Health inspection·June 7, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 3 residents (Resident #1) reviewed for blood glucose monitoring, in that: Residents Affected - Few The facility failed to ensure Resident #1 received glucose monitoring and injection of insulin according to sliding scale order based on blood glucose level when LVN A did not obtain a blood glucose level before lunch on 6/06/2023. These failures could place residents at risk for untreated changes in blood sugar and could result in a decline in health. The findings were: Record review of Resident #1's face sheet dated 6/06/2023 revealed an admission date of 2/26/2022 with a readmission date of 4/02/2022 with diagnoses which included: type 2 diabetes mellitus without complications, diffuse traumatic brain injury with loss of consciousness of unspecified duration subsequent encounter and unspecified severe protein-calorie malnutrition. Record review of Resident #1's Care Plan dated 3/18/2022 and last revised on 2/24/2023 revealed Resident #1 had diabetes and was at risk for complications associated with diabetes including hyper/hypo glycemia (high/low blood sugar levels) with interventions to include: administer my medications as recommended by my doctor, monitor labs as indicated. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 1 (scale of 0-15) which indicated a severe cognitive impairment. The MDS assessment revealed Resident #1 received insulin injections 7 days a week. Record review of Resident #1's physician orders dated 3/28/2023 revealed: Insulin Lispro solution (fast acting insulin used to control elevated blood glucose levels), inject as per sliding scale. If [blood glucose level] 151-200 give 2 units; if 201-250 give 4 units; if 251-300 give 6 units; if 301-350 give 8 units; if 351-400 give 10 units. If blood sugar level greater than 401 give 12 units, recheck and report to MD, subcutaneously (by injection) before meals and at bedtime for diabetes mellitus. Record review of Resident #1's licensed nurse MAR for June 2023 revealed blood glucose monitoring and insulin administration was not documented on the medication administration record for 11:00 a.m. Page 1 of 6 675968 675968 06/07/2023 Stone Oak Care Center 505 Madison Oak Dr San Antonio, TX 78258

F 0684 (before lunch) on 6/06/2023. Level of Harm - Minimal harm or potential for actual harm During an observation on 6/06/2023 from 10:20 a.m. to 11:40 a.m. LVN A was observed at the nurse's station with her assigned medication cart parked at the nurse's station beside her chair. LVN A was not observed performing blood glucose monitoring or insulin administration and the medication cart was not moved from its position at the nurse's station. Residents Affected - Few During an interview on 6/06/2023 at 11:41 a.m. LVN A stated she keeps a handwritten notebook with her that she documented important information in and then later transcribed into the computer. She stated sometimes she gets busy and in unable to document directly into the computer, so she relied on her notebook as a reminder. During an observation on 6/06/2023 from 11:42 a.m. to 12:10 p.m. LVN A was observed at the nurse's station with her assigned medication cart parked at the nurse's station beside her chair. LVN A was not observed performing blood glucose monitoring or insulin administration and the medication cart was not moved from its position at the nurse's station. During an interview/observation on 6/06/2023 at 12:10 p.m. LVN A stated it was lunch time and she had lunch duties. She was observed leaving the nurses station with her computer and notepad and going to the main dining area. LVN A's assigned medication cart remained parked at the nurse's station. Resident #1 was observed seated at a table in the dining room. During an observation on 6/06/2023 from 12:10 p.m. to 1:08 p.m. LVN A was observed checking meal trays and assisting residents with meal service. She did not administer medication, check blood sugar levels, or administer medications in the dining room. LVN A's medication cart remained at the nurse's station during lunch meal service. During an interview on 6/07/2023 at 1:29 p.m., LVN A stated did not know if she performed blood glucose monitoring on 6/06/2023 for Resident #1 before lunch, although she normally completed that task. LVN A stated if she did take his glucose level, she wrote it in her notebook that she keeps with her at the facility. LVN A stated she was not able to review or show she completed Resident #1's blood glucose because she did not have the notebook with her and had left it at home. She stated she did not give insulin to Resident #1 and does not remember why. She stated after thinking about it she does not remember completing a blood glucose level for Resident #1 before lunch on 6/06/2023. LVN A stated she had lunch duties on 6/06/2023 and could not leave the lunchroom to perform the blood glucose monitor. She stated she had a lot of stuff going on and the task was forgotten. LVN A stated blood glucose should be obtained within 30 minutes of a meal. During an interview on 6/07/2023 at 3:10 p.m., ADON C stated he was aware that LVN A had trouble with time prioritization and sometimes at the end of a shift she had a lot of stuff she still needed to do. He stated LVN A had been given repetitive teaching (undocumented) which was paying off. He stated he was available for assistance to nursing staff, if needed. ADON C stated LVN A should be able to finish her work, and if she did not have time to do a blood glucose level or administer insulin, he would want to know why she did not have time. He stated LVN A should have found a nurse manager for assistance. ADON C stated LVN A should always let management know if she did not have time to complete her work and was not aware she did not complete Resident #1's blood glucose or insulin administration on 6/06/2023. ADON C stated no matter how busy LVN A was, patient care should be prioritized. ADON C stated blood glucose monitoring was important because if the blood sugar got too high it could potentially be an emergency. He stated if it was part of a physician order it needed to be 675968 Page 2 of 6 675968 06/07/2023 Stone Oak Care Center 505 Madison Oak Dr San Antonio, TX 78258

