Health inspection·June 3, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the residents environment remained free from accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #1 and Resident #2) reviewed for accidents, hazards, and supervision. 1.The facility failed to adequately supervise Resident #1 when being transferred. Resident #1 sustained a fracture of the distal femur (broken bone above the knee) when the Hoyer Lift Sling broke while being transferred with a Hoyer lift device on 1/31/2023. 2. The facility failed to adequately supervise Resident #2 while in a shower chair on 2/28/23. Resident #2 sustained a fracture of the distal third tibial and fibular shaft fracture with comminution and slight displacement. An Immediate Jeopardy was identified on 06/02/23 at 4:03 p.m. While the Immediate Jeopardy was removed on 06/03/23 at 2:00 p.m., the facility remained out of compliance at a scope of isolated with actual harm, due to the facility's need evaluate and monitor the effectiveness of corrective systems. These failures could place residents at risk of falls, fractures, and other accidents . Findings include: 1.Record review of Resident #1's face sheet, dated 5/15/2023, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included: Unspecified fracture (broken bone) of the lower end of right femur, subsequent encounter for closed fracture with routine healing, tachycardia (rapid heart rate), pain right knee, chronic kidney disease stage 4, acute kidney failure (kidneys fail to filter), and osteoarthritis (bone degenerating). Record review of Resident #1's admission MDS, dated [DATE], revealed a Brief Interview for Mental Status of 3, which indicated severe cognitive impairment. The MDS further revealed the resident's functional status was a 4 for transfers which indicated total dependence and a 3 for support in transfers which indicated she required two or more person assist. Record review of Resident #1's Nurses Notes, by LVN D, dated 01/31/23, read, 8:00 a.m. called to room by [LVN C] nurse observes resident on floor, leaning back against recliner, nurse observes Hoyer lift in room, staff state CNAs x 2 were transporting resident from shower chair to recliner with Page 1 of 10 675358 675358 06/03/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few nurse in room, one strap on Hoyer pad broke, resident slide out of lift pad, resident's right leg bumped Hoyer lift and head fell on recliner. Orders per Medical Doctor (MD) for Mobile X ray of lower extremities and pelvis.1:30 p.m. - x-ray findings - Right Lower Extremity - fracture to distal femur, notified MD, states to send resident to hospital, Emergency Medical Service (EMS) contacted. 1:55 p.m. EMS arrives at facility, resident transported out of facility via stretcher to emergency room (ER). 4:30 p.m. - received report from ER, states XRAY confirmed fracture to right femur. ER MD recommends resident follow up with orthopedist. Resident is discharged from hospital at this time, returning to nursing facility. Record review of Resident #1's Nurses Notes, by LVN E, dated 01/31/2023, read, 12:45 p.m. EMS arrived at facility, resident transferred to stretcher for transport to Hospital for surgical consult of fracture right distal femur. Record review of a witness statement, dated 1/31/2023 and signed by CNA A, reflected, Me, another CNA and nurse used proper procedure to lift resident from bed to chair and the lift pad strap snapped. Got more help after. Record review of a witness statement, dated 1/31/2023 and signed by CNA B, reflected, Upon transferring [Resident #1] from her bed to her recliner, the color-coded hooks tore apart. Resident began slipping out of the lift pad. My co-worker [CNA A] caught her upper body to keep resident from hitting her head on the recliner. I continued to lower the lift pad to the floor. The treatment nurse was in the room and witnessed the entire ordeal. We immediately called for help and [Resident #1] was assessed by the charge nurse. Record review of a witness statement, dated 1/31/2023 and signed by LVN C, reflected, I was in the room to provide wound care to resident. After I completed care [CNA A] and [CNA B] hooked the lift pad to the lift. They began lifting the resident to move her from the bed to the recliner. I began walking away and was about to leave the room when the leg strap on the lift pad broke. The resident's legs slide down onto the floor and the resident slide down onto the floor as the CNA's tried to catch her. I immediately called for assistance and began an assessment of the resident. The resident denied pain during the entire process, we notified the ADON and the DON immediately. Record review of Resident #1's Nurses Notes by Charge Nurse E, dated 02/06/2023, reflected, Returned to facility via EMS, post open reduction with internal fixation of right distal femur (surgery to repair broken bone above knee). Record review of Resident #1's care plan, with revision date 2/23/23, revealed Impaired physical mobility with an intervention/approach .resident unable to be transferred with Hoyer lift due to location of fracture, surgical repair of right femur fracture 2/3/23 During an observation and interview on 5/15/23 at 10:30 a.m., the Administrator