Health inspection·April 14, 2023

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 residents' right to formulate an advance directive for 2 of 8 residents (Resident #5 and #6) reviewed for advanced directives, in that: Resident #5's Out-of-Hospital Do Not Resuscitate (OOHDNR) form did not have the physician's printed name and license number on the spaces indicated on the form. Resident #6's Out-of-Hospital Do Not Resuscitate (OOHDNR) form did not have the resident's signature at the bottom of the form as required. This deficient practice could place residents at-risk for not having their end of life wishes honored and of having CPR performed against their will. The findings were: Record review of Resident #5's admission Record revealed a [AGE] year-old female admitted to facility [DATE] with diagnoses that included acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure [Both systolic and diastolic heart failure affect the left ventricle. In systolic heart failure, the heart muscle is weak, and the ventricle can't contract normally. With diastolic heart failure, the heart muscle is stiff, and the left ventricle can't relax normally], muscle wasting and atrophy, hypothyroidism [a condition in which the thyroid gland doesn't produce enough thyroid hormone] and cognitive communication deficit [difficulty with thinking and how someone uses language]. Record review of Resident #5's active physician orders as of [DATE] documented an order for DNR. Record review of Resident #5's annual MDS assessment dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Record review of Resident #5's care plan with a revision date of [DATE] documented resident has physician's orders that include an order for DNR. Record review of Resident #5's DNR form on the electronic chart showed that only Resident #5's signature and one witness could be deciphered on the bottom of the form and a white shadow at the bottom of the form obscured any other signatures. The physician's signature and the second witness's signature required at the bottom of the form were missing. The physician's printed signature and license number were also missing. Page 1 of 10 675134 675134 04/14/2023 Whispering Oaks Rehab & Nursing 105 Hospital Dr Cuero, TX 77954

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #6's admission Record revealed an [AGE] year-old male admitted to facility [DATE] with diagnoses that included Alzheimer's Disease [brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks], unspecified sequalae of unspecified cerebrovascular disease [cerebrovascular disease is a term for conditions that affect blood flow to your brain - sequelae of cerebrovascular disease specifies the type of stroke that cause the sequelae (late effect) as well as the residual condition itself], and other obstructive and reflux uropathy [Obstructive uropathy occurs when urine cannot drain through the urinary tract]. Record review of Resident #6's active physician orders as of [DATE] documented an order for DNR. Record review of Resident #6's annual MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Record review of Resident #6's care plan with a revision date of [DATE] documented resident has physician's orders that include an order for DNR. Record review of Resident #6's OOHDNR forms revealed the form was signed by the resident at the top of the form but lacked the second signature at the bottom of the form as required. The physician's name was also not printed on the form. During an interview on [DATE] at 3:50 pm with the ADON, she discussed the process for getting the DNR. The ADON stated the BOM gets the DNR signed while completing the admission Packet with the Responsible Party and/or resident. The BOM then gives the form to the ADON to get the physician to sign it when he comes to the facility or else the Medical Records person takes it to the doctor's office. After it is signed, the ADON looks at it again and Medical Records scans it into the EHR chart. The ADON stated it was her responsibility to ensure the form is witnessed, either the resident or the responsible party has signed and then the physician has signed it. The ADON stated that everyone needs to sign the form twice and if it is not signed properly then it wouldn't be valid. On [DATE] at 04:16 PM, during an interview and record review with the ADON, Resident #5's original DNR on the hard chart was reviewed. The ADON pointed out that the DNR on the chart included the physician's signature at the bottom along with the second witness but the scan obscured the signatures. The physician's license number was not on the form and the physician's name was not printed. The ADON stated the form needed be corrected before it was valid. Record review of the Advance Directives/Advance Care Planning facility policy with a revision date of 12/2019 documented This facility will honor a resident's wishes and advanced directives pertaining to his/her own medical treatment, including wishes to withhold treatment.In the absence of the Social Worker the Administrator appoints a staff member to assume the responsibility for advance directives and advanced care planning. Review of the Health and Safety code Title 2, Subtitle H, chapter 166 document the sections required to be in a valid DNR form. Section 166.082 includes: (6) places for the printed names and signatures of the witnesses or the notary public 's acknowledgment and for the printed name and signature of the attending physician of the person and the medical license number of the attending physician; 675134 Page 2 of 10 675134 04/14/2023 Whispering Oaks Rehab & Nursing 105 Hospital Dr Cuero, TX 77954

