's linen was removed by a staff member and had not been without linen longer than 10 minutes on 12/20/23. At the time of the interview with the Administrator, he said CNA I had removed the linen from Resident #1's bed. In an interview on 01/09/24 at 4:33 PM CNA I stated she did not remove Resident #1's linen from his bed on 12/20/23. CNA, I did not observe Resident 1 lying on mattress without linen. CNA I did not receive a complaint from FM C about bed linen not being on the bed. She said it was unsanitary to allow residents to lay on mattresses without linen, and the facility protocol was to remove the linen, disinfect, then re-install the line. In a record review of an email from the Administrator dated 01/09/24 at 5:18 PM after exit 01/09/24 reflected: We have more details on Mr. [Resident #1] laying in the bed without sheets. CNA who gave him a shower on the afternoon of the '[ 12/20/ 23].' She gave him a bath and cleaned his bed. He did not want to wait on her to get sheets to get back into bed after cleaning and told her so. His Right to do so. His family also tried to get him to get up to allow sheets on, but he refused. The CNAs did come back to put sheets on. Can you call her as this should resolve both issues, RN was also here that evening and observed some of the happenings with the family. Record review of environment was not reviewed by surveyor. 676127 Page 6 of 6