Health inspection·November 21, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 4 residents (Resident #5), reviewed for resident assessment. Residents Affected - Few Resident #5's PASRR level 1 screening form did not indicate mental illness and the resident did not have a PASRR level II evaluation. This could place residents at risk of not receiving necessary specialized services to meet their individual needs. The findings were: Record review of Resident #5's face sheet dated 11/20/24 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included major depressive disorder recurrent severe with psychotic symptoms (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life with hallucinations, delusions, disorganized thoughts, speech, and actions), psychotic disorder with delusions due to known physiological condition (severe mental disorders that cause abnormal thinking and perceptions), and unspecified dementia severe with other behavioral disturbance (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #5's EHR on 11/20/24 diagnoses list revealed the primary diagnosis for the resident was listed as unspecified dementia severe with other behavioral disturbance, but this was not entered until 6/25/24. Further review revealed psychotic disorder with delusions was entered on the day of admission to the facility on 3/19/24 indicating the resident had a mental illness not dementia upon admission to the facility. Record review of Resident #5's admission MDS assessment dated [DATE] section A1500 indicated the resident was not considered by the state level II PASRR process to have serious mental illness and section A1510 serious mental illness was not checked. The resident usually understands and was usually understood. The resident had a BIMS score of 3 out of 15 indicating the resident was severely cognitively impaired. The resident had delusions with physical and verbal aggression towards others 4-6 days but less than daily. The resident was frequently incontinent of urine and always incontinent of bowel and the resident had a psychotic disorder and unspecified dementia and received antipsychotic medications on a routine basis. Page 1 of 7 675071 675071 11/21/2024 Yorktown Nursing and Rehabilitation Center 670 W Fourth St Yorktown, TX 78164

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #5's undated care plan revealed a focus initiated on 3/19/24 for the resident receiving psychotropic medications and a focus initiated on 3/19/24 for behaviors which include cursing, hitting during care, yelling during care, refusing care, and exit seeking. Record review of Resident #5's EHR revealed a PASRR level 1 screening dated 3/19/24 which indicated the resident had a primary diagnosis of dementia and mental illness was marked 0 indicating no mental illness. Record review of Resident #5's EHR revealed no PASRR level 2 evaluation was completed, and no documents signed by the physician that dementia was the primary diagnosis. In an interview on 11/21/24 at 1:16 p.m. the DOCC stated resident #5 did not have a level II PASRR evaluation or form 1012 signed by the physician indicating dementia as the primary diagnosis. The DOCC stated they were going to contact the physician regarding the PASRR screening form and the resident's diagnoses. The DOCC stated it was important for residents with mental illness to have a level II PASRR evaluation, so the residents receive needed or specialized services to meet their needs . Review of the facility PASRR policy with an effective date of [DATE] revealed (Company name) follows the Long-Term-Care user guide for Preadmission Screening and Resident Review published by the Texas Medicaid and Healthcare Partnership (TMHP ). 675071 Page 2 of 7 675071 11/21/2024 Yorktown Nursing and Rehabilitation Center 670 W Fourth St Yorktown, TX 78164

