Health inspection·March 6, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 4 (Resident #5, Resident #9, Resident #18, and Resident #24) of 4 residents reviewed for care plans. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified for Resident #5, Resident #9, Resident #18, and Resident #24. This failure could place residents at risk for not receiving care and services individualized to meet their specific physical, mental, and/or emotional needs. Findings included: Review of Resident #5's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of stroke, left side paralysis, anxiety, depression, loss of muscle mass, and difficulty walking. Review of Resident #5's MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score, Resident #5 scored 15 out of 15 indicating intact cognition. Review of Resident #5's Comprehensive Care Plan revised 01/11/24 revealed the following focus care areas with objectives that were not measurable: Focus: Fragile Skin: [resident] has fragile skin related to the aging process and is at risk for bruising easily and skin tears with an objective of [Resident's] risk for the development of skin tears and bruising will be minimized ., Focus: Cognitive Impairment: [resident] has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: recent CVA with an objective of [Resident] will have needs met in a timely manner. , Focus: [Resident] has impaired visual function and is at risk for falls, injury, and a decline in functional ability d/t my glaucoma (a group of diseases that damage the nerve in the back of the eye), with an objective of [Resident] will maintain optimal quality of life . , Focus: [Resident] is at risk for the following items and/or diagnosis: Falls with an objective of Staff will be aware of the risks factors and/or diagnosis in POC (Plan of Care)/[NAME] (information quick reference used in nursing), Focus: [Resident] has a communication problem related to Hearing deficit with an objective of [Resident} will have needs met in a timely manner ., Focus: I, [resident], have renal (kidney) failure r/t Kidney disease with an objective of I, [resident], will be able to resume normal daily activities of daily living . , Focus: [Resident] has oral/dental health problems Page 1 of 6 675038 675038 03/06/2024 Clyde Nursing Center 806 Stephens St Clyde, TX 79510

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some broke/carious (decaying) teeth r/t Poor oral hygiene with an objective of [Resident] will tolerate diet . , Focus: [Resident] uses psychotropic medications (antidepressants) related to depression with an objective of [Resident] will maintain the highest level of function possible and not experience a decrease in functional abilities . , Focus: [Resident] is at risk for pain related to: Post CVA - hemiplegia or Hemiparesis Arthritis with an objective of Pain or discomfort will be relieved within a timely manner of receiving pain medications or treatments as ordered by the physician, Focus: I, [resident], have OsteoArthritis (tissue breakdown in the joints) with an objective of I, [resident] will maintain acceptable level of comfort ., Focus: I, [resident], have Hemiplegia (paralysis on one side of the body)/Hemiparesis (complete paralysis of half of the body) d/t my recent Stroke with an objective of I, [resident] will maintain optimal status and quality of life within limitations imposed by Hemiplegia/Hemiparesis ., and Focus: [Resident] has fragile skin related to the aging process and is at risk for bruising easily and skin tears with an objective of [Resident's] risk for the development of skin tears and bruising will be minimized . Review of Resident #9's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of macular degeneration (loss of central vision), anxiety, major depression, post-traumatic stress disorder (disorder that develops after a shocking, scary, or dangerous event), low level of potassium in her blood, low thyroid function, high blood pressure, spondylosis (abnormal wear on the cartilage and bones in the neck and vertebrae), right and left shoulder pain, and heart disease. Review of Resident #9's MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score Resident #9 scored 14 out of 15 indicating intact cognition. Review of Resident #9's Comprehensive Care Plan revised 02/24/2024, revealed the following focus care areas with objectives that were not measurable: Focus: Resident has impaired visual function and is at risk for falls, injury, and a decline in functional ability r/t her macular degeneration with an objective of Resident will maintain optimal quality of life and not experience a decline in ADL functional abilities or an injury related to vision loss. , Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner with an objective of Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs). The resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, . Resident will be able to: , Focus Resident is on a Regular Diet, NAS and at nutritional & hydration risk related to Anxiety, Depression with an objective of Resident will maintain a normal bowel elimination pattern, Focus: The resident has dentures with an objective of The resident will tolerate diet . , Focus: Resident uses psychotropic medications (antidepressants, antipsychotics, and hypnotics) related to depression, generalized anxiety disorder, Pain management, and hallucinations with an objective of The resident will show decreased episodes of signs and symptoms of depression . , Focus: The resident is on Potassium with an objective of I [Resident], will have electrolyte (minerals in the blood that carry an electrical current) balance restored . , and Focus: Resident has fragile skin elated to the aging process and is at risk for bruising easily and skin tears with an objective of The resident's risk for the development of skin tears and bruising will be minimized . Review of Resident #18's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of Alzheimer's disease, dementia, major depression, hearing loss, heart disease, high blood pressure, atrial fibrillation (upper chambers of the heart beat irregularly), diverticulitis (bulging pouches in the digestive tract), and post-traumatic stress disorder. 675038 Page 2 of 6 675038 03/06/2024 Clyde Nursing Center 806 Stephens St Clyde, TX 79510