provided the Hoyer lift pad used to transfer Resident #1 on 1/31/23. The blue lift pad was faded, the green straps were faded to a turquoise color, the red straps were faded to a pink color. The lower right strap that was originally black in color was cream colored with the last loop and second loop broken into with frays. The Administrator said it was the pad used during the transfer of Resident #1 and it was defective , most likely due to contact with bleach. During an interview on 05/15/2023 at 11:59 a.m. with CNA A, she stated she had been working at the 675358 Page 2 of 10 675358 06/03/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility since February 2022. CNA A said she received training on Hoyer lift safety and was checked off on the procedure on 2/01/2023. She stated it was policy to use 2 people for the Hoyer lift, to check Hoyer pad straps for signs of wear before use, but she forgot them on 1/31/23 before lifting Resident #1 . She said she observed Resident #1 bumping her knee against the Hoyer lift leg as she slid onto the floor. During an interview on 05/16/2023 at 2:35 p.m., CNA B stated she had been employed at the facility for 20 years. She said she received training on Hoyer lift safety and was checked off on the procedure on 2/01/2023. CNA B said using a Hoyer was always a 2 person assist, the straps were to be inspected before they were connected to the lift for signs of wear, but she forgot check the Hoyer pad straps for signs of wear before lifting Resident #1 on 1/31/2023 . She said she observed the resident bumping her knee against the Hoyer lift leg as she slid to the floor. During an interview on 05/18/2023 at 2:37 p.m., LVN C stated she had been employed at this facility a little over 4 years. LVN C said she received training on Hoyer lift safety and was checked off on the procedure on 2/01/2023. She said using a Hoyer lift would always be at least a 2 person assist, the Hoyer pad straps should always be inspected before use. She said she was not actively participating in the transfer when the incident occurred but observed the resident sliding to the floor and the resident bumping her right leg on the Hoyer lift leg. During an interview on 05/16/2023 at 12:03 p.m., CNA F stated she had been working at the facility for 2 years. She stated she would always use 2 people when making transfers with a Hoyer lift and inspect the straps on the Hoyer sling before use as that was the facility policy , and safer. She said she received training on 1/31/2023 after the incident with Resident #1. During an interview on 05/16/2023 at 12:30 p.m., CNA G said she worked at the facility for 9 years. She stated it was the facility's policy to always inspect the Hoyer sling before attaching it to the lift. CNA G stated she would not transfer anyone without help and would make sure the sling straps were not worn or discolored .CNA G said she received training after the incident on 1/31/23 and would remove any sling from service if it had signs of wear. During an interview on 05/16/2023 at 2:30 p.m., CNA K stated she worked at the facility for over 25 years. She stated a Hoyer transfer was always a 2 person assist, staff should always check the sling straps for discoloration, signs of wear including seams and stitching. CNA K said all staff were checked off on Hoyer lift safety including signs of wear to the slings and straps after the incident with Resident #1 and she received training after the incident on 1/31/23. CNA K said the Hoyer sling used to transfer resident #1 had been damaged since it was cream colored. During an interview on 05/17/2023 at 9:30 a.m., the ADON said she worked at the facility for 6 months. The ADON said she went to the room to assist CNA A, CNA B and LVN C immediately after the incident. The ADON said there was one on one training with CNA A and CNA B on 1/31/2023. She said all nurses and aides were in-serviced on 1/31/2023 and 2/1/2023 on Hoyer lift transfers and inspection of sling straps for signs of deterioration. The ADON stated the facility policy was to use 2 people when using the Hoyer lift to transfer residents and to inspect the straps prior to placement on the hooks of the lift. The ADON said a Quality Assurance meeting was held the day of the incident and a plan was immediately put in action. During an interview on 05/16/2023 at 1:00 p.m., the Administrator stated regarding the incident with Resident #1, he remembered it was reported to him as he arrived at the facility that morning. The 675358 Page 3 of 10 675358 06/03/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Administrator said the MD and family were notified, and orders were obtained. The Medical Director was informed, and a Quality Assurance Performance Improvement meeting was conducted on 1/31/23. A Quality Assurance Action Plan was developed, all slings were examined, new slings were ordered and labeled. Slings were monitored weekly for four weeks then monthly. The Administrator stated proficiencies were done with all aides due to this incident. The Administrator stated CNA A and CNA B were given a one-on-one in-service. He said there were risks of harm to residents by using a Hoyer sling that had any signs of deterioration, such as