Health inspection·October 29, 2024

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 a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 5 residents (Resident #5) reviewed for ADLs. Residents Affected - Few The facility failed to ensure Resident #5's bed linens were clean when her bed linens were visibly dirty with a dark yellow stain with a brown ring around the outer edges on 10/28/2024. This failure could place residents at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: Record review of admission Record for Resident #5 dated 10/29/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included diagnoses of Pneumonia (a respiratory infection) Muscle Wasting (loss of muscle mass and strength), Weakness, and Difficulty Walking. Record review of Resident #5's quarterly MDS Assessment, dated 8/02/24, indicated no cognitive impairment in thinking with a BIMS score of 15. Resident #5 required Supervision or touching assistance for all ADLs and she was occasionally incontinent of bladder. Record review of a Care Plan for Resident #5 dated 08/05/2024, reflected she had an ADL Self Care Performance Deficit related to weakness and poor balance and bowel/bladder incontinence related to disease process and weakness. An observation on 10/28/24 at 3:30 PM revealed Resident #5's room had a strong odor of ammonia. Her bed had a dark yellow, circular, stain, with a brown ring around the outside edges. The stain covered almost the full horizontal width of the bed and roughly 2 feet vertically. During an interview on 10/28/2024 at 3:55 PM, Resident #5 said she had been wet for hours this morning, staff did not check her bed they only brought her tray in. She said she had been in the facility for 5 years and it had been an ongoing problem with staff not doing what they were supposed to. She was thinking about leaving and moving to another facility because of the issues. She said this wasn't the first time. She said not receiving ADL assistance made her feel not good and she was dealing with pneumonia at this time. She said she used to be able to change her own linens, but she needed help now. She said the staff was always changing and she never knew who was working her hall. Page 1 of 3 675962 675962 10/29/2024 Southland Rehabilitation and Healthcare Center 501 N Medford Dr Lufkin, TX 75901

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/28/2024 at 4:12 PM, ADON B said she and ADON C were working on Resident #5's hall today and ADON B was taking care of Resident #5 today. She said the standard was to round on residents every 2 hours or as needed. She said Resident #5 was usually continent and took care of herself and changed her own linens. She said Resident #5 was known to throw wet briefs into her trash can and stated, my sinuses are messed up, I'm not negating that there may have been a urine smell in the room. She said risks to residents wearing wet briefs or lying on wet linens would be skin impairment. During an interview on 10/28/24 at 4:20 PM, ADON C said ADON B was assigned to Resident #5's hall today and she had only been assisting. She said she was helping with transfers, bed changes, or activities that required a second staff member. She said Resident #5 was usually continent and changed her own briefs. She said residents should be rounded on at least every two hours. She said when she entered Resident #5's room she saw the bed was wet with urine, and she could smell an odor of urine. She said if staff smelled a urine odor in a room they should be checking for soiled linens and briefs. She said the risks to a resident wearing wet briefs or lying on wet linens would be skin breakdown and wound development. During an interview on 10/29/24 at 8:29 AM with CNA D, she said she sometimes worked on Resident #5's hall and she made rounds every 2 hours, checked the briefs, and saw if they needed anything. She said Resident #5 was very independent, but she checked on her to see if she would go to the bathroom, checked her bed and clothes, and took out laundry. She said Resident #5 had frequent accidents. She said she went into her room and found her bed frequently soaked with urine. During an interview on 10/29/24 at 12:45 PM with the Administrator, she said the standard and the expectation was residents would be rounded on every 2 hours or as needed. She said the nursing services were responsible for training and CNAS and nurses both received the same in-services, but nurses had extra training they completed. She said the risks for a resident who was not rounded on every 2 hours would be skin break down or they could hurt themselves in some way that we did not identify. During an interview on 10/29/24 at 1:10 PM with the DON, she said as the DON she was responsible for ensuring all CNAs and Nurses received training. She said her expectation was the residents were rounded on at least every 2 hours. She said the facility used special briefs with an indicator that alerted when they were wet. She said if a CNA or nurse entered a room and there was an odor of ammonia, the expectation was that they investigate to find where the smell was coming from. She said it was her expectation that patients who had a history of being noncompliant with care were still offered help. She said the risk to a resident being left in wet briefs or lying on wet linens was skin impairment. During an interview on 10/29/24 with MA A, she said when she went into Resident #5's room to pass medications, the first thing she noticed was a large stain with a brown ring around it, about the size of a pillow on Resident #5's mattress and the room smelled like urine. She said it wasn't uncommon for Resident #5's room to smell like urine. She said that if she had time, she would assist patients herself with ADL care, but if she had other duties such as passing medications, she would alert the CNA or nurse that the resident needed attention. Record review of Orientation and Annual Skills Checklist for ADON B, dated 3/10/24, indicated successful completion. Record review of the facility's Policy ADL, Services to Carry Out reflected . Residents who are 675962 Page 2 of 3 675962 10/29/2024 Southland Rehabilitation and Healthcare Center 501 N Medford Dr Lufkin, TX 75901

F 0677 unable to carry out activities of daily living (ADL) will receive necessary services to maintain Personal Hygiene Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675962 Page 3 of 3