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #18's MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score Resident #18 scored 14 out of 15 indicating intact cognition. Review of Resident #18's Comprehensive Care Plan revised 02/11/2024, revealed the following focus care areas with objectives that were not measurable: Focus: Resident has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: Alzheimer's and dementia with objectives of Resident will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained ., and Resident will maintain current level of cognitive function without a decline ., Focus: Resident has a communication problem related to Hearing deficit with an objective of Resident will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained ., Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to Cognitive impairment., Impaired balance/impaired coordination, with an objective of Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) . , Focus: Resident has a behaviors problem as evidenced by: getting in others personal space when she [NAME] they are in the way or her way with an objective of The resident's behavior will not interfere with the delivery of care or services, or result in harm to self or others ., Focus: Resident exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner. Cussing, derogatory comments, and bullying with an objective of Resident's verbal behaviors will not interfere with the delivery of ADL cares by staff . , Focus: Resident is on Mechanical Soft Diet and at nutritional & hydration risk related to Depression with an objective of Resident will maintain a normal bowel elimination pattern., Focus: The resident is edentulous (lacking teeth) and uses dentures with an objective of The resident will tolerate diet ., Focus: Resident uses psychotropic medications (antidepressants, anxiolytics) related to depression with an objective of The resident will show decreased episodes of signs and symptoms of depression . , and Focus: resident is able to effectively communicate the presence of pain and will notify staff when they are in pain. Resident is at risk for pain related to: Accident/Fall, Arthritis with an objective of Resident's pain level will be at or below their acceptable level as verbalized by the resident . Acceptable level of pain: , Review of Resident #24's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of epilepsy, bacteria in the urine, itching, history of falls, heart attack, coronary artery disease, high blood pressure, high cholesterol, and heartburn. Review of Resident #24's MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score Resident #24 scored 15 out of 15 indicating intact cognition. Review of Resident #24's Comprehensive Care Plan revised 01/11/24 revealed the following focus care areas with objectives that were not measurable: Focus: [Resident] has impaired cognition and is at risk for a further decline in cognitive abilities with an objective of [Resident] will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained. , Focus [Resident] is at risk for the following items and/or diagnosis: Behaviors, Falls with an objective of Staff will be aware of the risks factors and/or diagnosis in POC/[NAME], Focus: [Resident] has a communication problem related to her comprehension ability with an objective of [Resident] will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained. , and Focus: [Resident exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner with an objective of [Resident's] verbal behaviors will not interfere with the delivery of ADL cares by staff. 675038 Page 3 of 6 675038 03/06/2024 Clyde Nursing Center 806 Stephens St Clyde, TX 79510

