Health inspection·February 29, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #30) of 5 residents reviewed for resident rights. The facility failed to honor Resident #30's choice to not take Mirtazapine (anti-depressant). This failure placed residents at risk for loss of dignity and self-worth. Findings included: Record review of Resident #30's annual MDS assessment, dated 12/24/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was intact. His diagnoses included depression and non-Alzheimer's dementia. Record review of Resident #30's Order Summary Report for February 2024 reflected: 12/15/23 Mirtazapine Tablet 7.5 mg , give 1 tablet by mouth one time a day. Review of Resident #30's Informed Consent for use of Psychotropic Medication revealed the consent for mirtazapine was signed by a family member and dated 01/04/24. Record review of Resident #30's progress notes written by the DON reflected: 02/21/24 10:04 AM Resident refused to sign consent for Remeron (Mirtazapine). Stated he does not feel he needs it and request to have it discontinued. Psychiatry referral initiated. An interview on 02/28/24 at 10:05 AM with Resident #30 revealed he was awake, alert, and oriented x3. He said he did not want to take mirtazapine and thought it had been discontinued a long time ago. Resident #30 called the family member who signed his consent on 01/04/24. He placed the family member on speaker phone. The family member said if the resident did not want to take the medicine, then he did not have to. Resident #30 said he wanted the medication to be discontinued. An interview on 02/28/24 at 10:40 AM with the DON revealed she thought Resident #30 changed his mind and did want to take mirtazapine. She said it was the resident's choice to take or not take the Page 1 of 10 676475 676475 02/29/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0550 mirtazapine. The DON said failure to honor a resident's choice could cause unwanted feelings. The DON said there was no risk to the resident taking mirtazapine. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure, Resident Rights, dated 09/01/23, reflected: Residents Affected - Few The resident has the right to be informed of, and participate in, his or her treatment . 676475 Page 2 of 10 676475 02/29/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 resident (Resident #26 ) reviewed for accidents. The facility failed to supervise Resident #26 while smoking. This failure could place residents who required supervision while smoking at risk for burns. The findings included: Review of Resident #26's annual MDS assessment, dated 11/29/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included non-Alzheimer's dementia. Review of Resident #26's Care Plan, dated 04/15/22, reflected she smoked. Her facility interventions included: Smoking assessment by the SW and smoking in designated areas only. Review of Resident #26's, Safe Smoking Assessment, documented by the DON, dated 02/01/24, reflected the resident required direct supervision while smoking. An observation and interview on 02/28/24 at 1:35 PM with Resident #26 revealed she was outside smoking a cigarette with no staff around. Resident #26 said she was allowed to smoke outside by herself. An observation and interview on 02/28/24 at 1:40 PM with Laundry Staff E revealed she entered the smoking area with another resident. Laundry Staff E approached Resident #26 and told her that she was not supposed to be outside smoking without a staff present. Resident #26 replied and said there was not a staff member to go with her. Laundry Staff E told the resident that she would have taken her outside to smoke. An interview on 02/28/24 at 2:59 PM with LVN F revealed Resident #26 required supervision to smoke. LVN F said she was on her lunch break when the resident went out to smoke . An interview on 02/29/24 at 9:52 AM with LVN G revealed there was no way for staff to know which resident was going out to smoke. LVN G said the residents could keep their smoking paraphernalia with them. She said there was a risk to residents who smoked unsupervised. LVN G said residents could drop ashes or cigarettes on their laps and cause a smoke injury . An interview on 02/29/24 at 11:13 AM with Resident #26 revealed she was in the dining room. She was awake, alert, and oriented x3. She said staff usually went outside to smoke with her. Resident #26 said she kept her own smoking paraphernalia and kept them hidden from staff and residents. An interview on 02/28/24 at 1:50 PM with the DON revealed residents could smoke unsupervised as 676475 Page 3 of 10 676475 02/29/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few long as their smoking assessment said they could. The DON said residents could keep their smoking paraphernalia with them. The DON said residents could smoke anytime between 9:00 AM - 9:00 PM . Review of the facility policy and procedure, Resident Smoking, dated 12/14/23, reflected: Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if the resident is safe to smoke at all . Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff . 676475 Page 4 of 10 676475 02/29/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

