Health inspection·April 13, 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 assessments accurately reflected the resident's status for 4 of 4 Residents (Residents #54, #65, #75 and #85) reviewed for accuracy of assessment. Residents Affected - Some 1. The facility failed to ensure Resident #54's MDS, dated [DATE], accurately reflected the residents use of antipsychotics. 2. The facility failed to ensure Resident #65's MDS, dated [DATE]accurately reflected the residents use of antipsychotics. 3. The facility failed to ensure Resident #75's MDS, dated [DATE], accurately reflected the resident had a diabetic ulcer. 4. The facility failed to ensure Resident #85's MDS, dated [DATE], Accurately reflected the residents use of antipsychotics. These failures could place residents at risk of not receiving the proper care and services due to inaccurate records. Finding include: 1. Record review of Resident #54's admission record revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included bipolar disorder (mental disorder characterized by periods of depression), Major Depressive Disorder (clinical depression) and Anxiety (state of anxiousness). Record review of Resident #54's Physician Orders, dated 04/13/2023, revealed the resident was ordered Seroquel 25 mg, 1 tablet by mouth every morning and bedtime for treatment of Bipolar (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]). Review of Resident #54 ' s MDS, dated [DATE], indicted in section N0410 the resident received Antipsychotics the last 7 days, but in section N0450 it was checked no that antipsychotics were not received. 2. Record review of Resident #65's admission record revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included bipolar disorder (mental disorder characterized by periods of depression), Major Depressive Disorder (clinical depression) and Anxiety Page 1 of 10 455931 455931 04/13/2023 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

F 0641 (state of anxiousness) and psychosis (emotions are lost with external reality). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #65's Physician Orders, dated 04/13/2023, revealed the resident was ordered Quetiapine 25 mg, 1 tablet by mouth at bedtime for treatment of psychosis and hallucinations. Residents Affected - Some Review of Resident #65 ' s MDS, dated [DATE] indicated in section N0410 the resident received Antipsychotics the last 7 days, but in section N0450 it was checked no that antipsychotics were not received. 3. Record review of Resident #75's care plan revealed the resident had a Diabetic Ulcer and osteomyelitis related to Diabetes. Goal: Resident's wound will show improvement by next review date. Interventions: Ensure appropriate protective devices are applied to affected areas; Monitor Blood Sugar Levels; Monitor pressure areas for color, sensation, temperature; Monitor/document wound size, depth, margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene, document progress in wound healing on an ongoing basis. Notify MD as indicated; Monitor/document/report to MD PRN any signs or symptoms of infection: green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever; monitor/document/report to MD PRN changes in wound color, temp, sensation, pain, or presence of drainage and odor. Review of Resident #75 ' s MDS, dated [DATE], indicated in section M1040 the resident did not have a diabetic ulcer. 4. Record review of Resident #85's admission record revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder (clinical depression) and Anxiety (state of anxiousness) and schizophrenia. Record review of Resident #85's Physician Orders, dated 04/13/2023, revealed the resident was ordered Abilify 5 mg, 1 tablet at bedtime for treatment of Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior). During an interview on 12/09/2022 at 11:10 AM, the MDS Coordinator said Resident #18 was not aware an order for heel boots while in the bed would be considered a pressure reducing device. She pulled up the order and said she was not aware the resident even had an order for heel boots. The order at the time showed it was being care planned and it was being documented on the ADL flow sheet as being administered. After reviewing the records, she said she completed a correction of the 10/05/2022 assessment to reflect the administration of heel boots. She said this failure could place residents at risk for not receiving an accurate assessment. When asked about guidance on completing an MDS, she said they followed the CMS RAI 3.0 Manual. During an Interview with the MDS Coordinator on 04/13/23 at 10:13 AM, she revealed Resident #75 did not have any type of skin problem. She stated the Resident #75 was admitted with the error and the admission MDS was incorrectly document by her and it was a diabetic ulcer. She revelated Residents #54, #65 and #85's Section N0450 was not completed accurately. She stated she should have checked yes for that box so it would trigger additional assessments and questions boxes below. She stated these inaccurate assessments could result in the resident not receiving needed care and it likely occurred because she was doing the MDS for 108 resident's and she was in a hurry and made a mistake. Record review of the facility's policy and procedures regarding MDS Accuracy guidelines, dated 10/24/2022, revealed in part: 455931 Page 2 of 10 455931 04/13/2023 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

