Health inspection·November 10, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure preadmission Screening for individuals with a mental disorder for 1 of 1 (Resident #18) residents in that: The MDS/Care Plan Nurse did not screen Resident #18 with diagnoses of mental illness (major depressive disorder (2/7/2020) and psychosis (3/6/2020). Making Resident #18 a positive PASRR. This could affect all residents with mental illness and could result in a lower quality of care. The Findings were: Record review of Resident #18's face sheet dated 11/10/2022 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnosis of major depressive disorder (2/7/2020) and psychosis (3/6/2020). Resident #18's age is 90. Record review of Resident #18's Quarterly MDS dated [DATE] revealed for Section I Active DiagnosesDepression, manic depression (bipolar disease). Record review of PASRR level 1 screening dated -2/5/2020 and 9/2/2021, section C0100 Mental illness was marked as no (negative). Interview on 11/10/22 at 3:54 PM the MDS/care plan nurse stated she was not aware that residents needed to check yes, for Resident #18's diagnoses of mental illness on the PL 1. The MDS/care plan nurse was responsible for all the resident PASARR forms. Record review of Comprehensive Assessments dated February 2017 revealed, The community will conduct the following types for assessments during its relationship with the resident Pre-admission screening determines whether the community can provide the level and scope of services required by the resident's medical and mental condition. Pre-admission screening and resident review (PASRR) screen i required of all individuals with mental Illness (MI). Page 1 of 9 676233 676233 11/10/2022 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

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 interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical needs for 1 of 8 residents (Resident #57) reviewed for care plans in that: Resident #57 care plan for her tube feeding formula did not match the orders. Resident was receiving bolus feeding if Resident #57 did not eat percentage of food and the care plan was documented for her to receive continuous tube feedings. This could affect all residents with tube feedings and could result in decrease of quality of care. The findings were: Record review of Resident #57's face sheet dated 11/8/2022 with an admission date of 2/10/2022 and re-admitted on [DATE] with diagnoses of protein calorie malnutrition, adult failure to thrive, cognitive communications deficit, and dysphagia (swallowing difficulties). Record review of Resident #57's consolidated physician's orders for November 2022 revealed an order for three times a day Isosource 1.5 - If resident eats less than 50% of breakfast, lunch or dinner then administer per tube: Isosource 1.5: 500cc (2 cartons) = 750kcal/500cc formula) & flush with 150cc water pre and post each bolus (a single dose of a drug or other medicinal preparation given all at once.) of formula. Record review of Resident #57's admission MDS dated 2/18//2022 revealed for section K Swallowing/Nutritional Status- Feeding Tube. Record review of Resident #57's care plan dated 8/19/2022 revealed the resident requires a feeding tube related to Failure to thrive, Malnutrition Enteral Nutrition: Isosource 1.5 @ 65ml/hr x12 on:(7p-7a) with free water flushes 150ml q3hr from (7p-7a) which provides: 1170 kcal, 53g protein and 1149ml total water (594 water from formula and 600ml water from flushes. The care plan was continual feedings, instead of bolus feedings. Interview 11/10/22 10:52 AM the MDS/care plan Nurse stated Resident #57's care plan was wrong and the physician's order was correct. The MDS/care plan nurse stated she assisted feeding Resident #57 during meals in the dining area. THE MDS/care plan nurse stated she was responsible for resident MDS's, and she had not updated to match the order, mistake. Interview on 11/10/22 at 10:47 AM Dietician stated Resident #57 received Isosource formula as a backup for her weight decrease in past, now her weight was stable and was assisted by staff in feeding during meals. Interview on at 11/10/22 at 12:05 PM the DON stated the resident care plans was the responsibility of the IDT, TEAM, to include the MDS/care plan nurse, ADON, and DON all review resident care plans. The potential risk would be resident not receive the accurate order and a decrease in quality of care for resident. 676233 Page 2 of 9 676233 11/10/2022 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of policy Care Plans dated February 2017 revealed, The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a residents' medical nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Residents Affected - Few 676233 Page 3 of 9 676233 11/10/2022 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observations, interviews, and record reviews the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for 2 of 2 residents (Residents #20 and #25) reviewed for receiving meals as prescribed, in that: 1. Residents #20 and #25 did not receive their ice cream at meals as prescribed by their physician. This deficient practice could place residents at risk of not receiving their meal to meet their needs for allergy aversions, unwanted weight loss, and meal textures and/or consistencies. The