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 observations, interviews, and record review, the facility failed to ensure each resident received food prepared by methods that conserve nutritive value, flavor, and appearance that is palatable, attractive, and at a safe and appetizing temperature for 1 (Resident #33) reviewed for food and nutrition services. Residents Affected - Few The facility failed to ensure the pureed meal which consisted of steak patty with brown gravy, broccoli and cauliflower blend, au gratin potatoes, and roll were prepared in a way to preserve vitamins and taste by not following required measuring when adding thickener and water to the food items. This failure could place residents at risk of nutrition and hydration and negatively impact the recovery from, illness or injury. Findings included : During the test tray tasting, with the Dietary Manager present, on 02/28/24 at 12:39 AM, the food was mildly warm. The regular plate was palatable. No complaints or concerns were noted with the regular plate; however, the puree plate was not visually pleasing, and the taste of the food was void of flavor. The plate consisted of scalloped potatoes, beef patty in gravy, and broccoli and cauliflower blend. Each food was spread through its section. The potatoes looked like a gelatin paste. None of the foods tasted like what they were. The Dietary Manager looked at the plate and said the potatoes looked like glue. She stated the food did not taste like what it was. She stated they were to follow the recipes for pureed foods and she did not know why the cook, made the food like that. She stated she did not taste the food before it was served, and she did not know if the cook tasted it. She stated the taste and appearance of the food would make her not want to eat, if it was served to her. She stated she believed the resident who received that meal today, would not feel good about it and probably would not eat it. During an interview with the Administrator on 02/28/24 at 3:33 PM, he stated he had been made aware of the pureed test tray. He stated he understood the issue to be that the food processor was not working properly and had he known about it sooner, he would have had it replaced. He stated he was going to replace it the evening of this interview. He would not say what the risk to the resident would be, if they consumed meals in the state of the meal on the test tray. During an interview and observation with the [NAME] on 02/29/24 at 11:49 AM, she stated the food processor had cracks in it which caused the liquids to leak out. She stated she had been complaining about it for over two years. She stated she and the Dietary Manager had told the former Administrator about it and nothing was done about it. She stated she always followed the recipe for the pureed foods; however, with the liquids leaking out, she would just add more broth or water to the mixture until the foods had reached the appropriate consistency. She stated she did not know what else to do. She stated at the time of this interview, there was only one resident who was on a pureed diet. She identified that resident to be Resident #33. She stated she had not received any type of feedback about the food, from the resident. She stated she did not believe any residents who were on a pureed diet were happy about their food. She stated the Administrator purchased a new food processor and it was in the kitchen when they arrived to work on this day. The food processor was new, and the food was the proper consistency. Each food item tasted like what it was supposed to be. During an interview with Resident #33 on 02/29/24 at 1:44 PM, he stated he did not always care for 676475 Page 5 of 10 676475 02/29/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the food, but he still ate it because it was all he could eat. He stated he had not ever felt sick from eating it and he had not noticed any negative effects from it, so he was fine with it. Record review for Resident #33's weight, did not reflect a significant weight loss. There was no documentation found, reflecting the resident had complained about the food or digestive issues due to the food. Review of the facility's Food Preparation and Handling policy, dated 06/01/19, reflected Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and HACCP guidelines. The Nutritional Policies and Procedures for Sanitation & Food Safety in Food and Nutrition Services, dated 08/01/2020, reflected, Food and beverages prepared by the culinary staff are tasted in a sanitary manner to test for proper flavor, seasoning, and texture. Procedures: The facility will use the International Dysphagia Diet Standardization Initiative as the foundation for texture modified foods and thickened drinks provided to the residents. 676475 Page 6 of 10 676475 02/29/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

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 observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's dry goods storage, was labeled and dated according to guidelines. These failures could place residents at risk for food-borne illnesses. Findings included: Observations on 02/27/24 from 09:10 AM to 09:21 AM in the facility's only kitchen reflected: Three opened cans of Baking Powder, dated 9/29 and there was no visible expiration date. Three 1-gallon container of Worcestershire sauce, dated 5/22 and there was no visible expiration date. One of the containers had been opened and had congealed sauce, which adhered to the inside of the container and dried sauce drip stain on the outside of the container. A plastic container labeled Baking Soda, dated 12/30 and there was no visible expiration date. The label on the lid had an aged yellowish color to it. A plastic bin labeled Flour, dated 11/1 and there was no visible expiration date. A plastic bin labeled Corn Meal, dated 11/1 and there was no visible expiration date. A plastic bin labeled Butter Beans, dated 11/23 and there was no visible expiration date. A plastic bin labeled Sugar, dated 8-14 and there was no visible expiration date. A plastic bin labeled Pinto Beans, dated 9/8 and there was no visible expiration date. Three containers of Chicken Base Paste, dated 9/11 and there was no visible expiration date. Eleven containers of Iodized Table Salt, dated 11/13 and there was no visible expiration date. A can of mixed vegetables, dated 2/14 and there was no visible expiration date. During initial rounds of the facility's only kitchen on 02/27/24 at 09:16 AM, multiple items were noted to have only the month