Health inspection·April 17, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents' had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 of 8 residents (Resident #3 and resident #73) reviewed for advanced directives. The facility failed to ensure Resident #3's and Resident #73's Out-of-Hospital Do Not Resuscitate (OOH-DNR) documents had the Physician's Statements signed by the physician and included the physician's license number, rendering the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. Findings include: 1) Record review of Resident #3's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #3's Quarterly MDS Assessment, dated [DATE], reflected she had a BIMS score of 03, which indicated severely impaired cognition. Her diagnoses included Alzheimer's Disease (a progressive disease that affects memory and mental functions); Non-Alzheimer's dementia (neurodegenerative disease causing dementia that is not Alzheimer's disease); hypertension (high blood pressure); and depression. Record review of Resident #3's Physician Order Report reflected the following order, dated [DATE],: Code Status: DNR. Record review of Resident #3's Care Plan reflected the following entry initiated [DATE]: Problem: Resident has an order for Do Not Resuscitate (DNR) Goal: Resident/Responsible Party's decision for DNR will be honored through the next review date. Approaches included: All aspects of DNR will be explained to resident or responsible party; In absence of b/p, pulse, respiration, CPR [procedure used in an attempt to revive a person who is at or near death] will not be initiated .Social Services to consult with resident and RP regarding their decision to continue DNR. Page 1 of 7 676127 676127 04/17/2025 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #3's Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) order reflected it was initiated and signed by Resident #3 on [DATE]. The Physician's Statement portion of the document reflected, I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct healthcare professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue resuscitation measures for the person. The document contained an area designated for the physician's signature, date, license number and printed name. This portion was left blank on Resident #3's order. 2) Record review of Resident #73's face sheet, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #73's Quarterly MDS Assessment, dated [DATE], reflected she had a BIMS score of 03, which indicated severely impaired cognition. Her diagnoses included Non-Alzheimer's dementia and unspecified dementia with psychotic disturbance (dementia with symptoms such as hallucinations and paranoia). Record review of Resident #73's Physician Order Report reflected the following order, dated [DATE]: Code Status: DNR. Record review of Resident #73's Care Plan reflected the following entry initiated [DATE]: Problem: Resident has an order for Do Not Resuscitate (DNR) Goal: Resident/Responsible Party's decision for DNR will be honored through the next review date. Approaches included: All aspects of DNR will be explained to resident or responsible party; In absence of b/p, pulse, respiration, CPR [procedure used in an attempt to revive a person who is at or near death] will not be initiated .Social Services to consult with resident and RP regarding their decision to continue DNR. Record review of Resident #73's Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) order reflected it was initiated and signed by her Medical Power of Attorney on [DATE]. The Physician's Statement portion of the document reflected, I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct healthcare professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue resuscitation measures for the person. The document contained an area designated for the physician's signature, date, license number and printed name. This portion was left blank on Resident #73's order. During an interview and record review on [DATE] at 6:52 AM, the DON stated the Social Worker was responsible for monitoring the resident's Advanced Directive and DNR forms. She reviewed Resident #3's and Resident #73's EMR and noted both had physician orders and Care Plans in place for DNR. She confirmed neither resident had physician signatures on their OOH-DNR forms. The DON stated she believed the risk to residents was low because both had active orders not to resuscitate and it was unlikely EMS would be called in the event they became nonresponsive. She stated the facility had never encountered an issue where emergency personnel refused to honor a DNR document. During an interview and record review on [DATE] at 6:55 AM, the DON asked the Social Worker to review the OOH-DNR documents she kept in a binder for the residents. The DON and Social Worker noted the 676127 Page 2 of 7 676127 04/17/2025 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documents in their binder were the same ones located in the residents' EMRs and neither contained a physician's signature. The Social Worker stated she assisted with the initiation of the documents and always ensured they were complete, but some residents arrived with them or had them initiated with hospice companies. She stated she performed audits to ensure they had the forms on file with the orders but had not always checked to ensure the documents were completed if they were initiated before she started there. She stated the risk included emergency personnel may not accept them if they were not completed properly and initiate CPR. The DON and Social Worker stated they planned to conduct a full audit of all resident documents. During an interview on [DATE] at 9:55 AM, the Administrator stated the Social Worker oversaw the advanced directives for the facility. He stated she retrieved the information from the resident's or Responsible parties and ensured they were included in the medical record and should have scanned the records to ensure they were completed. He stated he was aware of the findings