Health inspection·February 21, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #1) of five residents reviewed for ADLs. Residents Affected - Few The facility failed to provide showers or bed baths consistently for Resident #1 per the facility bathing schedule in February 2025. This failure placed residents who were dependent on staff for bathing at risk for poor personal hygiene, odors, and a decline in their quality of life. Findings include: Review of Resident #1's Face Sheet, dated 02/19/25, reflected she was a [AGE] year-old female, who most recently admitted to the facility on [DATE]. Resident #1 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side (when a person has experienced a stroke (cerebral infarction) which has resulted in paralysis (hemiplegia) or significant weakness (hemiparesis) on the left side of their body). Review of Resident #1's MDS Assessment, dated 01/15/25, reflected she had moderate cognitive impairment. Resident #1 was identified as being dependent upon staff for toileting, showering/bathing, and dressing her lower body. Review of Resident #1's Care Plan, dated 12/04/24, reflected Resident #1 had an ADL self-care deficit and required extensive assistance for bathing/showering three times per week, as well as on an as-needed basis. Review of Resident #1's Shower Sheets from 02/06/25 to 02/18/25 reflected no evidence that Resident #1 received her scheduled showers on 02/13/25 or 02/15/25. During an interview with Resident #1 on 02/19/25 at 11:30 AM, she stated she had been having issues with both call light response time and scheduled showers. Resident #1 stated that although she received her scheduled shower yesterday (02/18/25), facility staff had not been ensuring that she was receiving them regularly and as scheduled (three times per week on Tuesdays, Thursdays, and Saturdays). During an interview with the DON on 02/19/25 at 12:05 PM, she stated she was aware that Resident #1 reported not receiving her scheduled showers. She stated review of her shower sheets indicated no Page 1 of 5 675810 675810 02/21/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evidence that she received her scheduled showers on 02/13/25 or 02/15/25. The DON indicated she felt as though this was likely due to an underlying staffing issue within the facility. A telephone interview was attempted with CNA D, who was responsible for ensuring Resident #1 received her scheduled showers on 02/13/25 and 02/15/25, on 12/19/25 at 4:07 PM. The telephone call was not returned. A policy related to ADL care, including showers/bathing, was requested but was not received at the time of exit. 675810 Page 2 of 5 675810 02/21/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed the have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population for 2 (Resident #1 and Resident #2) of 5 residents reviewed for sufficient staffing. The facility failed to ensure the facility had sufficient staffing to meet the needs of Resident #1 and Resident #2. This failure could place the residents at risk of their needs, safety, and psychosocial well-being not being met. Findings include: 1.) Review of Resident #1's Face Sheet, dated 02/19/25, reflected she was a [AGE] year-old female, who most recently admitted to the facility on [DATE]. Resident #1 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side (when a person has experienced a stroke (cerebral infarction) which has resulted in paralysis (hemiplegia) or significant weakness (hemiparesis) on the left side of their body). Review of Resident #1's MDS Assessment, dated 01/15/25, reflected she had moderate cognitive impairment. Resident #1 was identified as being dependent upon staff for toileting, showering/bathing, and dressing her lower body. Review of Resident #1's Care Plan, dated 12/04/24, reflected Resident #1 had an ADL self-care deficit and required extensive assistance for bathing/showering three times per week, as well as on an as-needed basis. Review of Resident #1's Shower Sheets from 02/06/25 to 02/18/25 reflected no evidence that Resident #1 received her scheduled showers on 02/13/25 or 02/15/25. Review of a Resident Grievance form, dated 01/31/25, reflected Resident #1 reported her call light had not been answered in a timely manner and that she would like more showers. During an interview with Resident #1 on 02/19/25 at 11:30 AM, she stated she had been having issues with both call light response time and scheduled showers. Resident #1 stated there had been times recently in which she was having to wait for hours for her call light to be answered. Resident #1 also stated that although she received her scheduled shower yesterday (02/18/25), facility staff had not been ensuring that she was receiving them regularly and as scheduled. 2.) Review of Resident #2's Face Sheet, dated 02/19/25, reflected he was a [AGE] year-old male, who most recently admitted to the facility on [DATE]. Resident #2 had diagnoses including central pain syndrome (a chronic neurological condition that affects how you feel pain) and lack of coordination (the inability to move smoothly and control your body's movements). 675810 Page 3 of 5 675810 02/21/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #2's MDS Assessment, dated 01/14/25, reflected he was cognitively intact. Resident #2 was identified as requiring either supervision or touching assistance by staff for toileting, showering/bathing, and for positioning from sitting to standing. Review of Resident #2's Care Plan, dated 10/31/24, reflected he had limited physical mobility due to chronic pain. During an interview with Resident #2 on 02/19/25 at 2:00 PM, he stated the facility recently cut back on the number of staff they assigned to work each shift. He stated because of this, he often had to wait a long time (upwards of one hour) for his call light to be answered. He had filed a grievance regarding this issue, but there had not yet been a resolution. Review of the facility's Resident Roster, provided by the Administrator in Training on 02/19/25, reflected a current census of 41 residents. A total of 10 of these