Health inspection·July 12, 2022

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Potential for minimal harm Based on interviews and record review, the facility failed to ensure the residents received mail for 6 of 6 residents reviewed for rights to forms of communication. (Resident #s #9, #13, #28, #31, #44 and Residents Affected - Many #112). The facility did not ensure residents received their mail promptly. This failure could place the residents at risk of not receiving mail in a timely manner and a diminished quality of life. Findings included: During an group interview on 07/11/2022 at 10:30 a.m., Residents #9, #13, #28, #31, #44 and #112 said they did not know if mail was delivered on Saturday's. The residents said they only received mail Monday through Friday. During an interview on 07/11/2022 at 10:40 a.m., the Activity Director said she is not sure who handles the mail on the weekend. She said the Receptionist brings her the mail during the week and she distributes it to the residents. She said she is not sure how the mail is handled on the weekend. During an interview on 07/12/2022 at 10:49 a.m., the weekday Receptionist said she received the mail Monday through Friday, she sorts it and takes the remainder to the Business Officer Manager. She said the Business Office Manager sorts it and gives her the mail for the residents and she takes that mail to the Activity Director. The Receptionist said the weekend mail is collected by the weekend receptionist on Saturday and locked in the desk drawer. She said when she arrives on Monday, she retrieves the mail, sorts it, and she takes the remaining mail to the Business Office Manager. She said she receives the residents' mail back from the Business Office Manager and takes it to the Activity Director for distribution. During an interview on 07/12/2022 at 11:01 a.m., the Business Office Manager said she receives the mail from the weekday Receptionist Monday through Friday. She said she sorts it and gives the residents' mail back to the Receptionist to give to the Activity Director. She said Saturday mail is locked in the desk drawer until Monday, when the weekday Receptionist gets it and brings it to her. Record review of the facility's Policy/Procedure; Resident Rights and Responsibility Notice of: Privacy and Confidentiality, dated 11/23/2016, revealed, 3. personal privacy, including the right to privacy in your oral (that is, spoken), written, and electronic communications, including the right to Page 1 of 4 675597 675597 07/12/2022 Crestwood Health and Rehabilitation Center 1448 Houston St Wills Point, TX 75169

F 0576 promptly receive unopened mail and other letters, packages and other materials delivered to the facility for you . Level of Harm - Potential for minimal harm Residents Affected - Many 675597 Page 2 of 4 675597 07/12/2022 Crestwood Health and Rehabilitation Center 1448 Houston St Wills Point, TX 75169

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received and consumed foods with the appropriate nutritive content as prescribed by the physician for 1 of 1 resident reviewed for therapeutic diets. (Resident #45). The facility did not prepare or serve a fortified food product to Resident #45 on 07/10/2022 and 07/11/22 as indicated on the dietary slips and physician orders. This failure could place residents at risk for weight loss and not having their nutritional needs met. Findings included: Review of Resident #45's physician's orders dated July 2022 indicated Resident #45 was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including dementia, Parkinson's disease, psychotic disorder and weight loss. The orders indicated she was to receive a regular diet, pureed texture on the fortified meal plan. She was also to receive Resource (liquid nutritional supplement) 120 ml three times a day during the medication pass. The physician's orders indicated the resident was receiving Remeron (mirtazapine) 7.5 mg. daily at bedtime for weight loss. Review of Resident #45's annual MDS dated [DATE] indicated Resident #45 was severely cognitively impaired, required extensive assistance of one staff with eating, and had unplanned weight loss. Review of Resident #45's progress notes and weight logs indicated the following: *On 05/09/2022 11:06 AM: Magic Cup and Resource 2.0 were discontinued due to a BMI of 24. The weight log dated 05/05/2022 indicated Resident #45 weighed 140 lbs. *On 06/01/2022 the weight log indicated the resident weighed 116.2 lbs. *On 06/03/2022 11:05 AM: Resident #45 had Resource TID 120 ml for weight loss for 14 days. Resident #45 was assisted with meals to encourage food intake. FMP for 7 days. The MD and family were notified. The weight log dated 05/26/2022 indicated Resident #45 weighed 119.6 lbs. The Dietary Manager and DON met for an interdisciplinary team meeting to address the weight loss, resident had eaten 75% of breakfast, Resource 120 ml, FMP, MD orders entered and would continue to encourage the resident to eat. The family notified. *On 06/09/2022 01:22 PM: The MD was contacted, and an order was received for Remeron (appetite stimulant) 7.5 mg orally at bedtime. The staff would continue to monitor weekly weights. Resident #45 was on FMP and Resource 2.0. *On 06/14/2022 03:37 PM the Registered Dietitian note indicated the resident had an order for FMP and Resource 2.0 120 ml for 14 days. The new recommendation was to continue Resource 2.0 120 ml three times a day for 90 days. *On 06/23/2022 08:22 AM: Per the Dietitian's recommendation and physician's approval a new order 675597 Page 3 of 4 675597 07/12/2022 Crestwood Health and Rehabilitation Center 1448 Houston St Wills Point, TX 75169

