Health inspection·August 23, 2023

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 that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 17 residents reviewed for care plans. Resident #11 did not have a completed comprehensive care plan for several care areas. This failure could place residents at risk of not having their care needs met. Findings included: Review of the undated face sheet for Resident #11 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of history of urinary tract infections, cerebral infarction, expressive language disorder, muscle weakness, cognitive, communication deficit, type two diabetes mellitus, chronic, obstructive, pulmonary disease, asthma, aphasia, atherosclerotic, heart, disease, hyper lipidemia, unspecified, convulsions, repeated falls, depression, anxiety, disorder, lipoprotein deficiency, gastroesophageal, reflux, disease, hypothyroidism, and edema. Review of the admission MDS for Resident #11 dated 08/05/23 reflected a BIMS score of 13, indicating an intact cognitive response. It reflected that no rejection of care or other behaviors were exhibited. It reflected she was occasionally incontinent of bladder and bowel. It reflected a history of falls prior to admission. It reflected the following in the area of functional status: Bed Mobility- limited assistance of one person Transfer- extensive assistance of one person Dressing- extensive assistance of one person Toilet Use- extensive assistance of one person Personal Hygiene- extensive assistance of one person Bathing- total dependence Reflection of a care area assessment summary reflected the following: For each triggered Care Area, Page 1 of 9 675937 675937 08/23/2023 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0656 Level of Harm - Minimal harm or potential for actual harm indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan. The following areas were marked as triggered care areas and also marked for a care planning decision: Residents Affected - Few Communication. Functional/Rehabilitation Potential. Urinary Incontinence and Indwelling Catheter Activities. Nutritional Status. Pressure Ulcer. Psychotropic Drug Use Review of the care plan for Resident #11 dated 08/07/23 reflected the following, with no information specific to the resident in any care plan item where specify is noted: PROBLEM: The resident has an ADL self-care performance deficit r/t _____. GOAL: The resident will maintain current level of function in through the review date. INTERVENTIONS: ORAL CARE: The resident has (SPECIFY: own teeth, upper/lower dentures, broken teeth, carious teeth, sore gums, bridgework). The resident requires oral inspection (SPECIFY FREQ) Report changes to the Nurse.o SIDE RAILS: 1/4 rails up as per Dr.s order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. PROBLEM: The resident has a behavior problem (SPECIFY) r/t______ GOALS: The resident will have fewer episodes of (SPECIFY: behavior) (SPECIFY: daily/weekly) by review date. o The resident will have no evidence of behavior problems (SPECIFY) by review date. NO INTERVENTIONS PROBLEM: The resident is/has potential to be (physically/verbally) aggressive (SPECIFY) r/t_____ GOAL: The resident will verbalize understanding of need to control physically aggressive behavior through the review date. o The resident will not harm self or others through the review date. NO INTERVENTIONS 675937 Page 2 of 9 675937 08/23/2023 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0656 PROBLEM: The resident has impaired cognitive function/dementia or impaired thought processes r/t_____ Level of Harm - Minimal harm or potential for actual harm GOALS: The resident will maintain current level of cognitive function through the review date. o The resident will maintain current level of decision-making ability by (SPECIFY how) by review date. Residents Affected - Few NO INTERVENTIONS PROBLEM: The resident has a communication problem r/t_____ GOAL: The resident will be able to make basic needs known by (SPECIFY) on a daily basis through the review date. INTERVENTIONS: Anticipate and meet needs. PROBLEM: The resident wishes to (SPECIFY return/be discharged ) to (SPECIFY home, another facility). GOAL: The resident will (SPECIFY) verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date. o The resident's discharge goals are: (SPECIFY abilities, dates, milestones). NO INTERVENTIONS PROBLEM: The resident has dehydration or potential fluid deficit r/t_____ GOAL: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. INTERVENTIONS: Administer medications as ordered. Monitor/document for side effects and effectiveness. PROBLEM: The resident is (SPECIFY High, Moderate, Low) risk for falls r/t GOALS: The resident will be free of falls through the review date. o The resident will be free of minor injury through the review date. NO INTERVENTIONS PROBLEM: The resident has nutritional problem or potential nutritional problem (SPECIFY) r/t______ GOAL: o The resident will maintain adequate nutritional status as evidenced by maintaining weight within (X)% of (SPECIFY BASELINE), no s/sx of malnutrition, and consuming at least (X)% of at least (SPECIFY) meals daily through review date. INTERVENTIONS: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. 