Health inspection·June 2, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed ensure assessments accurately reflected the resident's status for one (Resident #54) of eight residents reviewed for resident assessments. The facility failed to do Resident #54's admission and Quarterly MDS assessments, despite her being a private pay resident. Findings included: Record review of Resident #54's face sheet dated 06/02/23 revealed she was private pay with Managed care insurance as secondary and her most recent hospital stay was 12/13/22 - 12/17/22. Record review of Resident #54's MDS Assessment completed by MDS A dated 12/24/22 revealed, A check marked coded 99 None of the Above .5 day scheduled PPS assessment .a [AGE] year old female who initially admitted [DATE] .with a BIMS score of 05 (severe cognitive impairment) with active diagnoses part of neck of left femur fracture, muscle wasting, unsteadiness on feet, benign neoplasm of mesothelial tissue of peritoneum (Tumor of stomach lining) . Record review of Resident #54's MDS Assessment completed by MDS A dated 12/13/22 revealed, A check marked coded for 99 None of the above . PPS Assessment .a [AGE] year old female who initially admitted [DATE] with a BIMS score of 02 (severe cognitive impairment) . Interview on 06/01/23 at 2:13 pm, MDS A stated she was the MDS Coordinator for a year and stated she had no issues with completing the MDS assessments. She said after she completed the MDS Assessments, she and the DON signed them and then she submitted them to the CMS Portal. She stated Resident #54 was a current resident and private pay now and she had done her MDS Assessment on 12/24/22 but she had not done any other MDS Assessments on Resident #54 because she was a private pay patient. She stated she was not required to do Resident #54's MDS Assessments unless she applied for Medicaid or if her Medicare became her primary payor source. She stated she was not sure why she did Resident #54's MDS Assessment on 03/23/22 and it should not have been done. She stated she was responsible for ensuring the MDS Assessments were completed timely and accurately was not sure what could happen if MDS assessments were not completed in a timely manner. Interview on 06/01/23 at 4:37 pm, the DON stated not having accurate MDS Assessments could result in not having the full picture of the goals and outcomes of the residents. She stated MDS A did the MDS Assessments and reviewed them to ensure they were accurate. Page 1 of 8 675908 675908 06/02/2023 Avante Rehabilitation Center 225 N Sowers Rd Irving, TX 75061

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/02/23 at 1:44 pm, the MDS A stated after she spoke to her friend who was also an MDS Coordinator she learned no matter what the resident's payor source she was supposed to do their MDS assessments for tracking purposes and for quality measures and census. Interview on 06/02/23 at 6:44pm, the DON stated her expectations for MDS Assessments was for them to be done timely and according to the schedule and was not sure who was responsible for ensuring the MDS Assessments were complete and accurate. She stated she was not sure when MDS A had an MDS Assessment training. Interview on 06/02/23 at 7:04 pm, the Administrator stated her expectations for the MDS Assessments was to better improve their processes correctly and accurately. Record Review of the facility's Resident Assessment policy dated 2019 revealed, Policy Statement: A comprehensive assessment of every resident's needs is made at intervals designed by OBRA and PPS requirements .Policy interpretation and Implementation .1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: OBRA required assessments - Initial assessment, Quarterly assessment, Significant Change in Status Assessment, Annual Assessment, Discharge Assessment . Record Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1, dated October 2019, reflected, 1.3 Completion of the RAI: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. 675908 Page 2 of 8 675908 06/02/2023 Avante Rehabilitation Center 225 N Sowers Rd Irving, TX 75061

