Health inspection·August 4, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 assessments accurately reflected the resident's status for 1 of 4residents reviewed (Resident #101) for accuracy of assessments. Residents Affected - Few The facility failed to accurately assess Resident #101 at admission which resulted in meal ticket notes reflecting diet restrictions. This failure could place residents at risk for inaccurate assessments which could lead to a decline in quality of life. Findings include: Record review of Resident # 101's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included: unspecified dementia. Record review of Resident #101's Comprehensive MDS, dated [DATE], reflected the resident's admission from another nursing home on [DATE]. Section K for Swallowing disorder indicated the resident had coughing or choking during meals or when swallowing medication. The Care Area Assessment Summary; Nutritional Status triggered. Record review of Resident # 101's Order Summary Report, dated 07/06/2022, reflected Regular diet: Mechanical Soft texture, Thin consistency, No straws. Extra gravy on meat: Order date: 12/16/2021, Start Date 12/16/2021. Admissions orders were from a previous facility. Record review of Resident #101 Speech Therapy SLP Evaluation and Plan of Treatment, dated 12/27/2022-02/24/2023, reflected Diagnoses; Dysphagia, unspecified, Dysphagia, oropharyngeal phase. Within the last six months, the patient had a history of receiving skilled ST services for dysphagia due to presence of signs and symptoms of aspiration. Clinical Bedside Assessment of Swallowing reflected Clinical S/S of Dysphagia: No overt s/s of aspiration noted during trials of cup sip and by straw. The evaluation did not indicate the resident was restricted from the use of straws. Record review of Resident #101's Meal Ticket, dated 08/01/2023, reflected Notes: no straws; extra gravy on meats. Record review of Resident #101's Meal Ticket, dated 08/02/23, reflected Notes: no straws; extra gravy on meats. Observation on 08/01/2023 at 12:30 PM revealed Resident #101 was sitting at the dining table Page 1 of 4 455798 455798 08/04/2023 Bedford Wellness & Rehabilitation 2001 Forest Ridge Dr Bedford, TX 76021

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few coughing. The resident was offered a cup of liquid which contained a straw. Resident #101 consumed the liquid through the straw but was not observed aspirating or choking as a result of consuming liquid through the straw. Observation on 08/01/2023 at 9:40 AM revealed Resident #101 in bed with his head elevated. The meal tray was on the bedside tray with three cups of liquid. Two of the three cups contained straws. The cup of light brown liquid revealed half the liquid was consumed. There was no sign of aspiration or choking. Interview on 08/02/2023 at 10:01 AM with Speech Therapy revealed if the meal ticket noted No straws the resident should not consume liquid through straws. The risk of using a straw could cause the resident to aspirate. Interview on 08/02/2023 at 11:00 AM with the Director of Nursing revealed the nurses reviewed meal tickets for accuracy of diet and diet texture. The DON stated she was not aware of the no straws note on Resident # 101's meal ticket. Interview on 08/02/2023 at 1:55 PM with the Dietary Manager revealed the dietary team only added preferences to meal tickets. The note of no straws could not be added to the meal ticket by dietary, only nursing and not without a diet order. The meal tickets were generated by an electronic system. The risk of not following the meal ticket would result in residents not having their recommendations honored. Interview on 08/02/2023 at 2:00 PM with the Regional Dietitian revealed the meal ticket should reflect resident care. She stated everyone should follow the meal ticket. The RD stated she was not aware of the no straws note on Resident # 101's meal ticket. Record review of Care Planning Nursing Manual-nursing administration, dated 06/2020, reflected A comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. A. in the event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and provided to the resident and/ or resident's representative. 455798 Page 2 of 4 455798 08/04/2023 Bedford Wellness & Rehabilitation 2001 Forest Ridge Dr Bedford, TX 76021

F 0642 Ensure a qualified health professional conducts resident assessments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to submit a discharge MDS assessment for two of four residents (Resident #90 and Resident #108) reviewed for timely MDS submission. Residents Affected - Some The MDS Coordinator failed to successfully submit a discharge MDS assessment for Resident #90 and Resident #108 when they discharged from the facility. This failure could place residents at risk of communication about a resident's status from not being transmitted to CMS and could interfere with residents receiving needed services after discharge. Findings include: Record review of Resident #90's face sheet, dated 08/07/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 04/28/23. Resident #90 had diagnoses which included Parkinson's Disease (Brain and Nervous System Disease); Type 2 Diabetes Mellitus without Complications (High levels of sugar in the blood); and Hypertensive Heart Disease (Constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). Record review of the Discharge Instructions for the Care document for Resident #90, dated 04/28/23, reflected he was discharged to an Assisted Living Facility. Resident #90 was under the care of Veterans Administration contact. All discharge needs (Primary Care Physician, Durable Medical Equipment, and Home Health) were set up through the VA. There was a home health provider on file . Resident's Primary Care Physician was documented, and Durable Medical Equipment ordered was a wheelchair. Record review of Resident #90's EMR on 03/29/23 reflected a 5-day MDS assessment, marked accepted on 03/29/23. Resident #90 discharged on 04/28/23. No discharge MDS was completed. Record review of Resident #108's face sheet, dated 08/07/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 04/04/23. Resident #108 had diagnoses which included muscle wasting and atrophy (decrease in size and wasting of muscle tissue); malignant neoplasm of prostate (disease of malignant cancer cells form in the tissues of the prostate); other and unspecified ventral hernia with obstruction, without gangrene (protrusion of contents of the abdominal cavity through abdominal wall, without mention on necrosis of the herniated content). Record review of nursing progress notes dated 04/04/23 revealed Resident #108 discharged from the facility and was sent to the ER on [DATE]. The nursing progress notes revealed resident #108's family member notified the facility of transfer to the ER from the Oncologist Office. Resident #108 did not return to the facility. Record review of Resident #108's EMR, dated 02/09/23, reflected a 5-day MDS assessment, marked accepted on 02/09/23. The Quarterly MDS assessment, was marked accepted on 03/03/23. Resident #108 discharged from the facility on 04/04/23. No discharge MDS assessment was completed. Interview on 08/04/23 at 12:22 PM, with the MDS Coordinator revealed Resident #90's and Resident #108's names did not have the discharge MDS's completed. The admission and discharge date s were provided. The MDS Coordinator reviewed the MDS's for both residents. The MDS Coordinator returned and 455798 Page 3 of 4 455798 08/04/2023 Bedford Wellness & Rehabilitation 2001 Forest Ridge Dr Bedford, TX 76021

F 0642 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed she did not complete the discharge MDS's. The MDS Coordinator stated she missed completing them . Record review of the RAI Process policy, from the facility's Operational Manual - Administrative Policies with no revision dates, did not specifically address discharge MDS. The policy reflected the following under Documentation Storage. When a resident is discharged return anticipated and does not return within 30 days or is discharged return not anticipated, the previous admission's RAI will not be copied to the new clinical record. Record review of the Chapter 2: The Assessment Schedule for the RAI, Revised 12/02, https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MinimumDataSets20/Download reflected A Discharge-return not anticipated .is completed when it is determined that the resident is being discharged with no expectation of return after a comprehensive admission assessment has been completed. A discharge with return not anticipated can be a formal discharge to home, to another facility . 455798 Page 4 of 4