Health inspection·March 31, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment for 4 of 16 (Resident # 11, #51, #8, #66,) reviewed for accuracy of assessments. 1 Resident # 11's annual MDS assessment did not reflect her mental illness and dental care needs. 2 Resident #51 was not assessed for his race\ethnicity, His admission MDS did not reflect his use of assistive device for ambulating, his dental, vision, and hearing need, his fall history 3 Resident #8's significant change MDS did not reflect his bed rails, pressure reducing device for bed, pressure reducing device for chair, turning/repositioning program, and applications of ointments/medications. 4 Resident #66's significant change MDS did not reflect her oxygen therapy, suctioning, pressure reducing device for bed, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet, ability to hear (with hearing aid or hearing appliances if normally used), ability to see in adequate light (with glasses or other visual appliances), bowel patterns, and her swallowing disorder. These failures could place residents at risk of not having their needs met. The findings included: 1 Electronic record review of Resident #11's face sheet indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Major depressive disorder, Bipolar (is a mental health condition that causes extreme mood swings that include emotional highs) with psychotic Page 1 of 15 675234 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some features, Anxiety, (an intense, persistent fear of being watched and judged by others). Muscle weakness, type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), Record review of Resident #11's annual comprehensive MDS assessment with ARD of 12/29/22, revealed section A-1500 was checked as 0 indicating no mental illness. Section L on dental was checked as no problem with oral cavity. Record review of Resident #11's annual MDS assessment dated [DATE] revealed she had a BIMs score of 15 out of possible 15 indicating she was cognitively intact. Record review of Resident # 11's PASRR's evaluation dated 01/06/22 revealed she was positive for mental illness. Record review of Resident #11's care plan with a revision date of 03/17/23, revealed she was care planed for positive PASRR: Resident #11 is [NAME] positive for MI. Goal - Resident #11 will have all specialized services provided to meet needs (specify: MI (Bipolar) Resident #11 requires psychotropic medication for diagnoses of Bipolar. Goal Resident #11 will reduce the use of psychoactive medication through 04/16/23 . Observation and interview on 03/28/23 at 11:00 AM, revealed Resident # 11 was in bed alert and oriented. Observation revealed she had 4 natural teeth in her oral cavity. She said her dentures were in the bathroom. She said the dentures does not fit well. She said she had seen a dentist in the past and she need to go back for more treatment. She said she had not gone back. She said she manage with what she had. Record review of her clinical records revealed a dental assessment dated [DATE]. The assessment read in part patient tolerated examination very well. Patient reported #17 recently started to erupt . 2 Electronic record review of Resident #51's face sheet revealed Resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included Benign prostatic hyperplasia, chronic kidney disease stage 2, essential hypertension, anxiety, and Alzheimer's disease. Record review of Resident #51's admission MDS assessment with an ARD of 12/29/22, revealed his BIM score was 7 indicated severely impaired cognition. Review of section A-1000 Race, and ethnicity was left blank. Section B Hearing, speech and vision were all checked 0 indicating adequate hearing, vision, and speech. Section G-600 mobility device was checked none of the above indicated he ambulate without assistive device Section J 1700 fall history, number of falls since admission was left blank 675234 Page 2 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0636 Section L was checked 0 indicated he had all his natural teeth. Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 51's care plan dated 11/30/22 revealed he was cared plan for moderate risk for fall related to gait \balance problem, unaware of safety needs. Residents Affected - Some Care plan dated 12/06/22 revealed Resident #51 has impaired visual function, and communication problem Record review of Resident #51's facility's accident and incident report revealed Resident #51 had an unwitnessed fall on 11/25/22 at 8:00AM. During an interview with his nurse LVN E on 03/28/23 at 12:15PM, she said Resident #51 had hard time expressing himself and easily gets agitated. She said Resident #51 had few falls and need to use his walker but sometimes he forgets to use it. Observation and interview on 03/28/23 at 1:00PM, revealed Resident #51 standing beside his walker in his room. He was alert and oriented. During the interview he said he does not hear very well to speak louder. He said he needed to see a dentist and an eye doctor. His communication was not easily understood. Observation revealed he had two of his natural teeth in his oral cavity. 