falls, lacerations, and a second person was needed to assist with movements of resident. The Administrator said all nursing staff were trained on proper use of the Hoyer lift including inspection of the slings before each use. The Administrator stated all laundry staff were retrained on the proper policy and procedures regarding laundry care (washing and air drying) of the Hoyer lift slings . Record review of the facility's in-service log reflected in-services were conducted on 1/31/2023 to 2/05/23 with competency checkoff for all nursing staff regarding proper use of the Hoyer lift and inspecting equipment prior to use. Record review of the Quality Assurance and Performance Improvement meeting minutes on 2/14/2023 and supporting documentation revealed that individual checkoffs for RN's, LVN's and CNAs were completed in January and February of 2023 for using the Hoyer lift and inspecting the sling straps prior to use. New Hoyer slings were labeled and put into use. Monthly checklist inspection of Hoyer slings had been logged each month by the ADON. Laundry staff received in-service on proper methods of washing and air-drying of Hoyer slings and when to take slings out of rotation (When slings show signs of wear, such color fading of fabric or stitch fading). During interviews and observations with 5 CNAs (CNA A, CNA B, CNA F, CNA G, CNA K and 3 LVNs ( LVN C, LVN D and LVN E) on the morning and evening shift on 5/16/23, all employees indicated they would always use at least 2 persons when transferring a resident using the Hoyer lift and inspect the Sling straps before use. Demonstration of correct transfer using Hoyer lift with sling check observed on 5/16/23 during a shower with Resident #2 and two CNAs . During interviews with Laundry Supervisor and Laundry Staff on 5/16/23, both employees indicated they would wash the slings according to manufacturer's suggestions (using no bleach and air dry) and had received inservice on signs of wear, signs of improper laundering and when to remove slings from service. A record review of the facility's policy Mechanical Lift, revised January 2020, reflected, .Residents will be assisted with their activities of daily living, utilizing lifts according to manufacturer's guidelines A record review of Full Body Slings- Medline, Instructions for use www.medline.com 2022 reflected .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use 2. Record review of Resident #2's face sheet, dated 5/17/23, reflected a [AGE] year-old female who was admitted to the facility on 7/16/. Resident #2 had diagnoses which included: brain cancer, lung cancer, unspecified dementia (confusion), history of falling, osteopenia (brittle bones), chronic pain (pain non acute), distal third tibial and fibular shaft fracture (broken lower leg bone) with 675358 Page 4 of 10 675358 06/03/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0689 comminution and slight displacement (bone no longer joined together). Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a Brief Interview for Mental Status of 6, which indicated severe cognitive impairment. The MDS further indicated the resident's functional status for bathing was a 4 which indicated total dependence and a 2 for support in bathing which indicated she was one person assist. Residents Affected - Few Record review of Resident #2's care plan, dated 4/02/23, indicated the resident was high risk for falls Limited joint mobility caused resident to have a higher risk of falling, with an intervention/approach .Hoyer with 2 persons assist She had a self-care deficit need for assistance with personal care with interventions with extensive total assistance and provide assistance with self-care as needed. Record review of Resident #2's emergency room records indicated she visited the emergency room on 2/28/23 with a diagnosis of fracture of the distal third tibial and fibular shaft fracture with comminution and slight displacement. Record review of Resident #2's nurse note dated 02/28/23 at 5:17 p.m., LVN E wrote, 02/28/2023 called to room by CNA, Resident #2 fell while in shower chair in shower. Resident lying on right side with no complaints at this time, examined resident and large knot on front of head and indention in forehead on left side. Resident complained of head pain, Medical Doctor notified of incident and new order received to send to emergency room for evaluation. [3:10 p.m.] Emergency medical services called to facility [3:13 ] Responsible party notified called and requested [hospital name] hospital. [3:20 ]: Emergency Medical Services arrived at facility and resident transferred via stretcher. Record review of Resident's #2's nurse note dated 02/28/2023 at 7:00 p.m., and signed by LVN H, she wrote, received call from [hospital name] Hospital that resident is ready to return to facility. Ortho consult with [Doctor's name] to be follow up in the morning. Diagnosis: Left distal third tibial and fibular shaft fracture with comminution and slight displacement. Splint brace to Left leg. Record review of a witness statement, dated 02/28/23 and signed by ADON, reflected, CNA A said while showering resident, CNA reached to grab a towel to dry off the resident. At this time the resident grabbed the assist