residents required 2+ staff members for ADL assistance. Review of the facility's Nurse Staffing disclosure, provided by the Interim Administrator on 02/19/25 and identified as being the facility's current staffing pattern, reflected the facility scheduled 3 CNAs to work the 6:00AM-6:00PM shift, and 2 CNAs to work the 6:00PM-6:00AM shift. During an interview with the ADON on 02/19/25 at 11:40 AM, she stated the facility recently decreased the number of staff per shift due to budgetary reasons. Prior to the decrease, there were 4 CNAs assigned to work the 6:00AM-6:00PM shift, and 3 CNAs assigned to work the 6:00PM-6:00AM shift. The facility decreased the total number of CNAs per shift by one; meaning that there were now 3 CNAs assigned to work the 6:00AM-6:00PM shift, and 2 CNAs assigned to work the 6:00PM-6:00AM shift. She stated this change required one CNA to cover both the secured unit and part of the non-secured unit on the night shift. She stated since this decrease in staffing occurred, residents had complained of not receiving timely care and missing ADL care, such as showers. Staff had complained of not being able to provide timely care, as well. The ADON stated both she and the DON acted as the facility's Staffing Coordinators. She stated she felt as though the facility needed to increase the number of staffing to ensure residents received quality care. During an interview with the DON on 02/19/25 at 12:05 PM, she also stated the facility decreased the number of staff per shift due to budgetary reasons, which went into effect on 02/10/25. Prior to the decrease, there were 4 CNAs assigned to work the 6:00AM-6:00PM shift, and 3 CNAs assigned to work the 6:00PM-6:00AM shift. The facility decreased the total number of CNAs per shift by one; meaning that there were now 3 CNAs assigned to work the 6:00AM-6:00PM shift, and 2 CNAs assigned to work the 6:00PM-6:00AM shift. She stated since this decrease in staffing occurred, residents, families, and staff had complained about staff not being able to provide timely care. There had been multiple complaints regarding call light response time. The DON stated she provided in-servicing regarding call light response time, but without increased staffing, the issue was unlikely to resolve. The DON stated she was aware that Resident #1 reported not receiving her scheduled showers. She stated review of her shower sheets indicated no evidence that she received her scheduled showers on 02/13/25 or 02/15/25. During an interview with CNA A on 02/19/25 at 12:15 PM, he stated he had worked at the facility for approximately one year. He stated following the facility's annual survey in October of 2024, the facility increased staffing as a part of their Plan of Correction. However, CNA A stated the facility had been gradually decreasing the number of scheduled CNAs since that time. He stated currently, the 675810 Page 4 of 5 675810 02/21/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility only scheduled 3 CNAs to work the 6:00AM-6:00PM shift. CNA A stated he did not feel as though the facility maintained enough staff to meet resident needs. He stated a lot of the residents at the facility required an increased amount of care, and because of the decreased number of staff available, residents did not receive timely care. He stated it could take up to an hour for a resident's call light to be answered. CNA A stated both residents and families had complained about the timeliness and quality of care, since the number of assigned staff had decreased. During an interview with CNA B on 02/19/25 at 12:24 PM, she stated she had worked at the facility for approximately seven years. She stated she did not feel as though the facility maintained enough staff to meet resident needs. She explained that over the past few weeks, the facility had decreased the assigned number of scheduled CNAs per shift due to budgetary reasons. She stated because of this, residents were receiving less quality care than they were previously receiving. She stated there were several residents who required 2+ staff assist; these residents often had to wait a significant amount of time for assistance. She stated both residents and families had complained about the timeliness and quality of care, since the number of assigned staff had decreased. During an interview with CNA C on 02/19/25 at 12:35 PM, she stated she had worked at the facility for approximately one year. She stated she did not feel as though the facility maintained enough staff to meet resident needs. She said approximately two weeks ago, the facility decreased the scheduled number of CNAs per shift. She stated due to this, she was personally responsible for providing care on both the secured unit and the non-secured unit. She stated when she was working on the secured unit, she had no idea if her assigned residents on the non-secured unit had activated their call lights and/or if they needed assistance until she completed her resident rounds (a visual check on every assigned resident) every two hours. During an interview with the Administrator in Training (AIT) on 02/19/25 at 1:00 PM, she stated she had been employed by the facility for approximately 2.5 months. She stated when she first started working at the facility, the census was around 43-44 residents. She stated currently, the census was 42 residents. She stated the facility recently decreased the number of staff per shift due to the decrease in census (per the Administrator in Training, the decrease in census was a total of 1-2 residents). The Administrator in Training stated the risk of insufficient staffing included a lack of timely care. She said since the decrease in staffing took place, she had received complaints from residents regarding the timeliness of care. She stated she was not aware of any adverse effects toward residents. During an interview with the Interim Administrator on 02/19/25 at 2:15 PM, he stated he had worked at the facility for approximately one week. He stated the facility did not have a policy and procedure related to sufficient staffing. 675810 Page 5 of 5