Health inspection·January 18, 2024

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 interviews, and record reviews, 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 2 (Resident #416 and Resident #414) out of 6 residents reviewed for care plans in that: The facility failed to ensure Resident #416 and #414 had a baseline care plan created within 48 hours after admission with goals and interventions. This deficient practice affects residents who are new admissions or readmissions and could result in decreased quality of care. The findings included: 1)Record review of Resident #416's electronic face sheet dated 01/15/2024, reflected she was an [AGE] year old female, initially admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. Her diagnoses included: Chronic respiratory failure with hypoxia (decreased perfusion of oxygen to the tissues), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), heart disease, and hypertension (high blood pressure). Record review of Resident #416's admission MDS assessment 12/28/2023 reflected she scored a 09 out of 15 on her BIMS which indicated she had moderate cognitive impairment. Record review of Resident #416's baseline care plan dated 06/02/2023, revealed her baseline care plan had no interventions for the following: FOCUS: SKIN INTEGRITY: The resident is at risk for impaired skin integrity related to: Date Initiated: 01/12/2024 GOALS: o The resident will remain free from alterations in skin integrity (i.e., pressure ulcers .) by/through next review data. Date Initiated: 01/12/2024 Target Date: 04/04/2024 o The resident will understand the risks associated with my choice to not adhere to the IDT recommendations to prevent skin breakdown and maintain skin integrity regarding (specify) by/through next review date. Date Initiated: 01/12/2024 Target Date: 04/04/2024 INTERVENTIONS/TASKS: No interventions listed. Page 1 of 12 675785 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

F 0655 FOCUS: The resident has an ADL self-care performance deficit r/t Date Initiated: 01/12/2024 Level of Harm - Minimal harm or potential for actual harm GOALS: o The resident will improve current level of function in (SPECIFY ADLs) through the review date. Resident will be able to: (SPECIFY) Date Initiated: 01/12/2024 Target Date: 04/04/2024 Residents Affected - Few INTERVENTIONS/TASKS: No interventions listed. FOCUS: o The resident is (SPECIFY High, Moderate, Low) risk for falls r/t Date Initiated: 01/12/2024 GOALS: o The resident will be free of falls through the review date. Date Initiated: 01/12/2024 Target Date: 04/04/2024 INTERVENTIONS/TASKS: No interventions listed. FOCUS: The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t Date Initiated: 01/12/2024 GOALS: o The resident will be free from injury (SPECIFY) to (SPECIFY location) through the review date. Date Initiated: 01/12/2024 Target Date: 04/04/2024 o The resident's will have no complications r/t (SPECIFY skin injury type) of the (SPECIFY location) through the review date. Date Initiated: 01/12/2024 Target Date: 04/04/2024 INTERVENTIONS/TASKS: No interventions listed. FOCUS: o The resident has (SPECIFY: URGE, STRESS, FUNCTIONAL, MIXED) bladder incontinence r/t Date Initiated: 01/12/2024 GOALS: o The resident will decrease frequency of urinary incontinence from (SPECIFY) to (SPECIFY) times per week through the next review date. Date Initiated: 01/12/2024 Target Date: 04/04/2024 o The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Date Initiated: 01/12/2024 Target Date: 04/04/2024 INTERVENTIONS/TASKS: No interventions listed. FOCUS: o The resident has oxygen therapy r/t Date Initiated: 01/12/2024 GOAL: o The resident will have no s/sx of poor oxygen absorption through the review date. Date Initiated: 01/12/2024 Target Date: 04/04/2024 INTERVENTIONS/TASKS: No interventions listed. Observation on 01/14/24 at 03:46 p.m. Resident #416 was lying in bed with the head of bed inclined. Resident had an IV site in right forearm with antibiotics running. Oxygen was running at 2 Lpm via nasal cannula. 2) Record review of Resident #414's electronic face sheet dated 01/15/2024, reflected she was a [AGE] year old female, admitted to the facility on [DATE], from the hospital. Her diagnoses included: Legal blindness, type 1 diabetes mellitus (a chronic condition in which the pancreas produces little 675785 Page 2 of 12 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

