Health inspection·July 18, 2023

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 observations, interviews, and record reviews the facility failed to develop and 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 care for 1 (Resident #130) of 12 residents reviewed for care planning. Resident #130's baseline care plan was inaccurate, in that it stated Resident #130 was taking antipsychotic medication and it did not state Resident #130 was taking antidepressant medication. This failure could place newly admitted residents at risk of having inaccurate or misleading baseline care plans. Findings include: Record review of Resident #130's face sheet, dated 07/17/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute cystitis without hematuria (infection of the urinary bladder without blood in the urine), infectious gastroenteritis and colitis (irritation and inflammation of stomach and intestines resulting in nausea and diarrhea), type 2 diabetes, dementia (a group of thinking and social symptoms that interferes with daily functioning), and bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings). Record review of Resident #130's baseline care plan, dated 07/08/23, revealed a focus area of resident requires antipsychotic medications. The baseline care plan did not mention antidepressant medication. Record review of Resident #130's active physician's orders revealed an order for an antidepressant medication [Buspirone HCI] and no order for an antipsychotic medication. Record review of Resident #130's discontinued, struck out, and completed physician's orders revealed no antipsychotic medication. During an interview on 07/17/23 at 08:23 AM, Resident #130 stated she did not remember being on antipsychotic medications, she said, Psychotic, that sounds scary. During an interview on 07/17/23 at 09:47 AM, Resident #130's family member and secondary medical power of attorney stated Resident #130 lived with her before admission to the hospital for 10 days and Page 1 of 11 675970 675970 07/18/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0655 from there admission to the facility. She said Resident #130 did not take antipsychotic medication. Level of Harm - Minimal harm or potential for actual harm During an interview on 07/18/23 at 09:52 AM, the DON stated charge nurses are responsible for writing baseline care plans when a resident is admitted . Residents Affected - Few During an interview on 07/18/23 at 09:53 AM, the ADON stated a possible negative outcome of having an inaccurate baseline care plan was, You could miss important medication or care that is not transcribed to the next shift. Record review of an undated facility policy titled; Base Line Care Plans revealed the following: Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety . This facility will develop and 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 care. The baseline care plan will . Include the minimum healthcare information necessary to properly care for a resident including, but not limited to . Physician orders . It will be based on the admission orders, information about the resident available from transferring provider, and discussion with the resident and resident representative, if applicable. 675970 Page 2 of 11 675970 07/18/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 2 (Resident #13 and Resident #18) of 12 residents reviewed for care plan timing. 1. Resident #13 had a comprehensive assessment completed on 05/10/23 and her most recent care plan was developed on 05/31/23. 2. Resident #18 had a comprehensive assessment completed on 06/18/23 and her most recent care plan was developed on 05/23/23. These failures could place residents at risk of not receiving appropriate levels of care for needs identified in the comprehensive assessment. Findings include: 1. Record review of Resident #13's face sheet, dated 07/16/23, revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, frontal lobe and executive function deficit following cerebral infarction (impaired memory, problem solving, inhibition, and decision making due to stroke), protein calorie malnutrition, muscle wasting, cognitive communication deficit, unsteadiness on feet, need for assistance with personal care, major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #13's Quarterly MDS completed on 05/10/23 revealed a BIMS of 3 out of 15 which indicated severely impaired cognition. Section G of the assessment indicated Resident #13 needed extensive assistance to total dependance on 1-2 staff members across all ADLs except for eating which required supervision by one staff member. 2. Record review of Resident #18's face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), acute and chronic respiratory failure with hypoxia (respiratory system fails in gas exchange function resulting in below-normal levels of oxygen in the blood, specifically in the arteries), muscle wasting and atrophy, anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings), history of falling, and cognitive communication disorder (impaired ability to use language and speech to exchange information, thoughts, or feelings). Record review of Resident #18's Quarterly MDS completed on 06/18/23 revealed a BIMS of 5 out of 15 675970 Page 3 of 11 675970 07/18/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0657 Level of Harm - Minimal harm or potential for actual harm which indicated severely impaired cognition. Section G of the assessment indicated Resident #18 needed