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/06/24 at 11:18 AM, RN A stated if an objective could not be measured there would be no way to determine if an objective was achieved. During an interview on 03/06/24 at 11:34 AM, the DON stated the DON or designee were responsible for monitoring care plans. She stated LVN B was responsible for compiling care plans. The DON explained that all staff work together to identify care focus areas. The DON stated changes on care plans were communicated to direct care staff on the [NAME]. She stated acute changes were communicated to staff during daily clinical meetings conducted by the DON, or by posted in-services. The DON stated she or the ADON would come in early to make sure the night staff were informed. She stated objectives on the care plans must be measurable in order to monitor resident's progress or to identify if resident's progress was not occurring. The DON acknowledged the objectives reviewed needed to be reworded. She was unable to state why the objectives were not measurable. She stated the effect of unmeasurable objectives on residents may be if a decline were happening, they would not be able to appropriately address because there was no baseline to compare to. During an interview on 03/06/24 at 12:02 PM, LVN B stated she was responsible for creating care plans. She stated the failure occurred because objectives were computer generated selections and due to time constraints, she did not go through and individualize the objectives. LVN B was not able to state how unmeasurable objectives could affect a resident. LVN B stated restructuring objectives was an option to make the objectives individualized and measurable. Review of the facility policy titled Comprehensive Care Plans dated 02/10/2021 revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 675038 Page 4 of 6 675038 03/06/2024 Clyde Nursing Center 806 Stephens St Clyde, TX 79510

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments for 1 of 2 medication carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure 1 of 2 medication carts were locked when unattended. This failure could place residents at risk of having access to unauthorized medications, wound care and medical supplies leading to possible harm or drug diversions. Findings included: During an observation on 03/04/2024 at 8:55 a.m. an unlocked medication cart was seen on North Hall in between nurses' station and administration offices. There were residents sitting in wheelchair around cart and two residents walking down the North Hall. Inside of treatment cart were one pair of bandage scissors, more than five Nystatin (prescription anti-yeast) powders, and one bottle of Hibicleanse (Antiseptic/Antimicrobial) wash soap. During an interview on 03/04/2024 at 08:55 a.m., the ADON stated that she expected the treatment cart to be locked when unsupervised. She stated that she was unaware of which nurse was responsible for the treatment cart at this time. During an interview on 03/04/2024 at 2:26 p.m., RN A stated that he was not clocked in at the time treatment cart was found unlocked. He stated that after 9:00 a.m., he was responsible for the treatment cart. He stated that he received keys from LVN B after the treatment cart was found unlocked. He stated that the treatment cart should be locked when not supervised. During an interview on 03/04/2024 at 02:27 p.m., LVN B stated she was in the building working as a nurse during the time that treatment cart was found unlocked. She stated that she had not touched the treatment cart during that time. During an interview on 03/04/2024 at 02:29 p.m., the ADMN stated LVN C worked the shift prior to the treatment cart being unlocked. He stated she worked from six o'clock p.m. to six o'clock a.m. The ADMN stated the best way to contact LVN C would be to call her during her work hours and that she would be at work 03/04/2024 at 6 o'clock p.m. During a phone interview on 03/04/2024 at 06:08 p.m., LVN C stated she received treatment cart keys from RN A on 03/03/2024 at six o'clock p.m. LVN C stated she gave treatment cart keys to LVN B when she left at 03/04/2024 at six o'clock a.m. LVN C stated the treatment cart should be locked when unsupervised. LVN B stated treatment cart could have not been locked back when she opened it later in her shift to get out a bandage. She stated it was a busy time and she may have forgotten to lock treatment cart back. She stated it was the nurse's responsibility to lock treatment cart when not supervised. LVN C stated not locking treatment cart could affect residents by allowing resident to have access to items in the treatment cart such as scissors and prescription medications that could cause harm. She stated the ADON and the DON were who were to monitor that treatment carts were locked appropriately by the nurses. 675038 Page 5 of 6 675038 03/06/2024 Clyde Nursing Center 806 Stephens St Clyde, TX 79510

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/05/2024 at 11:23 a.m., the DON stated the nurses were responsible for locking both medication and treatment carts. She stated she and the cooperate nurse attempted to find a facility policy on locking treatment carts, and they could not find one. She stated that they used the CDC and CMS guidelines for ensuring treatments and medications were stored appropriately. The DON stated her expectation would be for the treatment cart to be locked when unsupervised. She stated that unlocked treatment cart could affect residents by them having adverse reaction to substances in the cart that could lead to harm. She stated she was unaware of why the treatment cart was unlocked. The DON stated both her and the ADON were responsible for monitoring staff locked carts appropriately. According to the Centers for Medicare and Medicaid Services website https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-C accessed on 03/06/2024 revealed: Medications and biologicals are accessible only to authorized staff and are locked when not under the direct observation of the authorized staff. 675038 Page 6 of 6