675937 Page 3 of 9 675937 08/23/2023 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/23/23 at 01:20 PM, the MDSN stated she was responsible for creating care plans and overseeing the care plan creation process for compliance. The MDSN stated when they admitted a new resident, the charge nurse started the care plan and within 21 days the comprehensive care plan was done. She stated she thought she was trained to do it that way by her corporate MDS nurse a long time ago. The MDSN stated in an ideal world, they would have put in what they already knew, and they would have a couple weeks to get to know the resident and then complete the care plan. The MDSN stated staff used the care plans when they went over them with family members, and the nurses used them on the halls. She stated she was not sure if the CNAs used information from the care plans on their point of care documentation system. The MDSN stated she had not entered any of the specific information on Resident #11's care plan, and it should have been done. The MDSN stated there was probably an opportunity for there to be a negative impact when a comprehensive care plan was not completed, but there was so much information in other areas of the chart that she did not know if it would negatively impact any residents. She stated the care plans were a work in progress, and Resident #11's care plan was one she had on her list but had not finished yet. During an interview on 08/23/23 at 02:50 PM, the DON stated the actual facts should have been on Resident #11's care plan. She stated the template that said Specify and did not specify was not adequate. She stated the MDSN was responsible for ensuring those got done, but she oversaw the MDSN. During an interview on 08/23/23 at 03:00 PM, the ADM stated it was her expectation that the care plans be person-specific and created on time. She stated Resident #11 should have had a completed care plan. Review of facility policy dated March 2022 and titled Care Plans, Comprehensive Person-Centered reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1.The interdisciplinary team, IDT, in conjunction with the resident and his/her family, or legal representative, develop and implement a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (admission, annual or significant change in status), and no more than 21 days after admission. 7. The comprehensive person-centered care plan: a. Includes measurable, objectives, and b. Describe the services that are to be furnished to a attain or maintain the residence, highest practicable, physical, mental, and psychosocial well-being, including (1) services that would otherwise be provided for the above, but are not provided due to the resident, exercising his or her rights, including the right to refuse treatment c. Includes the resident stated goals on admission and desired outcomes d. Builds on the residence, strengths; & 675937 Page 4 of 9 675937 08/23/2023 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0656 e. Reflect currently recognized standards of practice for problem, areas and conditions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675937 Page 5 of 9 675937 08/23/2023 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

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 that a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 10 residents reviewed for toileting and incontinent care. Resident #11 was not provided with incontinent care or assistance to the toilet on 8/23/23 from 01:51 AM to 10:55 AM. This failure could place residents at risk of urinary tract infection, skin breakdown, and indignity. Findings included: Review of the undated face sheet for Resident #11 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of history of urinary tract infections, cerebral infarction, expressive language disorder, muscle weakness, cognitive, communication deficit, type two diabetes mellitus, chronic, obstructive, pulmonary disease, asthma, aphasia, atherosclerotic, heart, disease, hyper lipidemia, unspecified, convulsions, repeated falls, depression, anxiety, disorder, lipoprotein deficiency, gastroesophageal, reflux, disease, hypothyroidism, and edema. Review of the admission MDS assessment for Resident #11 dated 08/05/23 reflected a BIMS score of 13, indicating an intact cognitive response. It reflected that no rejection of care or other behaviors were exhibited. It reflected she was occasionally incontinent of bladder and bowel. It reflected the following in the area of functional status: Toilet Use- extensive assistance of one person. Review