and a full audit had been completed and no other incomplete documents were located. He stated the risk to residents was paramedics could question the validity of the DNR order and not follow the resident's wishes. The Administrator stated he felt confident the facility staff would have followed procedures and not called emergency services if a resident had an active DNR order. He stated all staff had received additional in-service training related to DNR orders and were aware of the facility's procedures. Record review of the facility's policy titled, Code Status Listing, dated 6/2022, reflected the following: Policy: It is the policy of this home to allow residents the opportunity to file an advance directive document declaring the resident/family/responsible party's end of life wishes . Procedure .1. Residents will be informed of their opportunity to file advanced directives upon admission and at least annually. 2. Social Services or designee will be responsible to keep the code status list current and updated whenever a change occurs. 3. Interdisciplinary Care Plan Team (IDCPT) will discuss advanced directives with resident/responsible party during quarterly care plan conference and update as necessary. 676127 Page 3 of 7 676127 04/17/2025 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the dry storage pantry, refrigerator, and freezer areas on 04/15/25. 2. The facility failed to ensure expired items in the dry storage pantry, refrigerator and freezer areas were removed on 04/15/25. 3. The facility failed to ensure the dented cans in the dry storage area were removed from the shelf on 04/15/25. These deficient practices could place residents at risk for cross contamination and other food-borne illnesses . Findings Include: Observation of the facility's kitchen dry storage, refrigerator and freezer areas on 04/15/25 at 8:40 AM, revealed the following food items were dented cans, unsealed packages and containers , expired , and dented cans. * 1 unsealed clear plastic container of cereal with a clear lid, with date of 2/2 and use by 6/2. The unsealed plastic container was exposed to air. * 1 unsealed clear plastic container of cereal with a clear lid, with date of 4/5 and use by 6/2. The unsealed plastic container was exposed to air. * 1 unsealed clear plastic container of cereal with a clear lid, with date of 4/2 and use by 6/4. The unsealed plastic container was exposed to air. *1 unsealed clear plastic container of cereal with a clear lid, with date of 4/10 and use by 6/10. The unsealed plastic container was exposed to air. * 1 unsealed plastic bag of cereal. The unsealed plastic bag was exposed to air. * 1 unsealed plastic bag of mini marshmallows. The unsealed plastic bag was exposed to air and did not have an expiration date. * 1 unsealed container of 80 oz. oats. The unsealed container was exposed to air. * 1 unsealed package of 10 oz. pasta. The unsealed package was wrapped in plastic wrap and was exposed to air. * 1 unsealed package of fish fry. The unsealed package was exposed to air. 676127 Page 4 of 7 676127 04/17/2025 Avir at North Richland Hills 5600 Davis Blvd North Richland Hills, TX 76180

F 0812 * 1 unsealed package of parboiled rice. The unsealed package was exposed to air. Level of Harm - Minimal harm or potential for actual harm * 1 unsealed package of tortillas. The unsealed package was wrapped in plastic wrap and was exposed to air. Residents Affected - Some * 1 dented 10 1b. can of cream style corn. * 1 dented 6 lb. can of tropical fruit. *1 dented 6 lb. can of sliced peaches * 1 dented 6 lb. can of pork and beans. Refrigerator area: * 1 clear plastic container with red lid labeled Grape Jelly was unsealed and exposed to air. Freezer area: *1 unsealed package of 5 hamburger patties labeled use by 04/13. The unsealed package was exposed to air. In an interview with the Dietary Manager on 04/15/25 at 9:53 AM, revealed she had been employed at the facility for 2 months. She stated she was unaware there were expired and unsealed items in the kitchen's dry storage, refrigerator, and freezer areas. The Dietary Manager stated she was unaware there were 4 dented cans stored on the shelves with the other canned food. She stated all kitchen staff were responsible for ensuring all food items in the kitchen's dry pantry, refrigerator, and freezer areas were sealed, labeled and checked for expiration dates. She stated there should not have been any dented cans on the shelf with the other dented cans . She stated the dented cans were to be separated from the other canned food on the shelves and placed in another place in the dry pantry area that was labeled, Dented Cans. She stated there should not be any food items in the kitchen's dry pantry, refrigerator, and freezer areas that were not sealed and expired . The Dietary Manager stated she had a total of 8 staff members who she supervised, and they worked various shifts. She stated the kitchen staff regularly received In-Service trainings on proper food handling, storage which included ensuring all food in the kitchen was dated, labeled, sealed, included food expiration, food handling and sanitization to prevent food-borne illness per the facility's policy. She stated the kitchen staff received in-service trainings at least two times per month on their paydays. She stated she would immediately throw away all expired items and unsealed items that were found in the kitchen. She stated she would audit the dry pantry, refrigerator, and freezer areas to ensure everything in the area was labeled, dated, sealed and check the expiration dates on the food items. The Dietary Manager stated it was her responsibility to oversee everything in the kitchen was audited which included all food items in the kitchen's dry pantry, refrigerator, and freezer areas were labeled correctly, sealed and checked for expiration dates. She stated her expectation was that if staff were to see anything in the kitchen's dry pantry, refrigerator and freezer areas not labeled, they were to