Health inspection·November 8, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental and psychosocial needs for 1 of 12 residents (Resident #34) reviewed for care plans. Resident #34 did not have appropriate interventions for a DNR documented in the care plan and electronic [NAME] (summary of ordered interventions) in Point Click Care (electronic medical record). This failure could place residents at risk for inappropriate interventions by staff when reading information in the clinical record, (that is inaccurate or incomplete) which could delay emergency treatment or incur unwanted treatment. Findings: Review of Resident #34's physician's order summary dated [DATE] revealed she was [AGE] years old and admitted on [DATE] with diagnoses including Anorexia (Not Eating), Hypertension (High Blood pressure) and Age-Related Cognitive Decline. The Orders included a prescriber written order dated [DATE] for a DNR. Record review of Resident #34's EMR in PCC indicated the Code Status was DNR. Record Review of Texas Department of State Health Services Standard Out of Hospital Do-Not-Resuscitate Order revealed it was fully executed on [DATE]. Record review of Resident #34's Baseline Care Plan dated [DATE] indicated Code Status of DNR. Review of Resident #34's comprehensive care plan with revision date [DATE] for code status revealed it included the following: Goal: Resident is a FULL CODE status. Goal: Resident/Representative part decision for full Code will be honored through the next review date. Interventions: Initiate BLS/CPR if Resident #34 is without heartbeat or not breathing. Page 1 of 8 675729 675729 11/08/2022 Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972

F 0656 Notify EMS. Level of Harm - Minimal harm or potential for actual harm During an Interview, record review and observation on [DATE] at 09:29 AM, LVN B said that she would view the Profile or [NAME] in PCC, the EMR, if she needed to know the code status of a resident, if she found someone not breathing or without a pulse and she would have someone verify in the chart if they were available. LVN B said that there was a listing on the Crash Cart (a cart that contains supplies used during CPR), that reflects the Code Status of the Residents also and it was updated frequently. LVN B accessed Resident #34's profile and DNR was listed in PCC. LVN B accessed the [NAME] for Resident #34, which included: Residents Affected - Few [NAME]: o Initiate BLS/CPR if Resident #34 is without a heartbeat or not breathing. Notify EMS. [LVN, CNA, PT, SW] H Shows on [NAME]. o Notify the charge nurse immediately if the resident is not breathing or does not have a heartbeat. [LVN, CNA, PT, SW] H Shows on [NAME] Continued interview with LVN B on [DATE] at 09:29 AM revealed the [NAME] does not match, she said we would not initiate CPR or notify the charge nurse that the resident is not breathing and she would correct it right away. LVN B said she would never look at the care plan for code status, but the care plan should be accurate. LVN B reviewed the latest care plan and she said it has Full Code. LVN B said that needs to be changed and she can correct it. LVN B said the Care Plan flows to the [NAME] and staff of all disciplines do access the [NAME], and it could cause problems if incorrect. During an interview on[DATE] at 09:46 a.m. with the DON and ADON revealed the DON said that the ADON completes the care plans and the DON is ultimately responsible for all care plans. The DON said she had just reviewed Resident #34's Care plan and she would change it today since it was not accurate. The DON said all records should be accurate and reflect the resident's wishes. The DON said Records including the Care Plan should reflect interventions that are accurate from MD orders and DNR status. Inaccurate care plans increase the risk of a resident receiving inappropriate interventions. During an interview on [DATE] at 10:02 a.m. the ADM said that the DON and ADON are responsible for Care Planning. Review of facility policy, undated, titled Advance Directives and Advance Care Planning Procedure revealed upon admission 1) admitting charge nurse will obtain an order for code status. After admission: 1) Social worker will meet with the newly admitted resident or representative within 72 hours of admission to verify the code status and document the discussion/education in the chart. 675729 Page 2 of 8 675729 11/08/2022 Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that residents needing respiratory care were provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #25) reviewed for respiratory care and services. Residents Affected - Few Resident #25 used oxygen at night and had a water bottle on her oxygen concentrator dated 10/03/22 with orders for oxygen tubing and supplies to be changed at least weekly. This deficient practice could place residents who receive respiratory care and services, at risk of developing respiratory infections and complications. Findings Included: Clinical record review of Resident #25's face sheet dated 11/07/22 indicated resident #25 was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including: Urinary tract infection, edema (swelling), hypertension, chest