Health inspection·February 29, 2024

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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 reviews, the facility failed to ensure that residents had physician orders for the resident's immediate care for 1(Resident #17) of 5 residents reviewed for physician orders in that Residents Affected - Few LVN-A failed to update the physician orders for Resident #17, to reflect changes in the physician's plan of care. This failure could place the resident at risk of not receiving the care intended by the physician. Findings included: Review of Resident #17's undated admission Record revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses that included fracture of her left kneecap, non-displaced fracture of left arm, and a history of falls. Review of Resident #17's admission MDS, dated [DATE], revealed a BIMS score of 10 indicating she had mild cognitive impairment. Her functions Status indicated she required total assistance with most of her ADLs. Her Health Conditions listed fractures of the arm and knee. Review of Resident #17's care plan, dated 1/27/24, revealed she was at risk for pressure ulcers related to decreased mobility, and a decline in her ADL functions related to her fractured knee cap. Review of Resident #17's physician orders revealed an order dated 1/22/24 to keep the resident non-weight bearing on her left leg and to please keep immobilizer intact as tolerated to left leg due to left patellar fracture. No orders found addressing the resident's back brace. Review of Resident #17's Scanned Documents revealed on 2/13/24 the Physician had changed her leg immobilizer to a hinged knee brace and to remain non-weight bearing. On 2/27/24 the Physician ordered the resident to weight bear as tolerated. Observation and interview on 2/27/24 at 11:53 AM Resident #17 stated she had fallen at home, resulting in fractures to her left kneecap, left upper arm, and back. Resident #17 stated she had to wear her leg brace at all times, except to bathe and dress, and her back brace any time she was out of bed. She stated her left arm fracture had healed. Resident #17 stated she had just come from a follow up visit with her orthopedist and had been cleared to start weight bearing on her left leg. She was hopeful she could make better progress with her therapy now. Interview on 2/29/24 at 11:40 AM LVN-A stated Resident #17 wore her back brace only when she was Page 1 of 7 676127 676127 02/29/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few out of bed, and her leg brace all the time. LVN-A stated Resident #17 was now able to weight bear on her left leg. When asked why Resident #17's physician orders had not been updated to reflect the changes LVN-A stated it was because nursing staff had not done so. When asked how he knew Resident #17 was now able to weight bear, he stated he had seen the order when she returned from her appointment on 2/27/24. When asked if he should have updated the order at that time, LVN-A stated he should have. When asked where the order for Resident #17's back brace was, LVN-A was not able to locate such an order. When asked how he knew Resident #17 had to have her brace on when out of bed, he stated it must have been passed on from nurse to nurse in report. LVN-A stated the risk of not having up to date orders for residents was they might not receive the care intended by the physician. The Administrator provided a policy Medication Orders but did not have a policy on updating physician orders specifically 676127 Page 2 of 7 676127 02/29/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

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 ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #74) reviewed for MDS assessment accuracy in that: Residents Affected - Few Resident #74's quarterly MDS assessment dated [DATE] was coded incorrectly for insulin injections when he was not receiving insulin. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Review of Resident #74's face sheet dated 02/29/2024 indicated Resident #74 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #74 had a diagnoses of chronic kidney disease, Type 2 diabetes mellitus (body does not make enough insulin) with diabetic neuropathy (nerve damage), essential hypertension (high blood pressure), acute kidney failure. Review of Resident #74's quarterly MDS dated [DATE] revealed Resident #74 had a BIMS score of 12 which indicated moderate impairment. The MDS Assessment for Resident #74 revealed Medications: Injections - Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. - It was coded 7 days. Insulin - Insulin Injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days It was coded 7 days. Review of Resident #74's care plan, revised date 01/29/24 revealed Problems: [Resident #74] has a diagnosis of Diabetes Mellitus. Goal: The resident will have no complications related to diabetes through the review date. Approach: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #74's Physician Orders from November 2023 through February 2024 revealed no orders for insulin. Review of Resident #74's Discontinued Physician Orders revealed insulin lispro solution; 100 unit/ml; amountt: Per Sliding Scale; order date: 09/20/23 discontinued date: 10/03/23. Review of Resident #74's October 2023 and November 2023 MAR revealed no insulin was administered. Interview on 02/27/24 at 11:35 AM with Resident #74 revealed he had a diagnosis of diabetes; however, he does not require insulin. Resident #74 stated he does not recall if he was ever on insulin. He stated he was getting his blood sugar checks but that had stopped months ago, resident could not recall how many months since his blood sugar checks were stopped. Interview on 02/29/24 at 10:00 AM with LVN B revealed he was the nurse assigned to Resident #74. LVN B stated Resident #74 was not on insulin, he stated resident had a physician order for PRN insulin, but it was discontinued around October 2023. He stated Resident #74's blood sugars were stable, and insulin was not needed. He stated Resident #74 was not provided with insulin 7 days a week. 676127 Page 3 of 7 676127 02/29/2024 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/29/24 at 01:26 PM with the MDS Coordinator and the Regional MDS revealed the MDS Coordinators were responsible for completing the MDS assessments and Regional MDS oversees the assessments. The MDS Coordinator stated she would gather all the resident's information during IDT meetings, care plan meetings, and reviewing clinical records to complete the residents initial, quarterly, and annual MDS's. She stated on the resident's MDS they trigger any special treatment the resident was receiving. The MDS Coordinator and Regional MDS reviewed Resident #74's quarterly MDS assessment dated [DATE] and reviewed resident physician orders; and stated the assessment was inaccurate. The Regional MDS stated she reviewed Resident #74's quarterly MDS assessment dated [DATE] and it was also inaccurately coded for insulin. The Regional MDS stated the previous MDS staff coded the incorrect medication treatments, she stated it was her responsibility to ensure MDS assessment were completed correctly. The Regional MDS stated there was no potential risk to the residents if assessments were not accurate. The Regional MDS stated the facility used the RAI manual as a reference and policy. Interview on 02/29/24 at 02:05 PM with the DON revealed the MDS Coordinator was responsible for completing MDS assessments. She stated the Regional MDS oversaw the assessments. She stated Resident #74 was on insulin for a couple of days but then the insulin order was discontinued. She stated her staff were only checking his blood sugars once the insulin order was discontinued. She stated the previous MDS Coordinator might have coded the wrong thing. The DON stated there was no risk to the resident if the MDS assessment was not accurate. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, October 2023, revealed the following: an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. 676127 Page 4 of 7 676127 02/29/2024 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 - Few 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 reviews the facility failed to develop a comprehensive care plan for 1 (Resident #17) of 5 residents reviewed for comprehensive care plans. The MDS Coordinator failed to care plan to address Resident #17's orthopedic braces. This failure could result in the resident not receiving appropriate care for her fractures. Findings included: Review of Resident #17's undated admission Record revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses that included fracture of her left knee cap, non-displaced fracture of left arm, and a history of falls. Review of Resident #17's admission MDS, dated [DATE], revealed a BIMS score of 10 indicating she had mild cognitive impairment. Her functions Status indicated she required total assistance with most of her ADLs. Her Health Conditions listed fractures of the arm and knee. Review of Resident #17's care plan, dated 1/27/24, revealed she was at risk for pressure ulcers related to decreased mobility, and a decline in her ADL functions related to her fractured knee cap. The resident was not care planned for orthopedic braces. Observation and interview on 2/27/24 at 11:53 AM Resident #17 stated she had fallen at home, resulting in fractures to her left knee cap, left upper arm, and back. Resident #17 stated she had to wear her leg brace at all times, except to bathe and dress, and her back brace any time she was out of bed. She stated her left arm fracture had healed. Resident #17 stated she had just come from a