3 Record review of Resident #8's face sheet indicated he is a [AGE] year-old male, readmitted on [DATE], with diagnoses of legal blindness, pressure ulcer of sacral area (pressure ulcer above the tailbone), unspecified protein-calorie malnutrition (inadequate intake of proteins and calories to meet nutritional needs), muscle weakness, dysphagia (trouble swallowing), abnormalities of gait and mobility (trouble walking), lack of coordination, delusional disorders (irrational/intense beliefs or suspicions that a person believes to be true), malignant neoplasm of the prostate (cancer of the prostate), insomnia (inability to go to sleep or stay asleep), anxiety (feelings of tension, worried thoughts, dread, or uneasiness), hypertension (high blood pressure), GERD (acid reflux), stenosis of the coronary artery (narrowing of the artery to the heart), and hyperlipidemia (high cholesterol). Record review of Resident #8's significant change MDS, with an ARD date of 2/14/23 did not have a BIMS score on it. Question M1200 Skin and Ulcer/Injury Treatments, had D- nutrition or hydration intervention and E- pressure ulcer/injury care marked. Also, under section P (restraints and alarms) for question P0100 Physical Restraints, a 0, or not used, was marked for bed rails. Record review of Resident #8's physician orders revealed an order for a pressure relieving mattress, with an order date of 12/28/22. There was an order for ¼ side rails to bed every shift, with an order date of 2/7/23. Also, a physician's order for turning and repositioning every 2 hours to prevent skin breakdown, was ordered on 2/12/23. There was also an order for Nystatin Powder 100000 unit/gm, apply to groin topically two times a day for groin/scrotum redness, ordered on 1/5/23. Lastly, there was an order for Lotrisone Cream 1-0.05% (Clotrimazole-Betamethasone), apply to back topically every 12 hours as needed for itching, which was ordered on 12/28/22. Record review of Resident #8's care plan initiated on 2/1/23 and revised on 3/24/23, revealed he had a stage 2 to his sacrum, and resident was started on vitamin C, zinc, promod, and multivitamins with minerals. The resident's stage 2 will show signs of healing and remain free from infection through the review date: Resident needs assistance to turn/reposition at least every 2 hours, more often 675234 Page 3 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as needed or requested, initiated 2/1/23. The resident requires a cushion to their wheel or Geri chair, initiated 2/1/23. The resident requires the use of an air mattress, initiated 2/1/23. Further record review of Resident #8's MDS revealed question M1200 Skin and Ulcer/Injury Treatments did not have A- pressure reducing device for chair, B- pressure reducing device for bed, Cturning/repositioning program, and H- applications of ointments/medications other than to feet, marked. Also, bed rail was not marked for P0100 Physical Restraints. Observation and interview of Resident #8 on 3/28/23 at 11:51am revealed he did have a pressure relieving mattress in place, and side rails on his bed. 4 Record review of Resident #66's face sheet indicates she's a [AGE] year-old female, admitted on [DATE], with diagnoses of cerebral infarction (stroke), candidiasis of skin and nail (fungal infection of skin and nail), pressure-induced deep tissue damage of left heel (damage to the tissue of the left heel from pressure that can cause a pressure ulcer), pneumonia (infection of the lungs), protein-calorie malnutrition (inadequate intake of proteins and calories to meet nutritional needs), anemia (body doesn't have enough red blood cells), atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), memory deficit, peripheral vascular disease (narrowed blood vessels to limbs causing circulation problems), chronic embolism and thrombosis of deep veins of left upper extremity (long standing problem with clots to the deep veins of the left upper arm), and dysphagia (trouble swallowing). Record review of Resident #66's significant change MDS, with an ARD date of 3/6/23, revealed a BIMS score of 5 out of 15 (indicating severe impairment with cognition). Section B (hearing, speech, and vision) question B0200 Hearing was marked as 0 or adequate ability to hear. Also under section B, question B1000 Vision was marked as 0 or adequate ability to see. Section K (swallowing/nutritional status) on the MDS, specifically K0100 Swallowing Disorder said to check all that apply for signs and symptoms of possible swallowing disorder. Z- none of the above was marked. Record review of Resident #66's physician orders revealed an order for oxygen ordered on 2/9/23. There was also an order for barrier cream to both buttocks/sacrum, every brief change and as needed, ordered on 2/8/23. Also, there was a physician's order to apply split gauze dressing and secure with occlusive dressing, to PEG tube site every day and PRN, ordered on 2/8/23. An order for oral suctioning as needed, for increased secretions was ordered on 2/8/23. On 2/8/23 there was an order for a pressure relieving mattress. Record review of Resident #66's