F 0684 carried out. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/07/2023 at 3:33 p.m., the DON stated her expectations of nursing staff were to deliver care as ordered by a physician and to document the care was delivered. Residents Affected - Few Record review of a facility policy, titled Diabetes Management dated 3/12/2019 and last revised January 2023 revealed: Routine Care: Blood glucose measurements shall be taken per the physician order .Anti-diabetic agents (insulin or oral anti-diabetic agents) should be administered per physician order). 675968 Page 3 of 6 675968 06/07/2023 Stone Oak Care Center 505 Madison Oak Dr San Antonio, TX 78258

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 interviews and record reviews the facility failed to ensure, in accordance with accepted professional standards and practices, complete, accurately documented, readily accessible, and systemically organized medical records for each Resident, for 1 of 6 residents (Resident # 1) reviewed for accurate records, in that: The facility failed to document Resident #1's behaviors on multiple days in May and June 2023. These failures placed residents at risk for untreated or unmanaged behaviors by inaccurate and missing records documentation. The findings were: Record review of Resident #1's face sheet dated 6/06/2023 revealed an admission date of 2/26/2022 with a readmission date of 4/02/2022 with diagnoses which included: diffuse traumatic brain injury with loss of consciousness of unspecified duration subsequent encounter, bipolar disorder, and major depressive disorder. Record review of Resident #1's Care Plan dated 4/28/2023 revealed Resident #1 required anti-depressant medication for agitation/anxiety, sexual verbal comments and insomnia with interventions which included: monitor for target behaviors/symptoms and monitor/document/report to MD ongoing signs/symptoms depression. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 1 (scale of 0-15) which indicated a severe cognitive impairment. The MDS assessment revealed Resident #1 had no documented behaviors and had a total mood severity score of 0. Record review of Resident #1's [NAME] 2023 Behavior Monitoring Record revealed behavior tracking was not documented on day shift (6am-2pm shift) for: -Monday 5/01/2023 -Tuesday 5/02/2023 -Wednesday 5/03/2023 -Sunday 5/14/2023 -Monday 5/15/2023 -Tuesday 5/16/2023 -Wednesday 5/17/2023 -Friday 5/19/2023 -Tuesday 5/23/2023 675968 Page 4 of 6 675968 06/07/2023 Stone Oak Care Center 505 Madison Oak Dr San Antonio, TX 78258

