Health inspection·December 14, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable and homelike environment for 3 of 4 halls (halls 100, 200, and 300) and 1 of 2 common areas (central great room) reviewed for environment. The facility failed to ensure that halls 100, 200, 300 (secure unit), and the common great room did not have a pervasive foul urine odor. This failure placed residents at risk of diminished quality of life. Findings included: Observation on 12/12/23 at 09:59 AM in the 300 hall secure unit revealed a faint foul urine odor in the entrance area and dining room of the unit. The smell was stronger further down the hall. Observation on 12/12/23 at 10:00 AM revealed a foul smell was present in the 200 hall with no immediately apparent cause. Observation on 12/12/23 at 11:57 AM revealed the foul urine odor was still present just outside the doors to the secure unit and immediately upon entrance into the unit. The hallway of the secure unit also had a strong foul smell. Observation on 12/12/23 at 01:30 PM revealed the foul smell of urine was still present in the 200 hall. Observation on 12/12/23 at 02:40 PM revealed the foul urine odor was still present in the secure unit. During an interview on 12/12/23 at 03:50 PM, the ADM stated the facility policy on safe, clean, comfortable, and homelike environment was included in the overall facility policy titled Resident Rights. Review of the policy reflected no mention of the physical environment. During a confidential interview with 13 anonymous residents, every resident agreed they had noticed the foul urine odor in the building being very strong. Several residents stated they believed the smell was coming from the facility carpet. Several of the residents stated the bad odor smelled like urine and they had gotten used to it, but they still greatly disliked it. Observation on 12/13/23 at 08:18 AM revealed a foul urine odor in the 100 hall. Page 1 of 17 455960 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During interviews on 12/13/23 between 09:54 AM and 03:32 PM, the RPs of four residents stated they had noticed the foul urine odor in the facility and more particularly in the secure unit. One of the RPs stated she had noticed the odor in other areas of the facility. Observations on 12/13/23 at 10:56 AM and 02:07 PM revealed the secure unit still had the foul urine odor, somewhat faint in the common area and stronger down the hallway. No resident in the unit was observably the source of the odor. Observations on 12/14/23 from 09:50 AM to 12:15 PM revealed a strong odor of air freshener, but the unpleasant odor was still detectable underneath it. During an interview on 12/13/23 at 20:39 PM CNA E stated she had noticed the odor in the secure unit, and she believed it was the carpet. CNA E stated the residents with dementia and Alzheimer's disease sometimes urinated in places that were not the toilet, and while the staff came back and cleaned up, they could not get it entirely clean. CNA E stated she had not heard the residents complain about the smell, but they all had dementia and were not able to speak about their feelings very easily. CNA E stated the management staff had recently done a much better job at trying to get rid of the smell. CNA E stated she thought they started trying to fix the problem a few months ago and had been using a carpet cleaner almost every day and putting in air fresheners. During an interview on 12/14/23 at 08:42 AM CNA D stated the foul urine odor on the secure unit used to be very noticeable when they walked in but recently, she had noticed it had lessened compared to what it was during the summer. CNA D stated they had been more on top of getting residents changed as soon as they smelled anything funky. She stated they had also been keeping the linen cart away in the restroom, so the odor did not linger. CNA D stated the carpets would be removed from the building because they were old carpets and there had been toileting accidents on them. CNA D stated housekeeping had brought the carpet cleaner back to the unit every other day. CNA D stated Resident #80 had commented that it smelled bad in the unit, but no other resident had complained about it. CNA D stated she did not think the other residents noticed the odor, but she would not want to live in it and did not think it was the best situation for them. CNA D stated there were a lot of heavy wetters in the secure unit, and it was difficult to catch them before they got urine on the carpet. During an interview on 12/14/23 at 09:19 AM, CNA F stated she had worked in the secure unit for three years. She stated they had been trying to catch ithe source of the odor more and changing residents more frequently, but she felt the urine had sunk into eh carpet and could not be removed. She stated it was known that there was a urine odor in the secure unit. CNA F stated she did not think the smell bothered them except for Resident #80. During an interview on 12/14/23 at 09:45 AM, the AD stated he was immune to any odor in the facility, so it took a significant smell to hit his nose. The AD stated it was well known in the building that the carpet in the facility, especially the secure unit, had a bad odor. The AD stated he thought the smell was due to some residents having urinary accidents. He stated he had not heard any residents complain about the smell. During an interview on 12/14/23 at 02:13 PM, the DON stated she had noticed the urine odor in the facility on and off. The DON stated she had noticed it more specifically and prevalently in the secure unit. She stated the potential impact of unpleasant odors in the facility was a negative emotional impact on the residents. 