Health inspection·November 18, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #1, Resident #2, and Resident #3) of ten residents reviewed for reasonable accommodation of needs. Residents Affected - Some The facility failed to ensure the call light system in Resident #1, Resident #2, and Resident #3's rooms was in a position that was accessible to the resident. This failure could place the residents at risk of being unable to obtain assistance when needed and not get help in the event of an emergency. Findings included: Resident #1 Review of Resident #1's Face Sheet dated 11/18/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size of the muscle), aphasia (a comprehension and communication disorder) following cerebral infarction, and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting right dominant side. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected resident was unable to complete the interview to determine the BIMS score. Resident #1 required supervision for bed mobility, transfer, eating, and toilet use. The Quarterly MDS Assessment also indicated aphasia and hemiplegia or hemiparesis as primary medical conditions. Review of Resident #1's Comprehensive Care Plan dated 10/07/2023 reflected Resident #1 had a communication problem related to aphasia and one of the interventions was to have call light in reach. Review of Resident #1's Comprehensive Care Plan dated 10/07/2023 indicated Resident #1 was at risk for falls r/t confusion, deconditioning, gait/balance problems, incontinence, impaired communication/comprehension, vision problems, hemiplegia and one of the interventions was to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. Review of Resident #1's Comprehensive Care Plan dated 10/07/2023 indicated Resident #1 had an ADL self-care performance deficit r/t sided hemiplegia and one of the interventions was to encourage the resident to use bell to call for assistance. Page 1 of 8 455653 455653 11/18/2023 Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233

F 0558 Level of Harm - Minimal harm or potential for actual harm Observation and interview with Resident #1 on 11/18/2023 at 9:29 AM, revealed resident was inside the room sitting on a chair located at the left side of the bed. Resident #1 was unable to speak due to the diagnosis of aphasia. It was observed that her call light was on the floor at the right side of the bed. Resident #1 pointed to the floor at the right side of the bed, indicating the location of her call light. Residents Affected - Some Resident #2 Review of Resident #2's Face Sheet dated 11/18/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses information included muscle weakness, muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size of the muscle), fibromyalgia (a long-term health condition that causes pain and tenderness throughout your body), and unsteadiness of the feet. Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected resident had a severe cognitive impairment with a BIMS score of 06. Resident #2 required limited assistance for bed mobility, transfer, eating, and toilet use. The Quarterly MDS Assessment also indicated asthma as one primary medical condition. Review of Resident #2's Comprehensive Care Plan dated 10/26/2023 reflected Resident #2 was at risk for falls r/t confusion, deconditioning, gait/balance problems, incontinence, unaware of safety needs, wanders and one of the interventions was to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of Resident #1's Comprehensive Care Plan dated 10/26/2023 indicated Resident #2 had an ADL self-care performance deficit r/t Alzheimer's, impaired balance and one of the interventions was to encourage the resident to use the bell to call for assistance. Observation and interview with Resident #2 on 11/18/2023 at 9:56 AM, revealed resident was inside the room sitting on her wheelchair. It was observed that her call light was on the floor, on top of plastic bags at the at the right side of the bed. When asked where was her call light, Resident #2 shrugged her shoulders. Resident #2's roommate verbalized she would sometimes call the staff for Resident #2 because her call light was on the floor most of the time. Resident #3 Review of Resident #3's Face Sheet dated 11/18/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses information included muscle weakness, primary osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other) of the left ankle and foot, and difficulty in walking. Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected resident had a severe cognitive impairment with a BIMS score of 07. Resident #3 required extensive assistance for bed mobility, transfer, locomotion on unit, locomotion off unit, dressing, eating, and toilet use. The Quarterly MDS Assessment also indicated resident #3's primary medical conditions were muscle weakness, difficulty walking and primary osteoarthritis of the left ankle and foot. Review of Resident #3's Comprehensive Care Plan dated 11/11/2023 reflected resident was at risk for falls to occur. Has recent history of fall with fracture to right hip, cognitive impairment 455653 Page 2 of 8 455653 11/18/2023 Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some secondary to dementia, psychotropic (medications that alter mood, perceptions, and behavior) med use. One of the interventions was to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation and interview with Resident #3 on 11/18/2023 at 9:56 AM, revealed resident was inside the room sitting on her wheelchair. It was observed that her call light was clipped to the cord of the of the remote of the bed. The remote of the bed was hooked to the right side of the wooden headboard of the bed. The head of the bed was raised and was far from the headboard of the bed. When asked where