F 0641 Level of Harm - Minimal harm or potential for actual harm The purpose of the MDS guideline is to ensure each resident receives an accurate assessment by qualified staff that are familiar with his/her physical, mental, and psychosocial well-being in order to identify the specific needs of the resident in accordance with the RAI Manual. The assessment must accurately reflect the resident's status. Residents Affected - Some Review of Resident #85 ' s MDS, dated [DATE], indicated in section N0410 the resident received Antipsychotics the last 7 days, but in section N0450 it was checked no that antipsychotics were not received. 455931 Page 3 of 10 455931 04/13/2023 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

F 0694 Provide for the safe, appropriate administration of IV fluids 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, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physicians' orders, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 3 residents (Resident #83) reviewed for receiving parenteral (administered through a vein) fluids. Residents Affected - Few The facility failed to ensure Resident #83's midline intravenous catheter (an intravenous catheter that is suitable for long term infusion therapy) dressing to her right upper arm, was changed every Wednesday as ordered by her physician. This failure could place residents at risk of complications such as infection and/or sepsis and midline catheter displacement and/or infiltration. Findings include: Record review of Resident #83's face sheet, dated 04/10/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease (a circulatory condition and where narrow blood vessels reduce blood flow to the limbs), hypertension (high blood pressure), and hyperlipidemia (high blood pressure). Record review of Resident #83's care plan, dated 03/31/23, revealed she required IV Therapy via a midline intravenous catheter. The facility would assess the catheter site for signs and symptoms of infection, dislodgement, pain, streaking or drainage. The catheter site dressing changes were not listed on the care plan as an intervention. Record review of Resident #83's active physician orders, dated 04/05/23, revealed an order for Resident #83's midline dressing to the left upper extremity change, every Wednesday, on every AM shift (6AM-2PM) as needed, dated 03/31/23, and revised on 04/10/23, to include and as needed portion of the order. Record review of Resident #83's nursing medication administration record, dated 04/01/23 to 04/16/23, revealed the dressing change for the midline was initialed by LVN A as completed on 04/05/23. In an observation on 04/10/23 at 8:38 AM revealed the midline line dressing was dated 03/31/23 for Resident #83. In an observation on 04/10/23 at 10:38 AM revealed the midline line dressing was dated 03/31/23 for Resident #83. In an interview on 04/13/23 at 10:00 AM, ADON E stated on 04/10/23 she saw Resident #83's midline dressing on her left upper arm had not been changed since 03/31/23. She stated she knew the dressing should be changed every 7 days. She stated it was the responsibility of the charge nurse to change the midline dressing and the treatment nurse was also available to change the midline dressing if the charge nurse was busy. She stated the dressing was still dated 03/31/23 when it was changed however there was documentation on the medication administration record that the dressing had been changed on 04/05/23. She stated she did not know why It was documented as done, when the date on the dressing indicated it had not been done. She stated failing to change an IV site dressing could result in 455931 Page 4 of 10 455931 04/13/2023 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

F 0694 an infection in the resident. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/13/23 the DON stated her expectation was for a midline dressing to be changed every week. She stated she did not know why the dressing was initialed as changed by LVN A on 04/05/23 but she would find out and Inservice staff on the facility policy regarding vascular access devices. Residents Affected - Few In an interview with LVN A on 04/13/23 at 11:00 AM, she stated she did not change Resident #83's dressing on 04/05/23. She stated she remembered she initialed the medication administration record, but she stated she thought she was initialing a reminder that the resident had a midline dressing. She stated the consequence of not changing a midline intravenous catheter dressing was infection. Record review of the facility's Dressing Change for Vascular Access Devices policy, dated revised 02/21, revealed: . transparent dressings are changed every 7 days or changed immediately if nonocclusive or soiled, drainage or moisture is present under the dressing, or there are signs of irritation or inflammation, at the insertion site. 455931 Page 5 of 10 455931 04/13/2023 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