care plan dated 2/22/23, revealed the resident required tube feeding due to dysphagia, initiated on 2/16/23. Also, according to the care plan the resident had oxygen therapy that was initiated on 2/16/23 and revised on 2/17/23. The care plan also revealed the resident had a hearing deficit that was initiated on 2/17/23. Also noted on the care plan, the resident had impaired visual function that was initiated on 2/23/23. The resident had a swallowing problem noted on the care plan that was initiated on 2/23/23. Further record review of Resident #66's MDS revealed hearing deficit and impaired visual function were not marked on questions B0200 and B1000. Also, under section K of the MDS, question K0100 C- coughing or choking during meals or when swallowing medications or D- complaints of difficulty or pain with swallowing were not marked. Under section M, question M1200 B- Pressure reducing device for 675234 Page 4 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bed, G- Application of nonsurgical dressings (with or without topical medications) other than to feet, and HApplications of ointments/medications other than to feet were not marked. Then, under section O question O0100 C- Oxygen Therapy and D- Suctioning were not marked. Observation of Resident #66 on 3/28/23 at 11:24am revealed she was using oxygen 2.5L via nasal cannula, and resident had a pressure relieving mattress on her bed. Resident #66 also had a PEG tube infusing Jevity 1.2 at 36ml/hr via feeding pump. During an interview on 03/30/23 at 3:00PM, the MDS coordinator said she was responsible for completing the MDS. The MDS nurse said the assessments were wrong because she did not physically assess the residents to complete the MDS but depended on nursing documentation. She entered information on the MDS based off what the nurse's assessed the resident's for, and documented in the chart. She said not having an accurate assessment for residents would result in residents not receiving the type of care and services they needed. She also said the outcome may result in diminished quality of health. During an interview with the DON on 03/30/23 at 4:00PM, she said the MDS staff were supposed to assess residents to ensure that the assessment accurately reflected resident's conditions. Record review of facility's policy dated 2001 revised November 2019 titled Care Area Assessments did not address accuracy of MDS assessment. 675234 Page 5 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program and to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for two of two residents (Residents #27 and #47) reviewed for PASARR assessment. The facility failed to refer Resident #27 and Resident #47 for a PASARR level II screening after a new mental disorder diagnosis was made. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Findings include: Resident #27 Record review of Resident #27's admission record dated 3/29/2023 revealed a [AGE] year-old admitted on [DATE] with diagnoses major depressive disorder, anxiety disorder (an intense, persistent fear of being watched and judged by others), and PTSD (a mental health condition that is triggered by a terrifying event, either experiencing it or witnessing it). Resident #27's admission record revealed the diagnosis related to PTSD was made on 1/18/2022. Record review of Resident #27's prescribed medication report revealed prescriptions for Tramadol HCL 50mg, Paxil 30mg, amlodipine besylate 10mg, Abilify 10mg, Rivastigmine Patch 24 hour 9.5mg/24hour, and Memantine HCI 10mg. Record review of Resident #27's quarterly MDS dated [DATE] with an ARD of 2/7/2023 revealed no BIMS score because she was rarely/never understood, and she was severely cognitively impaired. The MDS revealed no behaviors which impacted other residents. The MDS revealed Resident #27 required extensive assistance and two-person physical assistance with bed mobility and transfers and Resident #27 required extensive assistance and one-person physical assistance with locomotion, dressing, eating, and personal hygiene. Per the MDS, Resident #27 was totally dependent on two-person assistance for toileting and Resident #27 did not walk. The MDS revealed Resident #27 was frequently incontinent of bladder and always incontinent of bowel, and she was not on a toileting program. The MDS documented Resident #27 was prescribed antipsychotic and antidepressant medications. The MDS revealed Resident #27 received occupational and physical therapies and Resident #27 had no falls since the prior assessment. Record review of Resident #27's care plan created 3/20/2023 included a focus on her altered neurological status due to PTSD and Anxiety with interventions including monitoring for medication side effects, reorientation, and medication treatments. Record review of Resident #27's PASARR Level 1 completed 7/18/2019 revealed no reported mental illness, intellectual disability, or developmental disability. 