Health inspection·December 12, 2023

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 interviews and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Level 1 Screening for 1 of 6 residents reviewed for PASRR (Resident #32). The facility failed to ensure Resident #32 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 07/25/2023. This failure could place residents at risk of not receiving needed individualized care, and specialized services to meet their needs. Findings included: Record review of a face sheet dated 12/12/2023 indicated Resident #32 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder and major depressive disorder. Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated Resident #32 had a BIMS score of 15 (fifteen) indicating no impaired cognition. The MDS section for PASRR indicated Resident #32 did not have a serious mental illness. The MDS indicated Resident #32 had a diagnosis of depression and Post Traumatic Stress Disorder. Record review of Resident #32's PASRR Level 1 Screening completed at an acute care hospital on [DATE] indicated in section C0100 the resident did not have evidence of having a mental illness. During an interview with the MDS Nurse on 12/12/2023 at 10:12 AM, she said she was responsible for tasks related to PASRR and MDS processes. She said she was the MDS Coordinator at the time of Resident #32's admission. She said at the time of Resident #32's admission, the acute care hospital completed her PASRR Level 1 Screening and indicated she was negative for mental illness. She said Resident #32 had a diagnosis of Post Traumatic Stress Disorder upon admission and questioned whether she needed to follow up and send notice to the local authority but never did. She said Resident #32's PASRR Level 1 Screening was incorrect upon admission, and she should have notified the local authority Resident #32 had an incorrect PASRR Level 1 Screening and was positive for mental illness. The MDS Nurse said she understood the importance of PASRR Level 1 Screenings being accurate because the facility needed to make sure eligible residents were getting the correct resources. Page 1 of 3 675563 675563 12/12/2023 Colonial Nursing & Rehabilitation Center 508 Pierce St Lindale, TX 75771

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 of 4 quarters for 2023 (Quarter 3) reviewed for nursing services. *The facility did not have sufficient staff according to the PBJ report for Quarter 3 2023 (April 1 through June 30). This failure could place residents at risk of diminished quality of life and quality of care. Findings included: Record review of the CMS PBJ reports Quarter 3 2023 (April 1 through June 30) indicated: the facility had a 1-star staffing rating; * the facility failed to have Licensed Nursing Coverage 24 hours/Day from April 1st through June 5th. * the facility had excessively low weekend staffing. During an interview on 12/11/23 at 3:37 p.m., the Administrator said the facility changed ownership in June 2023 and he started working at the facility in July 2023. The Administrator said the facility did not submit the prior quarterly PBJ report regarding staffing under the previous owner. The Administrator said under the new ownership, they had a new payroll company and can access employee timecards to submit staffing data to the PBJ. The Administrator said the Regional Director of HR was responsible for submitting the staffing data to the PBJ. During an interview on 12/11/23 at 4:06 p.m., the DON said she started working at the facility in November 2023 and did not work for the previous owner. The DON said she had no knowledge regarding the prior quarterly PBJ report regarding staffing and tried to keep staffing according to the needs of the residents. During an interview on 12/12/23 at 4:30 p.m., the Regional Director of HR said she started working for the new ownership in May 2023 and was responsible for submitting the staffing data to the PBJ. She said she contacted the previous owners payroll company and asked them for the timecards, but they denied her access because there was an outstanding bill. She said she was not responsible for submitting the facility's prior quarterly PBJ report regarding staffing because she did not work at the facility for the previous owner at that time. The Regional Director of HR said they did not have a policy regarding PBJ reporting, and she followed the CMS guidelines for PBJ reporting. 675563 Page 2 of 3 675563 12/12/2023 Colonial Nursing & Rehabilitation Center 508 Pierce St Lindale, TX 75771

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure they had an RN for 8 consecutive hours 7 days a week for 1 of 4 quarters of 2023 (Quarter 3) PBJ reports reviewed for RN coverage. Residents Affected - Some The facility did not have RN coverage from April 1st through June 5th and 2 weekends in June 2023. This failure could place residents at risk of lack of nursing oversight and a higher level of care. Findings included: Record review of the CMS PBJ reports Quarter 3 2023 (April 1 through June 30) indicated there were no RN hours on the following dates: * April 1st through June 5th * 06/10 (Saturday) * 06/11 (Sunday) * 06/26 (Monday) During an interview on 12/11/23 at 3:37 p.m., the Administrator said the facility changed ownership in June 2023 and he started working at the facility in July 2023. The Administrator said facility did not submit the prior quarterly PBJ report regarding staffing under the previous owner. The Administrator said under the new ownership they have a new payroll company and can access employee timecards to submit staffing data to the PBJ. The Administrator said the Regional Director of HR was responsible for submitting the staffing data to the PBJ. During an interview on 12/11/23 at 4:06 p.m., the DON said she started working at the facility in November 2023 and did not work for the previous owner. The DON said she had no knowledge regarding the prior quarterly PBJ report regarding staffing and tried to keep staffing according to the needs of the residents. During an interview on 12/12/23 at 4:30 p.m., the Regional Director of HR said she started working for the new ownership in May 2023 and was responsible for submitting the staffing data to the PBJ. She said she contacted the previous owners payroll company and asked them for the timecards, but they denied her access because there was an outstanding bill. She said she was not responsible for submitting the facility's prior quarterly PBJ report regarding staffing because she did not work at the facility for the previous owner at that time. The Regional Director of HR said they did not have a policy regarding PBJ reporting, and she followed the CMS guidelines for PBJ reporting. 675563 Page 3 of 3