Health inspection·November 29, 2023

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of their personal and medical records for 2 of 20 residents reviewed for resident rights. (Residents #20 and #70) Residents Affected - Few The facility failed to ensure Resident #70's medical supply billing information was secured and protected from public access. The facility failed to ensure Resident #20's billing information and payment source information were protected from public access. This failure could place the residents at risk of their private records being exposed to public access. Findings included: During observation, interview and record review on 11/28/23 at 11:57 a.m., there were 5 invoices for Resident #70's medical billing in the garbage facing up in the garbage can near the entrance door to the BOM's office. At the bottom of 4 of the invoices was written Hospice. The invoices included Resident #70's name, description of supplies ordered, and the price of each supply with the total amount of money owed. The BOM said the can was a garbage can and the papers in the can were to be disposed of in the trash. She said the 5 invoices were Resident #70's but there was no HIPAA information on the resident and she had disposed of the information in the trash. She said she did not plan to shred the information. When asked if the resident's name, the medication the resident was billed for, the amount owed and the word hospice written at the bottom of the page was HIPAA information, she said she could either throw the invoices away or shred them. She then said the invoices were HIPAA information and needed to be shredded. She said the negative outcome would be nothing, then she said the resident's information could be exposed to the public. The BOM said she had been trained by corporate on HIPAA and resident rights. During interview and record review on 11/28/23 at 12:00 p.m., after reviewing Resident #70's invoices, the Administrator said the 5 invoices included the resident's private information and should be shredded. He said the information on the invoices did contain HIPAA information and should not be thrown in the garbage. He said not complying with HIPAA was against resident rights. He said his expectations were for the BOM to secure resident information. During observation and record review on 11/29/23 at 07:47 a.m., upon entrance into the facility, the surveyor entered the main door to the Administrator/HR/BOM's office with no staff present in the offices. The door to the BOM's office was open and there were 2 personal checks totaling $26,700 Page 1 of 20 675975 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attached with a paperclip to Resident #20's Cash Receipt Report (a document indicating the amount received in payment for a resident's account) and Deposit Detail Report (a detail of the money to be deposited for a resident) lying on an overbed table near the open door. The 2 checks included the payer sources' name and address. One of the checks indicated the payment was for Resident #20. During observation, interview and record review on 11/29/23 at 08:00 a.m., after observing there were no staff present and the door to the BOM's office was open with checks and billing information lying on the table inside, the administrator said Resident #20's checks and billing information should not be on the table with the door open and unlocked. After reviewing Resident #20's information, he said the resident's billing documents and checks included private information and should be kept in a secure locked cabinet when it was not being utilized. He said he had trained the BOM on 11/28/23 regarding HIPAA and would have to retrain her today 11/29/23 and she would be counseled. During interview and record review on 11/29/23 at 08:08 a.m., after reviewing Resident #20's private billing information and checks, the BOM said she had left them on the table with the door to the BOM's open and unlocked so that staff could get to the supply closet. She said the information did contain HIPAA information and should not have been left out with the door open and unlocked. She said leaving the information out could put the resident's information at risk of being exposed to the public and the checks could be stolen. She said she had been trained on HIPAA violations and resident rights and did know leaving the information unsecured with the door open was against the resident's rights. Record review of a Resident Rights policy dated February 2021 indicated: . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . t. privacy and confidentiality; . The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer. 675975 Page 2 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the rights of residents to be free from abuse or neglect for 1 of 20 residents reviewed for abuse or neglect. (Residents #22) The facility failed to ensure Resident #22 was free from verbal abuse/neglect by CNA A. The failure could place residents at risk for abuse/neglect, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of Resident #22's face sheet dated 11/29/23 indicated Resident #22 was a [AGE] year-old male admitted on [DATE] with diagnoses of autistic disorder (a developmental disability caused by difference in the brain), anxiety (nervousness) schizoaffective disorder (mental health condition), major depressive disorder ( mood disorder), severe intellectual disability (major delay in development