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to within 14 days after a facility completed a resident's assessment, electronically transmit encoded, accurate, and complete MDS data to the CMS system for three (Residents #23, #36 and #88) of eight residents reviewed for resident assessments. Residents Affected - Some The facility failed to ensure Residents #23, #36, #88's MDS discharge assessments was transmitted within 14 days after they discharged this facility. This failure could affect discharged residents from getting the appropriate continuity of care with other healthcare providers in the community or other Nursing facilities if they continued to appear to be a resident at this facility which could cause a decline in benefits and affect the facility's census statistics in the CMS database. The findings included: A)Record review of Resident #23's face sheet dated 06/02/23 revealed an [AGE] year old female who initially admitted [DATE] and re-admitted [DATE] with diagnoses of Spinal Stenosis, Protein -Calorie Malnutrition, Depression, Chronic pain, and Lack of Coordination. Further revealed the resident discharged [DATE]. Record review of Resident #23's Simple LTC Final Validation Report undated revealed an ARD target date days after the assessment reference date (ARD). B)Record review of Resident #36's face sheet dated 06/02/23 revealed a [AGE] year old female who admitted [DATE] with diagnoses Lymphedema, Iron Deficiency, morbid obesity, encephalopathy, hypertensive heart disease, congestive heart failure. Further review revealed the resident discharged on 03/30/23. Record Review of Resident #36's LTC Final Validation Report undated revealed an ARD target date after the assessment reference date (ARD). C)Resident review of Resident #88's face sheet dated 06/02/23 revealed an [AGE] year old female who admitted [DATE] with diagnoses left femur fracture, protein-calorie malnutrition, intellectual disabilities, end stage renal disease. Further review revealed the resident discharged on 03/06/23. Record review of Resident #88's Simple LTC Final Validation Report undated revealed an ARD target date days after the assessment reference date (ARD). Interview on 06/01/23 at 2:13 pm, MDS A stated she was the only MDS Coordinator and there were no issues with completing the MDS assessments. She stated if a resident was not coming back to this facility, she completed the discharge MDS assessments and she and the DON signed, then it was submitted to CMS. She stated she had seven days to submit the discharge MDS Assessments into the CMS Portal and stated the MDS assessments were done for billing purposes and when the resident's Medicare stays 675908 Page 3 of 8 675908 06/02/2023 Avante Rehabilitation Center 225 N Sowers Rd Irving, TX 75061

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ended. She stated she was responsible for ensuring the MDS Assessments were completed timely and accurate and was not sure what could happen if MDS assessments were not completed in a timely manner. She stated Residents #23, #36, and #88 went home with home health care services but she had not completed their discharge MDS Assessments. She stated she had started working on the Discharge MDS Assessments on 03/01/23 but had not completed them because of her workload and was behind on doing them. Interview on 06/01/23 at 4:37 pm, the DON stated MDS A did the MDS Assessments that were reviewed by her (the DON) to ensure they were accurate. She stated there were reminders on the EMR dashboard that showed which MDS Assessment were due and added MDS A was usually pretty good about completing the MDS assessments. Interview on 06/02/23 at 1:44 pm, MDS A stated she kept up with when she needed to complete the discharge MDS Assessments by checking the facility's communication forms for discharging residents. She stated she opened the resident's discharge MDS Assessment so that it would flag as a reminder in the EMR queue and also reviewed the MESAV reports but had not completed Residents #23, #36, #88's MDS Discharge Assessments. Interview on 06/02/23 at 6:44pm, the DON stated her expectations was for herself, MDS A and Corporate Nurse to split up the duties of completing the MDS assessments. She stated the discharge assessments had not been done because they had a busy schedule and MDS A was the only MDS Coordinator. Interview on 06/02/23 at 7:04 pm, the Administrator stated the expectations she had for MDS Assessment was to better improve their processes by accurately coding them and submitting them timely. Record Review of the facility's Electronic Transmission of the MDS policy dated 2001 revealed, Policy statement: All MDS assessments and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data .Policy Interpretation and Implementation: 1. All staff members responsible for completion of the MDS receive training on the assessment, data entry and transmission processes in accordance with the MDS RAI Instruction Manual before being permitted to use the MDS information system . Record Review of the CMS RAI Version 3.0 Manual dated October 2019 Page 2-10 revealed, A discharge assessment is required with all types of discharges .any of the following situations warrant a discharge assessment, regardless of facility policies regarding opening and closing clinical records and bed holds .5-3 675908 Page 4 of 8 675908 06/02/2023 Avante Rehabilitation Center 225 N Sowers Rd Irving, TX 75061