675234 Page 6 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of an HHS Form 1012-Mental Illness/Dementia Resident Review revealed Resident #27 was not eligible for further PASARR services or review. The Form 1012 was unsigned, undated, and there was no identification of the individual completing the form. Observation on 3/29/2023 at 1:43 PM. Resident #27 was lying on her bed watching television. Resident #27 was fully dressed and appeared clean and appropriately groomed. Resident #27's bed was in the lowest position and the call light was on the bed within reach. Interview and record review on 3/30/2023 at 3:03 PM with the MDS nurse she said the facility received the initial PASARR Level I from the location the resident was coming to the facility from. She said the PASARR LEVEL I was then submitted to the local authority for review. The MDS nurse said if the resident received a new diagnosis a new PASARR LEVEL I would be completed and submitted to the local authority. She said the facility's expectation for resubmission of a PASARR LEVEL I following a new diagnosis was to submit it within one week of the diagnosis. The MDS nurse said she did not complete Resident #27's PASARR 1 review. The MDS nurse said PTSD was a diagnosis requiring a new PASARR LEVEL I. She said if Resident #27 was diagnosed with PTSD on 1/8/2022 the resident should have had a new assessment. The MDS nurse said she was not sure why a new assessment was not completed. She said if the assessment was not completed appropriately the resident may not receive services to which he/she was entitled. Record review the MDS nurse reviewed Resident #27's Mental Illness/Dementia Resident Review and stated it was not signed or dated. She said she was unsure why it was unsigned or undated. 2 Resident #47 Record review of Resident #47's face sheet dated 3/29/23, indicated he is an [AGE] year-old male, admitted on [DATE], and had diagnoses including pulmonary fibrosis (lung tissue becomes damaged and scarred), anxiety (intense worry, fear or stress), anemia in chronic kidney disease (not enough red blood cells in long standing kidney disease), major depressive disorder (persistent depressed mood or loss of interest in activities), chronic systolic heart failure (left side of the heart cannot pump blood efficiently), type II diabetes mellitus (insulin resistance causing higher blood sugar levels in the blood), delusional disorders (type of psychotic disorder with one or more delusions), insomnia (unable to go to sleep or stay asleep), and essential hypertension (high blood pressure not caused by a medical condition). Record review of Resident #47's MDS dated [DATE], on question A1500, it asked if the resident was evaluated by Level II PASARR and determined to have a serious mental illness and/or mental retardation or a related illness. The answer was marked no. Resident #47 had a BIMS score of 12 out of 15, indicating moderately impaired cognition. On section I of the MDS, Resident #47 had depression and a psychotic disorder (other than schizophrenia) marked for active diagnoses, and on question N0410 it showed the resident had been taking antipsychotics and antidepressants for 7 days prior to admission. Record review of Resident #47's PASARR Level 1 Screening dated 11/10/22 indicated he had no mental illness and was given a negative PASARR Level 1 Screening. Record review of Resident #47's psychiatric evaluation dated 12/1/22, indicated the resident was diagnosed with delirium due to known physiologic condition, psychotic disorder with hallucinations due to known physiological condition, and major depressive disorder, severe without psychotic features. 675234 Page 7 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #47's MDS dated [DATE], revealed on question A1500, where it asked if the resident had been evaluated by Level II PASARR and determined to have a serious mental illness, it was left blank. On section I under active diagnoses, Resident #47 had depression, and psychotic disorder (other than schizophrenia) checked. Under section N, the MDS indicated the resident had been taking antidepressants and antipsychotics for the previous 7 days. Also, the MDS indicated no GDR had been attempted because the physician documented it as clinically contraindicated. Record review of Resident #47's MDS dated [DATE], revealed on question A1500, where it asked if the resident had been evaluated by Level II PASARR and determined to have a serious mental illness, it was left blank. On section I of the MDS, it was checked that Resident #47 had depression and a psychotic disorder (other than schizophrenia). The MDS also stated under section N, specifically N0410, that Resident #47 was taking antipsychotics and antidepressants. Also, the MDS indicated no GDR had been attempted because the physician documented it as clinically contraindicated. Record review of Resident #47's care plan dated 11/29/22 indicated he requires psychotropic medications. Resident will be/remain free of drug related complications .through review date: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Medications: Quetiapine . Resident #47 also requires antidepressant medication. Resident will be free from discomfort or adverse reactions .through the review date: Administer antidepressant medications as ordered by