Health inspection·October 5, 2022

F 0641 Ensure each resident receives an accurate assessment. 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 each resident received an accurate assessment, reflective of the resident's status at the time of the assessment 3 of 20 residents reviewed for accuracy of assessments. (Resident #s 4, 43, and 47) Residents Affected - Some The facility failed to ensure Resident #4's assessment accurately reflected the resident used tobacco. The facility failed to ensure Resident #43's assessment accurately reflected the resident used tobacco. The facility failed to ensure Resident #47's assessment accurately reflected the resident was on oxygen. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental and psychosocial well-being. Findings included: 1. Record review of the face sheet dated October 2022 indicated Resident #4, was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included nicotine (chemical compound present in tobacco) dependence. Record review of the Smoking Safety Evaluation dated 9/9/22 indicated Resident #4 smoked. The assessment indicated Resident #4 needed supervision with smoking. Record review of the most recent comprehensive MDS assessment dated [DATE] indicated Resident #4 had clear speech, ability to understand and be understood by others, a BIMS of 15 out of 15 indicating intact cognition response and did not indicate tobacco use. Record review of the care plans dated 12/14/21 indicated Resident #4 was at risk for injury due to smoking. During an interview on 10/05/22 at 8:46 a.m., Resident #4 said she smokes daily. During an observation on 10/05/22 at 11:08 a.m., Resident #4 was observed smoking. During an interview on 10/05/22 at 8:55 a.m., the ADON said the MDS Nurse was out on leave and not Page 1 of 11 675975 675975 10/05/2022 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some available for interview. The ADON reviewed Resident #4's MDS dated [DATE] with surveyor and said Resident #4's tobacco use was not indicated on the MDS assessment. The ADON said Resident #4's tobacco use should have been indicated on the MDS assessment. She said the possible negative outcome could be the resident would not receive the care and services she required. 2. Record review of the face sheet dated October 2022 indicated Resident #43, was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included nicotine (chemical compound present in tobacco) dependence. Record review of the Smoking Safety Evaluation dated 09/09/22 indicated Resident #43 smoked. The assessment indicated Resident #43 needed no supervision with smoking. Record review of the most recent comprehensive MDS assessment dated [DATE] indicated Resident #43 had clear speech, ability to understand and be understood by others, a BIMS of 14 out of 15 indicating intact cognition response and did not indicate tobacco use. Record review of the care plans dated 08/08/22 indicated Resident #43 was a safe smoker. During an interview on 10/05/22 at 8:38 a.m., Resident #43 said she smokes daily. During an observation on 10/05/22 at 10:45 a.m., Resident #43 was observed smoking. During an interview on 10/05/22 at 8:55 a.m., the ADON said the MDS Nurse was out on leave and not available for interview. The ADON reviewed Resident #43's MDS dated [DATE] with surveyor and said Resident #43's tobacco use was not indicated on the MDS assessment. The ADON said Resident #43's tobacco use should have been indicated on the MDS assessment. She said the possible negative outcome could be the resident would not receive the care and services she required. 3. Record review of physician orders dated October 2022 indicated Resident #47, admitted [DATE], was [AGE] years old with diagnoses of cerebral vascular accident (stroke), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) and respiratory failure. There was no documentation to indicate the resident had oxygen ordered. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #47 was cognitively severely impaired, had diagnoses of stroke and respiratory failure and had a tracheostomy. The assessment did not indicate the resident received oxygen. Record review of a care plan updated 07/01/22 indicated Resident #47 had a tracheostomy. The interventions indicated the resident received oxygen via trach collar at 40% continuously. During observations on 10/03/22 at 8:57 a.m., Resident #47 was lying in bed with his eyes open. The resident did not respond when spoken to. The resident had an oxygen concentrator set at 2.5 liters per minute connected directly to the resident's tracheostomy. During an interview on 10/05/22 at 8:55 a.m., the ADON said the MDS nurse was out on leave and was not available for interview. She said the MDS assessment for Resident #47 did not indicate the resident received oxygen and it was not correct. She said the resident did receive oxygen via tracheostomy. She said the possible negative outcome could be the resident would not receive the care and services he required. She said her expectations were for the assessment to accurately reflect the 675975 Page 2 of 11 675975 10/05/2022 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0641 resident's care needs. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/05/22 at 4:00 pm the DON said the MDS Nurse was responsible for ensuring the resident's assessments were accurate. She said the corporate MDS nurse was available to her for consultation. She said her expectations were for the assessments to be completed correctly. She said the potential negative outcome would be there could be care issues and the resident could possibly not receive the care he required. Residents Affected - Some During an interview on 10/05/22 at 4:00 p.m., the administrator said the MDS Nurse was responsible for ensuring the resident's assessments were accurate. He said the MDS nurse had worked in the position for 6-8 years and his expectations were for the assessments to be completed correctly. He said the DON was the MDS nurse's supervisor. She said the facility monitored the resident's care in their QA meetings. Record review of the MDS Coding Policy dated 03/25/22 indicated, . facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. 675975 Page 3 of 11 675975 10/05/2022 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