F 0842 -Thursday 5/25/2023 Level of Harm - Minimal harm or potential for actual harm -Friday 5/26/2023 -Wednesday 5/31/2023 Residents Affected - Some Record review of Resident #1's Jun 2023 Behavior Monitoring Record revealed behavior tracking was not documented on: -Thursday 6/01/2023 -Friday 6/02/2023 During an interview on 6/06/2023 at 11:41 a.m. LVN A stated she keeps a handwritten notebook with her that she documented important information in and then later transcribed into the computer. She stated sometimes she gets busy and was unable to document directly into the computer, so she relied on her notebook as a reminder. During an interview on 6/07/2023 at 1:29 p.m., LVN A stated she did not document behavior tracking for Resident #1 in May and June 2023. She stated she works full time as a charge nurse. She stated her schedule was Monday thru Friday 6 a.m. to 2 p.m. and she typically worked on the same hallway/unit. LVN A stated she documents resident behaviors in the MAR usually by noon. She stated if a behavior occurs after she documents she can edit the entry in the computer. LVN A stated behaviors are documented as a change from baseline behaviors. She stated she was not in the facility for a couple of the days but could not remember what days they were. LVN A stated she does remember having somedays where she was slammed busy with a lot going on, so she did not do behavior tracking. She stated some days (dates unknown) she had lunch duty in the dining room and had a lot going on and it was forgotten. LVN A stated she was still trying to grasp what was going on with her job responsibilities. She stated she was having time management problems due to a medical condition and carried the notebook. LVN A stated she had not really discussed with anyone in management her time management struggles because it was balls to the walls (very busy) when she was working. LVN A stated she was afraid to talk to management because of fear of losing her job. LVN A stated she told by the DON and former Administrator to document as the task was completed. LVN A stated it was important to accurately document behaviors so the staff could notice trends or patterns of behavior and so the behaviors were accurately recorded. During an interview on 6/07/2023 at 2:23 p.m., ADON B stated her job duties included managing staff which meant making sure they were completing their assignments and educating staff. ADON B stated during morning meeting documentation by had been discussed and the need to re-educate although she could not remember specifics. She stated she could not remember when this occurred. ADON B stated the re-education consisted of one-on-one and was not documented. She stated she could not remember if an in-service was completed on documentation. During an interview on 6/07/2023 at 3:10 p.m., ADON C stated the nursing staff know they need to click on behavior tracking to complete (in the computer). ADON C stated with LVN A he was very patient with her, and she was offered in-service training with the DON. ADON C stated the training occurred approximately 2 months ago and it was about making sure she documented everything that happened on the shift. ADON C stated he showed her how to prioritize her time on the floor and she was receptive to it. ADON C stated LVN A had never stated she was overwhelmed but sometimes he could kind of 675968 Page 5 of 6 675968 06/07/2023 Stone Oak Care Center 505 Madison Oak Dr San Antonio, TX 78258

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tell. He stated LVN A had not expressed why she was having difficulty documenting. ADON C stated he had discussed the documentation with the DON and former Administrator. He stated he told them her prioritization was not up to speed. ADON C stated the response was repetitive teaching. ADON C stated he expected nursing staff to ensure everything was documented so they could be accountable. He stated LVN A was trained to do the work, but he could not guide her the whole 8 hours of her shift. He stated LVN A she always let management know when she does not have time to finish her work. ADON C stated it was important to accurately document behaviors to trend baseline. He stated the physicians look at it and that was how they base their orders. During an interview on 6/07/2023 at 3:33 p.m., the DON stated her expectation was for nursing staff to deliver care as ordered by a physician and to document care that was delivered, to report any changes in patient condition, make notifications of behavior changes and let management know if their case load was more than they could manage. The DON stated she also expected communication. During an interview on 6/07/2023 at 3:45 p.m., the DON stated the facility did not have a policy for documentation of behavior monitoring. At the time of exit the information had not been received regarding LVN A timecard for May and June 2023 and in-service training for documentation. 675968 Page 6 of 6