bars in the shower and tried to pull herself up and resident fell out of the shower chair. CNA A notified charge nurse immediately .This nurse notified by [LVN H], nurse on A Hall, and when entered room nurse [LVN E], was in resident's room. Observed resident laying on her right side, noted to have a knot on her left forehead. MD notified and ordered to send resident to Emergency Room. Record review of a facility in-service, dated 2/28/2023, indicated education was provided: 1. All items within reach during showers when provided resident care, ensure all items are within reach to prevent leaving resident. During an observation on 5/15/23 at 9:15 AM, Resident #2 was lying in bed awake alert to person only. Resident #2 was asked questions but would not respond. Attempted phone interview with Resident #2's family member on 5/15/2023 at 3:00 PM, left a message with no return phone call. During an interview on 05/15/23 at 2:37 p.m., CNA A said she had been employed at the facility for 675358 Page 5 of 10 675358 06/03/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 1 year but had been a caregiver since 2019. She said on 02/28/23 she rolled Resident #2 into the shower in the shower chair. She said when she had completed the shower, she squatted down beside the shower chair with one hand on the arm of the chair to spread a towel on the floor to keep from slipping. CNA A said she turned away to grab a towel on the toilet, no more than two feet away from Resident #2. She said at that moment Resident #2 reached for the grab bar to pull herself up and fell out of the chair onto her knees on the floor. CNA A said she saw her falling and dove for the resident to try and keep her from hitting her head. She said she immediately called for her charge nurse to come and help. She said Resident #2 required 1 person for transfers and bathing. During an interview on 5/16/23 at 9:27 a.m., the ADON said CNA A turned away from Resident #2 to get a towel and that was when she fell. She said when the resident fell, she was grabbing the hand bar while CNA A turned to get a towel. The ADON said they in-serviced staff on keeping supplies within reach and safety of the resident. During an interview on 05/16/23 at 11:15 a.m., MA F said when she got through passing her medications, she tried to help the nurse aides on the floor. She said they had cut the aides because of their census. She said Resident #2 leaned forward a lot, and she would pull at things. She said Resident #2 really couldn't use her left side, but she could hold a cup in her right hand. MA F said she almost fell out of her wheelchair in the dining room last Friday (5/12/23). She said Resident #2 pushed herself back from the table and then she leaned forward and almost fell out of the chair. She said the lady cleaning the tables caught her . During an interview on 05/16/23 at 2:07p.m., CNA G said she worked at the facility since 2016. She said she always got another CNA to help her shower Resident #2 because she leaned. CNA G said she got another CNA because once she got wet with soap on her hands, it was hard to reposition the resident when she started leaning, to keep her from falling . CNA G said she had not reported the need for increased assistance to the MDS Coordinator but intended to do so. During an interview on 05/16/23 at 3:56 p.m., the Administrator said he thought CNA A left Resident #2 alone was the problem (stepping 2 feet away). The Administrator said CNA A was not suspended and had no prior disciplinary action besides frequently calling in. The Administrator said they did talk about falls every morning in the morning meeting, and they reviewed all falls during the monthly QAPI, meeting. The Administrator was unable to produce any Performance Improvement documentation involving the resident's fall. A record review of the facility's policy Fall Management, dated January 12, 2020, indicated, . The facility will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls. The community will manage falls by providing an environment that is free from potential hazards. This was determined to be an Immediate Jeopardy (IJ) on 06/02/2023 at 4:03 p.m. The Administrator was notified. The Administrator was provided with the IJ template 06/02/2023 at 4:03p.m. The following Plan of Removal was submitted by the facility was accepted on 6/03/2023 at 9:31 a.m. and included the following: On 01/31/2023 [Resident #1] was being transferred from bed to recliner with Hoyer lift by two CNA's. The strap broke on the right lower side and the resident slid to the floor hitting her knee on the leg of the lift causing a fracture. 675358 Page 6 of 10 675358 06/03/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0689 Level of Harm - Immediate jeopardy to resident health or safety [Resident #1] required surgery on 02/3/23 for fracture of right femur and returned to the facility on [DATE]. Resident was transferred to acute care . 03/25/23 for complications related to preexisting arterial circulation of the right lower leg and did not return to facility. In-services and training provided by DON and ADON to all nursing staff. New nursing staff receive competency upon hire and annually thereafter. Residents Affected - Few 1. Resident abuse and neglect on 1/31/23, 2/28/23 2. Hoyer Lift use, 1/31/23 3. Safe transfers, 1/31/23 4. Hoyer slings 1/31/23 5. Hoyer lift expectations. 