F 0655 Level of Harm - Minimal harm or potential for actual harm or no insulin), type 2 diabetes mellitus (a chronic condition where the body either does not produce enough insulin, or it resists insulin), hypertension (high blood pressure), heart failure, end stage renal disease (when your kidneys can no longer support your body's needs), kidney dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Residents Affected - Few Record review of Resident #414's admission MDS 12/30/2023, was not completed. Record review of Resident #414's baseline care plan dated 01/01/2024, revealed: FOCUS: o The resident has an ADL self-care performance deficit r/t Date Initiated: 12/30/2023 GOAL: None listed. INTERVENTIONS/TASKS: None listed. FOCUS: The resident is (SPECIFY High, Moderate, Low) risk for falls r/t Date Initiated: 12/30/2023 GOAL: None listed. INTERVENTIONS/TASKS: None listed. FOCUS: o The resident is on antibiotic therapy (SPECIFY medication) r/t Date Initiated: 12/30/2023 GOAL: None listed. INTERVENTIONS/TASKS: None listed. FOCUS: o The resident is on IV Medications (SPECIFY medications) r/t Date Initiated: 12/30/2023 GOAL: None listed. INTERVENTIONS/TASKS: None listed. FOCUS: o The resident has (SPECIFY acute/chronic) pain r/t Date Initiated: 12/30/2023 GOAL: None listed. INTERVENTIONS/TASKS: None listed. FOCUS: o The resident needs dialysis (SPECIFY type hemo/peritoneal) r/t Date Initiated: 12/30/2023 GOAL: None listed. INTERVENTIONS/TASKS: None listed. FOCUS: The resident has (SPECIFY: URGE, STRESS, FUNCTIONAL, MIXED) bladder incontinence r/t Date Initiated: 12/30/2023 675785 Page 3 of 12 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

F 0655 GOAL: None listed. Level of Harm - Minimal harm or potential for actual harm INTERVENTIONS/TASKS: None listed. Residents Affected - Few FOCUS: o The resident has (SPECIFY: Condom/Intermittent/Indwelling Suprapubic) Catheter: Date Initiated: 12/30/2023 GOAL: None listed. INTERVENTIONS/TASKS: None listed. FOCUS: o The resident has impaired visual function r/t Date Initiated: 12/30/2023 GOALS: None listed. INTERVENTIONS/TASKS: None listed. In an interview on 01/17/24 at 03:22 p.m., MDS/RN G stated the nurse who does the admission was the one who does the baseline care plan at the time of admission. The nurse who does the admission, gets the baseline care plan information from the admission evaluation. MDS/RN G stated MDS has 14 days to complete the comprehensive care plan. MDS/RN G stated focus, goals, and interventions/tasks should all be completed for the baseline care plan. MDS/RN G stated they all meet in the mornings and go over all new admissions to ensure care plans and documentation is complete. MDS/RN G could not say what the negative effect could be for the baseline care plan not being complete. Attempted telephone interview on 01/18/24 at 11:32 a.m., LVN H, the admitting nurse for Resident #416, and responsible for entering the baseline care plan for resident. No answer. Voicemail left. In an interview on 01/18/24 at 11:34 a.m., ADON C stated the admitting nurse was the one responsible for putting in the baseline care plan. ADON C stated management, MDS, and ADONs make sure the baseline care plan has been completed. ADON C stated as soon as the admission comes in, they make sure all the forms have been completed. ADON C stated they also go over the new admissions during their daily meetings. Attempted telephone interview on 01/18/24 at 11:44 a.m., with LVN I, the admitting nurse for Resident #414, admitted on [DATE], and responsible for entering the baseline care plan for resident. No answer. Voicemail left. In an interview on 01/18/24 at 12:01 p.m., the DON stated the admitting nurse was responsible for putting in and completing the baseline care plan. The DON stated at the morning meeting, they go over all new admissions to make sure all forms are filled out and completed (including the baseline care plan). Record review of the facility policy and procedure titled Baseline Care Plans reviewed/revised 10/05/23, revealed: Policy The facility will develop and implement a baseline care plan for each resident that includes the 675785 Page 4 of 12 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