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #23) reviewed for quality of care. Resident #23's tube feeding was not labeled with the required information. This failure could place residents at risk of decreased continuity of care, errors in tube feeding, and nutritional deficits. The findings were: Record review of Resident #23's face sheet dated 11/21/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included anoxic brain damage (damaged caused by a complete lack of oxygen to the brain), dysphagia following cerebral infarction (difficulty swallowing following a stroke that disrupted blood flow to the brain due to problems with the blood vessels that supply it), and aphasia (aphasia is a language disorder that affects your ability to speak and understand what others say). Record review of Resident #23's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 99 which indicated the resident was unable to complete the BIMS assessment and she was moderately cognitively impaired. The resident had a feeding tube, no significant weight loss or gain, and received all her nutrition and hydration through her feeding tube. Record review of Resident #23's undated care plan revealed a focus revised on 10/22/24 for tube feedings with interventions that included Resident #23 is NPO (Nothing by Mouth). Enteral formula and feedings as ordered. Osmolite 1.5 (Formula) at 55 ml/hr (milliliters per hour) to provide 1800 KCALS (kilocalories) 76 grams protein, 800ml of water per 22 hours. Flush feeding tube with 200ml H2O Q 4 hours (water every 4 hours). Record review of Resident #23's physician orders revealed an order with a start date of 11/19/24 for osmolite 1.5 at 55ml/hr to provide 1800 KCALS, 76gms of protein, 800ml of water per 24 Hours. Via G-tube. In an observation on 11/18/24 at 12:10pm Resident #23 was in bed, head of bed was elevated, the resident was non-verbal but made eye contact and would nod her head slightly when asked a question and was smiling. The tube feeding bag was clear and had approximately 500ml of an unidentified formula in it. A label affixed to the tube feeding bag had Resident#23's last name, no room#, dated 11/16/24 at 8:00 p.m. and the number 55 all written in black marker. No formula name was listed. The label also had areas to record any additions to the bag with amount, time, and initials slots that were all blank. The tube feeding was running via enteral feeding pump at 55ml/hr with a flush of 200ml water every 4 hours. The pump indicated the resident had already received 4307mls of the formula feeding and 5053mls of water flush. In an observation and interview on 11/18/24 at 12:14 p.m. LVN A was examining the tube feeding bag and stated that the night nurse told her in report that she had hung it last night despite being 675071 Page 3 of 7 675071 11/21/2024 Yorktown Nursing and Rehabilitation Center 670 W Fourth St Yorktown, TX 78164

F 0693 Level of Harm - Minimal harm or potential for actual harm dated 11/16/24 and the date was just written in error and should have been 11/17/24. LVN A further stated she trusted the night nurse and the formula was osmolite as ordered but admitted she had no proof but trusted the night nurse. When asked why it was important the label be filled out correctly, LVN A stated because when state walks in and then stated so that other nursing staff were aware of the feeding and when it was hung. Residents Affected - Few In an interview on 11/21/24 at 11:15 a.m. the DON stated the tube feeding label should have the name of the formula used, rate, date, and time hung. The DON further stated the resident's orders state to hang new tubing every 2 days or 48 hours . The facility policy and procedure for hanging and labeling a tube feeding was requested in an email sent to the Administrator on 11/21/24 at 10:32 a.m. Review of the facility provided enteral nutrition policy revised August 1, 2012, was from the food service manual regarding assessment, orders, and documentation. This policy did not cover nursing procedures for hanging a tube feeding and or labeling the tube feeding bag. 8/2023 revealed . These processes include ensuring timely turnover of enteral formula inventory well within the product expiration dates and appropriate labeling . Formula labels should include the following: person's name and room number, formula name and strength, date and time formula prepared and hung . 675071 Page 4 of 7 675071 11/21/2024 Yorktown Nursing and Rehabilitation Center 670 W Fourth St Yorktown, TX 78164