F 0578 (13) a statement at the bottom of the document, with places for the signature of each person executing the document, that the document has been properly completed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675134 Page 3 of 10 675134 04/14/2023 Whispering Oaks Rehab & Nursing 105 Hospital Dr Cuero, TX 77954

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to accurately reflect the resident's status for two residents (#4 and #9) of eight residents reviewed for accurate MDS assessments in that: Residents Affected - Few 1.Resident #4's quarterly MDS assessment with an ARD of 02/13/2023 reflected she was always incontinent of bowel and bladder when she was frequently incontinent. 2.Resident #9's quarterly MDS assessment with an ARD of 01/27/2023 reflected she had a pressure sore and did not reflect what stage. This deficient practice could affect residents who receive care based on assessment and could result in missed or inaccurate treatment provided. The findings were: 1. Review of Resident #4's electronic face sheet dated 04/12/2023 revealed she was admitted to the facility on [DATE] with diagnoses of cerebral infarction (a brain lesion in which the cluster of brain cells die because they do not get enough blood), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). Review of Resident #4's quarterly MDS assessment with an ARD of 02/13/2023 revealed Resident #4 was assessed a 3 for which indicated always incontinent of bowel and bladder. Further review revealed she scored a 14/15 on her BIMS which indicated she was cognitively intact. Staff could understand her and she usually was able to understand. Review of Resident #4's comprehensive person-centered care plan revised date of 12/22/2021 revealed Focus .is frequently incontinent of bladder r/t decreased mobility, obesity and refuses to go to the bathroom on her own. Review of the facility seven day look back of CNA task notes dated 02/07/2023 for ARD 02/13/2023 revealed she was continent of bladder for three days. Review of the facility seven day look back of CNA task notes dated 02/07/2023 for ARD 02/13/2023 revealed she was continent of bowel for three days. Interview on 04/13/2023 at 3:00 p.m. with Resident #4 revealed she sometimes went to the restroom with help and sometimes she did not. She stated there were days when she used the bathroom and did not urinate or defecate in her brief. Interview on 04/13/2023 at 4:08 p.m. with the MDS nurse revealed based on the seven-day lookback for Resident #4 that she was frequently incontinent of bowel and bladder instead of always. She stated she did not know how she missed not getting it right. She stated she reviewed the C NA tasks sheets for Resident #4 which showed if the resident was incontinent during the 7-day lookback. She stated that an inaccurate MDS assessment could result in staff not providing proper care for the resident. Interview on 04/13/2023 at 4:30 p.m. with the DON revealed that the MDS for Resident #4 needed to 675134 Page 4 of 10 675134 04/14/2023 Whispering Oaks Rehab & Nursing 105 Hospital Dr Cuero, TX 77954