extensive assistance by one to two staff members across all ADLs except eating which required supervision by one staff person. Residents Affected - Few During an interview on 07/18/23 at 09:52 AM, ADON stated MDS RN is responsible for completing MDS assessments and care plans. She said she was not sure about the timing of a care plan related to an MDS assessment. When asked for a possible negative outcome of having a care plan that has not been updated according to the latest MDS assessment, she stated, That is like being neglectful, if there is something we missed that is very important it could even lead to hospitalization. An interview was attempted via telephone with MDS LVN on 07/18/23 at 10:28 AM. There was no answer and no return call. (She was out of the facility attending a training.) During an interview on 07/24/23 at 02:16 PM, MDS LVN stated the RNs of the facility are responsible for developing comprehensive care plans. She stated she takes the information from the MDS assessment and puts it into the care plan. MDS LVN stated she uses the facility's policy as well as the Resident Assessment Instrument for determining the time frame between MDS assessment and care plan development. She confirmed the facility's policy states a comprehensive care plan will be developed within 7 days of a comprehensive assessment. When asked for a possible negative outcome of a care plan not being updated within 7 days of the MDS assessment she said, Things being missed from the last MDS. Record review of undated facility policy titled; Comprehensive Care Planning revealed the following: .When developing the comprehensive care plan, facility staff will, at minimum, use the Minimum Data Set to assess the resident's clinical condition, cognitive and functional status, and use of services.A comprehensive care plan will be-Developed within 7 days after completion of the comprehensive assessment.The resident's care plan will be reviewed after each Admission, Quarterly, Annual, and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. 675970 Page 4 of 11 675970 07/18/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 a resident who needs respiratory care is provided such care consistent with professional standards of practice, the person-centered care plan, and residents' goals and preferences for 1 (Resident #2) of 12 residents reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #2 was provided O2 at 4 lpm continuously as ordered. This failure could place residents requiring O2 therapy at risk of hypoxia and not receiving prescribed care and services. Findings include: Record review of Resident #2's face sheet dated, 07/17/23, revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), type 2 diabetes (insufficient production of insulin, causing high blood sugar), hypertension (high blood pressure), and acute respiratory failure with hypoxia (respiratory system fails in gas exchange function resulting in below-normal levels of oxygen in the blood, specifically in the arteries). Record review of Resident #2's Quarterly MDS dated , 04/21/23, revealed a BIMS of 2 out of 15 which indicated severe cognitive impairment. Section O of the MDS revealed Resident #2 was receiving O2 therapy while a resident. Record review of Resident #2's care plan dated, 05/08/23, revealed an intervention for Resident #2's altered cardiovascular status was Give oxygen as ordered by the physician. The care plan further revealed an intervention for Resident #2's oxygen therapy was, Oxygen at 4 lpm per nasal canula. Record review of Resident #2's orders revealed an order, dated 04/06/23, for continuous O2 via nasal cannula at 4 lpm related to acute respiratory failure with hypoxia. An observation on 07/16/23 at 10:30 AM, revealed Resident #2 lying in a geri chair in her room asleep. She was receiving O2 via nasal cannula at 2 lpm. During an interview on 07/17/23 at 02:52 PM, Resident #2's family member revealed Resident #2 began receiving O2 on a continuous basis in 2020 after having COVID. An observation on 07/17/23 at 09:15 AM, revealed Resident #2 lying in a geri chair in her room asleep receiving O2 via nasal cannula at 2 lpm. An observation on 07/17/23 at 11:57 AM, revealed Resident #2 in a geri chair at a table in the dining room receiving O2 via nasal cannula at 2 lpm. An observation on 07/17/23 at 01:30 PM, revealed Resident #2 lying in bed asleep on her back covered with a blanket to underneath her chin receiving O2 via nasal cannula at 2 lpm. 675970 Page 5 of 11 675970 07/18/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation on 07/18/23 at 09:15 AM, revealed Resident #2 asleep in a geri chair in her room receiving O2 via nasal cannula at 2 lpm. During an interview on 07/18/23 at 09:52 AM, ADON said charge nurses were responsible for setting the O2 concentration levels for residents. She stated they knew what level to set the O2 to because the orders were in the Electronic Health Record. ADON stated a possible negative outcome of not setting O2 concentration as high as ordered by the physician was, They could be confused. When asked why Resident #2 was not receiving O2 at the ordered concentration level, ADON said, I don't know. During an interview on 07/18/23 at 09:54 AM, DON stated a possible negative outcome of not setting O2 concentration as high as ordered by the physician was, Hypoxia. During an interview on 07/18/23 at 10:04 AM, CNA B stated the nurses were responsible for setting the O2 levels. During