455960 Page 2 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/14/23 at 03:01 PM, the ADM stated he was aware of odors in the secure unit, and he thought it was urine. He stated he thought it was because people were urinating on the floor multiple times, they had carpeted floors, and all the urine could not be removed. He stated the sent the carpet cleaner into the unit, but there were limitations on what the carpet cleaner could do. The ADM stated the whole facility was being renovated, and the floors would be replaced, but he did not know how long that would take. He stated he had been told the entire project would take six months. The ADM stated the renovation was happening with certainty, and they had already chosen all the flooring, fixtures, and paint. He stated the painting would be first, and the floors after that. The ADM stated he had somewhat of a say in the order in which the work was done but not a complete say. He stated the lobby in the front of the building was being done first, because the contracted vendors had been testing paint samples in that area, and the lobby did not require anyone to move out of the area. The ADM stated he felt the urine odor had less of an effect on the residents than it did the staff, and unfortunately the residents had probably become used to it and no longer noticed it. He stated it was not pleasant for the residents and might have an impact, but he did not know what the impact would be. 455960 Page 3 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0679 Provide activities to meet all resident's needs. 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 provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 8 residents (Resident #80) reviewed for activities. Residents Affected - Few The facility failed to ensure that Resident #80 was provided activities that met his unique recreational and social needs. This failure placed residents at risk of depression, withdrawal, and diminished quality of life. Findings included: Review of the undated face sheet for Resident #80 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Wernicke's encephalopathy (a disorder that primarily affects the memory system in the brain, usually resulting from a deficiency of thiamine, which may be caused by alcohol abuse), alcohol abuse, and cognitive communication deficit (communication problems caused by cognitive impairment). Review of the admission MDS assessment for Resident #80 dated 09/28/23 reflected a BIMS score of 01, indicating severe cognitive impairment. Review of the section titled Preferences for Customary Routine and Activities reflected the following were very important to him: to have books, newspapers, and magazines to read; listen to music he liked; be around animals such as pets; keep up with the news; do things with groups of people; do his favorite activities; go outside to get fresh air when the weather was good; and participate in religious services or practices. Review of the care plan for Resident #80 dated 09/29/23 reflected the following: Has little or no activity involvement r/t Anxiety, Disinterest, Poor adjustment to the facility/unit. Will express satisfaction with type of activities and level of activity involvement when asked through the review date. Explain the importance of social interaction and leisure activity time. Encourage participation by next review. Explain that may leave activities at any time and is not required to stay for entire activity. Invite to scheduled activities. Prefers a variety of activity types and locations to maintain interests. Provide activities calendar monthly . Review of the care plan also reflected the following: Elopement risk/wanderer r/t Disoriented to place, Impaired safety awareness, Resident wanders aimlessly, exit seeking Observations on 12/12/23 at 09:59 AM, 11:54 AM, and 02:30 PM revealed Resident #80 walking up and down the hall of the secure unit, [NAME] around the tables in the dining area, and attempting to talk with nurses at the nurse's station. The nurses did not engage with him. Observations on 12/13/23 from 10:00 AM to 11:30 AM revealed Resident #80 walking up and down the halls with no activity to engage him. Observation of his room revealed his drawers contained letters from a friend but no books or magazines or any other reading or writing material. Sports were on his television. 455960 Page 4 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/13/23 at 10:56 AM, Resident #80 stated he was miserable but had to stay at the facility. He stated he did not remember why he ended up at the facility, but he knew he would be there for the rest of his life. He stated he liked to go outside, but the staff did not let him go outside whenever he wanted to. Resident #80 stated he liked to watch television sometimes but did not like sports. He stated it smelled awful in the facility. He stated it smelled like strong, awful chemicals or piss all the time. He stated there was nothing that would make the situation better, but then he said he heard the question about what would make it better and was thinking about it. He stated no one at the facility had asked him anything like that. Resident #80 stated he enjoyed cards and chess and then asked the surveyor if he could have a deck of cards. He asked the surveyor if anyone would be able to play cards or chess with him. Resident #80 stated he loved to talk to interesting people, and he liked a healthy, organic lifestyle, but there was no one to talk to in there. He stated he had a cat at his house before and he hoped she was okay. He stated he