physician .Medications: Sertraline . Also noted on the care plan was that Resident #47 has a mood problem. Diagnosis: Delusional Disorders. Resident will have improved mood state through the review date: Administer medications as ordered .Medications: Quetiapine. Monitor/record mood . Resident also has depression. Diagnosis: Major Depressive Disorder. Resident will exhibit indicators of depression, anxiety, or sad mood, less than daily by review date: Administer medications as ordered Arrange for psych consult, follow up as indicated. Medications: Sertraline . In an interview and record review on 3/30/2023 at 3:03pm with the MDS nurse, she stated she received the initial PASARR Level 1 from the facility that sent the resident to them. The MDS nurse said the PASARR Level 1 was then submitted to the local authority for review if it was positive. The MDS nurse said if the resident received a new diagnosis, a new PASARR Level 1 would be completed and submitted to the local authority. She said the facility expectation for resubmission of a PASARR Level 1, following a new diagnosis, was within one week of the diagnosis. The Surveyor showed the MDS nurse the PASARR Level 1 Screening for Resident #47, and she confirmed it was negative on 11/10/22. However, she confirmed Resident #47 was diagnosed with a psychotic disorder on 12/1/22 and should have been re-evaluated at that time and sent to the proper authorities. The MDS nurse stated she just resubmitted Resident #47's Level 1 screening today, on 3/31/23. The MDS nurse said she was unsure of how she overlooked Resident #47's re-screening and that it was an accident. She also said if the assessment was not completed appropriately and mental health authorities were not notified, the resident may not receive services to which he/she were entitled. Record review of the facility's PL1/PASARR/NFSS/1012/PCSP policy dated 1/16/2019 revealed The facility will ensure compliance with all Phase I and II guidelines of the PASARR Process for Long Term Care. The policy identified the MDS coordinators, marketing/admissions team members/social worker, administrator, DON, and IDT members as the parties responsible for compliance. The policy documented procedures including submission of a PL1 for all entering the facility. The policy further revealed If at any time a resident has a significant change, ., or you receive information that might indicate the resident may have a MI/ID/DD diagnosis or condition mot contained in the medical record, please submit a PL1 form for the resident to be evaluated by the Local Authority. 675234 Page 8 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who had mental illness or intellectual disability for 2 of 2 residents (Residents #27 and #47) reviewed for PASARR Significant Change Notification. 1 The facility failed to notify the local mental health authority after Resident #27' significant change in mental illness diagnosis following a new PTSD diagnosis. 2 Resident #47 was identified with a significant change to their mental illness diagnoses and notification was not made to the me local mental health authority. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Findings include: Resident #27 Record review of Resident #27's admission record dated 3/29/2023 revealed a [AGE] year-old admitted on [DATE] with diagnoses major depressive disorder, anxiety disorder (an intense, persistent fear of being watched and judged by others), and PTSD (a mental health condition that is triggered by a terrifying event either experiencing it or witnessing it). Resident #27's admission record revealed the diagnosis related to PTSD was made on 1/18/2022. Record review of Resident #27's prescribed medication report revealed prescriptions for Tramadol HCL 50mg, Paxil 30mg, amlodipine besylate 10mg, Abilify 10mg, Rivastigmine Patch 24 hour 9.5mg/24hour, and Memantine HCI 10mg. Record review of Resident #27's quarterly MDS dated [DATE] with an ARD 0f 2/7/2023 revealed no BIMS score because she was rarely/never understood, and she was severely cognitively impaired. The MDS revealed no behaviors which impacted other residents. The MDS revealed Resident #27 required extensive assistance and two-person physical assistance with bed mobility and transfers and Resident #27 required extensive assistance and one-person physical assistance with locomotion, dressing, eating, and personal hygiene. Per the MDS, Resident #27 was totally dependent on two-person assistance for toileting and Resident #27 did not walk. The MDS revealed Resident #27 was frequently incontinent of bladder and always incontinent of bowel, and she was not on a toileting program. The MDS documented Resident #27 was prescribed antipsychotic and antidepressant medications. The MDS revealed Resident #27 received occupational and physical therapies and Resident #27 had no falls since the prior assessment. Record review of Resident #27's care plan created 3/20/2023 included a focus on her altered 675234 Page 9 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0646 Level of Harm - Minimal harm or potential for actual harm neurological status due