findings include: Resident #20 A record review of Resident #20's admission record revealed an admission date of 10/25/2020, with diagnoses which included protein-calorie malnutrition [deficient nutrition intake], Alzheimer's disease [a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks], and celiac disease [a digestive problem that hurts your small intestine. It stops your body from taking in nutrients from food]. A record review of Resident #20's physician's orders dated 11/08/2022 revealed a physician's order for Resident #20 to receive protein fortified ice cream with lunch and dinner. Resident #25 A record review of Resident #25's admission record revealed an admission date of 10/30/2019, with diagnoses which included protein-calorie malnutrition [deficient nutrition intake], Alzheimer's disease [a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks], and muscle wasting and atrophy [muscle loss], and cognitive communication deficit [difficulty communicating]. A record review of Resident #25's physician's orders dated 11/08/2022 revealed a physician's order for Resident #25 to receive protein fortified ice cream with lunch and dinner. During an observation on 11/7/2022 at 12:46 PM revealed the ADON in the dining room to handle the 400-hall meal cart as it left the kitchen. The ADON briefly overviewed the cart and passed the meal cart to CNA F. CNA F pushed the cart to the 400-hall. During an observation on 11/7/2022 at 12:48 PM revealed the meals for the secured 400-hall were delivered to the unit. Continued observation revealed MA E and CNA F were removing meals from the meal cart and serving the meals. Further observation revealed Residents #20 and #25 were seated at the dining room table and Residents #20 and #25 were served the noon meal without the ice cream their physician had prescribed. 676233 Page 4 of 9 676233 11/10/2022 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Residents #20 and #25's undated noon meal tickets revealed standing orders: ½ C Ice Cream. During an interview on 11/7/2022 at 1:01 PM MA E stated she did not review the meal tickets for accuracy prior to serving the meals due to the nurse in the dining room checked the meal trays for accuracy. MA E reviewed Residents #20 and #25's meals and meal ticket and concluded they were not served their ice cream as ordered. During an interview on 11/7/2022 at 1:14 PM the ADON stated he had not fully reviewed all the meals designated for the 400-hall residents against their meal tickets. The ADON stated he was responsible for reviewing all the meals against their meal tickets for accuracy prior to the meals being serve to the residents. The ADON stated residents could have been at risk for not receiving their meals as prescribed by the physician or their preferences. During an interview on 11/10/2022 at 3:50 PM the DON stated the facility's policy and training was for nurses to check all meals for accuracy against meal tickets for all residents prior to the meal being served. The DON stated the failure on 11/7/2022 was due to the ADON not checking all the meals for accuracy prior to serving the meal. the DON stated the residents could have been placed at risk for harm by not receiving their meals as prescribed or per their preferences. A record review of the facility's dietary services policy dated February 2017, revealed, the community provides each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident . residents receive and consume foods in the appropriate form and appropriate nutritive content as prescribed by a physician. 676233 Page 5 of 9 676233 11/10/2022 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interviews and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete and accurately documented for 3 of 3 residents (Residents #12, #65, and #136) reviewed for insulin administration, in that: 1. Residents #12, #65, and #136 were administered insulin and the administration was not promptly documented. This failure could have placed residents at risk for harm by inaccurate insulin medication administration. The findings include: Resident #65 A record review of Resident #65's admission record, dated 11/08/2022, revealed an admission date of 12/21/2021 with diagnosis which included type II diabetes (a person's body doesn't use insulin well and can't keep blood sugar at normal levels). During an interview on 11/08/22 04:02 PM Resident #65 stated he had been receiving his insulin late specifically from agency temporary nurses on the weekends. Resident #65 stated he received his insulin during his meals and after his meals, just this weekend this happened, by nurses I did not recognize. Resident #65 stated he had not reported the incident to any staff for concerns of not wanting to cause any trouble but had a change of heart considering there might be other residents who had similar experiences. During a record review of Resident #65's physician's orders revealed an insulin order dated 10/10/2022 for Resident #65 to receive Novolog (a rapid acting insulin to rapidly lower excess sugar in the body) before meals . During a record review of Resident #65's medication administration record, dated 11/09/2022, revealed LVN A documented she administrated an injection of NovoLog to Resident #65 on 10/02/2022 at 11:01 AM but the scheduled time for the administration