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 must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (Resident #7 and Resident #72) of three residents reviewed. The facility failed to 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 for Resident #7 and Resident # 72. This failure could place residents at risk of not meeting their immediate needs, long term and or short-term goals and could impede disease management by not monitoring short term and long-term goals and interventions. Findings included: Record review of Resident #7's admission MDS dated [DATE] revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease, Diabetes Mellitus (high blood sugar), Non-Alzheimer's Dementia. With a BIMs of 02 (severe cognitive impairment). Record review of Resident #7's Care Plans revealed there were no person-centered comprehensive care plans initiated. Record review of Resident #7's Care Plans dated 06/01/2023, after surveyor's interventions revealed person-centered comprehensive care plans were initiated 06/01/23. Record review of Resident # 72's admission MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Anemia (low red blood cells), hyperlipidemia (high cholesterol), and presence of right artificial knee joint. With a BIMs of 15 (no cognitive impairment). Record review of Resident #72's Care Plans revealed no person-centered comprehensive care plans were not initiated. Interview with LVN E on 06/01/23 at 11:09 AM revealed the MDS nurse was the one responsible for doing the person-centered comprehensive care plans. Interview and record review with MDS A on 06/01/23 at 2:04 PM revealed the DON or RN supervisor open the initial comprehensive care plans and after the care plans are opened, she would complete them and make them person-centered. MDS A reviewed Resident # 7's and Resident #72's care plans and revealed they were not completed, she stated it was due to oversight. She stated Resident #7 and Resident #72 were past their 7-day window allowed to get the care plans completed. She stated the care plans can be found under the care-plans tab in the EMR and if the care plans are not complete the nurses would not know how to properly care for the resident. The risk to the resident would be the resident 675908 Page 5 of 8 675908 06/02/2023 Avante Rehabilitation Center 225 N Sowers Rd Irving, TX 75061

F 0655 not receiving patient centered care. Level of Harm - Minimal harm or potential for actual harm Interview with DON on 06/01/23 at 4:26 PM revealed it was her expectation for care plans to have objectives and interventions, be person-centered, measurable, and include time frames to achieve the desired outcomes for residents. She stated she was the one who opened the initial care plans under the care plan tab, and it should be completed by MDS A. She stated they have been utilizing nursing department heads to help correct the issue of not having care plans completed. She stated this issue was caused by a breakdown in communication and education. The risk of not having care plans could be that the resident does not receive the proper care. Residents Affected - Few Interview on 06/02/23 at 1:10 PM with LVN F revealed nurses do new admission assessments that DON or MDS A can pull from to create baseline care plans. She stated she finds patient interventions under the care plan tabs in the EMR. Interview on 06/02/23 at 3:04 PM with Administrator revealed her expectations was comprehensive care plans would be initiated at admission and completed within the appropriate time frame. Moving forward she will also include in the monitoring process to ensure care plans are done according to facility policy. Record review of facility's policy Care Plans, Comprehensive Person-Centered revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident. Care plans is developed within seven days of the completion of the required comprehensive assessment. 675908 Page 6 of 8 675908 06/02/2023 Avante Rehabilitation Center 225 N Sowers Rd Irving, TX 75061

