Health inspection·November 10, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #19, #35 and #41) of 17 residents reviewed for advanced directives. Resident #19 had a DNR in her record with no date for the second witness's signature Resident #35 had a DNR in her record with no date, no printed signature, and no license number for the physician signature. Resident #41 had a DNR in her record with no second signature for the physician. The facility's failure to ensure accuracy of resident medical records for advanced directives such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #19 Record review of the face sheet dated [DATE] in the clinical record for Resident #19 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of the bones wears down), major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety (intensive, excessive, and persistent worry and fear about everyday situations), hypertension (a condition in which force of the blood against the artery walls in too high), Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce the blood flow to the limbs), and muscle weakness. Record review of the clinical record for Resident #19 revealed the last MDS completed was an admission on [DATE] with a BIMS of 15 indicating she was cognitively intact, and she had a functional status indicating she required one to two-person assistance with all activities. Record review of Resident #19's care plan dated 10-7-2022 revealed no care plan for her current DNR status Record review revealed a DNR in Resident #19's clinical record dated [DATE] (by the physicians date Page 1 of 7 675013 675013 11/10/2022 Crowell Nursing Center 200 South B Ave Crowell, TX 79227

F 0578 of signature) that had no date for the second witness in the Two Witnesses section. Level of Harm - Minimal harm or potential for actual harm Resident #35 Residents Affected - Few Record review of the face sheet dated [DATE] in the clinical record for Resident #35 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include fracture of the left femur, osteoporosis (a condition in which the bones become weak and brittle), depression (a group of condition associate with the elevation or lowering of a person's mood), insomnia (persistent problem falling and staying asleep), atrial fibrillation (an irregular and often rapid heart rate that commonly causes poor blood flow), diverticulosis (a condition in which small bulging pouches develop in the colon), and dorsalgia (physical discomfort occurring anywhere on the spine of back ranging from mild to disabling). Record review of the clinical record for Resident #35 revealed a Medicare 5-day MDS completed on [DATE] with a BIMS of 15 indicating she was cognitively intact, and she had a functional status that indicated she required one-person assistance with all activities. Record review of Resident #35's care plans dated [DATE] revealed the following care plan: Focus: DNR Intervention: Ensure physician order is review for DNR. Obtain out of hospital DNR. Place OOHDNR on chart with copy of physician order. Date initiated [DATE] Record review revealed a DNR in Resident #35's clinical record completed [DATE] (by Resident #35's date of signature) revealed in the Physicians Statement section there was no date of when the physician signed, no printed signature, and no license number for the physicians' signature. Resident #41 Record review of the face sheet dated [DATE] in the clinical record for Resident #41 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of the rectum (a disease in which malignant cancer cells form in the tissue of the rectum), fluid overload (a condition in which the fluid portion of the blood is too high), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypertension (a condition in which force of the blood against the artery walls in too high), atrial fibrillation (an irregular and often rapid heart rate that commonly causes poor blood flow), and chronic kidney disease (longstanding disease of the kidneys resulting in renal failure). Record review of the clinical record for Resident #41 revealed an admission MDS completed on [DATE] with a BIMS of 15 indicating she was cognitively intact, and she had a functional status that indicated she required two-person assistance with all activities. Record review of Resident #41's care plans dated [DATE] revealed the following care plan: Focus: DNR Intervention: Ensure physician order is review for DNR. Obtain out of hospital DNR. Place OOHDNR on chart with copy of physician order. Date initiated [DATE] 675013 Page 2 of 7 675013 11/10/2022 Crowell Nursing Center 200 South B Ave Crowell, TX 79227

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review revealed a DNR in Resident #41's clinical record completed [DATE] (by the physicians date of signature) revealed in the section All persons who have singed above must singe blow, acknowledging that this document has been properly completed there is no second signature for the physician. During an interview on [DATE] at 02:26 PM when asked if Resident #35 was reported to have coded what would ADON A do. ADON A reported that the current facility DNR process was to check the electronic chart which she did and found that Resident #35 was listed as a DNR on Resident #35's face sheet and in Resident #35's physician orders ADON A then reported that she would check the paper chart to see if it was tagged in red to indicate Resident #35's was a DNR, then staff would check the paper charts DNR section to see if there was further red paperwork indicating Resident #35's was a DNR, then staff would check the printed DNR which ADON A did and found the DNR. ADON A then reported that if Resident #35's had no pulse or respirations they would not perform CPR, they would notify the MD, get an order to pronounce, and notify the family. When asked to review Resident #35's DNR again and verify when the physician signed the DNR ADON A did and reported that the form was missing the physician date of signature and the physicians license number. When asked if the DNR was valid ADON A stated, without the date or license number it really wouldn't be. When asked if the resident coded at this time how would she handle it ADON A reported that with the DNR signed by the resident and the order in the resident's electronic chart signed by the physician she would have to call the family and ask their wishes. ADON A then reported that she would get the DNR corrected immediately. During an interview on [DATE] 09:14 AM the DON reported they had several new admissions and that the business office person, the MDS coordinator, and the charge nurses along with herself all review the DNR's and with all the paperwork that needed to be completed with the new admissions apparently several DNR's were missed for completion. That a review was completed of all DNR's on the evening of [DATE] and all were updated that could be immediately addressed but two were out today to update the physician's signature and those two would be corrected today. When questioned as to the potential complications if the DNR process is not completed and followed the DON reported that the facility would not be following the DNR procedure correctly. During an interview on [DATE] at 09:34 AM when asked about Resident #19, #35, and #41's DNR's missing required information the MDS Coordinator reported the DNR is part of the admission process and that they (the DON, the business office, the floor nurses, and herself) missed several that did not get completed correctly. The MDS Coordinator reported that she was going to color code the DNR's from this point forward as a part of the plan of correction in order to ensure they are completed correctly. Record review of facility provided policy titled Advance Directives/Advance Care Planning, with the date of revision 4/2015, revealed the following: Policy: .This facility will honor a resident wishes and advanced directives pertaining to his/her own medical treatment, including wishes to withhold treatment. v. An Out of Hospital Do Not Resuscitate (OOHDNR) should be discussed with the patient/resident/surrogate/proxy and completed if this is the patient's preference. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE 675013 Page 3 of 7 675013 11/10/2022 Crowell Nursing Center 200 South B Ave Crowell, TX 79227

