Health inspection·February 7, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 8 residents (Resident #18) reviewed for comprehensive assessments. The facility failed to complete an accurate quarterly comprehensive assessment dated [DATE] for Resident #18 by not including hospice services. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided. The findings included: Record review of Resident #18's face sheet, dated 02/06/24, documented a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #18 had diagnoses which included: Parkinson's Disease (a chronic degenerative disorder of the central nervous system that affects both the motor system and non-motor systems), dementia (general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), heart failure (a syndrome, a group of signs and symptoms, caused by impairment of the heart's blood pumping function), and dysphagia (difficulty in swallowing). Record review of Resident #18's Quarterly MDS assessment dated [DATE], reflected that the resident was not receiving hospice services. Record review of Resident #18's Annual MDS assessment dated [DATE], reflected that Resident #18 had a BIMS score of 09 which revealed the resident was moderately cognitively impaired. Record review of Resident #18's Physician's Orders, dated 02/06/24, reflected the resident had an order to admit to hospice on 09/19/22. In an observation on 02/05/24 at 10:36 AM Resident #18 was outside smoking with staff present. Resident #18 appeared to be in no sign of distress. Resident #18 was dressed appropriately for temperatures. She stated things were fine and staff treated her well. She stated she had no complaints. In an interview on 02/07/24 at 11:25 AM with the MDS nurse, she stated she had worked in the facility for about 14 years. She stated Resident #18 was no longer on hospice services, but that Resident #18 had been on hospice services from 10/30/22 to 07/04/23. She stated she had not been aware Page 1 of 7 455601 455601 02/07/2024 Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #18's quarterly MDS assessment, which was completed on 05/12/23, had not reflected Resident #18 received hospice services. She stated the MDS assessments should have reflected if a resident received hospice services. She stated there was no correction done to the MDS assessment completed on 05/12/23. She stated Resident #18's hospice orders should have been discontinued when the resident came off of hospice. She stated she had been trained on how to complete an MDS accurately and she was not sure how that MDS assessment which was completed on 05/12/23 got by. She stated if an MDS assessment was completed inaccurately, the facility could have money taken back or they could lose money. In an interview on 02/07/24 at 12:11 PM with the DON, she stated she had worked in the facility for about a year. She stated Resident #18 no longer received hospice care. She stated Resident #18 had received hospice care until around July of 2023. She stated they were not sure about taking Resident #18 off of hospice due to Resident #18's weight loss, so they had monitored Resident #18 closely. She stated the MDS nurse was responsible for completing all MDS assessments. She stated the MDS nurse worked at the facility before she did and she was not sure of the training the MDS nurse received. She stated she knew that the MDS's corporate supervisor came to the facility and worked with the MDS nurse on all those things. She stated she had not realized Resident #18's MDS assessment which was completed on 05/12/23 was not accurate. She stated MDS assessments should reflect if a resident was on hospice services. She stated a possible outcome could have been if the staff attempted to order medications from the hospice company, it could have prevented the medication from being delivered timely and could have caused all kinds of medication errors. She stated they had a process to keep them from doing that. In an interview on 02/07/24 at 12:42 PM with the ADM, he stated he had worked at the facility for about 2 years. He stated Resident #18 was not on hospice services at that time, but she had been on hospice before. He stated he was not sure when Resident #18 came off of hospice services, but he knew it was some time last year. He stated he was not aware that the MDS assessment completed on 05/12/23 was not accurate. He stated the MDS assessment should reflect if a resident was on hospice. He stated the MDS nurse was responsible for completing the MDS assessment and it was overseen by the DON. He stated the MDS nurse had been trained on accurate completion of the MDS assessments. He stated the outcome of an inaccurate MDS assessment could be a resident not receiving proper care, medications, or treatment. Record review of the facility's policy on Certifying Accuracy of the Resident Assessment, dated 2001, revised November 2019, reflected Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. 455601 Page 2 of 7 455601 02/07/2024 Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009