pain, and chronic atrial fibrillation (irregular heart rate & rhythm). Record review of MDS dated [DATE] revealed that Resident #25 had a BIMS score of 12, indicating that she had moderate cognitive impairment. During an observation and interview on 11/06/22 at 11:08 AM, Resident #25 was observed sitting up on the side of her bed, oxygen tubing and nasal cannula noted on the bed beside her. She said that she had just taken it off, and that she wore it at night while sleeping. The oxygen bottle on the concentrator was dated 10/3/22, and no date was noted on the tubing. Resident #25 said that she wore it every night and said that she thought it was changed 2 or 3 weeks ago. Record review of physician orders dated 11/7/22 revealed that Resident #25 had the following order .O2 @ 2LPM via NC; may titrate to keep O2 saturation above 92% as needed . and .oxygen tubing and supplies to be changed weekly and prn . Record review of care plan dated 11/7/22 stated .(Resident #25) has oxygen therapy . and .oxygen at 2LPM per nasal cannula PRN . During an interview on 11/08/22 at 11:30 AM, LVN B said the charge nurse on night shift is responsible for ensuring that tubing and bottles are changed weekly. During an interview on 11/07/22 at 1:04 PM, the ADON said that tubing and concentrator bottles should be changed every 7 days and that the risks included possible development of respiratory infections. During an interview on 11/8/22 at 09:30am, the DON said that the concentrator bottles were to be changed weekly, every 7 days, due to the increased risk of dryness in the nasal cavity and increased risk of infection if the nasal cavity gets dry and cracked. She said she would be in-servicing nursing staff on checking and changing bottles and tubing weekly. She said that going forward, she would expect night shift to change tubing and concentrator bottles weekly, as per policy. 675729 Page 3 of 8 675729 11/08/2022 Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972

F 0695 Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled [Facility] Departmental (Respiratory Therapy) Prevention of Infection Policy, undated, stated .pre-filled sterile humidification water bottle will be marked with date and initials upon opening and changed and discarded every 7 days and prn . Residents Affected - Few 675729 Page 4 of 8 675729 11/08/2022 Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 2 unit refrigerators (#2) and 1 of 2 storage rooms (#1). 1. Med Pass fortified dietary supplement was observed on 11/06/2022 in the #2 medication storage unit refrigerator used for resident snacks and dietary nourishment supplements that had expired on 11/2/2022. 2. Six containers of Med Pass fortified dietary supplement with expiration date of 11/02/2022 were observed on 11/06/2022 in the #1 medication storage cabinet. These failures could place residents at risk for food-borne illness. Findings: During an observation of medication storage #1 on 11/06/22 at 11:00 AM revealed six containers of Med Pass fortified dietary supplement were located in the cabinet with an expiration date of 11/02/2022. The DON was present and removed the product from the cabinet and placed it in the trash. During an observation of medication storage #2 on 11/06/22 at 11:25 AM revealed the unit refrigerator for nutritional supplement storage had one opened container of Med pass fortified dietary supplement present. The bottle was opened and dated on 11/02/2022 with an expiration date of 11/02/2022. The DON was present and removed the dietary supplement from the unit refrigerator and disposed of it in the trash. During an interview on 11/06/22 at 11:30 AM, the DON stated she had just received that shipment a few months ago and was not aware it had expired. The DON stated it is the charge nurse's responsibility to check the unit refrigerators for expired dietary supplements or snacks before distributing to residents. The DON stated the DM orders the Med Pass dietary supplement, and places it in medication storage. The nurses are responsible for it once it is placed in the medication storage unit. The DON stated it had been over a year since the last in-service with nurses regarding checking unit refrigerators for expired products. The DON stated she would retrain the nurses and put in place a system to monitor the unit refrigerators for expired dietary supplements and snacks. DON stated the risk could be sickness or infection. During an interview on 11/07/22 at 02:58 PM LVN A stated the charge nurses distribute the dietary supplements and shakes. LVN A stated all nurses are responsible for checking the expiration date before giving any snack or dietary supplement. LVN A stated she has had training on checking expiration dates before distributing supplements to residents. LVN A stated the risk could be sickness to the residents. During an interview on 11/07/2022 at 03:01 PM, the DM stated she orders the Med Pass dietary supplement for the nursing department but once it is delivered, the DON stocks it in the medication storage room. The DM stated after that she only reorders when the DON tells her the stock is low. During an interview on 11/08/2022 at 09:09 AM, the ADM stated that the DON and ADON are responsible 675729 Page 5 of 8 675729 11/08/2022 Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for ensuring the nursing staff are checking for expired products and following the policy for nutritional supplements. The ADM stated she expects the policy and procedure to be followed. Record Review of undated facility policy titled, Med Pass Fortified Nutritional Shake Program stated, .Procedure #4 Med pass will be delivered from dietary to the nourishment refrigerator located at the nursing unit. If the Med Pass remains in the nourishment refrigerator the stock will be rotated, #5. Med Pass needs to be kept refrigerated, V. Sanitation Issues, cover. label, and refrigerate opened containers of Med Pass products and discard after 4 days . 