F 0578 HEALTH SERVICES, undated revealed the following: Level of Harm - Minimal harm or potential for actual harm -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional Residents Affected - Few 675013 Page 4 of 7 675013 11/10/2022 Crowell Nursing Center 200 South B Ave Crowell, TX 79227

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 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 2 residents (Resident #4) observed for incontinent care. Residents Affected - Few -CNA B failed to prevent contamination of Resident #4's wipes before using them on the resident and failed to wash her hands before placing a new brief on Resident #4 during incontinent care. These deficient practices have the potential to affect residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: Resident #4 Record review of Resident #4's face sheet dated 11/9/2022 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include vascular dementia (brain damage caused by multiple strokes), dysphagia (difficulty swallowing foods or liquids), muscle weakness, difficulty walking, history of falls, lack of coordination, hypertension (a condition in which force of the blood against the artery walls in too high), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of the bones wears down), and muscle wasting. Record review of Resident #4's last MDS completed was a quarterly done on 9/12/22 with a BIMS of 11 indicating she was moderately cognitively impaired, and she had a functionality of requiring two-person assistance with most of her activities. Record review of Resident #4's care plan dated 8/30/22 revealed the following care plan: Focus: Incontinence Care-Resident is incontinent of bowel/bladder related to activity intolerance. Intervention: Monitor for and report to MD s/s of UTI. During an observation on 11/09/22 at 11:20 AM incontinent care was performed on Resident #4 by CNA B. At one point, CNA B pull two wipes apart and put one wipe on the incontinent pad that Resident #4 had been laying on before the procedure started. Resident #4 had her feet placed in the same spot that CNA B placed the extra wipe. CNA B used the first wipe to clean Resident #4's vaginal area then picked the second wipe up off the incontinent pad and used it to clean Resident #4's vaginal area. This was the last wipe CNA B used on the frontal area of Resident #4. CNA B then rolled the resident to her left side, retrieved a wipe from the open wipe package on the bedside table and used that wipe to clean Resident #4's rectal area, retrieved a wipe from the open wipe package on the bedside table and used that wipe to clean Resident #4's right buttocks, then retrieved a wipe from the open wipe package on the bedside table and used that wipe to clean Resident #4's left buttocks. CNA B then retrieved the new brief and placed it on the resident without changing her gloves. CNA B cleaned the peri-area, then the rectal area, and placed the new brief without changing her gloves or washing her hands. 675013 Page 5 of 7 675013 11/10/2022 Crowell Nursing Center 200 South B Ave Crowell, TX 79227

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/09/22 at 11:33 AM when questioned concerning using the wipe that CNA B had placed on the incontinent pad that the resident had been on and placed her feet on CNA B reported that she thought the wipe was considered clean and that she did not feel using it was a problem. When asked about placing the new brief on the resident after completing the vaginal and rectal care for the resident without washing her hands or changing her gloves CNA B reported that she forgot that step, that she was aware that it could cause cross contamination, and that a resident could develop and infection as a result. CNA B verified that she received regular training from the DON on infection control and incontinent care. During an interview on 11/10/22 09:19 AM when asked if staff should perform hand hygiene when performing incontinent care, the DON reported that hand hygiene should be performed before incontinent care is started, after it was completed, and between each glove change. When asked if hand hygiene should be performed between the dirty to clean portions of incontinent care, the DON reported that it should because if you do not it will violate infection control and result in the resident getting an infection. When questioned if the wipes used on a resident can be placed in a dirty area prior to use on a resident the DON reported that the wipes cannot be used due to contamination. The DON verified that she trains all her staff and reported that all CNA staff were trained in the previous week on incontinent care and stated, they know how to do this, they must have just gotten nervous. Record review of facility provided policy titled Hand Hygiene date implemented 2/20/2020 revealed the following: Policy: All staff will perform proper hand hygiene procedure to prevent the spread of infection . This applies of all staff working in all locations within the facility. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your tack requires gloves, perform hand hygiene prior to donning gloves, and immediate after removing gloves. Record review of the facility provided Hand Hygiene Table undated revealed the following Condition: -When, during resident care, moving from a contaminated body site to a clean body site -After assisting with personal body function (E.G., elimination . Record review of the facility provided policy titled Incontinent Care reviewed 4/10/17 revealed the following: 11. Cleanse peri-area and buttocks with cleansing agent . 12, Dry peri-area and buttocks . 13. Apply skin protectant . 14. Remove linen/under pad and discard. 675013 Page 6 of 7 675013 11/10/2022 Crowell Nursing Center 200 South B Ave Crowell, TX 79227

F 0880 15 Removes and discard gloves Level of Harm - Minimal harm or potential for actual harm 16 Wash hands 17 Apply clean linen/under pad, brief . Residents Affected - Few 675013 Page 7 of 7