an interview on 07/18/23 at 10:07 AM, RN D stated the physician decided the concentration for O2. She said the nurses were responsible for setting the O2 levels. She stated she knew what level to set the O2 concentration to by reading the physician's order. RN D said a possible negative outcome of not setting the O2concentration as high as ordered by the physician was, They can suffer from low O2 levels, hypoxemia, confusion, restlessness, and the resident can become ill. Record review of facility policy dated 02/13/07 and titled, Oxygen Administration revealed the following: Oxygen therapy includes the administration of oxygen in liters/minute by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases.The amount of oxygen by percent of concentration of lpm, and the method of administration, is ordered by the physician. The administration, monitoring or responses, and safety precautions associated with it are performed by the nurse.Goals 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.Procedure 1. Become familiar with the type of oxygen administration, medical diagnosis and reason for oxygen, intermittent or continuous use of oxygen, amount to be delivered. Record review of facility policy dated 2015 and titled, Physician's Orders revealed the following: .Physician's monthly consolidated orders must be reviewed by a licensed nurse to assure they reflect all current orders. 675970 Page 6 of 11 675970 07/18/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. The facility failed to store food at least 6 inches above the floor. This failure could place Residents at risk for foodborne illness. Findings Included: Observation of shelved/refrigerated foods on 7/16/2023 at 10:30am revealed the following: 1. Observation of freezer 1 on 7/16/23 at 10:30 am revealed onion rings with no label or date. 2. Observation of freezer 1 on 7/16/ 23 at 10:30 am revealed tater tots with no label or date. 3. Observation of freezer I on 7/16/23 at 10:33 am revealed chicken with no label or date. 4. Observation of shelf 1 on 6/16/23 at 10:34 am revealed vegetable oil open on shelf with no date. 5. Observation of shelf 1 on 6/16 at 10:34 am revealed Cal do [NAME] Bouillon on shelf with no date. 6. Observation of refrigerator 1 on 7/6/23 at 10:35 am revealed cooked bacon and sausage in a plasticzip lock bag with no label or date. 7. Observation of refrigerator 1 on 7/16/23 at 1035 am revealed watermelon in plastic zip lock bag with no label or date. 8. 675970 Page 7 of 11 675970 07/18/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation of refrigerator 1 on 6/16/23 at 10:35 am revealed open container of mustard in fridge with no date. 9. Observation of refrigerator 1 on 6/16/23 at 10: 37 am revealed unidentified white plastic container in fridge with no label or date. 10. Observation of pantry on 6/16/23 at 10:40 am revealed Items in pantry not stored six inches above the floor. An interview on 7/17/2023 at 1:30pm with [NAME] A, stated that all kitchen staff are responsible for safe food storage per their policy. [NAME] A stated that she would go to the policy to see what the policy stated concerning food storage. [NAME] A stated that the negative outcome for not practicing food storage would be contamination. An interview with Dietary Manager on 7/17/23 at 1:35 pm stated that kitchen staff are to follow facility policy for proper food storage. Dietary Manager stated that a negative outcome for Residents would be contamination. Record review of in-service dated 1/16/23 at 2: 30 PM, training contained proper labeling and storage. Record review of Dietary Services Policy & Procedure Manual, dated 2012, for storage area stated all stored items must be above the floor on surfaces which allow thorough cleaning. Record review of Food and Drug Administration Food Code, dated 1/18/23, stated in section 5-305.11 food storage should be at least 15cm (6 inches) above the floor. 675970 Page 8 of 11 675970 07/18/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #130) of 17 residents reviewed for infection control. Residents Affected - Few Resident #130 was on transmission-based precautions for C. diff (an infection of the large intestine caused by bacteria, resulting in diarrhea and possible drop in blood pressure) and staff failed to use proper hand hygiene when they exited her room. This failure could place all residents of the facility at risk of contracting C. diff. an infectious disease. Findings include: Record review of Resident #130's face sheet, dated 07/17/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute cystitis without hematuria (infection of the urinary bladder without blood in the urine), infectious gastroenteritis and colitis (irritation and inflammation of stomach and intestines resulting in nausea and diarrhea), type 2 diabetes (insufficient production of insulin, causing high blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), and bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings). Record review of Resident #130's baseline care plan, dated 07/08/23, revealed a focus area of resident has C. Difficile. The interventions listed for this focus area included, but were not limited to the following: Contact Isolation . Educate resident/family/staff regarding preventative measures to contain the infection. Record review of Resident #130's active physician's orders revealed an active order dated 07/08/23 that read Res. [Resident] to be placed on Contact precautions due to DX of