missed his cat very much and started to cry. During an interview on 12/14/23 at 08:50 AM, CNA D stated Resident #80 had accepted the facility was where he lived now. She stated he liked to hang out in the courtyard and went out there quite often. stated they had tried offering him bingo, but he was not into it. She stated he liked to read but did not have anything to read. She stated he had come into the facility with books, but she was not sure where they were now. CNA D stated his friend dropped off a guitar, and he loved it, but the AD kept it in the office to keep it safe. CNA D stated the AD sometimes brought out his guitar. CNA D stated Resident #80 liked to exercise and would sometimes just drop down and do pushups in the hallway. CNA D stated Resident #80 did not like to do the type of mild exercises they did where they tossed a balloon, and he did not like bingo or watercolor painting. She stated he was probably not having a good quality of life. She stated he would have enjoyed more conversations with residents outside the secure unit. She stated he wanted more people to talk to. CNA D stated the AD took residents from the secure unit out into the main part of the building frequently for activities but had never taken Resident #80, and he would probably benefit from that. During an interview on 12/14/23 at 09:19 AM, CNA F stated they tried to offer activities to Resident #80 and told him each day what would be going on in the secure unit. She stated they let him out on the patio, and he liked to be outside. She stated the AD [NAME] him his guitar a couple days a week. CNA F stated he mainly liked going outside and exercising. She stated they never brought him out to the main area. She stated they sometimes had musicians come into the secure unit, and they gave Resident #80 his guitar then, because he loved to play with the musicians. During an interview on 12/14/23 at 09:33 AM, the AD stated he (the AD) spent time with Resident #80 when he (Resident #80) was willing to stand close to the AD during group activities. The AD stated Resident #80 was easily distractable, so the focus was not there for activities. The AD stated Resident #80 did not participate in any arts and crafts activity. The AD stated once in a while Resident #80 would sit down and engage with what the other residents were doing, but it was never for very long. The AD stated the only thing he got involved in was the guitar, so they maintained a healthy schedule so Resident #80 could use the guitar. The AD stated a healthy schedule was two to three times a week for around an hour. The AD stated they did not like to leave the guitar with Resident #80 or bring it to him more often, because they were afraid he would develop an unhealthy attachment to it. The AD then said it might be unsafe for Resident #80 to have the guitar. The AD then said the guitar was too loud, and the nurses did not want the guitar in the room because other residents got overstimulated. The AD then stated the resident liked music, but the guitar was not tuned and needed new strings. The AD stated even when they tuned the guitar, it would fall out of tune almost immediately. The AD stated he had not 455960 Page 5 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few looked into new strings for the guitar, because usually when a resident had those types of needs and it was their property, then they or their family or friends were responsible for providing the resources. The AD stated he did not bring Resident #80 out into the main part of the facility for activities. He stated they had to be careful with Resident #80, because he was physically very functional and quick, and they had to prevent him from eloping. The AD stated he deferred to the nurses for Resident #80, and they said he was still too much of an elopement risk to go outside the secure unit. The AD stated he thought Resident #80 was happy in the facility's secure wing. During an interview on 12/14/23 at 02:13 PM, the DON stated Resident #80 had alcohol-induced encephalopathy (a disease that affects brain structure or function causing altered mental state and confusion), and his physician had said he would not improve. She stated he walked around a lot and liked to go to the courtyard. The DON stated he might be a part of the group that came out into the main part of the facility for activities. The DON stated musicians went back to the secure unit when there was a music program for a performance. The DON stated she had not heard Resident #80 was unhappy or had any problems. The DON stated she monitored for the activities program being sufficient by tracking behaviors. She stated a potential impact of a resident not receiving person-centered activities was depression. During an interview on 12/14/23 at 03:22 PM, the ADM stated the residents of the secure unit were able to participate in most activities if they wanted to. The ADM stated there were materials in the secure unit such as books, blocks, and the residents would sometimes come out of the unit for bingo, loteria (a Mexican game of chance), or music. The ADM stated he did not know if there was a specific activity designed for Resident #80. The ADM stated they could have provided Resident #80 with one-on-one activities for things he really liked to do that were not offered on the activity schedule. The ADM stated he monitored for compliance with activities regulations by reviewing resident council minutes, and the AD was present at most QAPI meetings. The ADM stated there were no procedures for him to monitor the activities programs of individuals, and that was left to the AD. The ADM stated a potential negative impact on the residents was a negative mental state. Review of facility policy dated 01/22 and titled Activities reflected the following: It is the policy of this facility to ensure the activities are available to meet resident needs and interests that support the physical, mental, and psychosocial well-being of the resident. Activities may be facility-sponsored, group, or independent. 