of the care plan for Resident #11 dated 08/07/23 reflected the following: PROBLEM: The resident has an ADL self-care performance deficit r/t _____. GOAL: The resident will maintain current level of function in through the review date. INTERVENTIONS: ORAL CARE: The resident has (SPECIFY: own teeth, upper/lower dentures, broken teeth, carious teeth, sore gums, bridgework). The resident requires oral inspection (SPECIFY FREQ) Report changes to the Nurse.o SIDE RAILS: 1/4 rails up as per Dr.s order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. PROBLEM: The resident has a behavior problem (SPECIFY) r/t______ GOALS: The resident will have fewer episodes of (SPECIFY: behavior) (SPECIFY: daily/weekly) by review date. o The resident will have no evidence of behavior problems (SPECIFY) by review date. NO INTERVENTIONS. Review of the POC (CNA documentation) for Resident #11 dated 08/23/23 reflected she was marked as 675937 Page 6 of 9 675937 08/23/2023 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0690 having been provided incontinent care at 01:51 AM by CNA C and at 11:37 AM by CNA D. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 08/23/23 at 07:45 AM, 08:57 AM, and 09:50 AM revealed Resident #11 was laying in bed in a nightgown. She was very hard of hearing but when asked if she needed to go to the bathroom, she stated no and when asked if she was dry and comfortable, she stated yes. Residents Affected - Few Observation on 08/23/23 at 10:50 AM revealed the call light for Resident #11 was on. She stated she needed to go to the bathroom. She was laying in her bed with one leg hanging off the side of the bed and tried to sit up next to her walker. Within one minute, CMA B came into the room and asked what Resident #11 needed. She said she did not need anything. CMA B asked if she needed to go to the bathroom, and she could not hear him. CMA B assisted her with applying her hearing aides and asked her again if she needed to go to the bathroom. She laughed and pursed her brow, and he asked if she would like the help of a female to use the bathroom. She stated yes, and CNA D entered the room a few minutes later. Resident #11 continued to say she did not need to go to the bathroom, and CNA D continued to encourage her and help her up. When Resident #11 stood up, the back of her pajamas was completely wet and soiled and her bed pad was completely wet and soiled. There was evidence of both urine and feces leaking out of her brief. During an interview on 08/23/23 at 12:50 PM, CMA B stated it was not usually his role to take residents to the bathroom, but he worked as a medication aide on that hall all the time, so he was close to the residents. CMA B stated the CNAs checked on Resident #11, and he sometimes worked on the hall as a CNA. He stated sometimes you had to push her to go to the bathroom and not accept her first answer. CMA B stated the current situation in healthcare was that there were staffing issues, and much of the staff were from a staffing agency. He stated for the staff who knew their residents, they knew Resident #11 needed extra encouragement. CMA B stated he told the nurse if she completely refused, as that was their procedure. CMA B stated if she had to sit or lay in her urine or feces for hours, it could cause her to feel embarrassed. During an interview on 08/23/23 at 01:00 PM, LVN A stated CNA C was the aide assigned to work with Resident #11. LVN A stated it was his expectation and facility policy that the CNAs checked on residents every two hours and provided toileting assistance or incontinent care if needed. LVN A stated he knew Resident #11 had a tendency to believe she was more independent than she was and would sometimes refuse help. LVN A stated the CNAs should have tried other methods or approaches to ensure Resident #11 was toileted or changed often enough, and they should have reported back any refusals, especially if there was loose stool leaking out of her brief. LVN A stated since Resident #11 was new to the facility, they were still learning what she could and could not do, and he felt sure they would have to take over her care at some point. LVN A stated the ADON or DON would need to reclassify her has more dependent. When asked how agency staff were oriented to the residents they were to care for, he stated they rounded with the tenured CNAs and the nurses on duty oriented them. When asked if he had oriented CNA C, he stated CNA C was not new to the facility and had worked there before, and someone else must have oriented him. During an interview on 08/23/23 at 01:10 PM, CNA C said his procedure was to check each resident every two hours or more often depending on the individual. CNA C stated Resident #11 admitted to the facility and could do very little for herself, and then she got more independent, and now even if he offered to help her, she said no. He stated he always checked on