and might have lack in communication or understanding), and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). Record review of the MDS assessment dated [DATE] indicated Resident #22 was usually understood and had difficulty communicating some words or finishing thoughts, but was able if prompted or given time. He was severely impaired with cognition with a BIMS of 3. The behavioral symptoms indicated he was yelling at others for 1 to 3 days with no refusal of care. Transfers, bed mobility and toilet use indicated extensive assistance of 2 persons. Record review of the care plan dated 11/14/23 indicated it did not address Resident #22's mobility or his transferring ability from bed to wheelchair. Record review of the six videos of the incident on 11/11/23 indicated the following: -4:30 a.m. CNA A was in Resident #22's room bedside Resident 22's bed with the wheelchair by the bed attempting to get Resident #22. While pulling on his left arm , she said no one can help, you help or I will have to put you back in bed, He yelled out no. -4:32 a.m. video: CNA A said last time grab the chair or I will put you in the bed to Resident #22 while she pulling on his left arm attempting to get him up from the side of the bed to standing position . She said to Resident #22, I am not playing with you. I have things to do. -4:34 a.m. video: Resident #22 was standing up and was facing his wheelchair and holding on to the wheelchair and CNA A said, turn around and sit down or I will put you back in bed. CNA A was holding on to the left side of the waist of Resident #22 's pajama pants. There was no gait belt (a belt you put around a patient waist to assist with transferring from bed to wheelchair) was on the resident's waist. There was no other staff assisting CNA A. -4:37 a.m. video: CNA A and Resident #22 were standing between the wheelchair and the bed and Resident #22 started leaning towards the bed and fell across the bed. CNA A said, See what you did. The 675975 Page 3 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident was assisted over on the bed on his side and was across the middle of the bed and was not in a secure position. CNA A left Resident #22 on the bed and walked out of reach of the resident, towards the door and yelled out, I am going to have to have help with Resident #22. -4:39 a.m. video: the Treatment Nurse was walking into the room. She began talking with Resident #22 and putting on a pair of gloves to assist the resident while CNA A was standing in the room. -4:40 a.m. video: The treatment nurse was explaining what they were doing, and she asked Resident #22 if he wanted up and then assisted with the transfer. CNA A and the treatment nurse placed their arms under his arms and lifted him to the wheelchair. During an interview on 11/27/23 at 11:37 a.m., Resident #22's family said there was an incident of abuse and she reported it on 11/11/23 to the Administrator. She said she sent the videos to the Administrator. She said the facility promptly terminated the CNA A and the facility investigated the incident. She said Resident #22 had a hard time understanding things and had difficulty communicating at times . She said she felt the staff (CNA A) was threatening him with the comments about being put to bed. She said she had sent the videos to the facility when she saw and heard the CNA A with Resident #22. During an interview on 11/29/23 at 2:25 p.m., CNA A said on 11/11/23, she tried to assist Resident #22 up from the bed to his wheelchair for the day. She said he usually required one person for assistance with transfers. She said she told the resident if he did not help by standing up, she would just have to put him back to bed. She denied she was trained on using gait belts during transfers. She said was trained on abuse/neglect upon hire. She denied abusing Resident #22, but said the facility told her she was terminated for abusing Resident #22. During an interview on 11/28/23 at 11:00 a.m., the Administrator said CNA A was terminated. He said the staff were trained to be encouraging and pleasant with residents, not to threaten residents. He said with the resident being half on and half off the bed the staff should have called for help without leaving Resident #22. The Administrator said Resident #22 could have fallen off the bed when she just left him. Record review of the facility's policy titled, Abuse Prohibition Policy - This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. dated 05/01/01, indicated 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff. Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal/mental abuse include, but are not limited to, cursing, yelling, saying things to frighten a resident, denying food or care, isolating a resident, etc. Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, good or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result 675975 Page 4 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0600 Level of Harm - Minimal harm or potential for actual harm in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Residents Affected - Few 675975 Page 5 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 2 of 20 residents (Resident #5 and #16) reviewed for PASRR. The facility failed to refer Resident #5 for PASRR Level II assessment to the state designated authority after their PL 1 was negative but acquired a diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). The facility failed to refer Resident #16 for PASRR Level II assessment to the state designated authority after their PL 1 was negative but acquired diagnoses of major depressive disorder (mental disorder characterized by persistent hopelessness, disinterest in and lack of enjoyment of normal activities, and prolonged sadness that affects people on a daily basis and can be recurring) and mood disorder (a group of mental conditions characterized by persistent disturbance of mood, especially depression). This failure could place all residents who had a mental illness at risk for not receiving needed assessment, care, and specialized services to meet their needs. Findings included: 1. Record review of the face sheet dated November 2023 indicated Resident #5 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of bipolar disorder as of 04/06/22. Record review of a PL 1 for Resident #5, completed by the referring facility on 12/29/21, indicated the resident was negative for mental illness, developmental disability, and intellectual disability. Record review of a significant change MDS dated [DATE] indicated Resident #5 was not considered by the state level II PASRR process to have serious mental illness or intellectual disability or a related condition and a negative Level II Preadmission Screening and Resident Review diagnosis. The assessment indicated Resident #5 had a BIMS score of 14 of 15 indicating intact cognition with a diagnosis of bipolar disorder. Record review of a care plan updated 06/19/23 indicated Resident #5 received psychotropic medication for bipolar disorder including monitoring for adverse reactions, side effects and behaviors. Record review of physician's orders dated 11/27/23, indicated Resident #5 was prescribed Wellbutrin (a medication to treat depression) 150 mg one time a day for depression related to bipolar disorder with a start date of 11/07/23. Record review of a MAR dated 11/1/23 through 11/30/23 indicated Resident #5 received Wellbutrin 150 mg daily for depression related to bipolar disorder from 11/07/23 to 11/28/23. 2. Record review of face sheet dated November 2023 indicated Resident #16 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE] with a diagnosis of major depressive 675975 Page 6 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0644 disorder and mood disorder as of 01/03/20. Level of Harm - Minimal harm or potential for actual harm Record review of a PASRR Level 1 Screening for Resident #16, completed by the referring facility on 08/19/17 , indicated the resident was negative for mental illness, developmental disability, and intellectual disability. Residents Affected - Few Record review of an annual MDS dated [DATE] indicated Resident #16 was not considered by the state level II PASRR process to have serious mental illness or intellectual disability or a related condition and a negative Level II Preadmission Screening and Resident Review diagnosis. The assessment indicated Resident #16 had a BIMS score of 15 of 15 indicating intact cognition with a diagnosis of bipolar disorder. Record review of a care plan updated 10/03/23 indicated Resident #16 received psychotropic medication for mood disorder and depression including monitoring for adverse reactions of psychotropic medication and behaviors. Record review of physician's orders dated 11/27/23, indicated Resident #16 was prescribed Duloxetine HCL (a medication to treat depression) 30 mg one time a day for major depressive disorder with a start date of 05/11/23. Record review of a MAR dated 11/01/23 through 11/30/23 indicated Resident #16 received Duloxetine HCL 30 mg daily for major depressive disorder from 11/01/23 through 11/27/23. During an interview on 11/28/23 at 2:30 p.m., the ADON and DON said they were not trained in the PASRR process. The DON said the MDS nurse was responsible for PASRR forms, but she quit 11/03/23. The DON said the Regional Case Mix nurse was currently responsible for PASRR forms. The DON said Resident #5 and #16's PL1's were negative and should have had a 1012 Form (a form a nursing home completes for residents with a current negative PL 1 to determine whether to submit a new positive PL1 form because futher evaluation is needed). She said they were overlooked. She said the risk of not completing a 1012 form timely was a resident could miss out on deserved services. She said a 1012 Form was completed after surveyor intervention for the two residents. The DON said her expectation was for PASRR forms to be completed timely and correctly. During an interview on 11/28/23 at 2:50 p.m., the Regional Case Mix nurse said the MDS nurse was responsible for PASRR forms but left a month ago. She said there was no back up in the building. The Regional Case Mix nurse said she was now responsible for PASRR forms. She said she completed the 1012 Forms for all residents that did not have one on 11/28/23 including Residents #5 and 16 but they should have been completed before now. She said they were just overlooked. The Regional Case Mix nurse said the risk of a 1012 Form not being completed timely was a resident could possibly miss out on PASRR services. During an interview on 11/28/23 at 3:07 p.m., the Administrator said the MDS nurse was responsible for completion of PASRR forms and now corporate was helping out with PASRR forms. He said it was overlooked for the residents. The Administrator said the risk of all PASRR forms not being completed timely and correctly was a resident may not receive PASRR services. He said his expectation was for PASRR forms to be completed timely and accurately. Record review of a facility policy, titled, PASRR Policy and Procedures revised 1/24/23 indicated, The facility uses the most current version of PASRR Rules, TAC Title 40, Part 1 Chapter 19, 675975 Page 7 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Sub-chapter BB as they pertain to PASRR Level 1, Level 2 (PE), specialized Services and IDT meetings. Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. 675975 Page 8 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 3 of 20 residents reviewed for PASRR (Residents #31, #60 and #67). Residents Affected - Some The facility did not have an accurate PASRR level 1 screening for Residents #31, #60, and #67 upon admission therefore a PASRR Evaluation was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: 1. Record review of a face sheet dated 11/28/23 indicated Resident #31 was a [AGE] year-old female admitted [DATE], and readmitted [DATE], with diagnoses of major depressive disorder (mental disorder characterized by persistent hopelessness, disinterest in and lack of enjoyment of normal activities, and prolonged sadness that affects people on a daily basis and can be recurring) as of 6/11/21 and schizoaffective disorder (mental condition including schizophrenia and mood disorder symptoms that can involve mania or depression) as of 02/11/22. Record review of an annual MDS dated [DATE] indicated Resident #31 had a BIMS score of 8 indicating she had moderately impaired cognition, was positive for PASRR, and had a diagnosis of depression and schizoaffective disorder and received medication for depression 7 of 7 days. Record review of a care plan revised 05/19/23 indicated Resident #31 was currently taking psychotropic medication including asenapine (antipsychotic medication), lithium (antipsychotic medication) and sertraline (antidepressant medication) and required monitoring for adverse reactions, side effects and behaviors. Record review of PASRR level 1 screening completed by the transferring facility dated 07/12/21 indicated Resident #31 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II Screening or Form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record from 11/01/23 through 11/27/23. Record Review of physician's orders dated November 2023 indicated Resident #31 had a diagnoses of major depressive disorder and schizoaffective disorder. The orders indicated Resident #31 was prescribed Lithium 300 mg two times a day for schizoaffective disorder with a start date of 03/03/23. Sertraline 150 mg daily for major depressive disorder with a start date of 10/18/23 and Asenapine maleate 10 mg at bedtime for schizoaffective disorder with a start date of 03/03/23. 2. Record review of a face sheet dated 11/29/23 indicated Resident #60 was a [AGE] year-old female admitted [DATE] with diagnoses of psychosis (severe mental condition where thoughts and emotions are so affected that contact is lost with external reality) with an onset date of 09/15/22 and schizoaffective disorder (mental condition including schizophrenia [disorder that effects a person's ability to think, feel and behave clearly] and mood disorder symptoms that can involve mania or depression) with an onset date of 11/10/22. 675975 Page 9 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of a PASRR level 1 screening completed by the transferring facility dated 09/23/22 indicated Resident #60 was negative for mental illness, intellectual disability, and developmental disability. There was no PASRR Level II Screening or Form 1012 found in the clinical record from the resident's admission on [DATE] to 11/28/23. Record review of an annual MDS dated [DATE] indicated Resident #60 was not PASSR positive. The resident had a diagnoses of psychotic disorder and schizophrenia and had mood problems with trouble concentrating. Resident #60 received antidepressant medications in the last 7 days. Record Review of physician's orders dated November 2023 indicated Resident #60 had diagnoses of psychotic disorder and schizoaffective disorder. 3. Record review of Resident #67's face sheet dated 11/28/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnoses of quadriplegia (paralysis below the neck and affects a person's extremities) and bipolar disorder. Record review of PASRR level 1 screening completed by the transferring facility dated 10/24/23 indicated Resident #67 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II Screening or Form 1012 was found in the clinical record from the resident's admission on [DATE] to 11/28/23. Record review of an annual MDS dated [DATE] indicated Resident #67 was not PASSR positive. The resident had diagnoses of bipolar and anxiety. Resident #67 received antianxiety medications in the last 7 days. Record review of care plans revised on 11/27/23 did not indicate Resident #67 was PASRR positive. A care plan updated on 11/28/23 indicated the resident received psychotropic medications related to bipolar disorder and was PASRR positive. Record Review of physician's orders dated November 2023 indicated Resident #6 had diagnoses of bipolar disorder. During an interview on 11/28/23 at 2:30 p.m., the ADON and DON said they were not trained on the PASRR process. The DON said the MDS nurse was responsible for PASRR forms but she quit on 11/03/23. The DON said the Regional Case Mix nurse was