and day written on them. There was no year provided and no Use By written on them. In an interview on 02/27/24 at 9:30 PM with the Dietary Manager, she stated she was the person who was overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. She was shown all of the concerns observed in the kitchen and she stated she had 676475 Page 7 of 10 676475 02/29/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few trained staff to date items with the month date and year, but the person who labeled some of the items was new and was still learning. She stated she should have checked to ensure the new staff member was dating the items correctly, but she had been busy. She then called the new staff member to the storage room and told her that the year needed to be included when writing the dates on the items. She stated the date which they write on the food items, reflect the date which the items were delivered to the facility. She stated the risk of all of these concerns observed in the kitchen could result in resident getting sick from eating expired food. In an interview on 02/28/24 at 11:37 AM with the Administrator, he stated he was made aware of the dry food items not being dated properly. He stated he understood it to be that the items were only dated with the month and date, but no year. He stated the issue there was no way to be certain if the food was any good, if there was no Use By date on the container. He stated if expired food items were served to the residents, it could cause them to become ill with vomiting and/or diarrhea. Record Review of the Facility's policy on Food Storage dated 06/01/19, revealed 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 HACCP guidelines. Procedure: 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 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. 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. 676475 Page 8 of 10 676475 02/29/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0880 Provide and implement an infection prevention and control program. 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 review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #56 and Resident #3) of 5 residents reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure LVN A performed hand hygiene during wound care for Resident #56. 2. The facility failed to ensure CNA B and RA C performed hand hygiene during incontinence care for Resident #3. Findings included: 1. Review of Resident #56's Face Sheet dated 02/29/24, reflected he was an [AGE] year-old male admitted on [DATE]. His diagnoses included Lupus. Review of Resident #56's Progress Notes written by LVN D reflected: 02/26/24 at 5:33 AM Note Text: CNA reported that resident had a wound on his right lower leg and the wound was bleeding. Assessment performed of the wound. Two abrasions, red in sight, and warm to touch, with reddish pink surrounding them. Area right above his ankle. The wound was covered with border gauze bandage. An observation of wound care for Resident #56 on 02/27/24 at 12:56 PM by LVN A revealed the resident had a wound on his right lower leg. The resident was awake, alert, and confused. He was sitting in his wheelchair in his room. LVN A performed hand hygiene, donned gloves, and removed the soiled dressing dated 02/26/24. LVN A cleaned the wounds. There were three red, open areas with slough. There was a small amount of brown drainage on the bandage. LVN A did not change her gloves or perform hand hygiene. LVN A put on a non-adherent dressing over the wound. LVN A removed her gloves but did not perform hand hygiene. LVN A put on new gloves and placed a foam dressing over the wound. An interview with LVN A on 02/27/24 at 1:18 PM revealed she knew she was supposed to change her gloves and perform hand hygiene but did not do it. LVN A said hand hygiene was important to prevent infection. 2. Review of Resident #3's Face Sheet dated 02/29/24, reflected he was an [AGE] year-old male admitted on [DATE]. His diagnoses included dementia. Review of Resident #3's Care Plans, dated 05/11/22, reflected: Resident had bladder and bowel incontinence related to dementia and impaired mobility. Facility interventions included: Check resident at least every 2 hours and as required for incontinence. 676475 Page 9 of 10 676475 02/29/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation on 02/29/24 at 1:17 PM of incontinence care for Resident #3 revealed the resident was lying on his back. RA C folded down his brief and cleaned the penis and scrotal area. RA C put on new gloves but did not perform hand hygiene. The resident was assisted to turn to his left side. CNA B cleaned the resident's buttocks of urine and bowel movement. CNA B did not perform hand hygiene or change her gloves after she cleaned the resident. CNA B grabbed a clean brief and bed pad and positioned them under the resident. An interview on 02/29/24 at 1:46 PM with CNA B revealed she had been trained to do incontinence care and perform hand hygiene. CNA B said she did not perform hand hygiene because she was nervous. She said hand hygiene was important to prevent infection. An interview on 02/29/24 at 1:50 PM with RA C revealed she had been trained to do incontinence care and perform hand hygiene when changing her gloves. RA C said she did not perform hand hygiene because there were no paper towels in the bathroom to wash her hands. She said hand hygiene was important to prevent germs and infection. An interview on 02/29/24 at 10:19 AM with the DON revealed staff were supposed to change gloves and perform hand hygiene after cleaning the wound and resident. The DON said hand hygiene was important to prevent the spread of infection. Record review of facility's policy, Infection Prevention and Control Program, revised 02/29/24, reflected: 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures . 676475 Page 10 of 10