Health inspection·November 22, 2024

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on interview sand record review, the facility failed to promote the residents' right to receive mail, for all facility residents. Residents Affected - Some The facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. Findings included: During a confidential group meeting on 11/20/24 at 1:08 PM, members of the resident group stated that they do not receive mail on Saturdays. The residents did not understand why the mail was not distributed on Saturdays, and stated they felt this practice was disrespectful. During an interview with the Business Manager on 11/20/24 at 2:55 PM, the Business Manager stated she or the receptionist collected the mail Monday through Friday and gave it to the Activity Director. The Business Manager stated they gave the Activity Director the mail the day it was received if the mail was delivered by 5:00 PM. If it was delivered after, 5:00 PM, they would get their mail the next day. On Saturday, the Business Manager stated the manager on duty was responsible for collecting the mail. The mail collected on the weekends was held until Monday for the business office to sort through before being passed to the Activity Director to deliver to the residents. The Business Manager stated the policy of the facility was to wait and give the mail to the business office on Monday. During an interview with the DON on 11/21/24 at 1:20 PM, the DON stated the business office gets the mail and sorts out the residents' mail from the facility's mail. Once the Business Manager has sorted the mail, she gives resident mail to the Activity Director who delivers it to the residents. The DON stated she does not know who gives mail to the residents on the weekends. When asked what could happen if mail is not received the day it is delivered, the DON stated the residents could experience disappointment and bills could be late. During an interview with the Administrator on 11/21/24 at 1:30 PM, the Administrator stated the business office gets the mail Monday through Friday unless the mail was delivered later in the day after the business office had closed for the day. If mail was delivered later in the day, the business office would sort the mail the next morning. The Administrator stated once the mail was sorted the next morning, it was given to the Activity Director to be passed out to the residents. The Administrator stated that on the weekends there was a manager on duty for six hours each day. The Administrator stated that if mail was delivered on Saturday, it was held for the business office the following Page 1 of 6 675159 675159 11/22/2024 Southbrooke Manor Nursing and Rehabilitation Cente 1401 W Main St Edna, TX 77957

F 0576 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Monday. The Administrator stated when the Business Manager gets in on Monday, she sorted through any mail received on the weekend and gave resident mail to the Activity Director to hand out to the residents. When asked what could happen if the mail was not received the day it was delivered, the Administrator stated the residents could feel heartbroken or experience sadness. Review of the facility's policy titled Selection of Resident Preferences, undated, stated all incoming mail will be directed to the resident. 675159 Page 2 of 6 675159 11/22/2024 Southbrooke Manor Nursing and Rehabilitation Cente 1401 W Main St Edna, TX 77957

F 0583 Keep residents' personal and medical records private and confidential. 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 had the right to personal privacy and confidentiality of his or her personal and medical records for one of three residents (Resident #63) reviewed for privacy. Residents Affected - Few The facility failed to ensure MA B locked the computer, which exposed Resident #63's morning medication list after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings included: Record review of Resident #63's face sheet, dated 11/20/24, revealed a [AGE] year old male admitted to the facility on [DATE]. Resident #63 had diagnosis that included: Hemiparesis (condition that causes partial paralysis or weakness on one side of the body), Intracerebral hemorrhage (occurs when a blood vessel in the brain bursts and bleeds into the brain tissue), and Gout (is a type of arthritis that occurs when the body has too much uric acid, which causes crystals to form in the joints). Record review of Resident #63's Quarterly MDS assessment, dated 10/18/24, reflected a BIMS score of 15 which suggested Intact cognition. Observation on 11/20/24 at 8:20 am, revealed that MA B prepared Resident's #63's morning medication, walked away from the computer (did not lock screen). During an interview on 11/20/24 at 8:20 AM, MA B stated she was not aware of the option to close the computer screen and believed that minimizing the screen was sufficient. MA B confirmed that when she stepped away from the computer, Resident #63's private medical information may have been exposed. During an interview on 11/20/24 at 9:21 AM, the DON stated she was not aware Resident #63's records were left open and unattended. The DON mentioned it was her expectation for the facility nursing staff to uphold HIPAA regulations and lock computer screens when they were away from them. The DON emphasized that all staff members were responsible for ensuring the protection of residents' information. The DON stated leaving residents' charts open and unattended could lead to unauthorized access. The DON also stated her ADON's would be responsible for overseeing compliance with this task, and she would monitor it by conducting random computer screen checks. Record review of the facility policy titled Medication administration, dated 10/1/2019 Revealed: Privacy is maintained at all times for all resident information by closing the medication administration record when not in use . 675159 Page 3 of 6 675159 11/22/2024 Southbrooke Manor Nursing and Rehabilitation Cente 1401 W Main St Edna, TX 77957