follow up visit with her orthopedist and had been cleared to start weight bearing on her left leg. She was hopeful she could make better progress with her therapy now. Review of Resident #17's physician orders revealed an order dated 1/22/24 to keep the resident non-weight bearing on her left leg and to please keep immobilizer intact as tolerated to left leg due to left patellar fracture. No orders found addressing the resident's back brace. Review of Resident #17's scanned documents revealed on 2/13/24 her leg immobilizer had been exchanged for a hinged knee brace and to remain non-weight bearing. On 2/27/24 the orthopedist ordered the resident to weight bear as tolerated. Interview on 2/29/24 at 11:35 AM the PTA stated he had worked with Resident #17 since her admission and they had been working on transfers with limited progress because she had been non-weight bearing, but now that she was able to bear weight he expected her to make fast progress. The PTA stated Resident #17 only had to wear her back brace when she was out of bed. Interview on 2/29/24 at 11:40 AM LVN-A stated Resident #17 only wears her back brace when she was out of bed, and she was able to weight bear as tolerated on her left leg. LVN-A was asked to locate the physician order for her back brace care and treatment, he was unable to locate an order. LVN-A was asked how he knew how to treat Resident #17's back brace, he stated he had been told in report 676127 Page 5 of 7 676127 02/29/2024 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 - Few that she was to wear it any time she was out of bed. When LVN-A was asked to locate the physician order changing the resident from a leg immobilizer to the hinged leg brace, he could not locate it as well. When asked to locate where in Resident #17's care plan it addressed her leg and back braces he could not locate anything. LVN-A stated the nurses were responsible for updating physician orders when a resident returned from a visit with a new order from the physician. LVN-A stated the nurses could also update the resident's care plan as needed but usually the MDS Coordinator updated the care plan. Interview on 2/29/24 at 2:40 PM the MDS Coordinator stated she was responsible for updating the resident's care plans as their needs changed. She stated she was made aware of the changes that needed to be made during the daily Interdisciplinary Team (IDT) meetings. She stated the nurses could also make changes as needed. Review of the facility's policy Care Plan-Resident, dated December 2018 reflected: The policy of the home was staff must develop a comprehensive care plan to meet the needs of the resident with long-term goals that must be measurable and must relate to the discharge goal. 676127 Page 6 of 7 676127 02/29/2024 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 - Few 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 for two of four staff (Dietary [NAME] and Dietary Aide) reviewed for kitchen sanitation in that: The Dietary [NAME] and Dietary Aide failed to properly wear a beard restraint while in the food preparation area. This failure could place residents at risk for food contamination and foodborne illness. The findings include: Observation on 02/27/24 at 09:00 AM revealed the Dietary [NAME] had facial hair and was placing left over food into plastic containers. The Dietary [NAME] did not have on a beard restraint. Further observations revealed the Dietary Aide had facial hair and was observed washing dishes and walking through the kitchen putting items away. Interview on 02/27/24 at 09:10 AM with the Dietary [NAME] revealed the first thing staff should do prior to entering the kitchen would be to put on a hairnet and a beard guard. He stated he had one on but he stepped out the kitchen and when he returned, he forgot to put another one on. He stated the risk of not wearing a hair net or beard guard could lead to hair follicles falling in the food. Interview on 02/27/24 at 09:12 AM with the Dietary Aide revealed the first thing he does when he enters the kitchen was to put a hairnet on and beard guard. He stated the reason he did not have on a beard guard was because he forgot to put one on. He stated the risk would be hair follicles falling in the food and in the dishwasher. Interview on 02/28/24 at 01:11 PM with the Dietary Manager revealed her expectations were for her staff to wear a hair and beard restraint while in the kitchen. She stated she did not notice her Dietary [NAME] and Dietary Aide not wearing a beard guard yesterday (02/27/24). She stated the potential risk would be hair falling in the food. Review of the facility's policy Employee Sanitation dated October 1, 2018, reflected the following: . 3. Employee Cleanliness Requirements: b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food contact surfaces. 676127 Page 7 of 7