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, interview and record review 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 2 of 2 residents (Residents #22 and #43) reviewed for respiratory care. Residents Affected - Few 1. The facility failed to ensure Resident #22's CPAP mask was kept in a bag while not in use. 2. The facility failed to ensure oxygen tubing for Residents #43 was changed weekly. These failures could place residents at risk for infections and transmission of communicable diseases. Findings include: 1. Record review of Resident #22's face sheet, dated 04/13/2023, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmission date of 03/02/2023. Resident #22 had diagnoses which included hypertension (high blood pressure), Obstructive sleep apnea (periods of not breathing while asleep) and a cognitive communicative deficit (not able to communicate effectively). Record review of Resident #22's MDS Quarterly Assessment, dated 03/09/2023, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #22's Care Plan, dated 03/02/2023, revealed the resident had an impaired respiratory status and was at risk for shortness of breath, respiratory distress, increased anxiety, and hypoxia. Her CPAP therapy should administer as ordered by MD. In an observation on 04/10/2023 at 3:32 PM, Resident #22 was lying in her bed. Her CPAP tubing and mask was lying on the floor, not covered or bagged. In an observation on 04/11/2023 at 3:24 PM, Resident #22's CPAP mask and tubing was on the floor face down, not covered or bagged. 2. Record review of Resident #43's face sheet, dated 04/13/2023, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #43 had diagnoses which included hypertension (high blood pressure), personal history of COVID (respiratory infection) and Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #43's electronic Physician Orders, accessed on 03/12/2023, revealed an order for Oxygen at 2-4 liters per minute via nasal cannula. Order date of 02/23/2023. The Physician Orders specified to change the Oxygen tubing weekly, every Wednesday on the 2-10 PM shift. The Resident's records revealed the documentation showed it was changed on Wednesday, 04/05/2023. Record review of Resident #43's Care Plan, dated 03/08/2023, revealed the resident received Oxygen therapy for ineffective gas exchange. Record review of Resident #43's MDS Quarterly assessment, dated 03/09/2023, revealed a BIMS score 455931 Page 6 of 10 455931 04/13/2023 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of 10, which indicated the resident was moderately impaired. Section I: Active diagnosis revealed: Personal history of COVID. Section O: Respiratory Treatments was not marked for Oxygen Therapy. In an observation and interview on 04/10/23 at 1:00 PM, Resident #43 was sitting in her recliner reading a book while receiving oxygen via nasal cannula at 2 liters per minute. Her oxygen tubing was dated 03/29/2023. She stated she was on oxygen continuously. In an observation on 04/10/2023 at 2:17 PM, Resident #43's oxygen tubing was changed with a new date of 04/10/2023. In an interview on 04/10/2023 at 02:45 PM with the ADON revealed oxygen tubing was changed weekly based on the resident's orders, or as needed if they become contaminated or occluded. She stated the oxygen tubing should have been changed on Wednesday, but it was not, even though staff checked off it was performed. She stated she went through the entire facility to make sure all of the tubing was changed. She stated all tubing should be stored in a plastic bag when not in use to prevent cross contamination and infection, as well as not on the floor. In an interview with the DON on 04/10/2023 at 3:00 PM, she revealed it was the floor nurse who worked on Wednesday's, responsibility to make sure the oxygen tubing was changed. She said she was unsure why it was not done, but it was reported to her by the ADON that it had not been completed the previous week. She was preparing for an all-staff in-service to resolve and correct the issue. Record review of the facility's policy Oxygen Administration, dated 09/12/2014, revealed in part: 1) When oxygen was not in use, store Oxygen tubing and nasal canula or mask in plastic bag. 2) Change disposable parts once a week and label with date. 455931 Page 7 of 10 455931 04/13/2023 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 2 residents (Resident #102) reviewed for accuracy of medical records. The facility failed to ensure Resident #102 medical record was complete and included physician orders for continuous oxygen. This failure could place residents at risk of receiving inadequate care and services. Findings include: Record review of Resident #102's medical record revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the a diagnosis which included: Chronic Obstruction Pulmonary Disease with exacerbation (chronic lung disease characterized by air flow limitation). Record review of Resident #102's electronic medical records, dated on 04/10/2023 did not reflect an order for oxygen. During an interview with the ADON on 04/13/2023 at 2:00 p.m. revealed she was the one who was responsible for admitting the resident and completing her orders accurately. She stated she somehow forgot to enter the order for her oxygen and the resident did not have a physician's order. She revealed it used to trigger under the admission task, but now it had to be entered manually. She stated she was going to enter one immediately and she would notify the DON. She said this failure could place the residents at risk for not receiving the correct treatments if an order was not administered. During an interview with the DON on 04/13/2023 at 3:30 p.m. revealed the resident did not have a physician's order, she said all residents receiving oxygen should have an order in the chart. She said she would be providing an in-service class to correct the failure. Record review of the facility's policy and procedure over transcribing or noting orders, dated 02/10/2021, revealed in part: When a physician order is completed, it is necessary to transcribe or note information received into the appropriate forms to ensure care provision. The instructions for care provision are entered into the physician order form then transcribed or noted on the medication administration record or treatment administration record and or other center designated areas. 455931 Page 8 of 10 455931 04/13/2023 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

