Health inspection·June 14, 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 interview and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 3 of 18 Residents (Resident # 15, Resident # 23, and Resident #20) reviewed for accuracy of assessments, in that: Residents Affected - Some 1. The facility failed to update Resident #15's MDS when the resident had not had COVID since 02/01/2023 or sepsis since 11/01/2022. 2. The facility failed to update Resident #23's MDS when the resident had not had COVID since 01/23/2023. 3. The facility failed to update Resident #20's MDS when the resident had not had pneumonia since 03/11/2023. These failures place residents at risk of inaccurate assessments and not receiving appropriate care according to their current status. Findings include: 1. Record review of the electronic face sheet for Resident #15 revealed an admission date of 09/02/2022. Resident was an [AGE] year-old female with diagnoses to include: high blood pressure, diabetes, and urinary tract infection. Further review revealed diagnosis of sepsis on 11/01/2022. Further review of electronic face sheet revealed no evidence of a COVID diagnosis. Record review of Quarterly MDS dated [DATE] for Resident #15 revealed a BIMS score of 03 which indicated severely impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed COVID and sepsis. Record review of electronic physician's orders from 04/20/2023 to 06/14/20223 for Resident #15 revealed no evidence of any treatments for COVID or sepsis. Record review of electronic progress noted from 04/20/2023 to 06/14/2023 for Resident #15 revealed Page 1 of 8 455929 455929 06/14/2023 Granbury Rehab & Nursing 2124 Paluxy Hwy Granbury, TX 76048

F 0641 no evidence of COVID or sepsis. Level of Harm - Minimal harm or potential for actual harm 2. Record review of the electronic face sheet for Resident #23 revealed an admission date of 03/04/2022. Resident was a [AGE] year-old male with diagnoses to include: high blood pressure, depression, and anxiety. Further review revealed diagnosis of COVID on 01/23/2023. Residents Affected - Some Record review of Quarterly MDS dated [DATE] for Resident #23 revealed a BIMS score of 14 which indicated no impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed COVID. Record review of electronic physician's orders from 05/20/2023 to 06/14/20223 for Resident #23 revealed no evidence of any treatments for COVID. Record review of electronic progress noted from 05/20/2023 to 06/14/2023 for Resident #23 revealed no evidence of COVID. 3. Record review of the electronic face sheet for Resident #20 revealed an admission date of 03/11/2023. Resident was a [AGE] year-old female with diagnoses to include: heart failure and respiratory failure. Further review revealed diagnosis of pneumonia on 03/11/2023. Record review of Quarterly MDS dated [DATE] for Resident #20 revealed a BIMS score of 12 which indicated moderately impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed pneumonia. Record review of electronic physician's orders from 05/20/2023 to 06/14/20223 for Resident #20 revealed no evidence of any treatments for pneumonia. Record review of electronic progress noted from 05/20/2023 to 06/14/2023 for Resident #20 revealed no evidence of pneumonia. During an interview on 06/14/23 at 3:00 PM, MDS nurse stated it was her responsibility to ensure the MDSs are accurate. She stated MDS is how the facility got reimbursed. She stated diagnosis should be removed when they are no longer active diagnosis. MDS nurse stated the MDS is a snapshot of resident during a 7-day lookback period. She stated she just missed them. During an interview on 06/14/23 3:20 PM, DON stated diagnosis such as COVID, pneumonia, and sepsis should be removed on the next MDS after they are resolved since they are no longer active. She stated she did not know why the failure occurred. DON stated the facility did not have a policy for MDS. She stated the facility followed the RAI. 455929 Page 2 of 8 455929 06/14/2023 Granbury Rehab & Nursing 2124 Paluxy Hwy Granbury, TX 76048