her call light was, Resident #3 just stared and at the same time checked her side if she had her call light on her side. Interview with CNA O on 11/18/2023 at 10:56 AM, CNA O stated he had been with the facility for nine months and had been a CNA for four years. CNA O said he is familiar with the care of the residents on his hall. When advised that some call lights were on the floor, CNA O replied he would do his round again and make sure the call lights were with the residents. CNA O said he always did his rounds to check on the residents but maybe missed it. CNA O stressed the residents needed their call lights because the resident used the call lights every time they needed assistance. He added if the residents do not have their call lights, their needs will not be met, and they might try to stand up and might fall. CNA O said if the call lights were not with the residents, it will not be good for the residents and will not be good for the staff because it reflected the staff were not taking care of the residents or the staff were not doing rounds. Interview with LVN E on 11/18/2023 at 11:17 AM, LVN E stated she was with the facility for a year. LVN E was advised that some call lights were on the floor or far from the residents. LVN E said it should not be the case. LVN E continued the call lights were important for the residents because the call lights were their form of communication. LVN E said the residents used the call lights if they need to go to the bathroom, need water refill for their pitchers, want to transfer to the wheelchair, need pain medications, or they were not feeling good. LVN E added if the residents were not able to reach the call lights, they might do it by themselves and might fall. Interview with LVN A on 11/18/2023 at 11:27 AM, LVN A stated she was with the facility for two years. When LVN A was advised some call lights were seen on the floor or far from the residents, LVN A replied some residents would drop the call light when they move in and out of the bed. LVN A added that was why it was important to clip it somewhere near the resident. LVN A said the call lights must be placed or clipped somewhere close to the residents but would not cause skin tears. LVN A added if the residents needed something, like they were wet or were hurting, and could not call the attention of the staff, the residents would be agitated, irritated and sometimes would start yelling. LVN A added the staff needed to do their rounds every two hours or every one hour for the non-verbal. Interview with CNA E on 11/18/2023 at 11:37 AM, CNA E stated she was with the facility for almost a year. CNA E said the staff must know the personality of the residents so the staff would know who needs more monitoring. CNA E added if the resident was non-verbal, the more she needed the call light. CNA E said the call light should be clipped on the bed to prevent from falling and if the resident was on the wheelchair, the call light should be clipped on the wheelchair. CNA E further said, the residents need the call lights to ask for assistance or ask for help. Interview with ADON O on 11/18/2023 at 11:54 AM, ADON O was advised that there were call lights on the floor. ADON O said call light should be the residents at all times to be able call for assistance. If the residents do not have their call light, the residents' needs would not be met. It could 455653 Page 3 of 8 455653 11/18/2023 Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233

F 0558 Level of Harm - Minimal harm or potential for actual harm cause stress for the residents. ADON O stated sometimes a resident needed assistance to go to the restroom. If they cannot call assistance, they might wet themselves and be embarrassed about it. For some, they might try doing it by themselves and fall on the process. ADON O said she would make a round to make sure the residents have their call lights and to make sure the staff were monitoring if the call light were within the reach of the residents. Residents Affected - Some Interview with the DON on 11/18/2023 at 12:14 PM, the DON stated she had been the DON of the facility for three weeks. The DON was advised there were call light on the floor. The DON said she would take a look at it and make sure the staff were monitoring closely if the call lights were within reach. The DON added if the call lights were not within reach, the residents cannot call for assistance, cannot ask for help in cases of emergencies, might fall if they try to stand up and be injured in the process. Interview with the Administrator on 11/18/2023 at 12:21 PM, the Administrator stated he was not aware about the call light on the floor. When asked what the purpose of the call lights was, the Administrator replied the call lights were important in cases of emergencies. He said anything could happen to the residents, they might fall reaching for the call lights or they might fall trying to do something that needed assistance from the staff. The Administrator said the expectation was the residents would have their call lights so that their need would be met. The Administrator said he would continue to remind the staff to make sure the call lights were within the grasp of the residents. Record review of Facility's Policy Communication - Call System, Nursing Manual - Nursing Administration rev. 06/2020 revealed Purpose: To provide a mechanism for residents to promptly communicate with nursing staff . Procedure . II. Call cords will be placed within the resident's reach in the resident's room. 455653 Page 4 of 8 455653 11/18/2023 Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233

