Health inspection·April 25, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation. interview and record review, the facility failed to provide the necessary services to maintain grooming and personal care for 4 of 5 residents (Residents #1, # 2, # 3 and #4) reviewed for ADL care in that: Residents Affected - Some A) Resident #1 was not provided with nail care. B) Resident #2 was not provided with nail care. C) Resident #3 was not provided with nail care. D) Resident #4 was not provided with brief changes and peri care. These failures could place residents at risk of skin breakdown, pain, infection, and loss of self-esteem. Findings included: A. Record review of the undated Face Sheet for Resident #1 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the undated Medical Diagnosis sheet for Resident #1 reflected he had a diagnosis of Cerebral Palsy (a congenital, present from birth, disorder of movement, muscle tone or posture due to abnormal brain development) dated 07/01/2019 and muscle weakness generalized dated 11/03/2020. Record review of the Quarterly MDS dated [DATE] for Resident #1 reflected there was no BIMS score recorded. His Functional Abilities and Goals reflected he required substantial/maximal assistance for personal hygiene. Page 1 of 5 676475 676475 04/25/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview on 04/25/2024 at 9:31 AM revealed Resident #1 had nails that were 1 inch long past the fingertips on both hands. Resident #1 stated he would like to have his nails trimmed. B. Record review of the undated Face Sheet for Resident #2 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the undated Medical Diagnosis sheet for Resident #2 reflected he had diagnosis of unspecified Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with other behavioral disturbance dated 10/01/2022. Record review of the Comprehensive MDS dated [DATE] for Resident #2 reflected he had a BIMS score of 7 indicating severe cognitive impairment. His Functional Abilities and Goals indicated he required set-up or clean-up assistance for personal hygiene. Record review of the Care Plan dated 05/11/2022 for Resident #2 reflected Focus: he had the potential for impairment of skin integrity r/t fragile skin, limited mobility, diagnosis, and incontinence. Goal: The resident will maintain or develop clean and intact skin by the review date 05/15/2024. Interventions/Tasks: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Observation and interview on 04/25/2024 at 9:36 AM of Resident #2 revealed he was lying in his bed and had fingernails on both hands that extended 1.5 inches past his fingertips. There was a brown stain on his nails and debris underneath his nails. Resident #2 was asked when he had his last shower and he stated he did not know. Resident #2 was asked if his nails could cause him to scratch himself and he made a growling sound, laughed, and scraped at the surveyor's arm but did not break the skin. In an interview on 04/25/2024 at 10:00 AM in Resident #2's room, CNA A stated he thought the resident's fingernails were 1-2 inches long past the fingertips. He stated the resident smoked a lot of cigarettes and he was not a diabetic. He refused to answer any further questions and left the room. In an interview on 04/25/2024 at 2:35 PM in Resident #2's room the ADON stated she saw he had long fingernails. She stated the resident could scratch himself or someone else. She stated there was most likely bacteria under his fingernails and she would not want to culture it. C. Record review of the undated Face Sheet for Resident #3 reflected he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the undated Medical Diagnosis sheet for Resident #3 reflected he had a primary diagnosis of Unspecified Sequalae of Cerebral Infarction (brain stroke) 07/01/2019, and muscle wasting and atrophy (decrease in size and wasting of muscle tissue), multiple sites 07/01/2029. Record review of the Comprehensive MDS dated [DATE] for Resident #3 reflected he had a BIMS score of 3 indicating severe cognitive impairment. His Functional Abilities and Goals reflected he required substantial/maximal assistance for personal hygiene. 676475 Page 2 of 5 676475 04/25/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Care Plan for Resident #3 initiated 11/15/2019 and revised on 05/11/2022 reflected he had an ADL self-care performance deficit r/t aggressive behavior, Dementia [impaired ability to remember, think, or make decisions that interferes with doing everyday activities], Hemiplegia [paralysis that affects only one part of body]. Limited mobility and resistant to ADL care at times. Goal: will maintain current level of function in performing my ADLs through the review date, 07/04/2024. Interventions/Tasks: Personal hygiene 1 staff member performs all hygiene needs (he refuses to participate) Resident only allows family members to cut toenails and only certain staff are allowed to cut fingernails. Observation on 04/25/2024 at 9:38 AM of Resident #3 in his bed revealed he had a contractures (permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joint to shorten and become very stiff) to his left hand and the fingernails on his right hand were 1 inch long past the fingertips. In an interview on 04/25/2024 at 2:26 PM the ADON stated Resident #3's fingernails on his left hand were ¾ inch past the fingertips and he had refused to let staff cut his nails. She stated the facility should come up with a plan to get his nails trimmed. In an interview on 04/25/2024 at 2:26 PM the PT stated it would be preferable for Resident #3's nails to be shorter. D. Record review of the undated Face Sheet for Resident #4 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Record review of the undated Medical Diagnosis sheet for Resident #4 reflected he had a diagnosis of Hemiplegia (paralysis that affects one side of body) and