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. 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 rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 24 residents (Resident #20) reviewed for care plans. The facility failed to develop a care plan to address Resident #20's anti-coagulant medication use. This failure could have placed residents at risk of not having their needs identified and met. The findings were: Record review of Resident #20's face sheet, dated 11/20/24, revealed an original admission date of 8/5/11 with diagnoses that included: unspecified dementia (a condition in which a person can experience memory loss, poor judgement, and confusion), unspecified atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly) and essential primary hypertension (a condition of high blood pressure with no known cause). Record review of Resident's #20's Quarterly MDS assessment, dated 10/31/24, revealed a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #20's Physician's orders dated 11/20/24 revealed Resident #20 was taking Xarelto, an anticoagulant medication, with a start date on 4/12/22. Record review of Resident #20's ongoing care plan initiated on 3/26/18 revealed that the Resident's anti-coagulant medication use was not documented in the care plan. During an interview with the Director of Nurses on 11/20/24 at 2:20p.m., she stated that Resident # 20's anti-coagulant medication use was not documented on his current care plan. She stated that having the anti-coagulant medication usage on the care plan was important for care staff to be aware of the resident's care needs so that the needs are met. During an interview with the Regional Care Management Support Specialist on 11/20/24 at 2:30 p.m., she stated that Resident #20's anti-coagulant medication use was not documented on his current care plan. She stated that the Resident's medication usages should be documented on the resident's care plan and the anticoagulant medication usage had been omitted. She stated that having this information documented would allow the resident care needs to be met. Record review of the facility's policy titled Comprehensive Care Plan dated 10/24/22 revealed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 675159 Page 4 of 6 675159 11/22/2024 Southbrooke Manor Nursing and Rehabilitation Cente 1401 W Main St Edna, TX 77957

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 4 medication carts observed. The medication aide cart for the 400/600 halls contained 17 loose pills. The medication aide cart for the 300/500 halls contained 6 loose pills. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others. Findings included: During an observation and interview on 11/20/24 at 10:30 AM of the medication aide cart for the 400/600 halls with MA B, 17 loose pills were observed in the bottom of the cart drawers holding the blister packs. When asked what could happen if loose pills were left in the cart, MA B stated the pills could drop to the floor and be picked up and consumed by residents they were not prescribed for which could cause unwanted and harmful adverse effects. During an observation and interview on 11/20/24 at 10:45 AM of the medication aide cart for the 300/500 halls with MA B, 6 loose pills were observed in the bottom of the cart drawers holding the blister packs. When asked what could happen if loose pills were left in the cart, MA B stated residents could pick up the loose pills and get undesirable effects if they ingested them. During an interview with the DON on 11/20/24 at 12:05 PM, the DON stated if loose pills were present, a resident could acquire and consume something they were not supposed to take resulting in harmful or unwanted effects. During an interview with the Regional RN on 11/20/24 at 3:30 PM, the Regional RN stated she could not find a specific facility policy on storage of medication. Review of the facility policy titled Medication Carts and Supplies for Administering Meds, revised on 10/01/19, stated the purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. 675159 Page 5 of 6 675159 11/22/2024 Southbrooke Manor Nursing and Rehabilitation Cente 1401 W Main St Edna, TX 77957

F 0944 Level of Harm - Potential for minimal harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews, and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 1 of 21 staff (CNA A) reviewed for training. The facility failed to ensure that 1 of 21 staff (c) had completed their mandatory QAPI annual training. This failure could place residents at risk for care by CNA staff who had been insufficiently trained while working in the facility. The findings included: Record review of the annual CNA training information revealed that: CNA A (re-hired-10/10/23) had not completed the mandatory QAPI annual training requirement. During an interview with the Human Resources (HR) Director on 11/21/24 at 12:30p.m., she stated that there was not a record of completed annual QAPI training for CNA A. The HR Director stated that she had responsibility for coordinating the employee's training program and that it was the staff member's responsibility to have completed their training assignments. The HR Director stated that the staff member's completion of the training would have improved their resident care service by increasing their knowledge base. During an interview with the Administrator on 11/21/24 at 12:45p.m., she stated that staff's completion of their QAPI training would have improved resident care services by meeting their training requirements. Record review of the facility's policy on Training Requirements dated 10/13/22 stated It is the responsibility of each employee, volunteer, or contract staff to complete required training. 675159 Page 6 of 6