her, and she said she was okay. When asked if she went to the bathroom by herself, he said she needed help to get to the bathroom and could not go by herself. When asked if he documented it as a refusal when she said she did not need help, he said no. He stated he had not seen her leak or soil her bed. When asked if he had assisted 675937 Page 7 of 9 675937 08/23/2023 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her with toileting since the episode he documented at 01:51 AM, CNA C stated he had not helped her. When asked if he had told the nurse she had refused to be changed or toileted for nine hours, he stated he had not. During an interview on 08/23/23 at 01:40 PM, the ADON stated her expectation was that CNAs rounded every two hours on each resident and asked if they had to use the bathroom. The ADON stated the CNAs could not just ask them but needed to try to touch them and get near them to make sure they were dry and clean and did not need to be assisted. She stated they also needed to check using their senses of smell. She stated the briefs also had color sensors on them when they became wet. The ADON stated her expectation was the same for a resident who claimed to be more independent or refused care. She stated if residents refused, the staff were to try another way to communicate with them. The ADON stated the agency CNAs were oriented through skills checks and not necessarily to each individual resident. The ADON stated she had told the nurses she expected them to help orient new staff. The ADON stated she was familiar with Resident #11, and her understanding was the resident could get up and walk around in her room on her own, but it was not the expectation she had that staff let her toilet herself, because she was a fall risk. She stated a potential negative impact on the resident of not being changed for nine hours was skin breakdown. When asked how she monitored the floor staff for compliance with rounding, toileting, and incontinent care, she stated they had yearly skills checks. During an interview on 08/23/23 at 02:50 PM, the DON stated the management team monitored for compliance with provision of incontinent care with observations during frequent rounds she and the ADON made. She stated she also looked at trends in skin issues as well as resident complaints. The DON stated she told her floor staff they needed to plan that new residents always needed more care and assistance than they expected. She stated if the resident was not cognitively intact, then the needs should have been anticipated. The DON stated it was not consistent with her expectations for staff to stick their head in a door and just leave if the resident refused for nine hours. The DON said it is not consistent with what she would hope would happen. She stated she hoped when the CNA got Resident #11 up, he would have provided incontinent care. The DON stated she understood he may not have gotten her up. The DON stated each resident was different and their bodies would respond to stressors differently, but skin breakdown was a possible negative impact. She stated Resident #11 had been assessed and did not have skin breakdown. During an interview on 08/23/23 at 03:00 PM, ADM stated she monitored for compliance with toileting and incontinent care policies by running through morning clinicals and the CNA documentation system to make sure it was being completed. She stated the two main ways she oversaw the process was to review the documentation and make observations on the halls. The ADM stated she would hope going nine hours without provision of incontinent care would not happen to any resident. The ADM stated the CNA who experienced the refusals should have reported to the nurse who should have reported to them so they could investigate if something in the resident's plan of care needed to change. She stated a potential impact of the failure was skin issues over time and discomfort in the short-term. Review of facility policy dated March 2018 and titled Activities of Daily Living (ADLs), Supporting reflected the following: Residents will provided with care, treatment and services, as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living are independently will receive the service is necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs 675937 Page 8 of 9 675937 08/23/2023 Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support, and assistance with: c. Elimination (toileting). 4. If residents with cognitive impairment or dementia, resist care, staff will attempt to identify the underlying cause of the problem, and not just assume the resident is refusing or declining care. Approaching the resident in a different way, or at a different time, or having another staff member, speak with the resident may be appropriate. 7. The resident's response to interventions will be monitored, evaluated and revised as appropriate. 675937 Page 9 of 9