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 establish and 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 diseases and infections for 1 of 3 (Resident #31) residents reviewed for infection control. Residents Affected - Few CNA C failed to thoroughly clean feces from the area between the buttocks and around the anus during incontinent care for Resident #31. This failure could place resident at risk of unnecessary infections. Findings include: Record review of Resident #31's Annual MDS, dated [DATE], revealed a [AGE] year-old female with an admission date of 04/02/18. Resident #31 had diagnoses which included, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and hypertension (high blood pressure). Record review of Resident #31's Annual MDS, dated [DATE], revealed Resident #31 had a short- and long-term memory problem and her cognitive skills were severely impaired. ADL and hygiene care needs included extensive 1-person physical assistance, and she was always incontinent of bowel and bladder. During an observation and interview on 04/13/23 at 11:15 AM, Resident #31 was lying in her bed awake and oriented. CNAs C and D performed hand hygiene and donned gloves before touching the resident. CNA C provided incontinent care while CNA D assisted. CNA C cleaned the outer area of the resident's vagina. She did not separate the labia to wipe until CNA D told her to do so. CNA C then appropriately wiped and cleaned resident's vaginal area and discarded soiled wipes appropriately. CNA C took her gloves off and washed her hands. CNA C reapplied gloves and repositioned the resident towards CNA D. CNA C wiped Resident #31's outer buttocks 5 times without cleaning the inner buttocks and anal area. CNA C turned the resident back on her back. CNA's C and D washed their hands and applied a new set of gloves and started to apply the resident's clean brief without cleaning the inner buttocks and anus. The surveyor questioned if they had cleaned the inner buttocks. CNA C stated she had not, she forgot. She then began to spread the resident's buttocks and wiped her from front to back. There was a large amount of feces on the wipe. She obtained a clean wipe and cleaned her vaginal area and there was feces on the wipe. She stated she had forgotten to clean that area because she was nervous and did not realize the resident had a bowel movement before providing incontinent care. There was dried feces visible on Resident #31's inner buttocks area before CNA C cleaned the area. Both CNAs C and D performed hand hygiene and put on new gloves and applied a new brief. They covered the resident with her bed in the lowest position and left the room. In an interview on 04/13/23 11:35 AM, CNA D said she was unable to see what CNA C was doing, but Resident #31 should not have dried feces on her. CNA D said this failure could allow the resident to develop skin issues and cause the resident to get an infection. During an interview on 04/13/22 at 12:13 PM, the DON said her expectation was CNAs should clean residents thoroughly when performing incontinent care to prevent infection. She stated the CNAs knew 455931 Page 9 of 10 455931 04/13/2023 Advanced Rehabilitation and Healthcare of Vernon 4401 College Dr Vernon, TX 76384

F 0880 Level of Harm - Minimal harm or potential for actual harm how to perform incontinent care correctly and stated she did spot monitoring of their performance frequently. She stated she did competency checks on hire and annually and the failure occurred because CNA C was nervous. Record review of the facility's policy and procedure titled Incontinence, dated 4/10/17, revealed in part: Residents Affected - Few .Position on side. If feces present wipe away with tissue by wiping from front of perineum toward the rectum. Discard soiled materials and wash hands. Put on gloves and cleanse peri-area and buttocks wiping from front toward the rectum. 455931 Page 10 of 10