was 07:00 AM. LVN A documented she administrated an injection of NovoLog to Resident #65 on 10/02/2022 at 01:26 PM but the scheduled time for the administration was 11:30 AM. LVN D documented she administrated an injection of NovoLog to Resident #65 on 10/03/2022 at 01:11 PM but the scheduled time for the administration was 11:30 AM. LVN C documented she administrated an injection of NovoLog to Resident #65 on 10/24/2022 at 10:00 AM but the scheduled time for the administration was 07:00 AM. LVN D documented she administrated an injection of NovoLog to Resident #65 on 10/29/2022 at 08:58 AM but the scheduled time for the administration was 07:00 AM. During an interview on 11/9/2022 at 10:02 AM the FSM stated she trains her staff to prepare and serve a hot nutritious meal for all residents three times a day on time. The FSM stated on time meant the breakfast meal should be served to the last Resident by 08:00 AM, the noon meal by 01:00 PM, and 676233 Page 6 of 9 676233 11/10/2022 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0842 the evening meal by 6:00 PM. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/10/2022 at 12:53 PM LVN D stated, she had administered Resident #65's NovoLog on 10/03/2022, prior to his noon meal but did not document the administration until 01:11 PM due to her workload of caring for 30 plus residents on 100 and 400-hall. LVN D stated insulin injections are ordered to be administered prior to meals. LVN D stated she had not alerted any staff of her concerns and stated she had a dilemma, either administer the insulins and document as she provided care and run late with administrations or document late and provide insulin injections prior to meals. Residents Affected - Some During an interview on 11/10/2022 at 02:38 PM LVN C stated she had administered Resident #65's NovoLog insulin injection on 10/24/2022 at 7:00 AM but did not document the administration until 10:00 AM due to her large caseload. LVN C stated she was assigned to the 100 and 400-halls which comprised of 30-35 residents and used a handwritten note pad to document her care as she provided care for residents. LVN C stated she would need to go down the hall and administer the residents' insulins as the meals arrived from the kitchen. LVN C stated if she documented in the electronic record as she administered the injections, she would not have enough time to provide the insulin injections for her residents before their meals. During an interview on 11/10/2022 at 4:10 PM LVN A stated she did administer an injection of NovoLog to Resident #65 on 10/02/2022 at 11:30 AM but did not document the injection until 01:26 PM. LVN A stated she began her employment at the facility in May 2022 as a temporary agency nurse and routinely worked 100-hall and 400-hall, on the weekends and weekdays whenever the facility needed nurses. LVN A stated the facility grouped the work assignments for nurses by hallways and the 100-hall and 400-hall were always bundled together and assigned to 1 nurse. LVN A stated 100-hall was a memory care secured unit with 20 residents and was staffed by 1 dedicated CNA who never left the unit unless she was temporarily relieved by a fellow CNA or a nurse like herself. LVN A stated the 400-hall was a new admissions hallway and usually had 15 to 20 residents. LVN A stated due to her caseload of 35 to 40 residents to care for of which included residents with needs blood sugar checks and insulin administrations she would not document insulin administrations until after she could stop her care for residents and document her work, i.e., insulin injections. LVN A stated she would have a handwritten worksheet and would quickly write down her insulin injections details as she worked and then later in the day, she would use the notes to document the administrations. LVN A stated she would check residents blood sugars before meals and would then wait to administer insulins until she saw the meal trays being delivered by the dietary staff, if I documented the administrations as I gave the insulin injections, I would not have enough time to administer all the insulin injections on time. LVN A stated she had not officially reported the incidents to her supervisor but did state, They [Leadership] know, they make the schedule, work assignments, and they know the census. Resident #12 A record review of Resident #12's admission record, dated 11/08/2022, revealed an admission date of 3/16/2022 with a diagnosis which included type II diabetes (a person's body doesn't use insulin well and can't keep blood sugar at normal levels.) During an interview on 11/09/2022 8:31 AM Resident #12 stated she had received her insulin late on several occasions and at times she had received her insulin during her meals or after her meals. 