Health inspection·April 6, 2023

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 observation, interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Residents #16 and #22) of fifteen residents reviewed for care plans. 1) The facility failed to ensure Resident #22's careplan addressed his tracheostomy, oxygen use or need for suctioning. 2) The facility failed to ensure Resident #16's careplan addressed her oxygen use. This failure could negatively impact the resident's quality of life, as well as the quality of care and services received if care planning is not complete or is inadequate. 1) Review of Resident #22's admission Record dated 04/06/23 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #22 had diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, bacterial pneumonia, heart failure (when the heart cannot pump enough blood and oxygen to support other organs in your body), hypertension (High blood pressure that is higher than normal), chronic kidney disease stage 4, type 1 diabetes mellitus , cerebral infarction (a loss of blood flow caused by blood clots and broken blood vessels, which damages brain tissue in the brain), and hyperlipidemia (high cholesterol) (an excess of lipids or fats in the blood). Review of Resident #22's admission MDS assessment dated [DATE] revealed he required extensive assistance of two persons for bed mobility, dressing, and personal hygiene. He required extensive assist of one person for eating and toileting and was totally dependent on one person for bathing. Resident #22 also required oxygen therapy, suctioning and tracheostomy care. An observation on 04/04/23 at 10:53 AM revealed Resident #22 was in a low bed with a fall mat on the floor. He was under the covers, in a hospital gown, and appeared well groomed. He had a trach with misted O2, was slightly on his left side, with the head of the bed up 30 degrees. There was an Ambu bag (used for resuscitation) hanging on the light, and suction was set up and ready for use. His trach collar was clean, and there was extra canula and trach cleaning supplies in his room. Resident #22's comprehensive care plan, initiated on 02/22/23, reflected the following areas of focus: ADL Functional/Rehabilitation Potential, Psychotropic Drug Use, Pressure Ulcer, Dehydration/Fluid Maintenance, Feeding Tube, Nutritional Status, Falls, and Indwelling Catheter. There was not a care plan for his tracheostomy, oxygen use, or need for suctioning. Page 1 of 3 455477 455477 04/06/2023 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2) Review of Resident #16's face sheet, dated 04/06/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with an original admission date of 05/20/2020, with diagnoses that included Chronic Obstructive Pulmonary Disease, mild intermittent asthma, and congestive heart failure. Review of Resident #16's Annual MDS, dated [DATE], reflected a BIMS score of 13, which indicated the resident's cognition was intact. The MDS further reflected oxygen use while a resident. Review of Resident #16's order summary report with active orders as of 04/06/2023, reflected the following: O2 at 3 liters per minute via nasal cannula continuously. May titrate to 3-4 LPM to keep O2 sats >90% every shift for O2 sat >90%. Review of Resident #16's care plan, dated 02/10/2023, did not reflect the use of oxygen. An observation on 04/04/23 on 10:47 AM revealed Resident #16 was lying in bed with O2 on via nasal cannula. An observation on 04/06/23 on 12:52 PM revealed Resident #16 was lying in bed with O2 on via nasal cannula and O2 set at 3.5 LPM. Review of Resident #16's care plan, dated 02/10/2023, did not reflect the use of oxygen. During an interview with the DON on 04/06/23 at 2:02 PM she said No care plan for [Resident #22's] tracheostomy, that should definitely be care planned. The DON stated oxygen use was required to be care planned for Resident #16. She said care plans were important to follow up and make sure care was being provided. The DON said the SW was responsible for care plans, but she had taken them over. The DON stated when she came in August of 2022 the care plans were not being done, so when she came, she was told the SW/Administrator was doing them, and when they left, herself and the MDS coordinator had taken them over. During an interview with the CCS on 04/06/2023 at 4:00 PM she said the care plan was supposed to be individualized to the resident's care. She said she had already started care plans on things when they were noticed and, was not sure if the previous company had used generic care plans. The CCS said who was responsible for the care plans depended, MDS coordinator normally did them, nursing did them, but she did not know how the previous company had done them. She said an RN did not have to do them but had to sign off on them. She said LVN's could do the care plans, but an RN must sign off on them. The CCS also said the purpose of care plans was to know the residents, know what was going on. She gave an example of a care plan for a resident receiving anticoagulant medication that they should monitor for bruising. She said care plans should be curtailed to each resident or individualized. Review of the policy Care Plans, Comprehensive Person-Centered reviewed January 2023, reflected in part: A comprehensive, person-centered care plan that includes measure objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; .g. Incorporate identified problem areas; .k. Reflect treatment goals, timetables and objectives in measurable outcomes 455477 Page 2 of 3 455477 04/06/2023 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one of two residents (Resident #16) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #16's oxygen tubing was changed weekly per physician's orders. This deficient practice could place residents at risk for respiratory infections. Findings included: Review of Resident #16's face sheet, dated 04/06/2023, reflected a [AGE] year-old female who was admitted on [DATE] with an original admission date of 05/20/2020, with diagnoses that included Chronic Obstructive Pulmonary Disease, mild intermittent asthma, and congestive heart failure. Review of Resident #16's Annual MDS dated [DATE] reflected a BIMS score of 13, which indicated the resident's cognition was intact. The MDS further reflected oxygen use while a resident. Review of Resident #16's care plan dated 02/10/2023 did not reflect the use of oxygen. Review of Resident #16's order summary report with active orders as of 04/06/2023 reflected the following: change, label/date O2 tubing weekly every night shift every Sunday. Observation on 04/06/23 at 12:52 PM revealed Resident #16's oxygen tubing dated 3/20. Observation and interview on 04/06/23 at 01:21 PM with LVN A revealed Resident #16's O2 tubing was dated 3/20. LVN A stated the tubing should be changed on Sunday's and they usually changed it at night. LVN A stated it was the nurse's responsibility and any nurse that noticed it could change the tubing. LVN A stated it was important to change the tubing weekly because it decreased bacteria, and the cannula got hard and really firm and could irritate the nose if not changed. Interview on 04/06/23 at 01:34 PM, the ADON stated O2 tubing should be changed every Sunday at night, going forward with the new company they were working on a nursing night duties list, one included to change O2 tubing. The ADON stated she would be responsible for monitoring and reviewing if that was done. The ADON stated the risk was condensation build up, infection, and discomfort for the resident. Interview on 04/06/23 at 02:02 PM, the DON stated the night nurses were responsible for changing the tubing every Sunday night and the ADON and DON were responsible to monitor. The DON stated the tubing needed to be changed to prevent infection. Review of the facility's policy Oxygen Administration revised February 2023 reflected the procedure for safe oxygen administration but did not indicate when O2 tubing was to be changed. 455477 Page 3 of 3