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, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #4, Resident #5, and Resident #6) of five residents reviewed for respiratory care. Residents Affected - Some The facility failed to ensure Resident #4 and Resident #5's mask for breathing treatment were dated and bagged when not in use. The facility failed to ensure Resident #6's nasal cannula (a device used to deliver supplemental oxygen to an individual. It consists of a lightweight tube on which one is connected to the oxygen source and the other end splits into two prongs and are placed in the nostrils) was dated and bagged when not in use. These failures could place the residents at risk of respiratory infections and not having their respiratory needs met. Findings included: Resident #4 Review of Resident #4's Face Sheet dated 11/18/2023 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unspecified heart failure, unspecified chronic atrial fibrillation (an irregular, rapid heartbeat), and anemia (deficiency of healthy red blood cells in blood). Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected resident had a moderately intact cognition with a BIMS score of 12. Resident #4 required extensive assistance for bed mobility and toilet use; required total dependence for transfer. Review of Resident #4's Physician Order dated 06/16/2023 reflected Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate). 1 vial inhale orally via nebulizer (a device that delivers liquid medicine into a fine mist that can be inhaled into the lungs) every 6 hours as needed for Shortness of Breath. Observation and interview with Resident #4 on 11/18/2023 at 9:14 AM, revealed resident was on his bed, resting. It was noted the resident's mask for breathing treatment was on top of the overbed table beside the nebulizer, facing down. The mask was not bagged nor dated. Resident #4 stated he had the breathing treatment since he was in the building. According to the resident the nurse would put on the breathing mask and the nurse would also take it off when the treatment was done. Resident #4 said it was the nurse who put the mask on the table. Resident #4 added sometimes he would notice plastic bag on the table, but he did not know what that was for. Resident #5 Review of Resident #5's Face Sheet dated 11/18/2023 reflected resident was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unspecified tachycardia (a condition that makes the 455653 Page 5 of 8 455653 11/18/2023 Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some heartbeat more than 100 times per minute) and chronic systolic heart failure (the heart cannot pump enough blood to the body). Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected resident had an intact cognition with a BIMS score of 15. Resident #5 supervision for required bed mobility, transfer, eating, and toilet use. Review of Resident #5's Physician Order dated 06/16/2023 reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally four times a day for cough/dyspnea (shortness of breath). Observation and interview with Resident #5 on 11/18/2023 at 9:49 AM, revealed resident was on his bed, resting. It was noted the resident's mask for breathing treatment was on top of the side table, facing down, and beside a rolled comforter. The mask was not bagged nor dated. Resident #5 he had been using the breathing treatment for five months. Resident #5 stated the nurse would put on the breathing mask and the nurse would also take it off sometimes. Resident #5 said if the nurse were not there to take it off, he would take it off and would place the mask on the table beside his bed. Resident #5 said he was not aware the mask should be bagged. Resident #6 Review of Resident #6's Face Sheet dated 11/18/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation, unspecified anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissue), and acute and chronic respiratory failure with hypoxia(insufficient amount of oxygen in the body). Review of Resident #6's Quarterly MDS assessment dated [DATE] reflected resident had an intact cognition with a BIMS score of 15. Resident #6 required supervision for bed mobility, transfer, eating and toilet use. The Quarterly MDS Assessment also indicated chronic lung disease and respiratory failure as primary medical conditions. Review of Resident #6's Physician Order dated 09/16/2023 reflected Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate. 2 puff inhale orally two times a day for COPD. Review of Resident #6's Physician Order date 09/25 2023 reflected Check O2 sat Q shift and PRN every shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION; UNSPECIFIED COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE. Observation and interview with Resident #6 on 11/18/2023 at 10:36 AM, revealed resident was on her wheelchair inside the room bed. It was noted the resident had an oxygen supplement via nasal cannula. The nasal cannula was connected to an oxygen concentrator. The nasal cannula was not dated. It was also noted Resident #6 had an oxygen tank at the back of her wheelchair. A nasal cannula was also connected to the oxygen tank. The tubing of the nasal cannula was coiled to the right push handle of the wheelchair with prongs of the nasal cannula touching the back of the wheelchair. Resident #6 stated she used the oxygen tank when she goes out of the room. Resident #6 said the staff would usually 455653 Page 6 of 8 455653 11/18/2023 Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some coil the nasal cannula on the handle of the wheelchair. Resident #6 added she does know anything about a plastic bag to put the nasal cannula. Interview with CNA O on 11/18/2023 at 10:56 AM, CNA O stated he had been with the facility for nine months and had been a CNA for four years. CNA O said he was familiar with the care of the residents on his hall. When asked if he noticed Resident #4's mask for breathing treatment was on top