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 are identified in the comprehensive assessment for 1 of 20 residents reviewed for care plans. (Resident #24). The facility failed to care plan Resident #24 for the use of trazadone (a medication used to treat depression and anxiety) and Cymbalta (a medication used to treat depression and anxiety). This failure could place the residents at risk of not receiving care and services to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of the face sheet dated October 2022 indicated Resident #24, was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included anxiety (intense, excessive, and persistent worry and fear about everyday situations). Record review of the physician orders dated October 2022 indicated Resident #24 had an order for trazadone 50 mg daily and Cymbalta 30 mg twice a day. Record review of the MAR dated October 2022 indicated Resident #24 received trazadone 50 mg daily and Cymbalta 30 mg twice a day. Record review of the MAR dated September 2022 indicated Resident #24 received trazadone 50 mg daily and Cymbalta 30 mg twice a day. Record review of the most recent MDS assessment dated [DATE] indicated Resident #24 had clear speech, ability to understand and be understood by others, a BIMS of 12 out of 15 indicating intact cognition response and received an antidepressant and antianxiety medication 7 of 7 days in the look back period. Record review of the care plans dated 08/11/22 indicated Resident #24 did not have a care plan for trazadone or Cymbalta. During an interview on 10/5/22 at 8:55 a.m., the Care Plan Nurse reviewed Resident #24's care plan with surveyor and said the trazadone and Cymbalta use for Resident #24 was not indicated on the care plan. The Care Plan Nurse agreed trazadone and Cymbalta use should have been indicated on the care plan. She said she was not sure why the medications were not included in the care plan. She said she was responsible for completing the care plan for Resident #24. She said the potential negative outcome would be there could be safety concerns and the resident could possibly not receive the services she required. During an interview on 10/05/2022 at 4:00 p.m., the DON said the Care Plan Nurse was responsible for ensuring the resident's care plans were completed accurately. The DON said her expectation was for the care plans to be completed accurately to reflect the residents care needs. 675975 Page 4 of 11 675975 10/05/2022 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/05/2022 at 4:00 p.m., the Administrator said the DON was the Care Plan Nurse's supervisor. He said the Care Plan Nurse had received training on care plans. The Administrator said the potential negative outcome would be there could be care issues and the resident could possibly not receive the care she required. Record review of the policy, titled Care Plans, Comprehensive Person-Centered dated December 2016 indicated, . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being; . g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; . o. Reflect currently recognize standards of practice for problem areas and conditions. 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions or added to the care plan. 675975 Page 5 of 11 675975 10/05/2022 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

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 needed respiratory care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 20 residents reviewed for oxygen therapy. (Resident #47) Residents Affected - Few The facility did not obtain orders for Resident #47's oxygen. The resident received oxygen via tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing). This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of the physician orders dated October 2022 indicated Resident #47, admitted [DATE], was [AGE] years old with diagnoses of cerebral vascular accident (stroke), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) and respiratory failure. There was no documentation to indicate the resident had oxygen ordered. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #47 was cognitively severely impaired, had diagnoses of stroke and respiratory failure and had a tracheostomy. The assessment did not indicate the resident received oxygen. Record review of a care plan updated 07/01/22 indicated Resident #47 had a tracheostomy. The interventions indicated the resident received oxygen via trach collar at 40% continuously. During observations on 10/03/22 at 8:57 a.m., Resident #47 was lying in bed with his eyes open. The resident did not respond when spoken to. There was an oxygen concentrator connected directly to the resident's tracheostomy set at 2.5 liters per minute. During observation, interview, and record review on 10/03/22 at 12:30 p.m., LVN A, as she was observing Resident #47's oxygen settings, said the resident did have oxygen therapy in progress at 2.5 liters per minute. During review of the resident's clinical record, she said there were no orders for the resident's oxygen. She said the negative outcome of not having orders would be the resident could receive the incorrect dose of oxygen and the nurses would not know how to care for the resident. She said the resident should have orders for the oxygen and she would call the physician to clarify. During an interview on 10/04/22 at 10:52 a.m., the DON said Resident #47 did have oxygen via tracheostomy. She said the resident should have orders for the oxygen and her expectations were for the nurses to ensure the residents had orders in place for their care needs. She said the nurse who admitted the resident should have obtained orders for the oxygen. She said the orders for new residents were reviewed in the facility morning meetings. She said not having orders for the resident's oxygen was overlooked. Record review of an Oxygen Administration policy dated October 2010 indicated: . Verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. 