Health inspection·April 24, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations and interviews, the facility failed to ensure only permitted and authorized personnel had access to the keys for 1 of 8 medication carts (Hall 400/500/600 cart) reviewed for drug storage. RN A failed to secure the keys for the medication cart for Halls 400/500/600 after shift change. This failure could place residents at risk of accessing medications not intended for them. Findings included: Observation on 04/24/25 at 9:45 AM of the medication cart for Halls 400/500/600 revealed it was locked, but the keys were in the medication count binder. The binder was closed and on top of the cart, the keys were not visible until the binder was opened. The surveyor was able to open the cart with the keys from the binder. Interview on 04/24/25 at 9:50 AM with RN A revealed the keys should not have been left in the binder. He stated he or the medication aide should have been in possession of the keys. He stated the normal process for shift change at 6:00 AM was for the night shift nurse to count the cart with the on-coming medication aide or the nurse if the medication aide was not available. He stated that obviously did not happen this morning since the keys were left in the binder. RN A stated he would have to take the keys and the cart to the medication aide and count with her. Interview on 04/24/25 at 10:00 AM with MA B revealed she was the only medication aide for the facility on the 6:00 AM-2:00 PM shift. She stated she was running late because of the weather, so she did not arrive for the 6:00 AM shift change. She stated it was normal for her to find the keys for the Hall 400/500/600 medication cart in the count binder because she started on the Hall 100/200/300 medication cart. She stated the night nurse did not count with her, so she counted with the day nurse. She stated after she finished the first set of halls, she went to the other halls. She stated she counted with the day nurse and then took possession of the keys which were almost always in the binder. Interview on 04/24/25 at 10:15 AM with the DON revealed the acceptable practice was for the night nurse to count with the day medication aide, or the day nurse, and hand the keys over. The keys should always be in the physical possession of the nurse or the med aide. The DON stated it was not acceptable for the keys to be left in the count binder because anyone could access the cart with the keys and gain access to medications not intended for them. Page 1 of 6 676132 676132 04/24/2025 Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Phone interview attempt on 04/24/25 at 1:04 PM with LVN C was unsuccessful due to the voice mailbox being full. A text message was sent; however, there was no response to either. Phone interview on 04/25/25 at 9:40 AM with MA D revealed when she went off shift at 10:00 PM on 04/24/25, she counted her medication cart with LVN C and handed the keys over to her. MA D stated she had never left the keys in the count binder. Phone interview on 04/25/25 at 10:38 AM with LVN C revealed on 04/24/25 at 6:00 AM shift change she counted the nurse medication cart with RN A, but they did not count the medication aide cart. LVN C stated she placed the keys to the medication aide cart in the count binder because RN A had walked away before they could count the cart. Review of the facility's Medication Labeling and Storage policy, dated February 2023, reflected: The facility stores all medications and biologicals in locked compartments under proper temperatures, humidity, and light controls. Only authorized personnel have access to the keys. 676132 Page 2 of 6 676132 04/24/2025 Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve nutritive value for 1 of 1 kitchen reviewed for food and nutrition services. Residents Affected - Few Cook E failed to prepare the pureed lunch meal in a manner to conserve nutrition, flavor, and palatability on 04/23/25 when she added water to the pureed scalloped potatoes and cornbread and did not follow the recipes. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss. Findings included: Record review of the lunch menu ticket for 04/23/2025 reflected the menu for the lunch service was Cheesy Sausage w/Sauteed onions, Scalloped Potatoes, Southern Style Turnip Greens, Cornbread and Fresh Baked Cookies. Record review of the facility's recipe for Pureed Scalloped Potatoes from the Dining RD 2025 Menu reflected the following: Ingredients: Scalloped Potatoes - Add milk if product needs thinning . 