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, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #7) reviewed for comprehensive care plans. The facility failed to ensure Resident #7's comprehensive care plan included a new intervention for a fall mat after Resident #7 fell on [DATE]. This failure could place residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: A record review of Resident #7's face sheet, dated 02/06/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses that included Weakness (lack of strength), Muscle wasting and atrophy (decrease in muscle mass), lack of coordination (difficulties in controlling and organizing movement) Spastic Hemiplegia affecting right dominant side (causing muscle tightness and involuntary contractions in the limbs or extremities), unspecified abnormalities of gait and mobility (change in walking pattern), and other muscle spasm (when a muscle involuntarily or forcibly contract uncontrollably). A record review of Resident #7's Quarterly MDS assessment, dated 12/28/23, reflected Resident #7 had a BIMS score of 15, which indicated cognitively intact. Section GG of the MDS indicated Resident #7 had impairment to one side of his upper extremity and had impairment to both sides of his lower extremities. Section GG also indicated that Resident #7 was dependent in the following areas upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A record review of Resident #7's Active Physicians Orders, dated 02/06/24, reflected there was an order, dated 11/30/23, for Resident #7 to have a fall mat at bedside. A record review of a Progress Note entry, dated 11/29/23, reflected Resident #7 was seen sitting on the floor next to the bed. According to the progress note Resident #7 stated that he slid to the floor trying to get out of bed. A record review of Resident #7's care plan, dated 12/18/23, did not reflect a fall mat for Resident #7 nor did it reflect Resident #7's most recent fall on 11/29/23. An observation of Resident #7 on 02/06/23 at 1:00 pm revealed the resident was lying in bed with the fall mat placed against the wall. An observation of Resident #7 on 02/07/23 at 10:00 am revealed the resident was lying in bed with the fall mat placed bedside the bed. In an interview with Resident #7 on 02/06/24 at 1:00 pm, Resident #7 stated sometimes the staff put 455601 Page 3 of 7 455601 02/07/2024 Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the fall mat down and sometimes they don't. Resident #7 stated that his entire right side was contracted due to several strokes. Resident #7 stated his most recent fall was in October or November of 2023. Resident #7 stated his fall mat was not near his bed during his most recent fall. In an interview with the MDS Coordinator on 02/07/24 at 12:15 pm. The MDS Coordinator stated she had worked at the facility for 10 years. The MDS Coordinator stated she was responsible for completing and updating the Care Plans. The MDS Coordinator stated during the morning meeting the DON would notify her if a resident had a fall and would notify her of any updated interventions that needed to be added to the care plan. The MDS Coordinator stated that if a resident had a fall mat, then it should have been used while the resident was in bed, and the fall mat should have been care planned. The MDS Coordinator stated if a resident''s fall mat was not placed beside the resident's bed, then the resident could have injured themselves if they had a fall. In an interview with the DON on 02/07/24 at 12:25 pm. The DON stated that if the residents had reoccurring falls the care plan should have been updated, but not if a resident had an isolated fall. The DON stated if a resident had a fall mat, then it should have been used correctly, and care planned. The DON stated if the fall mat was not placed beside the resident's bed, then the resident could have sustained injuries such as broken or fractured bones. In an interview with the Administrator on 02/07/24 at 12:35 pm. the administrator stated that if a resident had a fall the care plan should have been updated to reflect that fall and new interventions should have been added to the care plan. The administrator stated the MDS Coordinator was responsible for completing and updating the care plans. The administrator stated that if a resident had a fall mat, then it should have been care planned. The administrator stated if a resident has a fall mat, then it should have been correctly placed near the resident's bed when the resident was lying down. The administrator stated that if the mat was not placed on the floor near the bed, then the resident could have sustained injuries from falling. Record review of the facility's Using the Care Plan policy, not dated, reflected The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Policy Interpretation and Implementation 1. Complete care plans are placed in the resident's chart and/or 3-ring binder located at the appropriate nurses station. 2. The Nurse supervisor uses the care plan to continue the CNAs daily/weekly work assessments sheets and/or flow sheets. 3. CNAs are responsible for reporting to the Nursing Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved. 455601 Page 4 of 7 455601 02/07/2024 Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009