F 0655 instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Level of Harm - Minimal harm or potential for actual harm Policy Explanation and Compliance Guidelines: Residents Affected - Few 1.The baseline care plan will: a.Be developed within 48 hours of a resident's admission. 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. b. Interventions shall be initiated that address the resident's current needs. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 675785 Page 5 of 12 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

F 0656 Level of Harm - Minimal harm or potential for actual harm 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** F656 Care Plan Residents Affected - Few Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet resident's mental and psychosocial needs, for one (Resident #54) of six residents reviewed for care plans in that: The facility did not develop and implement a comprehensive person-centered care plan that addressed Resident #54's behavior of going out on pass without signing out. This failure could place residents in the facility at risk of not receiving the necessary care and services to maintain their health and safety. The findings included: Record review of Resident #54's admission record dated 01/17/24 documented a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Hydrocephalus (a buildup of fluid in the cavities deep within the brain), Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye (medical condition in which damage occurs to the retina due to diabetes mellitus. It is a leading cause of blindness.), age related debility, and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fats, cholesterol, and other substances in and on the walls of the arteries called plaque and causes narrowing of the blood vessels and sometimes causes chest pain or angina). Record review of Resident #54's Quarterly MDS assessment dated [DATE] indicated: -had adequate hearing and clear speech -was able to understand others, -was understood by others, -had moderate cognitive impairment, -did not have behaviors, -required supervision such as verbal cues or steadying assistance for his ADLs. Further review revealed Resident #54's comprehensive care plan dated 09/30/19 indicated Resident #54 has a behavior problem of hoarding, does not allow staff to clean his room, drawers, or tabletop, does not allow staff to remove household chemicals does not allow staff to wash his clothes. Interventions included explain all procedures to resident and allow the resident to adjust to adjust to changes, explain/reinforce why behavior is inappropriate, intervene as necessary to protect the rights and safety of others and document behavior and potential causes. Further review revealed Resident #54's care plan did not include a care plan to address his 675785 Page 6 of 12 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

