Health inspection·March 11, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good toileting hygiene for 1 (Resident #1) of 5 residents reviewed for ADLs. Residents Affected - Few The facility failed to change Resident #1's briefs and document all incontinent care performed on 03/07/24. This deficient practice could place residents at risk of a decreased quality of life. Findings included: Record review of Resident #1's undated face sheet revealed a female who was admitted to the facility on [DATE], readmitted on [DATE], and was her own RP. Record review of Resident #1's diagnoses report, dated 03/07/24, revealed she had diagnoses including unspecified degenerative disease of nervous system (affect many of the body's activities, such as balance, movement, talking, breathing, and heart function), unspecified severity of vascular dementia with other behavioral disturbance, age-related osteoporosis (A condition in which bones become weak and brittle) without current pathological fracture, weakness, unspecified anxiety disorder, left hand contracture (a condition of shortening and hardening of muscles, tendons, or other tissue), overactive bladder, restlessness and agitation, unspecified bipolar disorder, unspecified impulse disorder, unspecified single episode major depressive disorder, unspecified pain, and unspecified psychosis not due to a substance or known physiological condition. Record review of Resident #1's comprehensive MDS assessment, dated 02/09/24, revealed a BIMS score of 13, indicating she was cognitively intact. Resident #1 was dependent on staff with toileting hygiene. Resident #1 was always incontinent with urinary and bowel movements. Record review of Resident #1's care plan, dated 02/26/24, revealed she had functional bladder incontinence and bowel incontinence related to dementia, impaired mobility, and overactive bladder. CNAs, LPNs, and RNs were required to change Resident #1 every two hours and PRN. Record review of Resident #1's BIMS evaluation, dated 03/04/24, revealed a score of 14, indicating she was cognitively intact. Record review of Resident #1's quarterly bladder evaluation, dated 03/04/24, revealed she had functional incontinence contributing to her condition, was wheelchair bound, dependent, disoriented, had Page 1 of 5 675596 675596 03/11/2024 Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735

F 0677 decreased manual dexterity, and varied in her voiding (to urinate) pattern. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's POC, dated 03/07/24, revealed staff assisted Resident #1 with toileting hygiene at 2:26 a.m. and 6:20 a.m. There were no other entries. Residents Affected - Few During an observation and interview on 03/07/24 at 9:58 a.m., Resident #1 was lying on her back in her bed. Resident #1 appeared clean, comfortable, dressed, and had her call light resting on her stomach. Resident #1 revealed she wore briefs. Resident #1 stated staff changed her briefs. Resident #1 also stated she waited 15 minutes for staff to change her briefs. Resident #1 did not indicate when staff last changed her brief on 03/07/24. An observation on 03/07/24 at 10:18 a.m. revealed CNA A and B entered Resident #1's room to transfer Resident #1 from her bed to her wheelchair. As CNA A and B lifted Resident #1 using the gait belt and transferred her to her wheelchair, the surveyor observed Resident #1's pants were soaked from the buttocks to the hamstrings. The surveyor asked CNA A and B if they observed Resident #1's pants were soaked when lifting Resident #1 using the gait belt and transferring her to her wheelchair. CNA A and B lifted Resident #1 using the gait belt again, observed Resident #1's pants were soaked, transferred Resident #1 back into her bed, and changed Resident #1's brief and pants. The surveyor left the room before CNA A and B began changing Resident #1's brief. During an interview on 03/07/24 at 10:26 a.m., CNA A and B revealed they did not observe Resident #1's pants were soaked when they transferred Resident #1 from her bed to her wheelchair. CNA A stated she last changed Resident #1's brief one hour ago . CNA A did not indicate if she documented the incontinent care she performed on Resident #1. During an interview on 03/07/24 at 10:27 a.m., the ADON revealed she worked at the facility for five months. The ADON stated she was trained and in-serviced twice a month or more as needed on ADL care. The ADON stated she encouraged staff to round (check on residents) every 30 minutes. The ADON also stated nurses monitored residents' bladder and bowel movements according to the physician's orders. The ADON explained CNAs and nurses changed residents' briefs every two hours or more as needed. The ADON stated staff often changed Resident #1's briefs. The ADON did not indicate how often staff changed Resident #1's briefs. The ADON also stated Resident #1 was her own RP, had dementia, increased confusion, no urge to ask staff to change her briefs, and did not have any skin breakdown. During an interview on 03/07/24 at 11:22 a.m., Nurse C revealed she worked at the facility for 7 ½ months. Nurse C also stated she previously worked as a CNA at the facility for 2-3 years. Nurse C stated she was trained and in-serviced on ADL care by the ADON, DON, and ADM weekly or as needed. Nurse C also stated CNAs, MAs, and nurses changed residents' briefs every two hours. Nurse C stated CNAs documented ADL care performed in residents' POC. During an interview on 03/07/24 at 12:09 p.m., Nurse D revealed she worked at the facility for 10 months. Nurse D also stated she was trained and in-serviced on ADL care daily. Nurse D stated CNAs changed residents' briefs every two hours or more as needed. During an interview on 03/07/24 at 12:40 p.m., CNA A revealed she worked at the facility for six months. CNA A also stated she was trained and in-serviced on ADL care by the DON. CNA A stated she changed residents' briefs every two hours. CNA A also stated ADL care provided to or refused by the resident was documented in POC and reported to the charge nurse . CNA A stated she put Resident #1 in bed one hour before the surveyor observed Resident #1's pants were soaked. CNA A did not indicate if 675596 Page 2 of 5 675596 03/11/2024 Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she documented the incontinent care she