2. Attempts will be made to accommodate resident preferences, when safe to do so, for planning, activities, programs, and calendars. Program considerations may include group offerings, independent offerings, or religious/spiritual offerings. If a resident preference or hobby is not safe to be allowed at the facility, the resident should be advised at the safety concern and attempts may be made to identify alternative. Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations. Some options may include: cognitive impairment: task segmentation, settings that re-create past experiences, smaller groups without interruption, one to one, etc. 455960 Page 6 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents (Resident #5) reviewed for quality of care. Residents Affected - Few The facility failed to ensure the resident's wound treatment was performed on 12/11/23 according to physician's orders. This failure placed residents at risk of infection and worsening wound condition. Findings included: Review of the undated face sheet for Resident #5 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of anxiety disorder, adjustment disorder with mixed disturbance of emotions and conduct (A short term condition arising due to difficulty in managing the stressful life changes), dementia, pain, chronic kidney disease, polyneuropathy (is damage or disease affecting nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain). Review of the admission MDS assessment for Resident #5 dated 11/03/23 reflected a BIMS score of 00, indicating severe cognitive impairment. Review of the section titled Functional Abilities and Goals reflected she was always incontinent of bladder and bowel. Review of the care plan for Resident #5 dated 11/07/23 reflected the following: Has Skin Tear to LLE. Resident refuses treatment, refused me to see at this time x 2. Will be free from skin tears through the review date. Skin tear of the LLE will be healed by review date Keep skin clean and dry. Use lotion on dry scaly skin. Monitor location, size and treatment of skin tear. Report abnormalities, s/sx of infection, maceration (skin breakdown due to moisture and friction) etc. to MD. Monitor skin tear to LLE for any s/s of infection and report to MD two times a day. Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any hard surfaces. Review of physician's orders for Resident #5 dated 11/22/23 reflected the following: SKIN TEAR (LLE): CLEANSE WITH NS, PAT DRY, APPLY BACITRACIN OINT, COVER WITH DRY DRESSING every evening shift d/c when healed. Review of the December 2023 TAR for Resident #5 reflected the order SKIN TEAR (LLE): CLEANSE WITH NS, PAT DRY, APPLY BACITRACIN OINT, COVER WITH DRY DRESSING every evening shift d/c when healed was documented as completed by RN I on 12/11/23. Observation on 12/12/23 at 11:50 AM revealed Resident #5 lying in bed and watching television. She had a bandage on her left shin with the date 12/10/23 written on it and the letter D . Observation on 12/12/23 at 12:40 PM revealed Resident #5 was eating lunch in her bed; still with the bandage dated 12/10/23 on her left shin. During an interview at this time, Resident #5 stated she was fine and could not remember when someone last changed the dressing on her leg. During an observation and an interview on 12/12/23 at 01:45 PM, CNA G looked at the bandage on 455960 Page 7 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #5's shin and stated she could see the date was 12/10/23. She stated that was the day before yesterday. She stated she did not know how often the bandage should have been changed. During an interview on 12/12/23 at 04:10 PM, RN I stated she had already been told about the treatment for the skin tear that had not been changed. She stated she had not been aware that Resident #5 had a treatment, and she had been clicking through the TAR and had clicked as if she had done the treatment when she obviously had not. She stated she had to be honest about it; she had not completed the treatment but had signed the TAR as if she had. She stated it was an accident, and she had not realized she had done it until that afternoon (12/12/23) when CNA G began asking her questions about it. During an interview on 12/12/23 at 04:20 PM, the DON stated she had already heard about the missed skin treatment for Resident #5. She stated that was not her expectation and that she expected treatments to be performed as ordered and documentation to reflect what really happened . During an interview on 12/14/23 at 03:01 PM, the ADM stated he did not know how the nursing department monitored to ensure floor staff were performing their tasks. He stated he generally adopted a trust but verify approach for his staff, but he was not directly responsible for that system, so he did not know the oversight. The ADM stated he did not believe there was a potential negative impact of Resident #5 missing the one wound treatment. Review of facility policy dated 05/07 and titled Dressings, Clean reflected the following: It is the policy of this facility to: 1. Protect wound 2. Prevent irritation. 3. Prevent infection and spread of infection. Procedures: 10. Cleanse wound with prescribed solution if ordered. 11. Apply prescribed medication if ordered. 