currently responsible for PASRR forms. The DON said Residents #31, #60 and #67's PL1s were negative and should have been positive. She said they were overlooked. She said the risk of not completing a PL1 correctly was a resident could miss out on deserved services. She said a 1012 Form was completed on 11/28/23 after surveyor intervention for the residents. The DON said her expectation was for PASRR forms to be completed timely and correctly. During an interview on 11/28/23 at 2:50 p.m., the Regional Case Mix nurse said the MDS nurse was responsible for PASRR forms but left a month ago. She said there was no back up in the building. The Regional Case Mix nurse said she was now responsible for PASRR forms. She said she completed 1012 Forms for all residents who did not have one on (11/27/23) yesterday including Residents #31, #60 and #67, but they should have been completed before now. She said they were just overlooked. The Regional Case Mix nurse said the risk of an incorrect PL1 was a resident could possibly miss out on PASRR services. During an interview on 11/28/23 at 3:07 p.m., the Administrator said the MDS nurse was responsible 675975 Page 10 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for completion of PASRR forms, but now corporate was helping out with PASRR forms. The Administrator said the risk of all PASRR forms not completed timely and correctly, would be a resident may not receive PASRR services. He said his expectation was for PASRR forms to be completed timely and accurately. Record review of a facility policy, titled, PASRR Policy and Procedures revised 1/24/23 indicated, The facility . uses the most current version of PASRR Rules, TAC Title 40, Part 1 Chapter 19, Sub-chapter BB as they pertain to PASRR Level 1, Level 2 (PE), specialized Services and IDT meetings. This TAC may be found on Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. 675975 Page 11 of 20 675975 11/29/2023 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 #22) The facility did not develop a care plan for Resident #22's transfer assist and needs. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Record review of Resident #22's face sheet dated 11/29/23 indicated Resident #22 was a [AGE] year-old male admitted on [DATE] with diagnoses of autistic disorder (a developmental disability caused by difference in the brain), anxiety (nervousness) schizoaffective disorder (mental health condition), major depressive disorder ( mood disorder), severe intellectual disability (major delay in development and might have lack in communication or understanding) and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). Record review of the MDS assessment dated [DATE] indicated Resident #22 was usually understood; had difficulty communicating some words or finishing thoughts but was able if prompted or given time. He was severely impaired with cognition with a BIMS of 3. Transfers, bed mobility, and toilet use indicated extensive assist of 2 persons. Record review of the care plan dated 11/14/23 did not include what Resident #22's needs were for transferring. Record review of the nurse aide flowsheet for November 2023 indicated Resident #22 required a 1- person transfer. During an interview on 11/29/23 at 4:00 p.m., the DON said the care plans should be correct and should have addressed Resident #22's need for assistance with transfers and mobility. She said his care plan did not address his mobility for transfers and she was responsible to oversee the care plans. Record review of the policy titled Care Plans, Comprehensive Person-Centered dated January 2023 indicated Policy Statement 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.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 675975 Page 12 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 residents with pressure injuries receive treatment and care in accordance with the comprehensive assessments, professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 residents (Resident #67) reviewed for wound treatment. Residents Affected - Some The facility failed to accurately assess Resident #67's newly identified pressure injuries on both of his heels and coccyx area, failed to notify the physician and obtain treatment orders, and failed to provide wound care for both heels and his coccyx area when the areas were identified on 11/25/23. This failure could place residents at risk for developing new pressure wounds, inconsistent care resulting in the deterioration of existing wounds, a decline in health, pain, and hospitalization. Findings included: Record review of Resident #67's face sheet dated 11/28/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis below the neck and affects a person's extremities). Record review of an admission MDS assessment dated [DATE] indicated Resident #67 was cognitively intact with BIMS of 12. He was at risk for pressure injuries, and none were was noted on this assessment. Resident #67 had no issues with his skin. Record review of his admission evaluation dated 10/31/23 indicated Resident #67 had no issues with his skin. Record review of the weekly body skin check dated 11/24/23 for Resident #67 indicated he did not have issues with his skin. Record review of weekly body skin check dated 11/28/23 for Resident #67 indicated he had a DTI pressure injury to both heels and and coccyx shearing. Record review of Resident #67's physician's order summary dated 11/28/23 indicated