676233 Page 7 of 9 676233 11/10/2022 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #12's physician's orders, dated 11/09/2022, revealed Resident #12 was to be administered an injection of 5 units of Humalog before meals and an injection of insulin glargine before meals. During a record review of Resident #12's medication administration record, dated 11/09/2022, revealed LVN D documented she administrated an injection of Humalog to Resident #12 on 10/11/2022 at 03:35 PM but the scheduled time for the administration was 11:30 AM. LVN B documented she administrated an injection of Humalog to Resident #12 on 10/22/2022 at 10:19 AM but the scheduled time for the administration was 07:30 AM. LVN D documented she administrated an injection of insulin Glargine to Resident #12 on 10/23/2022 at 09:26 AM but the scheduled time for the administration was 07:00 AM. LVN B documented she administrated an injection of Humalog to Resident #12 on 10/23/2022 at 02:01 PM but the scheduled time for the administration was 11:30 AM. During an interview on 11/10/2022 at 02:17 PM LVN B stated she did administer an injection of Humalog to Resident #65 on 10/23/2022 at 11:30 AM but did not document the injection until 02:01 PM, and possibly other dates and times. LVN B stated she was not a temporary agency nurse and had worked at the facility longer than a year. LVN B stated she regularly worked the 100 and 400-halls. LVN B stated the 100 and 400-halls were grouped together and assigned 30 to 40 residents to 1 nurse. LVN B stated she was responsible for diabetic residents on her hall and due to her increased workload with time constrains, she checked residents' blood sugars prior to the residents eating but would not administer their insulin injections until the meal trays were coming down the halls. LVN B stated she had never given insulin injections after a resident's meal but had documented the insulin administration later in the day stating, I write down blood sugars and insulin injections on my worksheet as I go and then later in my shift, when I have time, I will document [in the electronic record] the administration with the info from my notes. LVN B stated, I understand, my mistake of not documenting it at that exact moment, but I go in I make sure, like you know, she gets her [insulin] .truthfully it just gets very chaotic Resident #136 A record review of Resident #136's admission record, dated 11/08/2022, revealed an admission date of 11/01/2022 with diagnoses which included type II diabetes (a person's body doesn't use insulin well and can't keep blood sugar at normal levels.) During an interview on 11/09/2022 09:18 AM Resident #136 stated she had received her insulin late on several occasions and at times she had received her insulin during her meals or after her meals. During a record review of Resident #136's physician's orders revealed an insulin order dated 10/10/2022 for Resident #136 to receive Novolog (a rapid acting insulin to rapidly lower excess sugar in the body) before meals . During a record review of Resident #136's medication administration record, dated 11/09/2022, revealed LVN B documented she administrated an injection of NovoLog to Resident #136 on 11/03/2022 at 12:22 PM but the scheduled time for the administration was 11:30 AM. During an interview on 11/10/2022 at 04:31 PM the DON stated nursing staff were trained to safely administer medications and to immediately document the administration of the medication prior to caring for another resident. The DON stated the Administrator informed her of Resident #65's allegation of neglect where he did not receive his insulin prior to his meals. The DON investigated the 676233 Page 8 of 9 676233 11/10/2022 Avir at Bandera 222 Fm 1077 Bandera, TX 78003

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some allegation and discovered the nurses were administering insulins to residents #12, #65, and #136 and then not documenting the administration until much later. The DON stated this practice was intolerable and was not in line with the facility's policy and training. The DON identified LVN A, LVN B, LVN C, and LVN D had administered insulin on time, before meals, but then did not document the administration until they felt they could take time to document the administration. The DON stated the nurses would receive further training for medication administration and documentation prior to continuing to care for residents. The DON stated she would continue the investigation to include the evolving information where nurses did not report their personal assessments for safe medication administrations. A policy request for medication administration was requested on 11/9/2022 from the Administrator and in response the facility provided a medical records policy which did not specifically address documentation of medication administration as the medication was administered. A record review of the Institute for Safe Medication Practice's website, https://www.ismp.org/guidelines/timely-administration-scheduled-medications-acute , Guidelines for Timely Administration of Scheduled Medications, accessed 11/18/2022, revealed, The guidelines are intended to be used as a resource when acute care organizations develop, or revise policies and procedures related to timely administration of scheduled medications. MAR [medication administration record] documentation: Require staff who administer medications to document the exact time the drug was administered, rather than just initialing the MAR entry, to provide nurses with the information they need to evaluate the actual dosing interval before administering medications early or late. If a medication was administered early or late, or has been omit- ted, require staff to document the reason. Ensure electronic and paper MARs provide sufficient space and prompts for this documentation. 676233 Page 9 of 9