Health inspection·June 30, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 9 residents (Resident #32) reviewed for baseline care plan, in that: The facility failed to ensure Resident #32's baseline care plan included information related to the resident's foley catheter. This deficient practice could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: Record review of Resident #32's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] , readmited 5/15/23 with a diagnosis that included: [Type II diabetes] characterized by high levels of sugar in the blood. [hypertension] pressure in your blood vessels is too high and [dementia] is characterized by progressive or persistent loss of intellectual functioning, especially with memory impairment and abstract thinking. Record review of Resident # 32's quarterly MDS assessment, dated 5/16/23, revealed a BIMS score of 10 suggesting moderate impairment, and an indwelling catheter. Record review of Resident #32's physician's orders for June 2023, dated 06/27/2023, revealead there was no order for the resident's indwelling urinary catheter. Record review of Resident # 32's Baseline care plan updated did not reveal a focus area or instructions for the resident's use of an indwelling urinary catheter. Observation and interview on 06/27/23 at 10:30 a.m. revealed that Resident # 32's catheter was in a leg bag with a strap to his right leg. The resident stated, I have this bag strapped on my leg because sometimes I have problems emptying my bladder. Interview on 06/28/23 at 9:40 am, the MDS Nurse stated that Resident #32 had a Foley catheter. The MDS Nurse stated she was responsible for care plans and had not had an opportunity to review the resident's charts prior to state survey. The MDS Nurse stated staff risked not being on the same page Page 1 of 7 675766 675766 06/30/2023 The Courtyard Rehabilitation and Healthcare Center 3401 E Airline Dr Victoria, TX 77901

F 0655 with care if something was not care planed for a resident. Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on 06/30/2023 at 10:25 a.m., the DON confirmed that Resident #32's needs should have been addressed on their baseline care plan. The DON stated she did not know why the resident's Foley catheter was unplanned by the MDS Nurse. The DON stated resident risked not receiving the care needed if it was not care planned. Residents Affected - Few Record review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised 1/2022, revealed, The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. 675766 Page 2 of 7 675766 06/30/2023 The Courtyard Rehabilitation and Healthcare Center 3401 E Airline Dr Victoria, TX 77901

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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical and nursing needs for one (Resident #1) of six residents reviewed for person-centered care plans: Resident #12's comprehensive person-centered care plan did not include/address or contain measurable goals and objectives for his pacemaker. This deficient practice could affect residents in the facility by placing in them at risk for not being provided necessary care and services, and not having plans developed to address their needs. The findings included: Record review of Resident #12's Face Sheet, dated 06/28/22, revealed an [AGE] year-old male an initial admission on [DATE] with diagnoses that included: [Generalized anxiety disorder] involves a persistent feeling of anxiety or dread, which can interfere with daily life. [hypertension] when the pressure in your blood vessels is too high. [dementia] loss of memory, language, and problem-solving. Record review of resident # 12's quarterly MDS, dated [DATE], revealed a BIMS score of 9 indicating moderately impaired. Record review of consolidated orders for June 2023 revealed that Resident #12 had a pacemaker. Observation and interview of Resident #12 on 06/28/23 at 10:26 am revealed pacemaker placement on the upper left side of the chest. Resident #12 stated that the pacemaker was implanted 6 years prior. Interview on 06/28/23 at 9:37 am, RN A stated that Resident #12 did not have a pacemaker. Interview on 06/28/23 at 9:39 am, the MDS Nurse stated that she was unsure if Resident #12 had a pacemaker. The MDS nurse stated she was responsible for care plans and had not had an opportunity to scrub the resident's charts. Record review of comprehensive care plan, dated 6/28/23, did not include address Resident #12's monitoring for a pacemaker. Interview with the Director of Nurses (DON) on 06/30/23 at 2:35 PM confirmed resident had a pacemaker, and that Resident #12's pacemaker should have been included in the resident's comprehensive care plan. The DON stated she did not know why pacemaker interventions were not in the Resident #12's comprehensive care plan. The DON stated that the MDS Nurse was responsible for care plans. The DON stated the nurses risked not having the necessary information on pacemaker in case of an emergency. Record review of facility policy, Comprehensive Person Centered care planning, dated 11/2016, revised, 1/2022, revealed, The facility IDT will develop and implement a comprehensive care plan within 7 days of completion of the MDS. 675766 Page 3 of 7 675766 06/30/2023 The Courtyard Rehabilitation and Healthcare Center 3401 E Airline Dr Victoria, TX 77901