455960 Page 8 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible for 1 of 4 halls (300 hall/secure unit) and 1 of 8 residents (Resident #66) reviewed for accident hazards. The facility failed to ensure that all electrical outlets in the secure unit were fully covered with socket plates and live parts of the outlet inaccessible to residents in the unit with dementia and wandering behaviors. This failure placed residents at risk of electric shock. Findings included: Review of the undated face sheet for Resident #66 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, Parkinson's disease, insomnia, anxiety disorder, cognitive communication deficit (communication problems caused by cognitive impairment), age-related cataract, and Alzheimer's disease. Review of the admission MDS assessment for Resident #66 dated 10/04/23 reflected a BIMS score of 01, indicating severe cognitive impairment. Review of the section titled Behaviors reflected behavior of wandering occurred 1 to 3 days. Review of the care plan for Resident #66 dated 10/02/23 reflected the following: Elopement risk/wanderer r/t Disoriented to place, Impaired safety awareness, Resident wanders aimlessly. Safety will be maintained through the review date. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Document wandering behavior and attempted diversional interventions. Monitor for fatigue and weight loss. Observation on 12/13/23 at 02:48 PM revealed a plastic mounting recess on the wall of the common area in the secure unit. The recess contained a metal electrical box with two outlets and two thick cables: one blue and the other black. Two thin metal mounting plates were attached to the front of the recess, and the open space between them was three inches wide, allowing room for an adult human hand to get through. Observation on 12/13/23 at 02:50 PM revealed Resident #66 was walking around and attempting to manipulate various fixtures in the common area of the secure unit such as doorknobs and hinges. During an interview on 12/13/23 at 02:55 PM, LVN B stated she had not noticed the exposed electrical outlet on the wall in the secure unit dining area. She stated Resident #66 was constantly fiddling with things around the secure unit, mostly trying to get out. LVN B stated they had just replaced a socket plate on an electrical outlet behind the nurse's station that Resident #66 had torn off. During an interview on 12/13/23 at 03:12 PM, MAINT stated he was not aware of the electrical socket being exposed in the mounting recess in the secure unit. When he observed the outlet, he stated the outlet had power running to it currently and thus did pose a risk of electrical shock to anyone who reached in to touch it. He stated the situation was not safe, and he would rectify it immediately. 455960 Page 9 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 12/13/23 at 03:40 PM revealed a socket plate had been installed over the electrical outlet cover and a plastic sheet placed over the opening to the mounting recess. During an interview on 12/14/23 at 02:13 PM, the DON stated she had been told about the exposed outlet in the mounting recess, and it was her understanding that MAINT had covered it up. The DON stated she went into the secure unit every day but had not noticed it. The DON stated a potential impact of the exposed socket was residents could put their hands in there. During an interview on 12/14/23 at 03:01 PM, the ADM stated they monitored for accident hazards in the secure unit by doing walkthroughs, but they obviously had not done a good job of monitoring if there was an exposed electrical outlet right there in the unit. The ADM stated the managers did rounding, and they had an electronic maintenance request system for people to enter work requests. The ADMstated he could not personally see everything that went on, but someone should have seen that exposed socket during rounds. The ADM stated a potential negative impact of the exposed socket was residents could be electrocuted. Review of facility policy dated 05/07 and titled Accident Intervention reflected the following: It is the policy of this facility that the resident environment remains as free of accident hazards as possible and then each resident receives adequate supervision and assistance devices to prevent accidents. Purpose: the purpose is to ensure that the facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident to prevent avoidable accidents. This includes systems and processes designed to: identify hazards and risks; evaluate and analyze hazards and risks; implement interventions to reduce hazards and risks; and monitor for effectiveness and modify approaches as indicated. 455960 Page 10 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 8 residents (Resident #5) reviewed for UTI and incontinent care. The facility failed to ensure that CNA A made a report to the charge nurse, according to the resident's care plan, when Resident #5 exhibited foul smelling urine. This failure placed residents at risk of discomfort, infection, and sepsis. Findings included: Review of the undated face sheet for Resident #5 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of anxiety disorder, adjustment disorder with mixed disturbance of emotions and conduct (A short term condition arising due to difficulty in managing the stressful life changes), dementia, pain, chronic kidney disease, polyneuropathy (is damage or disease affecting nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain). Review of the admission MDS assessment for Resident #5 dated 11/03/23 reflected a BIMS score of 00, indicating severe cognitive impairment. Review of the section titled Functional Abilities and Goals reflected she was always incontinent of bladder and bowel. Review of the care plan for Resident #5 dated 11/19/23 reflected the following: ( Resident #5) Has bowel/bladder incontinence r/t impaired mobility, Dementia. Risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. Will remain free from skin breakdown due to incontinence and brief use through the review date. ACTIVITIES: notify nursing if incontinent during activities. BRIEF USE: uses disposable briefs. Change prn. INCONTINENT: Check as required for incontinence. Wash, rinse and dry perineum (area between anus and genitalia). Change clothing PRN after incontinence episodes. Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 12/12/23 at 01:25 PM revealed Resident #5's door was closed. There was no audible response to knocking, so the door was opened, and CNA G called, patient care. Upon opening the door, an extremely pungent foul urine odor was apparent within. During observation and an interview on 12/12/23 at 01:45 PM, revealed Resident #5 was dressed and sitting up in her bed, but the strong foul urine odor was still present in her room. CNA G stated the odor was Resident #5's urine, and it smelled like that because she had a UTI. CNA G stated Resident #5 came over from a sister facility with several other residents during an evacuation, and they had been trying to get rid of a UTI with antibiotics, but it was not working. During an interview on 12/14/23 at 10:37 AM, CNA G stated she always changed her residents' briefs every two hours, and the strong foul urine odor of Resident #5's urine was just the way her urine 455960 Page 11 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0690 Level of Harm - Minimal harm or potential for actual harm smelled. CNA G stated she had been wrong about Resident #5 having a UTI, and it had been two other residents on the hall who came after their evacuation with UTIs. CNA G stated she had no idea why Resident #5's urine would smell that strongly. CNA G stated LVN C was aware of Resident #5's foul smelling urine on 12/10/23. When asked if LVN C knew about the urine because CNA G told LVN C, CNA G stated again LVN C knew about the foul-smelling urine on 12/10/23 and was going to get an order . Residents Affected - Few During an interview on 12/14/23 at 10:50 AM, LVN C stated she had just notified Resident #5's physician that the resident had foul smelling urine and requested an order for a UA. LVN C stated CNA G had told her five minutes prior when CNA G came from being interviewed. LVN C stated the CNAs were supposed to report abnormal smells, new skin tears, and anything else out of the ordinary. LVN C stated the potential negative impact of not having a UTI diagnosed as quickly as possible was a resident could get more agitated, more dehydrated, confused. LVN C stated she monitored to ensure CNAs were reporting new information to her by telling them to make sure residents had fluids and the proper perineal care. During an interview on 12/14/23 at 12:43 PM, the ADON stated she conducted infection control in-services all the time, and they talked about UTI prevention. She stated she talked to the CNAs about reporting. The ADON stated they had a huddle with the entire floor staff every day at 02:00 PM and went over the prevention methods with all staff not just CNAs. The ADON stated the potential outcome of having an undiagnosed, untreated infection could be sepsis (infection of the blood stream), pain, and discomfort. The ADON stated she monitored the floor staff by checking on them to make sure there was not anything they needed to tell her. The ADON stated she spoke every day to every nurse and went through the 24-hour book. She stated she also talked to the CNAs and the med aides to ensure they were sharing all the information they needed to. During the interview on 12/14/23 at 02:13 PM, the DON stated she monitored that CNAs were reporting symptoms to charge nurses mainly by delegating to her ADONs and nurse managers. She stated she looked at assessments being done and the whole process, but it was the nurse managers who attended to specific issues. The DON stated she mainly heard about changes in condition from the charge nurses. The DON stated the CNAs came to her if they thought there is something major and they did not feel it was being addressed. The DON stated they had immediately ordered a UA when they found out earlier today that Resident #5 had foul smelling urine. The DON stated her expectation was the CNA would notify the nurse when she detected the smell of Resident #5's urine, and the nurse would assess the patient and notify the doctor if it was appropriate. The DON stated the potential negative impact to the resident depended on the situation. She stated just foul-smelling urine alone without other symptoms did not mean anything. She stated they would need to check and make sure the resident is getting adequate hydration. The DON stated the urine odor could have been a symptom of dehydration or possible infection. During an interview on 12/14/23 at 03:01 PM, the ADM he did not know how CNAs knew to report changes. The ADM stated if the CNA reported to the nurse, the nurse could report to the physician, and the issue would be addressed, but he was not involved in that process. The ADM stated the potential impact to the resident was a UTI. The ADM stated everyone was affected a little differently by infections, and often they knew a resident had a UTI by the symptoms, so it was important to track symptoms. Review of facility policy dated 03/17 and titled Incontinent Care reflected the following: It is the policy of this facility to provide incontinence care for those residents requiring assistance with bladder and/or bowel incontinence. Staff providing incontinence care will do so while maintaining 455960 Page 12 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0690 the dignity of the resident and providing care in a respectful manner. Level of Harm - Minimal harm or potential for actual harm The ADM stated on 12/14/23 at 11:00 AM that the facility had no specific policy on prevention of UTIs. Residents Affected - Few 455960 Page 13 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0692 Provide enough food/fluids to maintain a resident's health. 