F 0656 4. Level of Harm - Minimal harm or potential for actual harm Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and /or the MDS Assessment Coordinator. Residents Affected - Few 5. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made. 6. Documentation must be consistent with the resident's care plan. 7. Information contained on the care plan and other documents used by the nursing staff shall be maintained in a confidential manner in accordance with established facility policy. 455601 Page 5 of 7 455601 02/07/2024 Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009

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 observation, interview, and record review, the facility failed to 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 disease and infection for one (Resident # 30) of six residents reviewed for infection control. Residents Affected - Few CNA A failed to change gloves or wash her hands while performing perineal care when removing a soiled brief and applying a clean brief. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #30's undated Face Sheet reflected a [AGE] year-old female who was admitted on [DATE] with a diagnosis of cerebral infarction (damage to tissues in the brain due to loss of oxygen and blood to the area causing the tissue to die also called a stroke or brain attack), mild protein calorie malnutrition, weakness, hypothyroidism (a hormone deficiency) , and hemiplegia (paralysis) following cerebral infarction (stroke). Record review of Resident #30's Quarterly MDS assessment dated [DATE], reflected a BIMs score of 14 indicating Resident #30 was cognitively intact. Section H reflected Resident #30 was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #30's care plan initiated 04/27/2022 and revised 01/22/2024 reflected Resident #30 had a care plan for bladder incontinence. Resident #30's goal was to remain free from skin breakdown due to use of incontinence briefs through review date. The care plan included an intervention to check the resident every 2 hours and as required for incontinence care, wash rinse, dry perinium, and change clothing as needed. In an observation on 02/06/24 at 11:02 AM CNA A was observed performing incontinent care. CNA A washed her hands and donned gloves prior to the start of the observation. CNA A cleaned Resident #30's front perineal area. Resident #30 rolled over and CNA A was observed washing buttocks and patting it dry. CNA A then removed the soiled brief and proceeded to put a clean brief under the resident, fastened the brief sides, and covered Resident #30 up with her blanket. CNA A did not wash her hands or change gloves between removing soiled brief and applying a clean brief. In an interview on 02/06/24 11:36 AM with CNA A she stated she had been a CNA for 10 years. CNA A reported she had been verbally trained in an in-service on perineal care and handwashing techniques. CNA A reported she was not trained to remove her dirty gloves and wash hands prior to applying a clean brief. CNA A stated the risk to the resident could have been a urinary infection. In an interview on 02/07/24 at 12:15 PM with the ADON reported she expected the staff to follow policy and procedure for handwashing. The ADON reported the staff had been instructed on handwashing in an in-service. She reported the nursing staff were visually checked off annually on all skills including perineal care and handwashing. She stated she was responsible for ensuring the CNAs had been educated on handwashing techniques. The ADON stated the negative outcome for failing to wash hands 455601 Page 6 of 7 455601 02/07/2024 Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009

F 0880 between removing a soiled brief and applying a clean brief could lead to increased urinary tract infections. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/07/24 at 12:33 PM with the DON she reported her expectation was for the staff to wash, wash, wash their hands and change their gloves when performing resident care. The DON reported the ADON was responsible for monitoring handwashing education for staff members and the DON monitored the ADON to ensure tasks were completed. The DON reported the negative outcome for not cleaning or washing hands between dirty and clean surfaces could increase urinary tract infections. Residents Affected - Few In a record review of a nurse aide proficiency dated 8/17/23 indicated CNA A had passed her handwashing skills check off and was signed by ADON. In a record review of an in-service dated 11/30/23 reflected that CNA A had signed she had viewed perineal care video in-service with handwashing techniques included. Record review of the facility's Policy and procedure for handwashing dated 2001 and updated in October 2023 reflected: 1) indications for hand hygiene -(c) after contact with blood, body fluids, or contaminated surfaces (f) before moving from work on a soiled body site to clean body site on the same resident and (g) immediately after glove removal. 455601 Page 7 of 7