1/31/23 6. Laundry- Lift Pads- Washing and drying -removing from service-1/31/23 provided by Housekeeping Supervisor to all Laundry Staff. All new laundry staff are trained upon hire and annually thereafter. 7. Hoyer Lift Skills and procedure for all nursing staff were completed 2/1/23 to 2/5/23 by administrative Nursing. All lift slings were removed from service and replaced with new slings by 2/2/23. Weekly monitoring of slings x 4 weeks then monthly completed by DON or designee. Verification of monitoring logs indicated all new slings in good condition and no old slings found in facility. The Medical Director was immediately notified and actively participated to develop improvement plan concerning Hoyer slings and training of staff. The plan was reviewed in Monthly QA Meeting with the Medical Director on 2/14/23 and monthly thereafter. On 2/28/2023 [Resident #2] leaned forward, reaching for the handrail and fell out of a shower chair when [CNA A] reached for a towel approximately 2 feet away. Resident #2 was diagnosed with a tibia and fibula fracture. Her leg was placed in a splint, and she returned to the facility. The leg was later placed in a cast. 18 nursing staff were in serviced by the ADON to ensure that all required items were in reach while showering a resident to prevent stepping away from the resident while being showered on 2/28/23. This in-service was repeated on 6/2/23 with nursing staff currently on shift. All nursing staff will be in serviced by 2 PM on 6/3/23. Any staff member that is not able to complete the in-service by this time will be removed from the schedule and not allowed to work until it is completed. [Resident #2] was care planned to require 2-person assistance on 5/16/23 by the MDS coordinator. All other residents were reassessed for level of assistance needed and care plan accuracy beginning 5/16/23 and completed by 5/18/23 by the MDS Coordinator and Regional Nurse Consultant. All nursing staff will be reeducated regarding ADL documentation accuracy and reporting changes via Point of Care (the documentation system used by the nurse aides) documentation by 6/3/23. 675358 Page 7 of 10 675358 06/03/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few DON or Designee will observe 2 showers per week for 4 weeks and periodically thereafter. Results will be reported to QA committee beginning 6/3/23 for 2 months. DON or Designee will observe 2 showers per week for 4 weeks and periodically thereafter. Results will be reported to QA committee beginning 6/3/23 for 2 months. Observations, Interviews, and record reviews were conducted 6/03/2023 from 12:30 p.m. through 2:00 p.m. and included (Administrator, ADON, 2 Laundry staff, 5 CNAs and 4 LVNs on the morning and evening shift) to ensure these interventions had been completed. Nursing staff were able to appropriately indicate they would always use at least 2 persons when transferring a resident using the Hoyer lift and inspect the sling straps before use. Laundry staff were able to appropriately indicate proper laundry methods for Hoyer slings and signs of deterioration. Nursing Staff were able to identify residents' care plans, the [NAME] system and how to find level of resident care. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Nursing Staff were able to discuss the required level of staff assistance for ADLs, documentation accuracy and reporting changes via Point of Care. Staff were able to demonstrate the use of the [NAME] system for resident care needs. A facility record audit from 5/16/2023 to 5/18/2023 by the MDS Nurse and Regional Nurse Consultant for all residents in current census indicated: each resident was reviewed for assistance to complete ADL tasks needed and the total number of staff members required. Nursing staff were in-serviced on 06/02/23 and 06/03/23 by the ADON to ensure that all required items were in reach while showering a resident to prevent stepping away from the resident while being showered. Nursing staff were in serviced by phone if not present at the facility and those who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. The care plan showed that Resident #2 was changed to a 2-person assist on 5/16/2023 by the MDS coordinator. Monitoring of the POR included the following: On 6/03/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: The facility completed an audit 5-16-23 to 5-18-23 of Care plans and [NAME]'s for level of assistance needed. Interviews with CNAs for all residents in current census to make updates to their POC. Each resident was reviewed for assistance required and the number of staff members required to complete ADL Tasks. CNAs Educated to continue to notify charge nurses of any changes with level of care needed with the 675358 Page 8 of 10 675358 06/03/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0689 Level of Harm - Immediate jeopardy to resident health or safety charge nurses/MDS nurse so POCs can be updated to reflect the correct amount of assistance needed. This in-service was completed by [NAME] RN, MDS Nurse. (There was a total of 4 residents that required a two person Hoyer Lift which indicates two persons for Bathing and Mobility) The staff in- serviced included: 38 Nursing Staff members,16 licensed vocational nurses, 2 registered nurses, Residents Affected - Few 20 CNA's certified Nurse Aides. The ADON, Regional Nurse Consultant, MDS Coordinator and Administrator were interviewed. LVN's and CNAs were interviewed from different shifts, on training and understanding to ensure compliance. All staff were able to verbalize understanding of in-service training regarding 1. Ensure POC is accurate with care/assistance needed. 