Resident #67 had no wound care orders for his heels or for the wound on his coccyx area. Record review of Resident #67's physician's order summary dated November 29, 2023, indicated Resident #67 had wound care orders for his heels to clean with normal saline and to apply skin prep. Record review of Resident #67's nursing notes dated November 2023 did not contain any evidence the resident's physician was notified of the new wounds or treatments were initiated for his heels and coccyx area or that the pressure injuries were assessed. During an observation and interview on 11/28/23 at 10:00 a.m., Resident #67 said his family saw the wounds on his heels and coccyx area Saturday (11/25/23). He said nobody at the facility was treating the wounds. His family, who was in the room, said they reported those areas on 11/25/23 and the nurses looked at his skin. The family said one of the nurses who looked was the ADON; however, no 675975 Page 13 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treatments were initiated. His family uncovered Resident #67 and revealed his heels. There was a raised fluid-filled area noted on the back of both heels approximately 1 inch by 2 inch. The resident's coccyx area had an open wound approximately 1 inch by 3 inches. During an interview on 11/28/23 at 10:45 a.m., the ADON said the treatment nurse was notified this weekend (11/25/23) about Resident #67's new wounds via the phone. The ADON said no new treatments were initiated when she was made aware. She said Resident #67's physician's was not notified because she thought the treatment nurse would call the physician and obtain new treatment orders. During an interview on 11/28/23 at 11:00 a.m., the Treatment Nurse said the ADON reported to her on 11/25/23 that Resident #67 had new pressure injuries on both of his heels and his coccyx area. She said, I did not double check [Resident #67's] orders, treatments, assess the wounds or notify the doctor during the weekend or follow up on Monday (11/27/23) for treatments. She said the nurses who identified the wounds should have notified the physician, obtained treatment orders or used standing orders, assessed the wounds, and initiated treatment. She said, I just got busy on Monday and did not follow up. During an interview on 11/28/23 at 2:00 p.m., the DON said her expectations were for the nurses to report to her if a resident has new skin issues and to notify the physician and the wound care nurse when new skin issues were identified. She said the wounds were to be assessed with measurements and for treatment to begin. She said the nurses did not follow the facility's policy during this past weekend and all nurses had been trained onin the wound care policy. She said wounds could get worse if not treated properly. The DON said the RNs performed the staging of pressure injuries and LVNs assessed and obtained orders. Record review of the facility's policy titled . Pressure Injury Prevention Program indicated All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on the results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or, to treat new/existing pressure injuries. 5. If a pressure injury/ skin breakdown is identified, the following will be done- If a pressure injury/ skin breakdown is identified, the following will be done- If new area found-if pressure injury- complete new wound evaluation / assessment if non-pressure area-complete new wound evaluation / assessment must include: Size, Stage (staged by RN or PT), Location, Drainage amount If odor if present Signs and symptoms of infection if present Wound bed description, Wound edge and surrounding tissue description, How the resident tolerated the wound care If pain with dressing change identified, treatment paused to allow for appropriate pain management before resumption. If pain with dressing change previously identified, confirm order for pain management in place and pre-medication completed per order.Any noted changes in condition requiring new or updated interventions Wound status Notify MD-obtain treatment orders Notify RP/ or family if they are RP or Resident has directed family to be updated Update care plan Note on 24-hour report Referrals to therapy, dietician or other consultant as deemed necessary Monitor weekly via weekly wound reporting and skin integry quality assurance processes . 675975 Page 14 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles in 2 of 2 nurse medication carts reviewed. (Halls 100 and 200 nurse medication carts) Four multi-dose Humalog insulin vials (used to lower blood sugar) had no label on bottle to identify resident and/or no open date on vial; A multi-dose glargine insulin vial (used to lower blood sugar) had no open date; A multi-dose Novolog insulin vial (used to lower blood sugar) had no open date; and Two multi-dose Humulin R insulin vials (used to lower blood sugar) had no open and no label on bottle to identify resident; This failure could place residents at risk of not receiving the therapeutic benefits of their medications. Findings included: 1. During an observation of Hall 100 nurse medication cart on 11/27/23 at 11:45 a.m., the following was found: *Two multi-dose Humulin R insulin vials had no labels on the bottles to identify the resident; and *A multi-dose Humalog insulin vial had no label on the bottle to identify the resident. During an interview at this time, LVN B acknowledged there were no identifying labels on