of the overbed table facing down, CNA O replied he did not notice the mask was on top of the table. CNA O said he was not sure who put it on top of the table. CNA O added the top of the table is not usually clean so the mask should be placed somewhere clean especially if the mask is for the nose and mouth. CNA O Further added the germs could enter the nose or the mouth and go straight to the lungs. Interview and observation with LVN E on 11/18/2023 at 11:17 AM, LVN E stated she was with the facility for a year. LVN E was advised that some masks used for breathing treatment were sitting on top of the tables, LVN E replied she did not notice the masks were sitting on the tables and said she would change the breathing masks immediately. LVN E said residents used a nebulizer because they have respiratory issues like shortness of breath or hypoxia. LVN E added the masks should be cleaned and bagged after using. LVN E further added if the residents used an unclean mask, it could cause infection and contamination. Interview with LVN A on 11/18/2023 at 11:27 AM, LVN A stated she was with the facility for two years. LVN A was advised some masks for breathing treatments were sitting on top a table and a nasal cannula coiled on the push handle of wheelchair , LVN A replied the masks, and the nasal cannula should be in a plastic bag when not in use. LVN A said the masks and the nasal cannula should be dated to have proof the respiratory apparatus was changed. She added this should be done to prevent infection and to provide an efficient respiratory care. LVN A further explained the masks and the nasal cannula should be changed every Sunday and as needed. Interview with RN U on 11/18/2023 at 11:48 AM, RN U said the masks for the breathing treatment and the nasal cannula should be bagged and dated. RN U said the staff must have a conscious effort to do the best practice. She continued if the masks and the nasal cannula were just lying somewhere, the masks and the nasal cannula would be dirty causing respiratory infections. Interview with RN U on 11/18/2023 at 11:48 AM, RN U said the masks for the breathing treatment should not be lying on the table. The table was sometimes a breeding ground for the bacteria. RN U continued the nasal cannula should not be touching the back of the wheelchair because the back of the wheelchair was not clean. RN U continued both scenario, the masks and the nasal cannula just lying somewhere would be dirty causing respiratory infections. RN U said the masks for the breathing treatment and the nasal cannula should be bagged and dated. RN U said the staff must have a conscious effort to do the best practice. Interview with ADON O on 11/18/2023 at 11:54 AM, ADON O was advised masks for breathing treatment were sitting on a table. She was also advised a nasal cannula was coiled around the handle of the wheelchair with the prongs touching the back of the wheelchair. ADON O stated the table and the handle of the wheelchair were not the proper place to put the mask and the nasal cannula. ADON O added the table was not always clean because the resident or the staff would put a lot of things on it. ADON O further explained the handles of the wheelchair would be obviously dirty because several staff would touch it to push the wheelchair. ADON O said the mask and the nasal cannula should be in a clean plastic bag when not in use to prevent exacerbation of respiratory issues. ADON O said the masks and the nasal cannula should be dated to know when was the last time the masks and the nasal cannula 455653 Page 7 of 8 455653 11/18/2023 Skyline Nursing Center 3326 Burgoyne Dallas, TX 75233

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were change and when they should be changed again. ADON O said the masks and the nasal cannula should be changed immediately to prevent infection from happening. ADON O concluded she would make a round to make sure the residents masks and nasal cannula were somewhere clean to prevent infection. Interview with the DON on 11/18/2023 at 12:14 PM, the DON stated she had been the DON of the facility for three weeks. The DON was advised there were mask for breathing treatment sitting on a table and a nasal cannula coiled around the handle of a wheelchair. The DON stated the masks should not be on top of a table nor the nasal cannula touching the back of the wheelchair. If the masks and the nasal cannula were on a table or coiled in the wheelchair, they could catch microorganisms that could cause infection and cross-contamination. The DON stated the masks and the nasal cannula must be place in a bag if the residents were not using them. The DON concluded the expectation was the staff to make sure everything the residents were using for their respiratory issues were clean and maintained clean. Lastly, the DON said the mask and the tube should be dated even though the policy did not say so because it was the best practice. Interview with the Administrator on 11/18/2023 at 12:21 PM, the Administrator stated he was not clinical but do understand everything the residents used for their respiratory issues should be kept clean. The Administrator said he would continue to remind the staff to make sure the residents used clean respiratory equipment. Record review of Facility's Policy Oxygen Administration Nursing manual - Nursing Care rev. 06/2020 revealed Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues .III . Oxygen items will be stored in a plastic bag . when not in use. Record review of Facility's Policy Infection Prevention and control Program Infection Control Manual rev. 06/2020 revealed Purpose: to ensure the facility establishes and maintain . a safe, sanitary . environment and to help prevent the development and transmission of disease and infection . 455653 Page 8 of 8