Health inspection·October 7, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's representative of the transfer or discharge for 1 (Resident #1) of 5 residents reviewed for transfers/discharges. The facility failed to notify Resident #1's representative of the resident's discharge to the hospital. This failure could affect residents at the facility by placing them at risk of being transferred/discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings include: Record review of Resident #1's face sheet dated 10-7-2023 revealed a [AGE] year-old male resident admitted to the facility originally on 7-16-2023 and readmitted on [DATE] with diagnoses to include acute respiratory failure (occurs when the respiratory system is unable to either adequately absorb oxygen or excrete carbon dioxide), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), hypertension (a condition in which the force of the blood against the artery walls is too high), neuromuscular dysfunction of the bladder (when the nerves and muscle of the bladder do not function together adequately), dysphagia (difficulty or discomfort in swallowing), pain, central cord syndrome (the most common form of an incomplete spinal cord injury), and fusion of the spin, cervical region. Section-Miscellaneous Information-Date of Discharge-09-28-2023. discharged to: Acute Care Hospital. (Resident continues to reside in this facility at the time of this investigation). Record review of Resident #1's last MDS assessment reflected a quarterly MDS completed 8-10-2023 listing him with a BIMS of 12 indicating he was moderately cognitively impaired and that he had a functionality of requiring one to two-person assistance with all his activities. Record review of Resident #1's care plan dated of 8-4-2023 noted no care plan for discharge. Record review of Resident #1's face sheet dated 10-7-2023 revealed the following: Section: Miscellaneous InformationDate of discharge: [DATE] Acute Care Hospital. Page 1 of 4 455551 455551 10/07/2023 Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -There was no documentation in the progress notes of his discharge and reason, no noted discharge summary, no noted notification of the resident or resident representative of Resident #1's discharge or reason for discharge. During an interview on 10-6-2023 at 4:56 PM Family Member A (Resident #1's POA (Power of Attorney) )verified that she suspected that the facility was going to discharge Resident #1 but that no staff member had contacted her or given her any reason why Resident #1 was going to be discharged . During an interview on 10-7-2023 at 09:49 AM Dr B reported that he and the facility felt that Resident #1 needs to be somewhere that Resident #1 can be treated more aggressively for his condition and that this facility cannot provide for his care safely and within family wishes. Dr B reported that he was not aware if the facility had contacted Family Member A concerning Resident #1's discharge since Resident #1 had been admitted to the hospital. During an interview on 10-7-2023 at 12:27 PM the DON reported that they notified Family Member A the day Resident #1 was transferred to the hospital that Resident #1 was being transferred and discharged but due to the difficulty of the situation with the family member the RN on duty that day gave her notice and quit and that she herself (the DON) was on vacation and she was aware that there was no documentation in Resident #1's chart of any notification to the resident or family of the discharge notice or discharge reason. During an interview on 10-7-2023 at 12:51 PM the DON reported that if a resident or family was not notified of their discharge or reason for discharge when they are discharged or to be discharged this can result in impeding the transition of the resident's care which can affect the resident care and their condition. Record review of the facility provided policy titled, Transfer or Discharge Notice revised March 2021, revealed the following: Policy Statement: Resident and/or representatives are notified in writing, and in a language and format they understand, at least thirty days prior to transfer or discharge. 4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: d. An immediate transfer of discharge is required by the resident's urgent medical needs . 455551 Page 2 of 4 455551 10/07/2023 Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 received treatment and care in accordance with professional standards of practice for 1 (Resident #2) of 5 residents reviewed for physician orders. Residents Affected - Few The facility failed to follow physician orders for completing wound care for Resident #2. The deficient practice could affect residents receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include: Record review of the clinical record for Resident #2 revealed a [AGE] year-old-male resident admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (a disease in which the immune system eats away a the protective covering of nerves), sciatica (pain radiating along the sciatic nerve, which runs down one or both legs from the lower back), fall, pain, hypertension (a condition in which the force of the blood against the artery walls is too high), and diabetes (a chronic condition that affects the way the body processes blood sugar (glucose) Record review of Resident #2's clinical record revealed he has not been in the facility long enough for a complete MDS assessment. Record review of Order Summary Report with Active Orders as of: 10-7-2023: revealed an order reading as follows: To right calf: cleanse area with wound cleanser. Pat dry with 4x4 gauze. Apply TAO to site. Apply xeroform to area. Cover with dry dressing. Wrap with Coban wrap. -order date of 10-5-2023. During an observation on 10-7-2023 at 11:01 AM wound care was performed by staff member LVN C on Resident #2 as follows: The old dressing was removed by LVN C. LVN C then cleaned the wound, covered the wound with xeroform, covered the wound with a dry dressing, and then wrapped the wound with Coban. LVN C did not apply any TAO to the wound site. LVN C then gathered his supplies and exited Resident #2's room. During an interview on 10-7-2023 at 11:20 AM LVN C verified that he forgot to put the TAO on Resident #2 wound site, that he thought it was a part of the xeroform dressing but upon inspection of the dressing noted that it did not contain TAO. LVN C verified that he did not follow the resident's order and that as a result the resident could develop an infection. LVN C reported that he would need to redo Resident #2's dressing to apply the TOA to the wound site. During an interview on 10-7-2023 at 11:23 AM the DON reported that resident orders, especially physician orders, should be followed and if they are not followed then the facility and staff will not know if a treatment is working. Review of facility policy titled Medication and Treatment Orders Revised July 2016, revealed the following: 455551 Page 3 of 4 455551 10/07/2023 Plainview Healthcare Center 2510 W 24th St Plainview, TX 79072

F 0684 Policy Statement-Orders for medications and treatment will be consistent with principles of safe and effective order writing. Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation- Residents Affected - Few -there is no information specific for order implementation for treatments. 455551 Page 4 of 4