to PTSD and Anxiety with interventions including monitoring for medication side effects, reorientation, and medication treatments. Record review of Resident #27's PASARR Level 1 completed 7/18/2019 revealed no reported mental illness, intellectual disability, or developmental disability. Residents Affected - Some Record review of an HHS Form 1012-Mental Illness/Dementia Resident Review revealed Resident #27 was not eligible for further PASARR services or review. The Form 1012 was unsigned, undated, and there was no identification of the individual completing the form. Observation on 3/29/2023 at 1:43 PM. Resident #27 was lying on her bed watching television. Resident #27 was fully dressed and appeared clean and appropriately groomed. Resident #27's bed was in the lowest position and the call light was on the bed within reach. Interview 3/30/2023 at 3:03 PM with the MDS nurse, she said the facility received the initial PASARR Level I from the location the resident was coming to the facility from. She said the PASARR LEVEL I was then submitted to the local authority for review. The MDS nurse said if the resident received a new diagnosis a new PASARR LEVEL I would be completed and submitted to the local authority. She said the facility expectation for resubmission of a PASARR LEVEL I following a new diagnosis was to submit it within one week of the diagnosis. The MDS nurse said she did not complete Resident #27's PASARR 1 review. The MDS nurse said PTSD was a diagnosis requiring a new PASARR LEVEL I. She said if Resident #27 was diagnosed with PTSD on 1/8/2022 the resident should have had a new assessment. The MDS nurse said she was not sure why a new assessment was not completed. She said no notification was made to the local mental health authority because a new PASARR Level 1 was not created. The MDS Nurse said notification should have been made to the local mental health authority. She said if the assessment was not completed appropriately the resident may not receive services he/she was entitled to. During a record review by the MDS nurse, she reviewed Resident #27's Mental Illness/Dementia Resident Review and stated it was not signed or dated. She said she was unsure why it was unsigned or undated. 2 Resident # 47 Record review of Resident #47's face sheet dated 3/29/23, indicated he is an [AGE] year-old male, admitted on [DATE], and had diagnoses including pulmonary fibrosis (lung tissue becomes damaged and scarred), anxiety (intense worry, fear or stress), anemia in chronic kidney disease (not enough red blood cells in long standing kidney disease), major depressive disorder (persistent depressed mood or loss of interest in activities), chronic systolic heart failure (left side of the heart cannot pump blood efficiently), type II diabetes mellitus (insulin resistance causing higher blood sugar levels in the blood), delusional disorders (type of psychotic disorder with one or more delusions), insomnia (unable to go to sleep or stay asleep), and essential hypertension (high blood pressure not caused by a medical condition). Record review of Resident #47's MDS dated [DATE], on question A1500, it asked if the resident was evaluated by Level II PASARR and determined to have a serious mental illness and/or mental retardation or a related illness. The answer was marked no. Resident #47 had a BIMS score of 12 out of 15, indicating moderately impaired cognition. On section I of the MDS, Resident #47 had depression and a psychotic disorder (other than schizophrenia) marked for active diagnoses, and on question N0410 it showed the resident had been taking antipsychotics and antidepressants for 7 days prior to admission. 675234 Page 10 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #47's PASARR Level 1 Screening dated 11/10/22 indicated he had no mental illness and was given a negative PASARR Level 1 Screening. Record review of Resident #47's psychiatric evaluation dated 12/1/22, indicated the resident was diagnosed with delirium due to known physiologic condition, psychotic disorder with hallucinations due to known physiological condition, and major depressive disorder, severe without psychotic features. Record review of Resident #47's MDS dated [DATE], revealed on question A1500, where it asked if the resident had been evaluated by Level II PASARR and determined to have a serious mental illness, it was left blank. On section I under active diagnoses, Resident #47 had depression, and psychotic disorder (other than schizophrenia) checked. Under section N, the MDS indicated the resident had been taking antidepressants and antipsychotics for the previous 7 days. Also, the MDS indicated no GDR had been attempted because the physician documented it as clinically contraindicated. Record review of Resident #47's MDS dated [DATE], revealed on question A1500, where it asked if the resident had been evaluated by Level II PASARR and determined to have a serious mental illness, it was left blank. On section I of the MDS, it was checked that Resident #47 had depression and a psychotic disorder (other than schizophrenia). The MDS also stated under section