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in that 1 of 3 residents reviewed for pacemakers (Resident #12) did not have documentation identifying normal pacemaker pulse limits or parameters in that: Residents Affected - Few The facility did not maintain medical information needed to monitor for proper functioning. The facility did not have record of Resident #12's make or model number information for the pacemaker, did not monitor parameters for pacemaker failure, and Facility Nursing Staff were unaware that Resident #12 had a pacemaker. This deficient practice could affect residents at put them at risk for complications due to cardiac pacemaker malfunction. The findings were: Record review of Resident #12's Face Sheet, dated 06/28/22, revealed an [AGE] year-old male an initial admission on [DATE] with diagnoses that included: [Generalized anxiety disorder] involves a persistent feeling of anxiety or dread, which can interfere with daily life. [hypertension] when the pressure in your blood vessels is too high. [dementia] loss of memory, language, and problem-solving. Record review of resident # 12's quarterly MDS, dated [DATE], revealed a BIMS score of 9 indicating moderately impaired Record review of consolidated orders for June 2023 revealed that Resident #12 had a pacemaker. Observation and interview of Resident #12 on 06/28/23 at 10:26 am revealed pacemaker placement on the upper left side of the chest. Resident #12 stated that the pacemaker was implanted 6 years prior. Interview on 06/28/23 at 9:37 am, RN A stated that Resident #12 did not have a pacemaker. Interview on 06/28/23 at 9:39 am, MDS Nurse stated that she was unsure if Resident #12 had a pacemaker. Interview on 06/28/23 at 11:05 am, DON confirmed that Resident #12 had a pacemaker, and DON further stated that the resident's pacemaker make, and model number were not available in Resident #12's medical record, but she would call resident's family and get the information needed. The DON stated resident risked the possibility of not having pacemaker property cared for if the needed information was not in the resident's chart. 675766 Page 4 of 7 675766 06/30/2023 The Courtyard Rehabilitation and Healthcare Center 3401 E Airline Dr Victoria, TX 77901

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure for a resident who enters the facility with an indwelling catheter or subsequently receives one had a clinical condition that demonstrates catheterization is necessary for 1 of 3 residents (Resident #32) reviewed for indwelling urinary catheterization necessity, in that: Resident #32 did not have a physician's order for an indwelling catheter. This deficient practice could affect residents in the facility who have an indwelling or external catheter and place them at risk for infection and improper care. The findings were: Record review of Resident #32 face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnosis that included: [Type II diabetes] characterized by high levels of sugar in the blood. [hypertension] pressure in your blood vessels is too high and [dementia] characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking. Record review of Resident # 32's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 suggesting moderate impairment, and an indwelling catheter. Record review of Resident #32's physician's orders for June 2023, dated 06/27/2023, revealead there was no order for the resident's indwelling urinary catheter. Observation on 06/27/23 at 10:30 a.m. revealed Resident # 32's catheter was in a leg bag with a strap to his right leg. During an interview on 06/27/23 at 1:59 p.m. RN A confirmed Resident #32 had an indwelling urinary catheter. RN A revealed the resident was admitted with an indwelling urinary catheter. RN A confirmed that the resident had no physician's order for the catheter. RN A revealed that she believed he was the nurse that re-admitted the resident into the facility's system and that the nurses were the ones who entered orders with the associated diagnoses onto the resident's record. During an interview on 6/28/23 at 2:35 p.m., the DON confirmed there were no orders for an indwelling urinary catheter in Resident #32's physician's orders. The DON stated reason why there were no orders for the urinary catheter was that the resident was sent out to the hospital, date unknown, and when the resident returned to the facility the admitting nurse did not properly assess the resident and did not reactivate previous orders. The DON stated Resident #32 risked possible improper care to the catheter site if the nurses did not know the resident had a urinary catheter. Record review of facility policy, Resident assessment, dated 11/2016, revised 1/2022, revealed, Residents will be assessed, and the findings documented in their clinical health record. 675766 Page 5 of 7 675766 06/30/2023 The Courtyard Rehabilitation and Healthcare Center 3401 E Airline Dr Victoria, TX 77901

