Health inspection·February 22, 2025

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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs, for 1 resident (Resident #1) of 5 residents reviewed for care plans. The facility did not care plan Resident #1's refusal of care to include shower refusals. These failures could place residents at risk for not receiving necessary care and services. The non-compliance was identified as past non-compliance. The deficient practice began on 11/25/2024 and ended on 12/18/2024. The facility had corrected the noncompliance before the survey began. The findings included: Record review of Resident #1's Face Sheet dated 02/22/2025 documented a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with the diagnoses of: heart failure, neuromuscular dysfunction of bladder (urinary bladder disfunction), delusional disorders, dementia (cognitive deficits), cellulitis (infection of the skin and the tissue beneath the skin), and dermatitis (inflammation of skin). Resident #1 was discharged [DATE]. Record review of Resident #1's Discharge Minimum Data Set assessment dated [DATE] revealed Resident #1 had a brief interview of mental status score of 10 (moderate impaired cognition). Resident #1 was not coded for rejection of care. Resident #1 was additionally coded for needing substantial assistance for toileting, showering, dressing, and personal hygiene. Resident #1 was coded for needing substantial/maximal assistance for transferring from chair/bed-to-chair transfer and tub/shower transfer. Record review of Resident #1's Care Plan date initiated 04/26/2024 reflected no plan of care for the specific behavior of showering refusal nor ADLs (including repositioning) throughout the care plan. Record review of Resident #1's ADL Bathing log dated 11/1/2024-11/30/2024 revealed on 11/01/2024, 11/04/2024, 11/06/2024, 11/08/2024, 11/11/2024, 11/13/2024, 11/15/2024, 11/18/2024, 11/20/2024, and 11/27/2024 Resident #1 refused bathing. The bathing log indicated Resident #1 refused showers throughout the month of November 2024. Page 1 of 3 675785 675785 02/22/2025 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 Record review of Resident #1's ADL Bathing log dated 11/1/2024-11/30/2024 revealed NA (not applicable) marked on 11/02/2024, 11/05/2024, 11/07/2024, 11/09/2024, 11/12/2024, 11/14/2024, 11/16/2024, 11/19/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/25/2024, 11/26/2024, 11/28/2024, 11/29/2024, and 11/30/2024. The bathing log indicated Resident #1did not shower throughout the month of November 2024. Record review of Resident #1's ADL Bathing log dated 12/1/2024-12/18/2024 revealed on 12/04/2024, 12/06/2024, 12/09/2024, 12/11/2024, 12/13/2024, and 12/18/2024 Resident #1refused bathing. The bathing log indicated Resident #1refused showers throughout the month of December 2024. Record review of Resident #1's ADL Bathing log dated 12/1/2024-12/18/2024 revealed NA (not applicable) marked on 12/02/2024, 12/03/2024, 12/07/2024, 12/10/2024, 12/12/2024, 12/14/2024, 12/16/2024, and 12/17/2024. The bathing log indicated Resident #1 did not shower throughout the month of December 2024. During an interview on 02/22/2025 at 10:38AM with the Treatment Nurse (TN) stated she does recall Resident #1 and stated Resident #1 would refuse care regularly. The TN stated Resident #1 would refuse bathing. TN stated several times she was notified by different aides that Resident #1 would refuse showering, and she herself would attempt to advocate for Resident #1 to be showered. However, TN stated Resident #1 would often decline. The TN stated multiple times a day she, as well as the clinical staff would advocate for Resident #1 to shower with the clinical staffs' assistance, but Resident #1 would refuse. TN stated she was involved with the IDT care planning process, and maintained her focus on nutrition and movement, and continued to state the CMS nurse would primarily edit care plans. The TN stated nurses have access to care planning, but the CMS nurse was the primary person who edits the care plan for each resident. The TN stated she believed that the behavior of refusing showers would be care planned to ensure residents are getting the appropriate care, and additionally, that staff know what care is necessitated for each resident. The TN stated Resident #1 was redirectable intermittently, but often, Resident#1 was non-complaint with showering and repositioning. During an interview on 02/22/2025 at 11:06AM the CMS nurse stated her scope of practice encompasses quarterly assessments of each resident, care planning for long term care, and reviews care plans quarterly. The CMS nurse stated care plans would include specific behaviors, including resident refusals. The CMS nurse stated she always includes family during the care plan process. The CMS nurse stated the expectation of the facility is if a resident refuses care (including showering) the aides will notify the nurses, then