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be accurate to communicate the care to staff that Resident #4 required. She stated Resident #4 did have times she could be continent with assistance and that was important for her to maintain proper bodily functions if she could. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 under Section H: Bladder and Bowel revealed Code 3, always incontinent: if during the 7-day look-back period, the resident had no continent voids. 2. Review of Resident #9's electronic face sheet dated 04/13/2023 revealed she was admitted to the facility on [DATE] with diagnoses of pressure ulcer of the right buttock, stage 2 (the sore area of skin has broken through the top layer of skin and some of the layer below), Alzheimer's Disease (brain disorder that gets worse over time leading to a gradual decline in memory), and moderate protein-calorie malnutrition (an imbalance of nutrients from food and drinks that are needed to keep the body healthy). Review of Resident #9's quarterly MDS assessment dated [DATE] revealed under Section M - Skin that Resident #9's pressure sore appeared to heal and the treatment discontinued on 01/27/2023. The MDS nurse stated that Resident #9 had a pressure sore during the 7-day look-back and that her MDS assessment should have reflected Stage II. Review of Resident #9's comprehensive person-centered care plan dated 02/27/2023 revealed Focus .was admitted with a stage 2 pressure ulcer on her right buttock and is at risk for pain, and a decline in functional abilities .Interventions .provide wound care per physician's order. Review of Resident #9's physician orders dated Active as of January 2023 revealed Clean Stage II pressure ulcer to buttock with wound cleanser apply hydrocolloid dressing (a dressing with gel like properties to absorb excretions from the wound) every third day .discontinued on 01/27/2023. Interview on 04/12/2023 at 2:00 p.m. with Resident #9, she stated she had an open skin area to her buttock when she arrived at the facility, and she no longer has skin breakdown. Interview on 04/13/2023 at 4:08 p.m. with the MDS nurse revealed that an inaccurate MDS assessment could result in staff not providing proper care for the resident. Interview on 04/13/2023 at 4:30 p.m. with the DON revealed that the MDS for Resident #9 needed to be accurate to communicate the care to staff that Resident #9 required. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 under Section M: Skin Conditions revealed Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is Stage 2. Review of the facility policy and procedure titled MDS Accuracy Guidelines revised date 10/24/2022 revealed the purpose of the MDS guideline are to ensure each resident receives an accurate assessment by qualified staff that are familiar with his/her physical, mental, and psychosocial well-being to identify the specific needs of the residents in accordance with the RAI Manual. 675134 Page 5 of 10 675134 04/14/2023 Whispering Oaks Rehab & Nursing 105 Hospital Dr Cuero, TX 77954

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for one resident (#34) of 8 residents reviewed for comprehensive care plans in that: Resident #34's DNR status was not in her comprehensive person-centered care plan. This deficient practice could affect residents who have comprehensive person-centered care plans and could result in their advanced directive wishes not done. The findings were: Review of Resident #34's electronic face sheet dated 04/12/2023 revealed she was admitted to the facility on [DATE] with diagnoses of cerebral infarction (a brain lesion in which a cluster of brain cells die when they do not get enough blood), dysphagia (a condition with difficulty in swallowing food or liquid) and cognitive communication deficit (may occur after a stroke and result in difficulty with thinking and how someone uses language}. Review of Resident #34's admission MDS assessment dated [DATE] revealed she scored a 14/15 on her BIMS which indicated she was cognitively intact. Others could understand her and she could understand them. Review of Resident #34's comprehensive person-centered care plan revised date 03/08/2023 revealed Focus .ADL's .has an ADL self-care performance deficit and is at risk for not having needs met in a timely manner. Her preference of DNR for an advanced directive was not in her care plan. Review of Resident #34's Out of hospital do not resuscitate order revealed a signature and date of 03/01/2023. Review of Resident #34's order summary report Active Orders as of: 04/12/2023 revealed DNR active as of 03/13/2023. Interview on 04/13/2023 at 4:08 p.m. with the MDS nurse revealed that Resident #34's DNR order should have been in the resident's person-centered care plan. She stated that it was important for staff to know her advanced directive wishes and could result in her getting CPR when she did not want that. She stated she reviewed the physician orders and progress notes for changes in the care plan. Interview on 04/13/2023 at 4:30 p.m. with the DON revealed that Resident #34's DNR needed to be in her care plan because her wishes to not get CPR if she had a code was important for staff to know. Review of the facility policy and procedure titled Care Plans and Care Area Assessments revised date 05/06/2016 revealed As acute problems or changes to intervention or goals are identified, an appropriate care plan will be developed or modified by a Nursing staff member. 675134 Page 6 of 10 675134 04/14/2023 Whispering Oaks Rehab & Nursing 105 Hospital Dr Cuero, TX 77954