F 0808 reflected Resident #45 had an order for FMP and Resource 2.0 120 ml for 14 days; and a recommendation to continue Resource 2.0 120 ml three times a day for 90 days. Level of Harm - Minimal harm or potential for actual harm *On 06/30/2022 03:35 PM the weight log indicated the resident weighed 120.4 lbs. Residents Affected - Few *On 07/05/2022 07:22 PM the weight log indicated the resident weighed 118.2 lbs. *On 07/12/2022 10:45 AM the Registered Dietitian's note indicated weight loss, had ordered FMP and Resource 2.0 120 ml three times a day. Resident #45 had 75-100% intake reported by staff. The new recommendation was to increase Resource 2.0 to 240 mL three times a day. During an observation on 07/10/2022 on the memory care unit at 12:30 PM, Resident #45's diet slip indicated she was to receive fortified foods. Observation of Resident #45's meal reflected she did not receive any fortified food items or extra butter. She received pureed baked chicken, baked beans and corn, as well as chocolate pudding for dessert. During an observation and interview on 07/10/2022 on the memory care unit at 12:39 PM, LVN A said she let Resident #45 eat as much of her lunch by herself as she could, then she would help her a bit. LVN A was observed feeding Resident #45 and the resident ate 100% of the food served. During an observation of tray line service in the kitchen on 07/11/2022 at 11:50 AM, the holding temperatures were taken on food prepared for the noon meal. The pureed items were ham, pinto beans, and broccoli. There were no fortified foods prepared on the steam table. Resident #45's meal tray was on the memory unit cart and left the kitchen at 12:08 PM and her tray did not contain a fortified food item. During an observation on 07/11/2022 at 12:13 PM, Resident #45 did not receive any fortified food item or extra butter. She received ham, pinto beans and broccoli in a pureed form. Her diet slip indicated she was to receive fortified foods. During an interview and observation on 07/12/2022 at 3:30 PM, the DM said the FMP consisted of extra butter (3 pats) placed on the tray and the nursing staff were to mix it into the food. She said the dietary department also prepared fortified items with extra butter and canned milk, like mashed potatoes and pudding. She said other fortified products could be used like a Magic Cup (frozen nutritional treat), ice cream, or health shake. She said oatmeal or cream of wheat at breakfast were prepared with extra butter and canned milk, but all residents received the fortified hot cereal. She said the dietary department placed the extra items on the trays. She said those were extra foods and did not replace a dessert or vegetable that was part of the meal. She checked the evening meal trays for 07/12/2022 that were partially set up with dietary slips and silverware and she pulled out Resident #45's meal tray and dietary slip. The dietary slip indicated FMP. She said the cook was to prepare any fortified foods. The DM was asked for a resident dietary roster, but it was not provided. During an interview on 07/12/2022 at 3:35 PM, the DM asked [NAME] B if she had prepared any fortified foods for the noon meals on 07/10/2022 and 07/11/2022. [NAME] B said she did not prepare any fortified foods because she was not aware any resident was receiving fortified foods. During an interview on 07/12/2022 at 5:15 PM, the DON said Resident #45 was receiving Resource 2.0 as a nutritional supplement. 675597 Page 4 of 4