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 residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 8 residents (Resident #43) reviewed for nutritional status. Residents Affected - Few The facility failed to ensure dietary orders for supplements and weekly weights were implemented promptly after the dietitian ordered them for Resident #43. The failure placed residents at risk of additional weight loss. Findings included: Review of the undated face sheet for Resident #43 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia, dysphagia (trouble swallowing), cognitive communication deficit (communication problems caused by cognitive impairment), gastroesophageal reflux disease (chronic acid indigestion), anemia, Crohn's disease (chronic disease that causes inflammation and irritation in your digestive tract). Review of the admission MDS assessment for Resident #43 dated 11/03/23 reflected a BIMS assessment should not be conducted due to cognitive impairment . The MDS did not reflect weight loss. Review of the care plan for Resident #43 dated 11/15/23 reflected the following: Has nutritional problem or potential nutritional problem r/t Anemia; swallowing issues, mechanically altered diet, dementia and communication issues. Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date. REGULAR diet, PUREE texture, THIN LIQUIDS consistency-no bread, no regular sugar packets on meal trays Adm(inister) probiotic as ordered If eats less than 50%, offer meal replacement Meals in dining room if resident is in agreement. Monitor and report to MD as needed for any s/s of: decreased appetite, N/V, unexpected weight loss, c/o stomach pain, etc. SNACKS BID BETWEEN MEALS two times a day. Review of weights for Resident #43 from 10/27/23 to 12/14/23 reflected the following weights, indicating an 11% weight loss since admission: 10/27/23 145.0 Lbs 11/03/23 138.4 Lbs 12/05/23 128.8 Lbs Review of the progress notes for Resident #43 reflected the following note documented on 12/8/2023 by the Registered Dietitian: Weight: 12/5/23: 128.8#, weight loss, trending X 2mos. Ht: 62, IBW: 118#, BMI 23.6. wnl. 109% IBW. 78y/o Male. At risk for dehydration and skin breakdown. Dx: Dementia. PMHx reviewed, no new dx. Regular, Puree, Thin Liquids, No bread. No regular sugar packets TID meals. Meds: lisinopril, lactobacillus, Flomax, metoprolol, omeprazole, other meds noted. No new labs to review at this time. No new skin Tx at this time. Snacks between meals, BID. Est needs: 128.8#, 58.5kg, 1750kcals (30kcals/kg/wt.) 69gms protein (1.2gms/kg/wt.) 1750mL (30mL/kg/wt.) PES: Swallowing difficulty related to dysphagia as evidenced by altered diet texture. Goals: no significant weight 455960 Page 14 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0692 Level of Harm - Minimal harm or potential for actual harm changes of >/=5% of 128.8# X 1mo. Recs: Add: house shakes TID meals. Add: Fortified Meal Plan. Weekly weights X 4wks. Encourage fluids as ordered. Review of the physician's orders for Resident #43 from admission on [DATE] to 12/14/23reflected no order for health shakes with meals, fortified meal plan, or weekly weights. Residents Affected - Few Observation on 12/12/23 at 12:20 PM revealed Resident #43 did not eat more than one bite of his lunch meal before ambulating away from the dining area in his wheelchair. His meal contained purees of chicken with gravy, mashed potatoes with gravy, bread, and cooked carrots, and did not include additional supplements or fortifications. LVN A said to another staff member, He just picks at it and leaves! and threw her arms into the air . Observation on 12/14/23 at 12:12 PM revealed Resident #43 eating independently from a puréed meal of chicken Alfredo, bread, and zucchini. He ate everything except the zucchini. The tray contained no health shake or other supplement or fortification . Review of Resident #43's meal ticket for lunch 12/14/23 reflected the ticket did not include health shakes, supplements, or fortifications. During an interview on 12/14/23 at 12:14 PM, LVN A stated she did not know if Resident #43 had supplements in his orders. She looked at his order list and confirmed there was no order for health shakes during meals, a fortified meal plan, or weekly weights. LVN A stated the DON and ADON were responsible for entering dietary orders. During an interview on 12/14/23 01:06 PM, the ADON stated she was responsible for entering dietary orders, and her process was that she checked her email when she returned at the beginning of each work week and checked her email for correspondence from the dietitian. The ADON stated any new orders that included medication were sent to the physician, but if the orders were for basic supplements, she could start them herself. The ADON stated the dietitian probably did email her about the updated orders for Resident #43, but the ADON did not work Monday 12/11/23, and Tuesday 12/12/23 the State Agency entered