performed on Resident #1 one hour before the surveyor made an observation of Resident #1's soaked pants. CNA A explained Resident #1's briefs were changed 3-4 times daily or more as needed. During an interview on 03/07/24 at 1:45 p.m., CNA E revealed she worked at the facility for three years. CNA E also stated she was trained and in-serviced on ADL care every month. CNA E stated CNAs changed residents' briefs every two hours daily. CNA E also stated ADL care provided to or refused by a resident was documented in a resident's POC. CNA E stated she rounded every two hours or more. During an interview on 03/11/24 at 11:08 a.m., Nurse F revealed she worked at the facility for seven months. Nurse F stated she was trained and in-serviced on ADL care. Nurse F also stated CNAs and nurses conducted rounds. Nurse F did not indicate how often CNAs and nurses conducted rounds. Nurse F stated CNAs and nurses checked residents to determine if they were soiled and changed residents' briefs every two hours. Nurse F also stated CNAs documented the care performed in residents' POC and nurses documented residents' refusals for care in nurse's notes. Nurse F stated residents could develop skin issues, become embarrassed, and have a foul odor if CNAs did not observe a resident was soiled. During an interview on 03/11/24 at 11:22 a.m., Nurse G revealed she worked at the facility for 10 months. Nurse G stated she was trained and in-serviced on ADL care by the ADM weekly. Nurse G also stated CNAs, MAs, or nurses could change residents' briefs every two hours or more as needed. Nurse G stated CNAs documented the care performed in residents' POC. Nurse G also stated resident were checked on every two hours or more. Nurse G stated residents could develop skin issues if CNAs did not observe a resident was soiled. During an interview on 03/11/24 at 1:34 p.m., the ADM revealed there was no policy and procedure for when to perform incontinent care, but she would check. During an interview on 03/11/24 at 1:37 p.m., the DON revealed she worked at the facility for one year. The DON stated she was trained and in-serviced on ADL care by the regional clinical specialist. The DON also stated she expected CNAs and nurses to change residents' briefs and round every two hours. The DON stated she also expected CNAs and nurses to change residents' briefs if the briefs were wet. The DON also stated ADL care was documented in residents' POC. The DON explained not all ADL care was documented in residents' POC due to the restriction in residents' electronic health records that only allows one entry per shift for ADL care performed per shift. The DON stated she did not know how staff confirmed ADL care was being performed as needed if the electronic health records allowed them to input one entry per shift. The DON stated she expected staff to observe residents' clothes. The DON also stated it was a dignity issue if a resident had food or stains all over their clothes. The DON stated residents could develop skin breakdowns if they were left sitting in their wheelchairs with soiled or wet pants over a duration. The DON also stated residents could also have dignity issues, feel embarrassed, and sad. During an interview on 03/11/24 at 2:00 p.m., the ADM revealed there was no policy and procedure for when to perform incontinent care. The ADM stated there was a universal understanding that incontinent care was performed every two hours. The ADM did not indicate if staff needed to document incontinent care. Record review of the facility's in-services revealed staff were trained on checking residents' clothes/shoes when getting residents out of bed and dressed on 02/13/24 and taught all staff must pay 675596 Page 3 of 5 675596 03/11/2024 Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attention to the residents as they passed them in hallways and to look at clothing/shoes. Staff were also trained on rounding on 02/20/24 and taught that CNAs and nurses should not leave their shift without doing a walking round or giving a report to the upcoming shift, another CNA and nurse from another hallway could round if the person relieving were running late, rounds should be done every shift and purpose was to ensure residents were being taken care of properly. Staff were also trained on daily work assignments on 02/20/24 and taught when the assignment says a staff member will be late or called in, the halls were then split, staff were responsible for rounding on the 'split' hall, and late staff member was to round immediately when they arrive. Record review of the facility's Pericare-Incontinent Care checklist, revised in January 2023, revealed a step-by-step guidance on how to perform perineal care on male, female, and indwelling catheter residents. The checklist did not indicate how often to round and perform incontinent care on residents. Record review of the facility's ADL policy and procedure, revised in March 2018, revealed the following, Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 1. Residents will be provided with care treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. b. Unavoidable decline may occur if he or she: (1) has a debilitating disease with a known functional decline; (2) has suffered the onset of an acute episode that caused physical or mental disability and is receiving care to restore or maintain functional abilities; and/or (3) refuses care and treatment to restore or maintain functional abilities and: a) the resident and or representative has been informed of the risk and benefits of the proposed care or treatment; and b) he or she has been offered alternative interventions to minimize further decline; and c) the refusal and information are documented in the resident's clinical record. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including 675596 Page 4 of 5 675596 03/11/2024 Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735

F 0677 appropriate support and assistance with: Level of Harm - Minimal harm or potential for actual harm a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); Residents Affected - Few c. elimination (toileting); 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the assessment reference date (ARD) and the following MDS definitions: e. Total dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period. 675596 Page 5 of 5