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a medication error rate was not 5% or greater. The facility had a medication error rate of 24%, based on 6 errors out of 25 opportunities, which involved 1 of 5 residents (Resident #34) and 1 of 4 staff (RN A) reviewed for medication administration. Residents Affected - Few The facility failed to ensure RN A administered medications according to the physician's orders and per professional standards which resulted in a 24% medication administration error rate. This deficient practice could place residents at risk of not receiving the therapeutic effects of their medications and possible adverse reactions. The findings are: Record Review of Resident # 34's face sheet dated, 6/28/23 revealed a [AGE] year-old female with an admission date of 12/3/2019 with a diagnosis that included: [Hypertension] when the pressure in your blood vessels is too high, [Muscle weakness] is a lack of muscle strength, and [Aphasia] disorder that results from damage to portions of the brain that are responsible for language. Record review of Resident # 34's quarterly MDS assessment, dated 5/11/23, revealed the resident was rarely/never understood and utilized a feeding tube. Record review of Resident # 34's person-centered comprehensive care plan, revision date 2/7/23, revealed the resident required tube feeding related to dysphagia with interventions that included administer GT medications as ordered. Record review of Resident #34's order summary report for June 2023 revealed the following orders: - Carbidopa-Levodopa 25-100 mg, give two tabs via PEG tube three times a day for anticonvulsant - Levetiracetam oral solution 100 mg/ml, give 15 ml via PEG two times a day for seizures - Levocarnitine oral tablet 330 mg, give one tablet via PEG two times a day for endocrine - Memantine 5 mg tablet, give one tablet via PEG once a day for psychotherapeutic - Modafinil 100 mg tablet, give one tablet via PEG three times a day for ADHD/narcolepsy - Senna Oral Tablet 8.6 mg tablet, give one tablet two times a day for constipation. Observation during the medication pass on 06/28/23 at 8:31 a.m., RN A prepared Resident #34's medications. RN A crushed each medication separately in a pouch, except for Levetiracetam oral solution, in which she poured 15 ml onto a medication cup. RN A poured 30 ML of water onto a cup and added all medication stirred well and poured the cup contents into peg tube. A notable amount of residual medication was noted in the cup. During an interview on 06/28/23 at 9:35 a.m., RN A stated, She tried to get it (the medication) out 675766 Page 6 of 7 675766 06/30/2023 The Courtyard Rehabilitation and Healthcare Center 3401 E Airline Dr Victoria, TX 77901

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the cup but there was a lot of residual. RN A stated she understood the physician's order for administering Resident #34's medications via a peg tube meant to put 10 cc of water into each medication cup before pouring the medication into the peg tube but realized she should have been flushing the peg tube with 10 cc of water after each medication. RN A stated the excess residual of medication left in the medication cup meant Resident #34 did not really receive her medication and, possibly didn't get the full dose. RN A stated if the resident did not receive a full dose of medication, it could cause a reaction. RN A stated Resident #34 took seizure medications and if the full dose was not administered it could lead to the resident having a seizure. During an interview on 06/28/23 at 4:28 p.m., the DON stated medication residual left in the medication cup during medication administration meant Resident #34 did not receive a full dose of the medication. The DON stated RN A should have put more water into the medication cup and stirred the medication to dissolve it and then try to dispense it. The DON stated Resident #34 had a seizure disorder and if the resident was not receiving a full dose of seizure medication the resident could have a seizure. Record Review of Facility policy titled, administering medications through an enteral tube, 2001, revised December 2011, May 2023, revealed, do not mix medications together prior to administering through an enteral tube, administer each medication separately. 675766 Page 7 of 7