675975 Page 6 of 11 675975 10/05/2022 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 20 residents (Resident #1) reviewed for medication administration in that:. Resident #1 scheduled doses of intravenous medications were missed and the starting of the antibiotic was delayed. This failure could place residents at risk of not receiving the therapeutic benefits of their medications and a decline in health. Findings included: Record review of the admission record dated 10/05/22 indicated Resident #1 was admitted on [DATE], was [AGE] years old with diagnoses of chronic kidney disease, urinary tract infection and heart failure. Record review of the MDS dated [DATE] indicated Resident #1 had a BIMS score of 04 which indicated severely impaired cognition. Record review of the Care plan dated 09/02/21 indicated Resident #1 was incontinent and at risk for septicemia (blood infection) approaches prompt recognition of UTI and treatment of symptoms. Record review of the Physician orders dated October 2022 indicated Resident #1 was ordered to have PICC line (a long, flexible catheter (thin tube) that is put into a vein in your upper arm and is a form of intravenous access that can be used for a prolonged period of time) inserted then start Imipenem-Cilastatin (antibiotic to treat a bacterial infection) 1000 mg IV every 12 hours times 7 days dated 9/30/22. Record review of the The MARS dated October 2022 indicated Resident #1 received the PICC line on 10/01/22 and the Imipenem-Cilastatin 1000 mg IV every 12 hours was not started until 10/04/22. During a review of medication error incident report log with a print date of 10/04/22 indicated Resident #1's antibiotic was not delivered and caused a delay in starting the antibiotic. During review of Resident #1's medical chart, the progress notes written by the DON indicated on 09/30/22 physician had ordered PICC line and IV therapy with Imipenem-Cilastatin 1000 mg IV every 12 hours times 7 days. Resident #1 received PICC per outside IV company on 10/01/22. Her physician was notified on 10/03/22 and he said to start antibiotic when available. During an interview 10/05/22 at 11:00 a.m., the DON said the nurses were responsible for notifying her if medications were not delivered. She said she was not notified of Resident #1 not receiving her Imipenem-Cilastatin 1000 mg IV every 12 hours times 7 days until 10/03/22. The DON said the pharmacy had not sent the medication because the pharmacy needed a clarification on the medication. She said all the nurses had been trained to notify DON when medications were unavailable. She said if residents did not receive their medications as ordered the residents could decline and infection could 675975 Page 7 of 11 675975 10/05/2022 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0755 increase. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/05/22 at 12:26 p.m., Resident #1's physician said he had ordered the PICC line and IV antibiotic and no one let him know the antibiotic was unavailable until 10/03/22. He said the delay of starting the antibiotic could have let Resident # 1 become septic and at this time there was no indication of her being septic. He said he was the medical director for the facility and had been working with the facility on medications being available. He said the facility had improved and he would continue to work with the facility. Residents Affected - Few During an interview 10/05/22 at 12:45 p.m. LVN D said she worked 10/02/22 on the IV medication Imipenem-Cilastatin for Resident # 1 was not available and she did not call the doctor, DON or the pharmacy, she said there was alot going on that day. LVN D said they were trained recently on medications not being available and the procedure of notifying DON physician and pharmacy. She said Resident #1 did not have a decline and the antibiotic delay could place residents at risk of decline. Record review of the Medication Orders: Guiding Principles dated June 2008 indicated 3. Medication orders will be accurate, timely, appropriate . 675975 Page 8 of 11 675975 10/05/2022 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 follow their written policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 3 of 13 residents reviewed for personal food. (Residents #5, 29 and 30) Residents Affected - Few The facility did not remove expired foods from Resident #5, 29, and 30's personal refrigerator. This failure could affect the quality of life and well-being of residents by failing to ensure foods were safe for consumption by residents. Findings included: 1. Record review of the face sheet dated 10/05/22 indicated Resident #5 was a [AGE] year-old female re-admitted on [DATE] with diagnoses including stroke, anxiety, and hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body). Record review of a quarterly MDS dated [DATE], indicated Resident #5 was severely impaired of cognition and needed extensive assist for bed mobility, dressing and hygiene and was independent for eating. During an interview and observation on 10/03/22 at 9:15 a.m., Resident #5 stated that she did not know if her refrigerator was cleaned out. Resident #5's personal refrigerator had one 236 ml carton of milk with an expiration date of 09/04/22 and 4 Jell-O cups size 3.3 oz of red Jell-O with an expiration date of June 2022. 