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 2 (Resident #131) reviewed for baseline care plans. The facility failed to develop a baseline careplan that included the needs of Resident #131's foley catheter. This failure placed residents that admitted to the facility with a foley catheter of having their needs met. Findings included: Record review of Resident #131's Facesheet dated 06/14/23 revealed a [AGE] year-old male that admitted to the facility on [DATE]. He had a diagnosis list that included dysuria dated 06/12/23. Record review of Resident #131's admission Evaluation dated 06/08/23 revealed that resident was incontinent of urine with no comment regarding Resident #131 had a foley catheter. Record review of Resident #131's Bowel and Bladder Program Screener dated 06/08/23 revealed that resident never voided appropriately without incontinence and no comment regarding he had a foley catheter. Record review of Resident 131's Physician's Orders dated 06/13/23 revealed: Change the BSD bag along with the catheter if visibly soiled, to collect a urine specimen, or if the closed system has been compromised. as needed. Start date of 06/08/23. Flush foley catheter with 60ml of sterile water or normal saline. as needed for non-patency. Start date of 06/08/23. Provide catheter care every shift for Urinary catheter use. Start date 06/08/23. Record fluid intake and output. Review each week for fluid imbalance. every shift. Start date of 06/08/23. Urinary catheter FR CC bulb to gravity (BSD). Change the catheter if it becomes occluded, to obtain a urine specimen, or if the closed system has become compromised. every shift for urinary retention. Start date of 06/08/23. Record review of Resident #131's Baseline Careplan initiated 06/09/23 revealed no problem regarding resident care needs for a foley catheter. During an observation and interview on 06/12/23 at 11:31AM of Resident #131, he had a foley catheter draining to gravity that had a noted blood clot in tubing and pink blood-tinged urine in the 455929 Page 3 of 8 455929 06/14/2023 Granbury Rehab & Nursing 2124 Paluxy Hwy Granbury, TX 76048

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few drainage bag. Resident #131 was repetitive in his remarks and spoke in a word salad. He was unable to express when and why he came to the facility. During an interview on 06/14/23 at 2:38PM with the DON, she said they had a baseline careplan assessment. She said, whatever is on the baseline assessment would be on their baseline careplan. She, or an RN if on weekends, would begin the comprehensive care plan within 24 hours. DON said the baseline careplan would have the ADL needs if any. DON said if a resident had a catheter, then that would be considered as they were incontinent. She said the baseline careplan assessment had a box to check that the resident was continent or incontinent. So, with that, a catheter would mean incontinent, and staff would know they needed to go check on that resident. She said the admission nurse would also put physician orders in to indicate that a resident had a catheter. The physician orders would include what type/size the catheter was, to empty it, monitoring of the catheter. DON said the nurse aides did not have direct access to resident physician orders so the only way they would know if a resident had a catheter would be by going into the resident room and checking on them. She said, the baseline care plan assessment did not have a direct question regarding if a resident had a catheter. DON said there was a section at the bottom of that assessment that the nurse could summarize what was answered in that assessment and nothing more. She said the admission assessment and the bowel and bladder assessment would also have been completed as well. DON review of all 3 assessments did not include an area to checkbox that a resident did or did not have a catheter. It only had a checkbox that they were continent or incontinent of bowel and bladder. She said the reason that Resident #131 did not have a baseline careplan area directly identifying his catheter was due to the system generated assessments not having an area of addressing a catheter directly. DON said that the comprehensive care plan would address the resident catheter with further details, however they had at least 7 days to complete the comprehensive care plan. She said the comprehensive care plan policy should address baseline care plans as well. Record review of facility policy labeled Comprehensive Care Plans revised September of 2010 revealed no area specifically addressing baseline careplans. 455929 Page 4 of 8 455929 06/14/2023 Granbury Rehab & Nursing 2124 Paluxy Hwy Granbury, TX 76048

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: Residents Affected - Many The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: Record Review of facility MDS Resident 672 dated 06/12/2023 revealed, there were 76 out of 76 residents that ate from the kitchen. During observation on 06/12/2023 at 10:25 AM, of 1 of 1 dry storage contained: 1. One 5-gallon bucket labeled Beef Broth was open to elements with the lid placed to the side. 2. One gallon of opened Liquid Smoke Beef Marinade with no opened date. 3. One gallon of opened Imitation Vanilla Flavor with no opened date. 4. One gallon of opened White Distilled Vinegar with no opened date, and an expired date of 2020. 5. One gallon of opened Karo with no open date, and an expired date of 01/12/2020. 6. One 32 oz. opened bottle of Seasoning Sauce, with opened date of 2021, and expired date of 12/2022. 7. One storage bin labeled Bulk Cereal,, dated 4/26/21, contained 3 bags of cereal, not labeled, or dated. 8. 455929 Page 5 of 8 455929 06/14/2023 Granbury Rehab & Nursing 2124 Paluxy Hwy Granbury, TX 76048