N, specifically N0410, that Resident #47 was taking antipsychotics and antidepressants. Also, the MDS indicated no GDR had been attempted because the physician documented it as clinically contraindicated. Record review of Resident #47's care plan dated 11/29/22 indicated he requires psychotropic medications. Resident will be/remain free of drug related complications .through review date: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Medications: Quetiapine . Resident #47 also requires antidepressant medication. Resident will be free from discomfort or adverse reactions .through the review date: Administer antidepressant medications as ordered by physician .Medications: Sertraline . Also noted on the care plan was that Resident #47 has a mood problem. Diagnosis: Delusional Disorders. Resident will have improved mood state through the review date: Administer medications as ordered .Medications: Quetiapine. Monitor/record mood . Resident also has depression. Diagnosis: Major Depressive Disorder. Resident will exhibit indicators of depression, anxiety, or sad mood, less than daily by review date: Administer medications as ordered Arrange for psych consult, follow up as indicated. Medications: Sertraline . In an interview and record review on 3/30/2023 at 3:03pm with the MDS nurse, she stated she received the initial PASARR Level 1 from the facility that sent the resident to them. The MDS nurse said the PASARR Level 1 was then submitted to the local authority for review if it was positive. The MDS nurse said if the resident received a new diagnosis, a new PASARR Level 1 would be completed and submitted to the local authority. She said the facility expectation for resubmission of a PASARR Level 1, following a new diagnosis, was within one week of the diagnosis. The Surveyor showed the MDS nurse the PASARR Level 1 Screening for Resident #47, and she confirmed it was negative on 11/10/22. However, she confirmed Resident #47 was diagnosed with a psychotic disorder on 12/1/22 and should have been re-evaluated at that time and sent to the proper authorities. The MDS nurse stated she just resubmitted Resident #47's Level 1 screening today, on 3/31/23. The MDS nurse said she was unsure of how she overlooked Resident #47's re-screening and that it was an accident. She also said if the assessment was not completed appropriately and mental health authorities were not notified, the resident may not receive services to which he/she were entitled. Record review of the facility's PL1/PASARR/NFSS/1012/PCSP policy dated 1/16/2019 revealed The 675234 Page 11 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility will ensure compliance with all Phase I and II guidelines of the PASARR Process for Long Term Care. The policy identified the MDS coordinators, marketing/admissions team members/social worker, administrator, DON, and IDT members as the parties responsible for compliance. The policy documented procedures including submission of a PL1 for all entering the facility. The policy further revealed If at any time a resident has a significant change, ., or you receive information that might indicate the resident may have a MI/ID/DD diagnosis or condition mot contained in the medical record, please submit a PL1 form for the resident to be evaluated by the Local Authority. 675234 Page 12 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

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 observation, interview, and record review, the facility failed to review and revise the care plan after each assessment, including both the comprehensive and quarterly review assessments for 2 (#9, and #66) out of 16 residents reviewed for care plans. 1. Resident #9's code status on his care plan was not updated from full code to DNR and it did not indicate he was Spanish speaking and needed a translator. The care plan also did not mention the resident was ordered oxygen, a pressure relieving mattress, to be turned and repositioned Q 2hr, and he required feeding assistance Q 4hr PRN. 2. Resident #66's care plan did not include heel protectors, oral suctioning, a pressure relieving mattress, and bowel rest from her PEG tube. This deficient practice could place residents at risk of not receiving care and services that are needed to attain/maintain their highest practicable quality of life. 1. Record review of Resident #9's face sheet indicated he is a [AGE] year-old male, readmitted on [DATE], with diagnoses of Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), abnormalities of gait and mobility (problems with walking and moving), major depressive disorder (sadness/loss of hope and loss of pleasure in daily activities), anxiety disorder (fear, stress, tension in daily life), hypertension (high blood pressure), dysphagia (trouble swallowing), pulmonary fibrosis (scar tissue/damage to lungs), and protein-calorie malnutrition (deficient in proteins and calories). Also on his face sheet was his code status, which was DNR. Record review of Resident #9's most recent care plan dated [DATE], revealed resident had a Full code CPR order in place initiated [DATE]. The goal: Request for CPR to be initiated will be followed initiated [DATE]. The interventions: Call 911 and initiate CPR, Review medical record to ensure that proper documents are signed, and Consult with nursing staff on changes in health all initiated [DATE]. The DNR was ordered on [DATE]. The care plan also did not have the order for the pressure relieving mattress that was ordered on [DATE], the oxygen ordered on [DATE], the turning and repositioning Q2hr ordered on [DATE], being a regular feeder Q4hr PRN ordered on [DATE], and the resident being Spanish speaking and requiring a translator. Record review of Resident #9's MDS, dated [DATE], indicated on A1100 A., the resident needed/wanted an interpreter to communicate with the doctor and health care staff. On A1100 B., it was indicated that the resident's preferred language was Spanish. Record review of Resident #9's physician orders revealed orders for a DNR code status on [DATE], a pressure relieving mattress on [DATE], oxygen 2-4 LPM via NC PRN on [DATE], turn and reposition Q2hr on [DATE], and for the resident to be a regular feeder Q4hr PRN ordered on [DATE]. Observation and interview on [DATE] at 1:53pm with Resident #9 revealed resident was Spanish speaking only and did not understand anything Surveyor was saying in English. Resident had a caregiver with him; however, she did not speak much English herself and did not understand most questions the Surveyor asked. 675234 Page 13 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with CMA D on [DATE] at 11:00am revealed the facility and staff did not use a translator to communicate with Resident #9. To communicate with resident, CMA D would call another employee who spoke Spanish, to speak with him. CMA D stated there were 1 or 2 staff members who spoke Spanish on the day shift and on the night shift. Interview with family member on [DATE] at 1:00pm revealed Resident #9 did not understand any English. Family member stated they were unsure of how he communicated with staff. Family member said they never saw a translator being used before. In an Interview with the ADON on [DATE] at 3:47pm revealed Resident #9 switched to hospice just this week and that was why the care plan had not been updated to DNR yet. Per the ADON, all the charts have a code sheet in the front of them that state if the resident is full code or DNR, and there is not a code book. So, there should not be a chance of getting mixed up with the codes. 2. Record review of Resident #66's face sheet indicates she is a [AGE] year-old female, admitted on [DATE], with diagnoses of cerebral infarction (stroke), candidiasis of skin and nail (fungal infection of skin and nail), pressure-induced deep tissue damage of left heel (damage to the tissue of the left heel from pressure that can cause a pressure ulcer), pneumonia (infection of the lungs), protein-calorie malnutrition (inadequate intake of proteins and calories to meet nutritional needs), anemia (body doesn't have enough red blood cells), atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), memory deficit, peripheral vascular disease (narrowed blood vessels to limbs causing circulation problems), chronic embolism and thrombosis of deep veins of left upper extremity (long standing problem with clots to the deep veins of the left upper arm), and dysphagia (trouble swallowing). Record review of Resident #66's physician orders revealed, orders for Bilateral heel protectors to feet, always while in bed, ordered on [DATE], bowel rest from 12:00am to 4:00am every night shift ordered on [DATE], gentle oral suction PRN for increased secretions ordered on [DATE], and a pressure relieving mattress ordered on [DATE]. Record review of Resident #66's most recent care plan, dated [DATE], did not have bilateral heel protectors, bowel rest, oral suctioning PRN, or a pressure relieving mattress on it. Observation of Resident #66 on [DATE] at 11:44am revealed resident was asleep, laying on her back, on a pressure relieving mattress. She had a PEG tube infusing Jevity 1.2 at 36ml/hr and was receiving oxygen 2.5L via NC. In Interview with the DON on [DATE] at 11:57am she stated everyone (nursing) was responsible for updating the care plans, but ultimately her and the MDS nurse were responsible for ensuring the care plans were updated to match the MDS. Per the DON, she did not check 100% of the time because she was too busy, so she was sure there were care plans that were not updated and were wrong. The DON said the care plan was very important, and if it was not correct it could cause the resident to miss needed interventions, because that was how they delivered care, based off the interventions on the care plan. Record review of the facility's policy and procedures for Care Plans, Comprehensive Person-Centered (Revised [DATE]) read in part: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 675234 Page 14 of 15 675234 03/31/2023 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being .g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems . l. Identify the professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. 675234 Page 15 of 15