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure review and revision of comprehensive care plans for two residents (#4 and #9) of eight residents reviewed for comprehensive care plan revisions in that: 1.Resident #4's comprehensive person-centered care plan updates did not address her bowel status. 2.Resident #9's comprehensive person-centered care plan updates reflected she had a pressure sore. This deficient practice could affect residents and place them at risk of not having care plans that are reviewed/revised when needed affecting their care.who have comprehensive person-centered care plans and could result in missed treatments. The findings were: 1. Review of Resident #4's electronic face sheet dated 04/12/2023 revealed she was admitted to the facility on [DATE] with diagnoses of cerebral infarction (a brain lesion in which the cluster of brain cells die because they do not get enough blood), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). Review of Resident #4's quarterly MDS assessment with an ARD of 02/13/2023 revealed Resident #4 was a 3 for which indicated always incontinent of bowel and bladder. Further review revealed she scored a 14/15 on her BIMS which indicated she was cognitively intact. Staff could understand her and she usually was able to understand. Review of Resident #4's comprehensive person-centered care plan revised date of 12/22/2022 revealed Focus .is frequently incontinent of bladder r/t decreased mobility, obesity and refuses to go to the bathroom on her own and did not address Resident #4's bowel status. Interview on 04/13/2023 at 3:00 p.m. with Resident #4 revealed she sometimes went to the restroom with help and sometimes she did not. She stated there were days when she used the bathroom and did not urinate or defecate in her brief. Interview on 04/13/2023 at 4:08 p.m. with the MDS nurse revealed that she did not know why Resident #4's bowel status was not on the care plan. She stated the resident's care plan is a form of communication needed for staff to do proper care for a resident. She stated this could result in a resident trying to be toileted if they were incontinent. Interview on 04/13/2023 at 4:30 p.m. with the DON revealed that the care plan for Resident #4 needed to be accurate to communicate the care to staff that resident #4 required. She stated Resident #4 did have times she could be continent with assistance and that was important for her to maintain proper bodily functions if she could. She stated the care plan needed to be revised after their assessment for any changes or if other changes in the resident's care were made, such as new physician orders. 2. Review of Resident #9's electronic face sheet dated 04/13/2023 revealed she was admitted to the 675134 Page 7 of 10 675134 04/14/2023 Whispering Oaks Rehab & Nursing 105 Hospital Dr Cuero, TX 77954

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility on [DATE] with diagnoses of pressure ulcer of the right buttock, stage 2 (the sore area of skin has broken through the top layer of skin and some of the layer below), Alzheimer's Disease (brain disorder that gets worse over time leading to a gradual decline in memory), and moderate protein-calorie malnutrition (an imbalance of nutrients from food and drinks that are needed to keep the body healthy). Review of Resident #9's quarterly MDS assessment dated [DATE] revealed under Section M - Skin that Resident #9's pressure sore appeared to heal and the treatment discontinued on 01/27/2023. The MDS nurse stated that Resident #9 had a pressure sore during the 7-day look-back and that her MDS assessment should have reflected Stage II. Review of Resident #9's comprehensive person-centered care plan dated 02/27/2023 revealed Focus .was admitted with a stage 2 pressure ulcer on her right buttock and is at risk for pain, and a decline in functional abilities .Interventions .provide wound care per physician's order. Review of Resident #9's physician orders dated Active as of January 2023 revealed Clean Stage II pressure ulcer to buttock with wound cleanser apply hydrocolloid dressing (a dressing with gel like properties to absorb excretions from the wound) every third day .discontinued on 01/27/2023. Interview on 04/12/2023 at 2:00 p.m. with Resident #9, she stated she had an open skin area to her buttock when she arrived at the facility, and she no longer has skin breakdown. Interview on 04/13/2023 at 4:08 p.m. with the MDS nurse revealed She stated that an inaccurate care plan could result in staff not providing proper care for the resident. Interview on 04/13/2023 at 4:30 p.m. with the DON revealed that the care plan for Resident #9 needed to be accurate to communicate the care to staff that resident #9 required. Review of the facility policy and procedure titled Care Plans and Care Area Assessments revised date 05/06/2016 revealed under Care Plan Updates: The IDT will review the care plans Annually, Quarterly and as needed to ensure all goals and approaches are appropriate. 675134 Page 8 of 10 675134 04/14/2023 Whispering Oaks Rehab & Nursing 105 Hospital Dr Cuero, TX 77954