F 0812 One 8.1 oz. can of Baking Powder with an expired date of 01/22/2023. Level of Harm - Minimal harm or potential for actual harm 9. Twenty separate opened containers of spices with no opened date. Residents Affected - Many During observation on 06/12/2023 at 10:44 AM, freezer #1 of 2 contained: 1. Two unopened bags of what appeared to be, frozen tater tots that had been removed from the original box, not labeled, or dated. 2. One opened bag of what appeared to be, frozen tater tots removed from the original box, not labeled, or dated. 3. Six unopened bags of what appeared to be, frozen French bread that had been removed from the original box, not labeled, or dated. 4. One opened bag of what appeared to be, frozen French Toast that had been removed from the original box, not labeled, or dated 5. Two unopened bags of what appeared to be, frozen French Toast that had been removed from the original box, not labeled, or dated. 6. One bag of what appeared to be, frozen Okra that had been removed from the original box, not labeled, or dated During observation on 06/12/2023 at 10:54 AM, refrigerator #2 of 3 contained: 1. One 32 fluid oz. opened bottle of Reconstituted Lemon Juice, with the expired date of 02/21/2022. During interview on 06/12/2023 at 12:30 PM, the DM stated all items should have an open date. She stated all products were to have written on the boxes or bags if removed, with a label and received date. The DM stated, once removed from the original box, a label and date should have been placed on that product. She stated, all products should be rotated and used, according to the in date. She stated, there should have been no expired products in the pantry, or refrigerator. She also stated, she 455929 Page 6 of 8 455929 06/14/2023 Granbury Rehab & Nursing 2124 Paluxy Hwy Granbury, TX 76048

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many was told by her corporate, the spices had not needed an open date so had not proceeded to do so. The DM stated she failed to monitor the dates and rotations of products due to being understaffed. She stated, she felt the failure that led to the products not having not been labeled correctly was, the staff getting in a hurry and her, as DM, had not followed up. She stated, the neg impact to residents was, food could have gone bad and led to residents getting sick. Her expectations were for all products to be labeled and dated when appropriate with no expired dates. During an interview on 06/13/2023 at 2:15 PM, the Admin stated, the DM was supposed to had monitored the labeling and storage of products in the kitchen. He stated, not following protocols of label and storing. As well as having had expired food products could have had a negative outcome of possibly causing harm to residents with an adverse reaction to bad food. The Admin stated his expectations were for staff to follow policies and procedures as well as state laws. Record Review of facility policy, Dry Food and Supplies Storage dated 07/22/2022, revealed: Policy: . . Desirable practices include managing the receipt and storage of dry food, regulating foods not safe for consumption, keeping dry food products in closed containers, and rotating supplies. Fundamental Information: . .All bulk food items (i.e., flour, sugar) That are removed from original containers into food grade containers must have cat fitting lids and must be properly labeled with the common name of the product Procedure: . .6. Expiration or use by dates will be checked and product will be put in order of use by or expiration date. Any product that is found to be out of date will be discarded .7. Bulk food products that are removed from original containers must be placed in plastic or metal food grade containers with tight fitting lid. Each container must be labeled with the common name of the food. Plastic food grade storage bags are also acceptable for storage. All storage bags must also be properly sealed and labeled with the common name of the food .9. All open products must be resealed effectively and properly labeled, dated and rotated for use .10. Use by, Best by Dates should routinely be checked to ensure that items which have expired or discarded appropriately. Record Review of facility policy Frozen and Refrigerated Foods Storage with the revised date of 11/16/2017, and a Review Date of 07/22/2022 revealed: . .Procedure . 455929 Page 7 of 8 455929 06/14/2023 Granbury Rehab & Nursing 2124 Paluxy Hwy Granbury, TX 76048

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many .10. Package frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage. This includes individual bags of frozen vegetables removed from the original storage box unless they have a common name and expiration date on the bag. 11. All refrigerated and frozen items in storage will contain a minimum label of common names of products and dated as noted above. 455929 Page 8 of 8