the nurses will attempt to persuade the resident to accept the care, and if the nurse is unsuccessful, they will attempt additional times while simultaneously notifying the RP each time of the refusal. The CMS nurse stated nurses should be documenting the shower refusal within the progress notes. The CMS nurse stated while reviewing Resident #1's progress notes, within the electronic health record, she stated she saw one note on 11/25/2024 regarding Resident #1 refused shower. The CMS nurse continued to state she did not see any additional note of Resident #1 refusing shower. The CMS nurse stated she involved Resident #1's RP within the care planning process and notified him about the Resident #1 refusing showers and care (ADLs), and that the RP wanted, since Resident #1 has dementia, to force showers for Resident #1, but reiterated to the RP the resident has a right to refuse showers. The CMS nurse stated they could encourage showers but could not forcefully make Resident #1 shower/bathe. The CMS nurse stated that she is the primary person responsible for care plan addendums. The CMS nurse stated care plans are important, as they are an individualized plan of care, which would include behaviors of refusal of care (showering/bathing) and what specific interventions are warranted for each concern. The CMS nurse stated while reviewing November 2024 and December 2024's bathing log for Resident #1, that her interpretation of the log indicated Resident #1 either refused or was not applicable for showers for both months. The CMS nurse stated that the 675785 Page 2 of 3 675785 02/22/2025 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 refusal of care including showers would be something that they would care plan. The CMS nurse stated while reviewing Resident #1's care plan, the behavior of refusal for ADLs and/or showers were not specifically care planned. The CMS nurse stated she was not sure why the refusal behavior for showering and ADLs were not care planned but should have been. The CMS nurse stated she missed it while referencing adding Resident #1's refusal behavior to his care plan. The CMS nurse stated she would have incorporated interventions for Resident #1's refusal behavior, such as administer medications, get psychosocial aspect, counseling services, or psych services, involve family members, redirect, and attempt on multiple times to advocate for resident to accept care. The CMS nurse stated by not updating Resident #1's care plan, Resident #1's well-being could have potentially been negatively compromised. The CMS nurse stated the facility administration would commence an impromptu in-service regarding documentation and care planning to all clinical staff to ensure this event does not get repeated. The CMS nurse stated the new process for residents that refuse ADLs would include, clinical staff will report the refusal to the managerial staff including the Assistant Director of Nurses and the Director of Nurses daily (past 24hour review), during the managerial staff's morning rounds. The CMS stated the managerial staff would then review the refusals during their morning daily IDT meetings and will additionally follow-up the afternoon on the same day. During an interview on 02/22/2025 at 5:56PM the DON stated Resident #1's RP would directly voice concerns to her but did not recall him voicing any concerns regarding repositioning. The DON stated Resident #1's family voiced that Resident was not cognitively aware and needed to be forced to be shower. The DON stated they would try to persuade Resident #1 to accept care (ADLs, repositioning, and showers), with different approaches, but Resident #1 would refuse. The DON stated Resident #1's refusal behaviors should have been care planned but was not. The DON stated care plans are important and Resident #1's behaviors should have been care planned to promote patient centered interventions, to ensure the well-being of Resident #1. The DON stated by not care planning Resident #1's refusing behavior, the well-being of Resident #1 could have been impacted negatively. The DON stated the facility managerial staff are amid conducting an impromptu in-service regarding documentation and care planning with ADONs, and CMS nurse. The DON stated the focus of the in-service would be to educate the managerial staff that if there are identified refusal behaviors (during the managerial staff morning nursing rounds), these concerns will be reviewed during the IDT daily morning meeting. The DON stated additionally, during the morning IDT meetings the care plans will be edited promptly and will be followed up on during their evening meeting to review if the interventions were successful. The DON stated the new implemented process was still a work in process. Record review of the facility's Comprehensive Care Plans Policy and Procedure date implemented 10/24/22 documented, 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. 675785 Page 3 of 3