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for four (Residents #23, #36, #54 and #88) of eight residents reviewed for Medical records. 1. The facility failed to ensure Residents #23, #36, #88's MDS discharge assessments were completed and in their medical records after they discharged this facility. 2 The facility failed to have accurate 14 day admission and Quarterly MDS Assessments completed for Resident #54, since she re-admitted [DATE]. These failures could cause all residents to be at risk of inadequate care if inaccurate diagnoses or missing documentation were not included in their medical records, resulting in not properly assessing, monitoring and treating a resident and causing them distress, pain and decreased psycho-social well- being. Findings included: A)Record review of Resident #23's face sheet dated 06/02/23 revealed an [AGE] year old female who initially admitted [DATE] and re-admitted [DATE] with diagnoses Spinal Stenosis, Protein -Calorie Malnutrition, Depression, Chronic pain, Lack of Coordination . and discharged [DATE]. Record review of Resident #23's Simple LTC Final Validation Report undated revealed ARD target date after the assessment reference date (ARD). B)Record review of Resident #36's face sheet dated 06/02/23 revealed a [AGE] year old female who admitted [DATE] with diagnoses Lymphedema, Iron Deficiency, morbid obesity, encephalopathy, hypertensive heart disease, congestive heart failure .and discharged on 03/30/23. Record Review of Resident #36's LTC Final Validation Report undated revealed ARD target date 04/14/23 assessment reference date (ARD). C) Record review of Resident #54's face sheet dated 06/02/23 revealed she was private pay with Managed care insurance as secondary and her most recent hospital stay was 12/13/22 - 12/17/22. Record review of Resident #54's MDS Assessment completed by MDS A dated 12/24/22 revealed, A check marked: None of the Above .5 day scheduled PPS assessment .a [AGE] year old female who initially admitted [DATE] .with a BIMS score of 05 (severe cognitive impairment) with active diagnoses part of neck of left femur fracture, muscle wasting, unsteadiness on feet, benign neoplasm of mesothelial tissue of peritoneum (Tumor of stomach lining) . Record review of Resident #54's MDS Assessment completed by MDS A dated 12/13/22 revealed, A check marked for None of the above assessment and none of the above PPS Assessment .a [AGE] year old female who initially admitted [DATE] with a BIMS score of 02 (severe cognitive impairment) . 675908 Page 7 of 8 675908 06/02/2023 Avante Rehabilitation Center 225 N Sowers Rd Irving, TX 75061

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some D)Record review of Resident #88's face sheet dated 06/02/23 revealed an [AGE] year old female who admitted [DATE] with diagnoses left femur fracture, protein-calorie malnutrition, intellectual disabilities, end stage renal disease .and discharged on 03/06/23. Record review of Resident #88's Simple LTC Final Validation Report undated revealed ARD target date late after the assessment reference date (ARD). Interview on 06/01/23 at 2:13 pm, MDS A stated she had been the MDS Coordinator for a year and added they did not have a Medical Records Director and was not sure who was responsible for ensuring the resident's medical records were accurate. She stated if the resident's medical records were not accurate something could be missed like medications, consents for treatment, tracking behavioral patterns, so many things. Interview on 06/01/23 at 2:13 pm, MDS A stated if the resident's medical records were not accurate something could be missed like medications, consents for treatment, tracking behavioral patterns, so many things. Interview on 06/02/23 at 6:44pm, the DON stated they needed to hire someone for the medical records position because they did not have a Medical Records Director. She stated she was responsible for ensuring the medical records were accurate. She stated she was aware of the issues with completing the MDS assessments but had not resolved the problem yet. She stated the plan was for she, MDS A and the Corporate Nurse to split up the MDS assessments to get them done because they had a busy schedule and MDS A was the only MDS Coordinator. She stated her expectations for MDS Assessments was for them to be done timely according to the schedule and was not sure who was responsible for ensuring the MDS Assessments were complete and accurate. She stated she was not sure when MDS A had an MDS Assessment training. Interview on 06/02/23 at 7:04 pm, the Administrator stated her expectations was for getting MDS Assessments and care plans done timely and accurately. She stated for medical records, making sure the staff accurately put in the the resident's information. Record review of the facility's Charting and Documentation Policy Dated July 2017 revealed, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . 675908 Page 8 of 8