Hemiparesis (partial weakness) following Cerebral Infarction (brain stroke) affecting left non-dominant side dated 05/09/2022. Record review of the Quarterly MDS dated [DATE] for Resident # 4 reflected he had a BIMS score of 12 indicating moderate cognitive impairment. His Functional Abilities and Goals indicated he required partial/moderate assistance for personal hygiene. He was totally dependent for toileting hygiene. Record review of the Care Plan for Resident #4 initiated on 07/11/2024 and revised on 01/27/2024 reflected he had an ADL self-care performance deficit r/t Dementia, Impaired balance. No goals were listed. Interventions/Task: Toileting: The resident needs assistance of one staff. Occasional incontinence of bowels and bladder. One staff to provide incontinent care q 2 hours and prn. Observation on 04/25/2024 at 9:44 AM of Resident # 4 in his bed revealed he was facing the window and his top sheet was covering his legs but not his adult brief. The back of his brief was soaked, there was a distinctive odor of urine and there was an approximately 2 foot in diameter ring of a yellow tinged liquid on his draw sheet. Resident # 4 was sleeping and did not wake up for an interview. In an interview on 04/25/2024 at 9:47 AM the APRN/PMHNP who was scheduled to see Resident #4 came into his room and observed what she stated was a urine ring on his bed. She stated his adult brief appeared to be soaked. She stated not receiving incontinent care could make a resident feel sad or depressed as they could not do things for themselves. 676475 Page 3 of 5 676475 04/25/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 04/25/2024 at 9:51 AM the interim DON stated Resident #4 had a ring on his bed that appeared to be urine and stated he should have been checked and changed earlier. He stated the potential risk to the resident of lying in a soaked brief on a soaked bed was it could cause skin breakdown and could affect his dignity. In an observation and interview on 04/25/2024 at 9:56 AM CNA A stated Resident #4 did not want to have his adult brief changed. He stated he saw a urine ring on the bed and did not know if the resident had been changed prior to his arrival that morning at 6:00 AM. He stated Resident #4 was a grouchy old man who did not want to be bothered and would not allow anyone to change him until he decided to get up. He further stated the resident's condition was not on me and he left the room. In an interview on 04/25/2024 at 11:13 AM the V.P. of Clinical Operations stated it was concerning that a CNA would say that a resident did not want to be changed until he decided to get up. She stated the facility was going to do a self-report and suspend the CNA. Record review of an undated Skin Monitoring: Comprehensive CNA Shower Review designed to be filled out by CNAs and reviewed by the charge nurses reflected a question regarding cutting toenails but did not mention fingernails. In an interview on 04/25/2024 at 1:50 PM LVN A stated she had worked at the facility for 18 months. She stated it was the nurse's responsibility to make sure the residents nails and toenails were trimmed. She stated they reviewed the Skin Monitoring sheets when the aides completed them after giving a bath or shower. When shown the Skin Monitoring sheet she noted it did not mention cutting fingernails and stated she had assumed it also said fingernails. She stated the potential risk to the resident of not getting their nails trimmed was they could dig into their palms and cause broken skin. She stated they could scratch themselves or others and it was an infection control issue. She stated she made nursing rounds on her residents but did not look at their fingernails. She stated she depended on her aides to point out if the residents' nails needed trimming. In an interview on 04/25/2024 at 2:40 PM the interim DON stated he had been at the facility since 04/01/2024 and had been an RN for almost twenty years. He stated long fingernails could cause skin tears if the residents scratched themselves and they could get an infection. He stated it was the staff's responsibility to keep the residents' nails trimmed and cleaned. He stated the nurses oversaw the aides. He stated he made rounds on residents, but he usually saw them in the dining room. He stated the aides were responsible for making rounds to check and change the residents every 2 hours. He stated if the residents were left wet or soiled they could have skin breakdown and potentially get an infection. He stated it could affect their self-esteem. In an interview on 04/25/2024 at 3:00 PM the V.P. of Clinical Operations stated the potential risk of a resident not having nails trimmed could be skin tears and not receiving brief changes and peri-care could lead to skin breakdown and infections. She stated it could affect their dignity. She stated her expectation was for administrative personnel to be making life rounds and reviewing resident care. She stated the DON and ADON needed to make patient rounds prior to their morning clinical meeting and the CNAs and nurses should also have ownership of the resident's care. She stated the staff were not following the processes in place and they need some education. She stated a resident has a right to refuse care however the staff need to show they were taking steps to resolve the problems. Record review of a facility policy and procedure dated 02/2023 and titled Activities of Daily Living reflected Policy: The facility will, based on the resident's comprehensive assessment and 676475 Page 4 of 5 676475 04/25/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0677 Level of Harm - Minimal harm or potential for actual harm consistent with the residents needs and choices, ensure a resident's abilities in ADLS do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Residents Affected - Some 676475 Page 5 of 5