C-DIFF. An observation on 07/16/23 at 10:07 AM, revealed yelling from behind the closed door of a room. The door had contact precaution signage and a cart with gloves, shoe covers, masks, and gowns next to the door in the hall. The signs on the door listed handwashing and hand sanitizing along with PPE necessary to enter the room. Resident #130 was inside the room lying on her back in bed with the head of the bed slightly elevated. She stated she had a bowel movement and needed someone to come clean her up. During an interview on 07/17/23 at 08:21 AM, Resident #130 stated staff wash their hands in her bathroom before they exit her room. An observation on 07/17/23 at 08:31 AM, revealed CNA B and CNA C donned PPE and entered Resident #130's room. 675970 Page 9 of 11 675970 07/18/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation on 07/17/23 at 08:37 AM, revealed CNA B and CNA C exited Resident #130's room and used the ABHR hanging from the hall wall outside the room. During an interview on 07/17/23 at 08:37 AM, CNA C was asked if she washed her hands in the bathroom of Resident #130's room before exiting and using ABHR. CNA C hesitated and looked at CNA B. CNA B was asked the same question and she replied, Are we supposed to? During an interview on 07/18/23 at 09:52 AM, ADON stated the transmission-based precautions for C. diff were contact precautions. She said ABHR does not work on C. diff. She stated a possible negative outcome of not washing hands with soap and water after providing care to a resident with a diagnosis of C. diff was passing C. diff or getting it yourself. When asked how staff were trained on the precautions necessary for C. diff, ADON stated, We do an in-service. When asked how staff were to know Resident #130 had C. diff and what precautions were necessary, ADON stated, We did an in-service prior to her [Resident #130] coming and set up the signs [on Resident #130's door] and gave a report of what to expect. ADON said she was responsible for letting direct care staff know what a resident is on transmission-based precautions for. During an interview on 07/18/23 at 10:04 AM, CNA B stated caring for a resident with C. diff required PPE and washing hands with soap and water. She said ABHR did not work on C. diff. She stated a possible negative outcome of not washing her hands after caring for a resident with C. diff would be spreading it. She stated staff were trained via in-services on the computer regarding what precautions to use with C. diff. CNA B said direct care staff found out what precautions were necessary by reading the signs on the door of a resident who is placed on transmission-based precautions. She said the nurse was responsible for letting direct care staff know what a resident was on precautions for. During an interview on 07/18/23 at 10:07 AM, RN D said precautions for caring for a resident with a diagnosis of C. diff were glove and gown and you can use sanitizer going in [to the resident's room] but you must wash with soap and water and leave your gloves and gown in the room. She stated ABHR did not work on C. diff. She said a possible negative outcome of not washing hands with soap and water after providing care to a resident with a diagnosis of C. diff was you can give it to yourself or any of your residents. She said staff were trained via in-services and handouts. RN D stated, We have handouts at the desk and instructions on the door [of the resident's room]. She stated nurses were responsible for notifying staff of residents on transmission-based precautions. Record review of facility in-service dated 07/07/2023 and titled, Contact Precautions/Hand Hygiene revealed a sign-in sheet containing CNA B and CNA C's signatures. The in-service revealed the following: . You must use soap/water for the following: (alcohol based hand cleaner is not recommended) . After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile . If someone with C. diff (or caring for someone with C. diff) doesn't clean their hands with soap and water .they can spread the germs to people and things they touch. C. diff can also live on people's skin. People who touch infected person's skin can pick up the germs on their hands .Washing with soap and water is the best way to prevent the spread from person to person. When C. diff germs are outside the body, they become spores. These spores are an inactive form of the germ and have a protective coating allowing them to live for months or sometimes years on surfaces and in the soil. The germs become active again when these spores are swallowed and reach the intestines. 675970 Page 10 of 11 675970 07/18/2023 Memphis Convalescent Center 1415 N 18th St Memphis, TX 79245

F 0880 Record review of facility policy dated 03/2023 and titled, Definitions revealed the following: Level of Harm - Minimal harm or potential for actual harm .'Contact precautions' are measures that are 'intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment.' Residents Affected - Few .'Hand washing' refers to washing hands with plain (i.e., nonantimicrobial) soap and water. Record review of facility policy dated 03/2023 and titled, Fundamentals of Infection Control Precautions revealed the following: . Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: .Before and after assisting a resident with toileting (hand washing with soap and water); After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile (hand washing with soap and water); . 675970 Page 11 of 11