the building on survey, so she had not implemented any of the recommendations from Friday 12/08/23, because she had been too busy with the recertification survey. The ADON stated a potential outcome of a delay starting new dietary orders could be more weight loss. During an interview on 12/14/23 at 02:13 PM, the DON stated the ADON entered dietary orders. She stated the State Agency beginning the recertification survey was not an adequate reason to delay starting new orders for dietary supplements. The DON stated she was not aware of Resident #43's severe weight loss but was aware he was not eating well. She stated she monitored for compliance with nutrition regulations by talking about any identified weight loss in their weekly risk management meeting and a monthly meeting with the dietitian. The DON stated a potential negative impact of the failure was the resident could continue to lose weight. During an interview on 12/14/23 at 03:01 PM, the ADM stated the delay in implementing dietary orders was not what he would expect to happen, but the ADON did not work on Mondays, and as soon as she returned, the State Agency entered the building on the recertification survey. The ADM stated they had a weekly meeting where they talked about weights. The ADM stated a potential impact of a delay in receiving supplements was further weight loss and skin conditions . 455960 Page 15 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure mechanical, electrical, and patient care equipment was in safe operating condition for 1 of 1 dish room. Residents Affected - Many The facility failed to ensure the kitchen dishwasher did not leak and the garbage disposal attached to the dishwasher worked. This failure placed residents at risk of food borne illness and staff at risk of slipping. Findings included: Observation on 12/13/23 at 09:21 AM revealed standing water on the floor outside dishwasher. The water was confined to the dish room and was ¼ inch deep. DA H was working on washing dishes and cautiously maneuvering around the standing water. During an interview on 12/13/23 at 09:21 AM, DA H stated she was trying not to get her shoes wet . She stated she had gotten some rain boots when she started to work at the facility, but they had been too slippery. She stated the drain was clogged and so the water was leaking out of the bottom of the drain. She stated it had been like that since she started working which was 11/17/23. DA H stated MAINT had been back to the kitchen and looked at it, but nothing had been done yet. During an interview on 12/12/23 at 09:32 AM, the DM stated she had notified MAINT of the leaking pipe on Friday 12/01/23 and then reminded MAINT again on Friday 12/08/23 and Monday 12/11/23. The DM stated sometimes it took a long time to get a response from MAINT with issues. The DM stated the problem with the dishwasher was the attached garbage disposal did not work, and there was a backup in the pipe, so when the dishwasher was running, the base of the pipe leaked. The DM stated the water stayed in the dish room, because the floor was sloped toward a drain in the middle of the room. The DM stated they had a squeegee and staff knew to squeegee the water into the drain when it got in the way. During an interview on 12/13/23 at 01:33 PM, the DM stated the garbage disposal did not work on the sink attached to the dishwasher. She stated she had entered a work order several weeks prior, but she was not sure what date, and she had not heard back from MANT about it. She stated MAINT had been in the kitchen to look at the machine and had seen the standing water next to the dishwasher. The DM stated the upkeep and monitoring of equipment in the kitchen was the responsibility of MAINT. The DM stated a potential risk of the dishwasher leaking was that someone could slip. The DM stated they scrubbed the floor after each meal to ensure the water leaking onto the floor was cleaned up. During an interview on 12/13/23 at 02:12 PM, MAINT stated he had worked at the facility for four years. The MAINT stated Friday afternoon 12/08/23 the DM contacted him and told him they had been doing dishes and noticed water was leaking heavily from the dishwasher. MAINT stated kitchen staff were able to squeegee the water, so it never reached the dining room or clean side of the kitchen. MAINT stated he had a plumber coming the next day, on 12/14/23. MAINT stated they called the plumber on Friday afternoon 12/08/23. MAINT stated the garbage disposal had not been fixed, because it needed to be replaced. He stated his procedure was that a maintenance request was closed when it either got fixed or became a project. He stated the garbage disposal had become a project. MAINT stated there had not been any incidents because of the dishwasher leak. MAINT stated a potential impact of the dishwasher malfunction was sanitation in the kitchen could have been compromised. 455960 Page 16 of 17 455960 12/14/2023 Hays Nursing and Rehabilitation Center 1900 Medical Pkwy San Marcos, TX 78666

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 12/14/23 at 03:01 PM, the ADM stated he monitored that equipment was in safe operating condition by relying on the department heads for the equipment. The ADM stated he did not wash dishes, so he did not know much about the dishwasher, and there were lots of problems he never found out about. The ADM stated he was not familiar with the actual problem, so he could not remark on the possible impact, but he thought standing water could grow bacteria and be a sanitation issue. He stated the facility had no specific policy for safe operating equipment. 455960 Page 17 of 17