F 0656 behavior of leaving the facility without signing out. Level of Harm - Minimal harm or potential for actual harm Record review of Nurse's Progress Note dated 08/04/23 at 21:21 (9:21 PM) revealed Resident #54 had gone out on pass and did not sign out. Note created by LVN F. Residents Affected - Few Observation on 01/15/24 at 9:50 AM RM during initial pool revealed Resident #54 was not in his room. In an interview on 01/15/24 at 10:00 AM CNA E said Resident #54 was out on pass. CNA E said he saw Resident go out toward the lobby. CNA E said Resident goes out on Pass often but would not sign out. In an interview on 01/17/24 at 11:04 AM Resident #54 said he had been going out every day for a week. Resident #54 said he and his friend go out and do errands. Resident #54 said he does not drive because his truck was not working, and he needs to fix it. Resident #54 said he signs the log when he goes out on Pass now. Resident #54 said he was not feeling good and did not want to answer any more questions. In an interview on 01/17/24 at 11:37 AM LVN F said Resident #54 would go out on pass but did not always sign out. Resident #54 did go out on pass on 08/04/23 and did not sign out. LVN F said it is important to develop a care plan so that staff can track the changes in a resident's behaviors, so they can provide the help the resident needs. In an interview on 01/17/24 2:14 PM The Administrator said Resident #54 has a history of not signing out, but the staff know when he goes out. Resident #54 has vehicles here at the facility. The Administrator said Resident #54 will tell staff that he was able to make his own decisions and knew his rights. The Administrator said she did not report the incident on 08/04/23 because staff knew Resident #54 had gone out on Pass. Administrator said, Yes, Resident did not sign out, but the staff knew he had gone out. The Administrator said Resident #54 was non-compliant with everything, he would not allow us to go into his room to clean it. In an interview on 01/17/24 at 3:22 PM RN/MDS G said she was the MDS Case Manager for the facility. RN/MDS G said if Resident #54 had left the facility frequently without notifying staff, then it should have been care planned. RN/MDS G said for her to develop a care plan she needed documentation from whoever provided his care so they could care plan the issue. RN/MDS G said if she had documentation that Resident #54 had his vehicles at the facility and that he was driving and leaving the facility without signing out, then yes it should have been care planned. RN/MDS G said she searched the care plan history to check if she had care planned Resident #54 having his vehicles at the facility and that he was driving but RN/MDS G said she had not seen anything in her notes. The RN/MDS said she would have completed a care plan for that behavior if she had any documentation and had known of Resident #54's behavior. In an interview on 1/18/24 at 8:58 AM The DON said Resident #54 would go out on pass very often but does not go out much now. The facility implemented a policy that residents need to sign the Release of Responsibility for Leave of Absence form when they go outside or out on pass. The facility educated residents of the need to sign out when they are going outside or out on pass. The residents were told about the importance of signing the form. The DON said she does not know why they did not care plan Residents #54's behavior of not signing out when going out on pass. The DON said the care plan was important because it showed the care the resident needed and it informed staff what the 675785 Page 7 of 12 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's likes and dislikes were and let staff know if they had certain behaviors. DON said the if a care plan is not complete or fully accurate the care plan would not provide staff correct information on how to care for the resident. The DON said, Resident #54's care plan for the most part did talk about his behavior of refusing medications, refusing care and being inappropriate toward females. Record review of facility's policy on Comprehensive Care Plans dated 10/24/22 revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 675785 Page 8 of 12 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 (Resident #87) of 3 residents reviewed for enteral nutrition, in that: The facility failed to appropriately label the formula bag with the time and the date the formula was started and initials of the nurse who hung the feeding for Resident #87. This deficient practice could affect residents receiving enteral nutrition and place them at risk of health complications and decline in health. Findings included: Record review of Resident #87 ' s electronic face sheet dated 01/15/2024 revealed the resident was [AGE] year-old female admitted to the facility on [DATE] and original admission date 02/20/2023. Her diagnosis included Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus without complications, Major Depressive Disorder, Essential Hypertension (high blood pressure), Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, End Stage Renal Disease (kidney failure), Scoliosis, and Osteoarthritis (degenerative joint disease). Record review of Resident #87 ' s quarterly MDS assessment, dated 12/8/2023 a BIMS score of 14, indicating Resident #87 was cognitively intact. Resident #87 ' s nutritional approach was feeding tube and mechanically altered diet. Record review of Resident #87 ' s comprehensive person-centered care plan, date initiated 06/16/2023 reflected Focus Resident #87 requires tube feeding related to diagnosis Dysphagia. Intervention Resident #87 is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Record review of Resident #87 ' s Physician Order Summary of all orders, dated 01/10/2024 revealed Enteral Feed Order every shift Jevity 1.5 at 40ml/hr x 22h =1320kcal, 669ml of water via G-tube stationary pump. Observation on 01/14/2024 at 10:13am of Resident #87, asleep lying in bed with head of the bed elevated. Call light within reach. Observed the feeding pump, next to Resident #87 ' s bed, running at 40mls/hr, 816 mls fed, and flush 100mls every 6 hours. A bag of water was hanging on one side of the pole labeled and a formula bottle was hanging on the other side. The formula bottle was not labeled. It was completely blank. The formula bottle had no time, no date, no rate, and no nurse initials. Observation and Interview on 01/14/2024 at 10:15am with LVN A, stated she was Resident #87 ' s nurse. LVN A stated she got report this morning upon shift change when she got here this morning, but she did not go into Resident #87 ' s room to check feeding pump. She stated she usually does check the resident ' s feeding pumps. LVN A was unaware Resident #87 formula bottle was not labeled. LVN A then walked to Resident #87 ' s room and verified that formula bottle label was blank. LVN A stated she was supposed to be checking the formula bottle expiration date, that the residents name matches, and that the feeding rate was correct. She stated that the formula bottle label was to be dated so 675785 Page 9 of 12 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