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #18) reviewed for pharmacy services. Resident #18's Tramadol (narcotic) medication was left unsupervised in the top drawer of the medication cart in a paper pill cup after it was popped out of the medication card. This could put residents at risk of pain, medication errors, and drug diversion. The findings were: Record review of Resident #18's face sheet dated 11/21/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included unspecified dementia unspecified severity with agitation (general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life and include agitation), muscle wasting and atrophy not elsewhere classified multiple sites (wasting or loss of muscle tissue), and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness or paralysis of right side of the body following a stroke due to damage to tissues in the brain due to a loss of oxygen to the area). Record review of Resident #18's annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 3 out of 15 indicating the resident was severely cognitively impaired. The resident had unclear speech and was sometimes understood and usually understands. The resident was continent of urine and usually continent of bowel. The resident had frequent pain up to a 5 on a scale of 1-10 with 10 being worst pain and received routine and PRN pain medication. Record review of Resident #18's undated care plan revealed a focus for pain revised on 2/19/24 and interventions included to administer pain medication as ordered. Record review of Resident #18's physician orders revealed an order dated 11/14/24 for tramadol 100 mg (milligram) 1 tablet by mouth every 6 hours for pain. (Give at 12 a.m., 6:00 a.m., 12 noon, and 6:00 p.m.) Record review of Resident #18's EMAR for November 2024 revealed the resident had pain levels from 0 up to 2 with most days being none. In an observation and interview during station 2 medication cart check on 11/19/24 at 5:05 p.m. witnessed by LVN A in the top drawer of the medication cart, a paper medication cup with an oblong white pill in it, and the bottom of the paper cup written in pen was Resident #18's last name. LVN A stated it was a tramadol 100mg tab for Resident #18's 5pm dose and she had pre-popped it and signed out for it. LVN A further stated she never does that, and she was unsure why she did it this time. LVN A stated she was not supposed to pre-pop the medication and leave it in the cart and apologized. When asked why it was important not to pre-pop the medications from the cards, LVN A stated because you can accidently give it to the wrong resident or wrong time. The narcotic count sheet for tramadol 675071 Page 5 of 7 675071 11/21/2024 Yorktown Nursing and Rehabilitation Center 670 W Fourth St Yorktown, TX 78164

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated LVN A signed out the tramadol at 5pm, the narcotic count was correct. LVN A wasted the tramadol with another nurse and documented it as wasted and signed by both nurses on the narcotic count sheet. In an interview on 11/21/24 at 11:05 a.m. the DON stated medications should be popped out of the card at the time they were given and not to be stored for later. The DON stated it was important not to pre-pop medications and store for later because it could get lost, the medication might be taken by someone else, or the nurse could forget to give it. The facility policy on medication administration was requested in an email sent to the Administrator on 11/21/24 at 10:32 a.m. A medication competency check off was provided . Review of the facility provided medication administration competency audit for oral meds undated revealed steps in administration of medications included . 3. punching med into cup using proper infection control technique . 10. Observe resident swallow medications 11. Documents after administration of meds . 675071 Page 6 of 7 675071 11/21/2024 Yorktown Nursing and Rehabilitation Center 670 W Fourth St Yorktown, TX 78164

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen. Residents Affected - Some The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 11/20/2024 at 11:20 a.m. revealed the DM assisting with the meal tray preparation. The DM had washed her hands and put on gloves for cutting the bread, after cutting the bread she assisted with taking plates from the cook and placed them on trays. The cook asked for diet tickets on the other side of the DM in which the DM reached and grabbed tickets handed them to the cook, and continued to assist with putting plates on trays and placing bread on plates using tongs. The DM then proceeded to reach in a bread bag, grabbed a large stack of bread, placed her gloved hand on the bread, cut the bread in half and continued to place bread on trays. The DM did all this without changing gloves and washing hands. During an interview on 11/20/2024 at 11:28 a.m. the DM stated she should have cut all the bread first before helping with the plates. The DM further stated by not changing her gloves and washing her hands it could cause cross contamination. During an interview on 11/21/2024 at 1:05 p.m. the ADM stated the DM should have changed her gloves once she finished what she was doing with the use of the gloves. The ADM further stated she should have removed the gloves and before touching the bread again she should have washed her hands and put new gloves on. The ADM stated once the DM had touched the meal tickets, she should have taken her gloves off. The ADM stated the importance of removing the gloves and washing her hands was to prevent cross contamination. The ADM further stated by touching the tickets the DM risked the contamination of the food and it could be passed on to the residents. Review of the facility's policy Meal Distribution, revised 2/2023, read Policy Statements: Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner., Procedures: 6. Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of service-dining. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-301.14, When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTNESILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;. 675071 Page 7 of 7