2. Update Charge Nurse with any assistance needed outside of current plan, so the Plan of Care can be updated to provide correct documentation. 3. Shower Safety to include: a. All items are within reach during showers. b. When providing care for the resident ensure all items are within reach to prevent resident from being Observations, Interviews, and record reviews were conducted 6/03/2023 from 12:30 p.m. through 2:00 p.m. and included (Administrator, ADON, 2 Laundry staff, 5 CNAs and 4 LVNs on the morning and evening shift) to ensure these interventions had been completed. During an interview on 6/03/2023 with Laundry Supervisor and one laundry staff member were able to appropriately indicate proper laundry methods for Hoyer slings and signs of deterioration. During an interview on 6/03/2023 with LVN K, LVN L, LVN M, and ADON, Nursing Staff on day and evening shifts were able to identify residents' care plans, the [NAME] system and how to find the level of resident care. Staff provided appropriate resident supervision and redirection. There were no observed concerns. During an observation and interview on 6/3/2023 with, MDS Co-Ordinator, ADON CNA N, CNA O, CNA P, CNA Q and CNA R on day and evening shifts were able to demonstrate the use of the [NAME] system for resident care needs and were able to discuss the required level of staff assistance for ADLs, documentation accuracy and reporting changes via Point of Care. A record review on 6/3/2023 of a facility record audit from 5/16/2023 to 5/18/2023 and by the MDS Nurse and Regional Nurse Consultant (RNC-T), for all residents in the current census indicated: each 675358 Page 9 of 10 675358 06/03/2023 Colonial Pines Healthcare Center 1203 Fm 1277 San Augustine, TX 75972

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident was reviewed for assistance to complete ADL tasks needed and the total number of staff members required . The facility completed an audit 5-16-23 to 5-18-23 of Care plans and [NAME]'s for level of assistance needed. Each resident was reviewed for assistance required and the number of staff members required to complete ADL Tasks. Interviews were conducted by the MDS Nurse with 5 CNAs for all residents in current census to make updates to their POC. 2- RNs, 16 LVNs and 20 CNAs were educated to continue to notify charge nurses of any changes with level of care needed with the charge nurses/MDS nurse so POCs can be updated to reflect the correct amount of assistance needed. This in-service was completed by the MDS Co-Ordinator. (There were 4 residents that required a two person Hoyer Lift which indicates two persons for Bathing and Mobility) A record review on 6/3/2023 of in-services on 06/02/23 and 06/03/23 for 38 Nursing Staff members by the ADON to ensure all required items were in reach while showering a resident to prevent stepping away from the resident while being showered. Nursing staff were in serviced by phone if not present at the facility. A record review on 6/3/2023 of the care plan showed Resident #2 was changed to a 2-person assist on 5/16/2023 by the MDS coordinator. During an interview on 6/3/23 at 12:20 p.m. to 1:15 p.m. with Nursing staff LVN K, LVN L, LVN M, ADON CNA N, CNA O, CNA P, CNA Q and CNA R were able to verbalize understanding of in-service training regarding: 1.Ensure POC is accurate with care/assistance needed. 2.Update Charge Nurse with any assistance needed outside of current plan, so the Plan of Care can be updated to provide correct documentation. 3.Shower Safety to include: a. All items are within reach during showers. b. When providing care for the resident ensure all items are within reach to prevent resident from being regarding level and care, needed assistance during ADL's, Shower safety and Abuse/ Neglect. During an observation and interview on 6/3/23 at 1:25 p.m. CNA P and CNA Q transferred Resident #3 using two person Hoyer lift to the shower chair (Hoyer sling appeared new in condition) and showered the resident. Resident #3 had no complaints with his level of care and said he felt safe with the staff. CNA's verbalized understanding to always check Hoyer Lift slings for signs of wear which included discoloration or loose stitching. CNA P and CNA Q were able to demonstrate and verbalize the need to obtain supplies before beginning a shower and keep all items in reach during showers. Staff were able to verbalize/ demonstrate knowledge of procedure. The Administrator was informed the Immediate Jeopardy was removed on 06/03/23 at 2:00 p.m. The facility remained out of compliance at a severity level of actual harm and a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 675358 Page 10 of 10