F 0693 Level of Harm - Minimal harm or potential for actual harm that they know when to change the formula. LVN A stated that the negative outcome of Resident #87 ' s formula bottle not being labeled was that the formula can coagulate and that it ' s not right to not have a date and time on the formula label. LVN A stated that an ADON comes in on Monday through Friday and checks labels on feeding pumps and oxygen tubing in the facility. There was a weekend supervisor that does this as well. She stated the weekend supervisor today was RN B. Residents Affected - Few Interview on 01/14/2024 at 10:20am with RN B, stated she was the weekend supervisor and got here early, around 7am today, to do room rounds. She stated she attended to another resident and did not have a chance this morning to do her rounds. RN B stated her room rounds consist of making sure everything was labeled, up to date, and that the foley catheters are covered. RN B stated she did not go into Resident #87 ' s room to check her feeding pump because she has not rounded today. She stated the negative outcome of not labeling the feeding formula is that Resident #87 can get sick if it was an old formula that she was receiving. Interview on 01/14/204 at 10:30am with ADON C, stated that the floor nurses are the ones who are supposed to be checking their assigned resident feeding pumps when they come in. They should be checking for formula rate, date, and name. The formula rate has to match what ' s on the pump. He stated the formula was good for 24 hours once it has been opened. ADON C stated in service for medication administration was done maybe a couple weeks ago. Interview on 01/14/2024 at 10:38am with ADON D, stated that rounding was part of the routine that the ADONs and weekend supervisors do every morning as well as the floor nurses. He stated that it was important to label the formula so that the nurses know the rate, what type of formula the resident is on and their down time. Interview on 01/14/2024 at 11:15am with Resident #87, she was awake at this time, stated she has no issues with care that she receives at the facility. She stated she does not remember when they hung the formula bottle. She has had no issues with feeding. She stated she has no complaints or concerns at this time. Enteral Feeding Administration Facility Policy not available. 675785 Page 10 of 12 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

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 observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #416) reviewed for respiratory care in that: Residents Affected - Few The facility failed to ensure Resident #416 had an oxygen sign posted outside her bedroom. This deficient practice could place residents at risk for inadequate care. The findings included: Record review of Resident #416's electronic face sheet dated 01/15/2024, reflected she was an [AGE] year old female, initially admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. Her diagnoses included: Chronic respiratory failure with hypoxia (decreased perfusion of oxygen to the tissues), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), heart disease, and hypertension (high blood pressure). Record review of Resident #416's admission MDS assessment 12/28/2023 reflected she scored a 09 out of 15 on her BIMS which indicated she had moderate cognitive impairment. Record review of Resident #416's baseline care plan dated 06/02/2023, revealed: FOCUS: The resident has oxygen therapy r/t Date Initiated: 01/12/2024 GOAL: The resident will have no s/sx of poor oxygen absorption through the review date. Date Initiated: 01/12/2024 Target Date: 04/04/2024 INTERVENTIONS/TASKS: No interventions listed. Record review of Resident #416's physician order for 01/12/24 revealed the following: -Oxygen at 2 Lpm via nasal cannula as needed for hypoxia Observation on 01/14/24 at 03:46 p.m., revealed no Oxygen in Use signage on door. Resident #416 was lying in bed with the head of her bed inclined. O2 running at 2 Lpm via nasal cannula. Attempted telephone interview on 01/18/24 at 11:32 a.m., LVN H, the admitting nurse for Resident #416, admitted on [DATE], and responsible for placing Oxygen in Use signage on door during admission of resident. No answer. Voicemail left. In an interview on 01/18/24 at 11:34 a.m., ADON C stated it was the responsibility of the admitting nurse to put signage on the doors whether it be contact precautions, isolation or O2 in use. ADON C stated all staff and the Infection Control Preventionist are to check to ensure that signage is on the doors on admission. In an interview on 01/18/24 at 12:01 p.m., the DON stated it was the admitting nurse's or the nurse 675785 Page 11 of 12 675785 01/18/2024 Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who took the order, who was responsible for putting signage on the doors (Precautions, Oxygen in Use, etc.). The DON stated there are morning rounds and the manager assigned (Guardian Angels) to each resident and they are assigned to checking for signage if there is to be any. They have a check-off list that needs to be completed. The DON stated there was no policy on Oxygen in Use signage. In an interview on 01/18/24 at 12:35 p.m., the administrator stated there was no policy on Oxygen in Use signage. 675785 Page 12 of 12