2. Record review of the face sheet dated 10/05/22 indicated Resident #29 was a [AGE] year-old female admitted on [DATE] with diagnoses including heart failure (a condition in which the heart does not pump blood as well as it should), dementia (a group of thinking and social symptoms that interfere with daily function), anxiety, depression, and schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions). Record review of the annual MDS dated [DATE], indicated Resident #29 was severely impaired of cognition and needed extensive assistance for bed mobility, dressing, hygiene and independent for eating. During an observation on 10/03/22 at 09:40 a.m., Resident #29's personal refrigerator had one 236 ml carton of milk with an expiration date of 09/15/22 and one open and empty 236 ml carton of milk with an expiration date of 09/25/22. 3. Record review of the face sheet dated 10/05/22 indicated Resident #30 was a [AGE] year-old female admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breath), dementia, anxiety, and depression. Record review of the MDS dated [DATE], indicated Resident #30 was moderately impaired of cognition and required supervision and set up for dressing, hygiene and eating. 675975 Page 9 of 11 675975 10/05/2022 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 10/03/22 at 9:40 a.m., Resident #30's personal refrigerator had one 236 ml carton of milk with an expiration date of 09/06/22, one 236 ml carton of milk with an expiration date of 08/21/22. During an interview on 10/03/22 at 9:45 a.m., LVN B said Resident #'s 5, 29 and 30's refrigerators had expired products that should have been removed and must have just been missed. LVN B said CNA A or the activities director were responsible for removing expired items from resident's refrigerators. She said the risk of refrigerators not being cleaned out of expired items was spoilage and the resident could become sick. During an interview on 10/03/22 at 9:50 a.m., CNA A said she was responsible for checking refrigerators for expired products and temperatures and she was checking them now. She said she must have missed the expired items in Resident #5, 29 and 30's personal refrigerators and they should have been removed. She said the risk of not removing expired products was residents could get sick. During an interview on 10/5/22 at 9:40 a.m., the activities director said she was responsible for cleaning out the resident's personal refrigerators and removing expired products. She said CNA A was her back up and the Neighbor program staff double check the rooms a few days a week. The activities director said she or CNA A must have missed Resident #5, 39 and 30's rooms. She said they had been in-serviced to remove expired products from the residents' personal refrigerators about 3 months ago. The activity director said the risk was bacteria growth and the resident getting sick. During an interview on 10/05/22 at 11:17 a.m., LVN C said she was the neighbor program staff member for Resident #5 and 30. LVN C said she checks on her residents a couple days a week, for concerns and problems and she tries to check for spoiled foods. LVN C said it was possible she just missed checking them. She said expired products should not be left in residents' personal refrigerators. LVN C said the risk was residents could get sick. She said they received instruction on expectations of the neighbor program at monthly meetings. During an interview on 10/05/22 at 11:20 a.m., the DON said she was the Neighbor program staff member for Resident #30. The DON said her expectation was all resident personal refrigerators be kept clean and without expired items. She said the expired items left in Resident #5, 29 and 30's personal refrigerators must have been overlooked. The DON said the CNAs or Neighbor program staff members were responsible for cleaning personal refrigerators and removing expired items with the activity's director as a double check or back up. She said the risk for residents was ingestion, food poison and potential gastrointestinal issues. During an interview on 10/05/22 at 12:02 p.m., the administrator said the expired items in Resident #5, 29 and 30's personal refrigerators should have been removed. He said the night aides were responsible for cleaning, checking the temperatures and removing expired items with the CNA A double checking. He said the expired items were just overlooked or missed. The administrator said the staff were instructed to clean refrigerators, remove expired items and check tamps daily. He said the risk for residents was potential sickness from expired items. The administrator said his expectation related to resident's personal refrigerators was to be cleaned, temperature checked and free of expired products. Review of the policy revised October 2017, titled Foods Brought by Family/ Visitors indicated, . 8. The nursing staff will discard perishable foods on or before the use by date. 12. Facility staff will assist the resident with accessing his or her food is unable to do so independently. 675975 Page 10 of 11 675975 10/05/2022 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a policy reviewed 08/11/20, titled, Guidelines for Resident Refrigerators indicated, . 2. All perishable items in the refrigerator must be dated and labeled. 4. Refrigerator will be cleaned and defrosted periodically. During the exit on 10/05/22 at 5:45 p.m., the administrator was asked for any additional information related to resident personal refrigerators. No additional information was provided. 675975 Page 11 of 11