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 reviews, the facility failed to ensure that resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one resident (#31) of two residents reviewed for incontinent care in that: CNA A wiped Resident #31 from back to front instead of front to back during incontinent care. This deficient practice could affect residents and place them at risk of disease and infections. The findings were: Review of Resident #31's electronic face sheet dated 04/12/2023 revealed she was admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), seizure disorder (sudden uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness) and other neurological conditions (a type of nervous system disorder that affects brain and neurons). Review of Resident #31's quarterly MDS assessment with an ARD of 01/19/2023 revealed she scored a 03/15 which indicated she was severely cognitively impaired. Further review indicated she was always incontinent of bowel and bladder. Review of Resident #31's person-centered comprehensive care plan dated 01/20/2023 revealed Focus .is always incontinent of bladder and bowel .Interventions .keep resident clean and dry. Observation on 04/13/2023 at 03:52 p.m. of CNA A and CNA B perform incontinent care for Resident #31 revealed CNA A wiped from back to front when she cleaned the backside of the resident. Interview on 04/13/2023 at 4:00 p.m. with CNA A revealed she did not think about what she was doing when she wiped Resident #31's backside in the wrong direction. She stated that she knew she needed to wipe from front to back and that the way she cleaned Resident #31 from back to front could introduce bacteria into her frontside and could result in a urinary tract infection. She stated she was trained to wipe from front to back for incontinent care. Interview on 04/13/2023 at 4:30 p.m. with the DON revealed that CNA A knew how to perform proper incontinent care and that it needed to be front to back because of the cross contamination of germs which could result in a urinary tract infection. Review of CNA A's competency checklist titled Discipline .Skill .Nursing Peri-Care, dated 09/02/2022 revealed she met all the requirements of incontinent care. Further review revealed cleans by wiping from vagina toward anus with one stroke. Review of the facility policy and procedure titled Incontinence Care with a review date of 04/10/17 revealed Cleanse peri-area and buttocks with cleansing agent wiping from front of perineum toward rectum. Turn patient side to side to cleanse entire affected area, as needed . Dry peri-area and buttocks from front to back. 675134 Page 9 of 10 675134 04/14/2023 Whispering Oaks Rehab & Nursing 105 Hospital Dr Cuero, TX 77954

F 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observations, record reviews and interviews, the facility failed to ensure that 44 out of 44 resident rooms provided a minimum of 80 square feet of floor space per resident in that: Residents Affected - Many Forty-Four of the two-bed resident rooms measured 156 square feet per room leaving 78 square feet per bed. This deficient practice could affect residents living in these rooms by restricting the amount of resident care equipment and resident's personal effects that could be accommodated in these rooms. The findings were: During an interview on 04/13/23 at 10:30 a.m., the Administrator confirmed the identified residents' rooms were 2-person rooms and did not provide a minimum of 80 square feet of floor space per resident. The Administrator requested a room size waiver for those resident rooms and completed Form 3762 Room Size Waiver for Facilities that stated that all justification criteria for the wavier had been met which would not adversely affect the residents living in the rooms. Per the facility Bed Classification Form 3740 dated 04/13/23 as completed by facility administrator, Resident Rooms 100 through 108, 201 through 207, 300 through 305, 401 through 404, 500 through 509, and 600 through 608 were listed as two resident bedrooms. Observation on 04/13/23 beginning at 3:30 pm and measurement of resident bedrooms using a laser measuring tool by the Life Safety code surveyor and facility Maintenance Director, revealed the following measurements which were consistent with the measurements obtained during previous annual surveys: Hall A - Rooms 100, 101, 102, 103, 104, 105, 106, 107, and 108 - measured 156 square feet, providing 78 sq. ft per bed Hall B - Rooms 201, 202, 203, 204, 205 206, and 207 - measured 156 square feet, providing 78 sq. ft per bed Hall C - Rooms 300, 301, 302, 303, 304, and 305 - measured 156 square feet, providing 78 sq. ft per bed Hall D - Rooms 400, 401, 402, 403, and 404 - measured 156 square feet, providing 78 sq. ft per bed Hall E - Rooms 500, 501, 502, 503, 504, 505, 506, 507 508, and 509 - measured 156 square feet, providing 78 sq. ft per bed Hall F- Rooms 600, 601, 602, 603, 604, 605 and 608 - measured 156 square feet, providing 78 sq. ft per bed. 675134 Page 10 of 10