place a label on the item (if not expired) and notify her. She stated her expectations were the same for the food items that were unsealed. The Dietary Manager stated if kitchen staff found anything that was unsealed in the kitchen's dry pantry, refrigerator and freezer areas that was not sealed, her expectations were for the staff immediately throw away the item(s) and notify her. She stated if staff saw a dented can on the shelves where the canned items were stored in the dry pantry area, they should 676127 Page 5 of 7 676127 04/17/2025 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 - Some immediately place the can(s) in the area in the dry pantry area that was labeled, dented cans. She stated her expectation for her staff, was that they were to use the FIFO (the principle and practice of maintaining precise production and conveyance sequence by ensuring that the first part to enter a process or storage location is also the first part to exit) procedures to ensure there were not any unsealed, and expired food items throughout the kitchen. She stated all staff in the kitchen were to use the First In, First Out Method, which meant kitchen staff should label the food with the dates they store them, and when staff were restocking the shelves, they were to put the older foods in front or on top so they could be used first. She stated this system allowed the kitchen staff to find the food quickly and use it more efficiently. The Dietary Manager stated the items found in the kitchen by the state surveyor was a mistake and she would continue to reeducate the staff to ensure everyone was on the same accord with her expectations in the kitchen and the facility's policy on Food Storage. She stated she would immediately retrain and reeducate all kitchen staff via in-service training on food storage. She stated the risk of someone, which included a resident eating food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, dented cans was that they could become ill and become sick due to eating something that could cause food-borne illnesses. She stated there were risks of food borne illness anytime someone ingested food items from the kitchen any items that had not been labeled and stored properly and from dented cans. She stated the harm of someone, which included a resident ingesting food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, eating something from a dented can could cause someone to have stomach aches, bowel issues, and food poisoning. She stated the harm of someone, which included a resident eating food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, eating something from a dented can could cause bacteria to enter the areas if a container or package was unsealed. She stated insects could also enter any area that was not sealed properly. In an interview with the Dietary Aide on 04/15/25 at 10:14 AM, she stated she had been employed at the facility for 10 months. She stated she was unaware there were expired and unsealed items in the kitchen's dry storage, refrigerator and freezer areas. She stated she was unaware there were 4 dented cans on the shelves with the other canned food items. She stated all the staff were responsible for storing the items on the shelf and checking the expiration dates, dented cans to make sure there were not any unsealed items in the kitchen. She stated at least 2 times per month, the Dietary Manager in-serviced the kitchen staff on food storage, labeling and dating, removing expired items from the shelves in the dry pantry, freezer, and refrigerator areas and for dented cans and the use of the FIFO method. The Dietary Aide stated per her in-service trainings pertaining to the food items in the dry pantry, refrigerator, and freezer areas needed to be stored properly by labeling the food items, with the date the food item were placed in the proper area and the use by date. She stated the use by date indicated when the food items should be used. She stated if any food item that was in the facility's dry storage, refrigerator, and freezer areas had a use by date and it was expired, the food item should be immediately thrown away and then she would notify the Dietary Manager of what she found. The Dietary Aide stated if something was not labeled, she would label it in and make sure the item was not unsealed, if it were unsealed, she would throw the item away and notify the Dietary Manager. She stated if she found any dented cans in the dry storage area, she would immediately remove the dented can and place it in the Dented Can area in the dry pantry. She stated she would notify the Dietary Manager. She stated there were risks of food borne illness anytime someone ingested food items from the kitchen's dry pantry, refrigerator, and freezer areas any items that had not been labeled, stored, which included dented cans. The Dietary Aide stated if any of the above 676127 Page 6 of 7 676127 04/17/2025 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 - Some food were to be ingested by anyone, they could or would become ill and have possible food-borne illnesses. She stated the risk of anyone ingesting any of the aforementioned items, they could have stomach aches and vomiting and have other illnesses. Record review of the facility's policy titled, Food Storage dated, October 1, 2022, and revised, June 1, 2019, reflected: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HAACP guidelines. Procedure: Dry storage rooms a. Keep the storage room well-ventilated with humidity controls to prevent mold growth . d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated . f. Where possible, leave items in the original cartons placed with the date visible. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first . 2. Refrigerators . d. Date, label and tightly seal all refrigerated foods .covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old . 3. Freezers . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated . Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 676127 Page 7 of 7