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. Record review of the facility's recipe for Cornbread/Margarine from the Dining RD 2025 Menu reflected the following: Ingredients: Corn Bread, Milk, 2%, this is an estimate based on industry standards and adjustments in added liquid may be 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. Observation on 04/23/25 at 11:35 AM revealed [NAME] E making pureed lunch. [NAME] E put scalloped potatoes in the blender and blended. [NAME] E added water without measuring, added breadcrumbs and blended the mixture. The pureed scalloped potatoes appeared to have a mashed potato consistency. [NAME] E then was observed to put cornbread in the blender and blended. [NAME] E added water without measuring it. She then added breadcrumbs and blended the mixture. Interview on 04/23/25 at 1:18 PM with [NAME] E revealed she had been employed at the facility for about a year and half. She stated prior to preparing a meal she reviewed the recipe. She stated she was aware the pureed food needed to have a smooth, mashed potatoes consistency. She stated when blending the food, she should add broth and breadcrumbs to obtain the consistency needed. She stated she added water to the scalloped potatoes and cornbread because she needed it to be soft and smooth. She stated she was not aware the recipe specified not to add water. She stated she had not been told not to add water to pureed food. She stated there was no risk to the resident if water was added to the food. Interview on 04/23/25 at 1:28 PM with the Dietary Manager revealed she and the [NAME] were responsible for reviewing the recipe prior to preparing the meal. The Dietary Manager stated when staff 676132 Page 3 of 6 676132 04/24/2025 Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few prepared pureed food, they should use the juice/broth of the food. She stated water could not be added to the pureed foods because it took the flavor out. Record review of the facility's Pureed policy, dated 2022, reflected the following: The Puree Diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency. . Drain liquid from portions needed for pureed preparation. Reserve liquid in case additional liquid is needed when pureeing to the correct consistency. NEVER USE WATER AS THE LIQUID ADDED TO A PUREED ITEM .the following liquids would be acceptable to use when pureeing foods: prepared broth, gravy, sauce, milk, juice and melted margarine/butter. 676132 Page 4 of 6 676132 04/24/2025 Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133

F 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 or 2 meals (lunch) reviewed for food meeting residents' needs. Residents Affected - Few The facility failed to prepare and serve pureed scalloped potatoes as a pudding consistency for residents who required pureed diets during the lunch meal on 04/23/25. This deficient practice could affect residents and place them at risk of not receiving meals that meet their needs. Findings included: Record review of the lunch menu ticket for 04/23/2025 revealed the menu for the lunch service was Cheesy Sausage w/Sauteed onions, Scalloped Potatoes, Southern Style Turnip Greens, Cornbread and Fresh Baked Cookies. Observation on 04/23/25 at 11:35 AM revealed [NAME] E pureed scalloped potatoes with a blender. After blending the scalloped potatoes, neither [NAME] E nor the Dietary Manager checked the consistency to ensure the scalloped potatoes were all blended to a pudding smooth consistency. Observation of the test tray on 04/23/25 beginning at 1:03 PM with the Dietary Manager revealed the test tray included the regular textured menu items and the pureed menu items. The pureed scalloped potatoes did not have a smooth, pudding consistency. The scalloped potatoes had chunks of potato not fully pureed. The Dietary Manager stated the pureed scalloped potatoes were not the correct consistency. Interview on 04/23/25 at 1:18 PM with [NAME] E revealed pureed food needed to have a smooth, mashed potatoes consistency. She stated when she blended the scalloped potatoes it appeared smooth. She stated she did not ensure it was all blended. She stated the potential harm to residents was the possibility choking. Interview on 04/23/25 at 1:28 PM with the Dietary Manager revealed the pureed food should had a smooth, pudding consistency. She stated the scalloped potatoes on the test tray were not the correct consistency because there were chunks of potatoes. She stated she and the [NAME] were responsible for ensuring the consistency was correct. She stated residents were at risk of choking if everything was not completely pureed. Record review of the facility's recipe for Pureed Scalloped Potatoes from the Dining RD 2025 Menu reflected the following: .2. If the product needs thickening, gradually add a commercial or natural food thickener to achieve a smooth, pudding or soft mashed potato consistency. Record review of the facility's Pureed policy, dated 2022, reflected the following: The Puree Diet is designed for those individuals who have difficulty swallowing or cannot chew 676132 Page 5 of 6 676132 04/24/2025 Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133

F 0805 foods of the dental soft consistency. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676132 Page 6 of 6