675729 Page 6 of 8 675729 11/08/2022 Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records that were complete and/or accurate for 1 of 12 residents (Resident #34) reviewed for advanced directives. Resident #34 did not have appropriate interventions for a DNR documented in the care plan and electronic [NAME] (summary of ordered interventions) in Point Click Care (electronic medical record). This failure could place residents at risk for inappropriate interventions by staff when reading information in the clinical record, (that is inaccurate or incomplete) which could delay emergency treatment or incur unwanted treatment. Findings: Review of Resident #34's physician's order summary dated [DATE] revealed she was [AGE] years old and admitted on [DATE] with diagnoses including Anorexia (Not Eating), Hypertension (High Blood pressure) and Age-Related Cognitive Decline. The Orders included a prescriber written order dated [DATE] for a DNR. Record review of Resident #34's EMR in PCC indicated the Code Status was DNR. Record Review of Texas Department of State Health Services Standard Out of Hospital Do-Not-Resuscitate Order revealed it was fully executed on [DATE]. Record review of Resident #34's Baseline Care Plan dated [DATE] indicated Code Status of DNR. Review of Resident #34's comprehensive care plan with revision date [DATE] for code status revealed it included the following: Goal: Resident is a FULL CODE status. Goal: Resident/Representative part decision for full Code will be honored through the next review date. Interventions: Initiate BLS/CPR if Resident #34 is without heartbeat or not breathing. Notify EMS. During an Interview, record review and observation on [DATE] at 09:29 AM, LVN B said that she would view the Profile or [NAME] in PCC, the EMR, if she needed to know the code status of a resident, if she found someone not breathing or without a pulse and she would have someone verify in the chart if they were available. LVN B said that there was a listing on the Crash Cart (a cart that contains supplies used during CPR), that reflects the Code Status of the Residents also and it was updated frequently. LVN B accessed Resident #34's profile and DNR was listed in PCC. LVN B accessed the [NAME] for Resident #34, which included: 675729 Page 7 of 8 675729 11/08/2022 Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972

F 0842 [NAME]: Level of Harm - Minimal harm or potential for actual harm o Initiate BLS/CPR if Resident #34 is without a heartbeat or not breathing. Notify EMS. Residents Affected - Few [LVN, CNA, PT, SW] H Shows on [NAME]. o Notify the charge nurse immediately if the resident is not breathing or does not have a heartbeat. [LVN, CNA, PT, SW] H Shows on [NAME] Continued interview with LVN B on [DATE] at 09:29 AM revealed the [NAME] does not match, she said we would not initiate CPR or notify the charge nurse that the resident is not breathing and she would correct it right away. LVN B said she would never look at the care plan for code status, but the care plan should be accurate. LVN B reviewed the latest care plan and she said it has Full Code. LVN B said that needs to be changed and she can correct it. LVN B said the Care Plan flows to the [NAME] and staff of all disciplines do access the [NAME], and it could cause problems if incorrect. During an interview on[DATE] at 09:46 a.m. with the DON and ADON revealed the DON said that the ADON completes the care plans and the DON is ultimately responsible for all care plans. The DON said she had just reviewed Resident #34's Care plan and she would change it today since it was not accurate. The DON said all records should be accurate and reflect the resident's wishes. The DON said Records including the Care Plan should reflect interventions that are accurate from MD orders and DNR status. Inaccurate care plans increase the risk of a resident receiving inappropriate interventions. During an interview on [DATE] at 10:02 a.m. the ADM said that the DON and ADON are responsible for Care Planning. Review of facility policy, undated, titled Advance Directives and Advance Care Planning Procedure revealed upon admission 1) admitting charge nurse will obtain an order for code status. After admission: 1) Social worker will meet with the newly admitted resident or representative within 72 hours of admission to verify the code status and document the discussion/education in the chart. 675729 Page 8 of 8