the 3 insulin vials that were being stored in the original boxes. She said she thought since a label was on the insulin box it would be okay. 2. During an observation of Hall 200 nurse medication cart on 11/27/23 at 12:15 p.m., the following was found: *A multi-dose glargine insulin vial had no open date; *A multi-dose Novolog insulin vial had no open date; *A multi-dose Humalog insulin vial had no open date; and *Two multi-dose Humalog insulin vials had no labels on the bottles to identify the residents. During an interview on 11/27/23 at this time, RN D said insulin vials should have open dates on them. She said she thought it was okay to have the resident's name on insulin box that the vials were 675975 Page 15 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0761 stored in, but said they did need a label to identify the resident along with open dates. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/28/23 at 1:58 p.m., the DON said all insulin vials should be dated when obtained from the refrigerator in the medication room and should have strip labels with the identifying resident name attached. She said she did monthly audits on nurse medication carts with last audit being in October. Residents Affected - Some A policy dated February 2023, titled Medication Labeling and Storage indicated the following:.5. Multi-dose vial that has been opened or accessed (needle punctured) are dated and discarded with 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 8. If medication containers have missing, incomplete, improper, or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. 675975 Page 16 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on interview and record review, the facility failed to hire a part time or contracted social worker for a facility of 120 beds or less to provide social services a sufficient amount of time to meet the needs of the residents for 1 of 1 facility reviewed for a social worker. The facility did not employ or contract a qualified social worker as required by state regulations from 05/24/23 to 11/29/23. This failure could place residents at risk of administrative duties not being carried out to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Findings included: Record review of an undated form, titled, Bed Classifications (Number and Location) completed and signed by the administrator on 11/27/23 indicated the facility had a licensed capacity of 120 beds. During an interview on 11/27/23 at 11:00 a.m., he Administrator said he was hiring a social worker today. During an interview on 11/29/23 at 11:00 a.m., the HR said the facility did not currently have a social worker. She said the previous social worker was termed on 05/24/23 and that was her last day she worked. The HR said the social worker that was being interviewed decided not to take the position until maybe next year 2023 . She said the facility had advertised online and with an internet-based agency that was sent out to multiple companies that advertised open jobs. HR said the administrator, DON, and administrative staff all had been doing the social worker jobs to the best of their ability. During an interview on 11/29/23 at 2:10 p.m., the Administrator said the facility did not have a social worker for about 6 months. The Administrator said nursing services, the DON, and the ADON were making podiatry and psychiatric service referrals. The Administrator said the residents had not suffered any negative effects. He said the risk of a facility not having a social worker as required was residents may not get needed services including referrals for psychiatric services, dental and podiatry. The Administrator said he was responsible for hiring a social worker for the facility. The Administrator said his expectation was for the facility to follow the HHS regulations. 675975 Page 17 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

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. Based on observation, interview and record review, the facility failed to safeguard medical record information against loss, destruction, or unauthorized use for 2 of 20 residents reviewed for resident records. (Residents #20 and #70) The facility failed to ensure Resident #70's medical billing information was secured and protected from loss and unauthorized access. The facility failed to ensure Resident #20's billing information and payments were secured from loss and unauthorized use. This failure could place the residents at risk of unauthorized access to the residents' private information. Findings included: During observation, interview and record review on 11/28/23 at 11:57 a.m., there were 5 invoices for Resident #70's medical billing in the garbage facing up in the garbage can near the entrance door to the BOM's office. At the bottom of 4 of the invoices was written Hospice. The invoices included Resident #70's name, description of supplies ordered, and the price of each supply with the total amount of money owed. The BOM said the can was a garbage can and the papers in the can were to be disposed of in the trash. She said the 5 invoices were Resident #70's but there was no HIPAA information on the resident and she had disposed of the information in the trash. She said she did not plan to shred the information. When asked if the resident's name, the medication the resident was billed for, the amount owed and the word hospice written at the bottom of the page was HIPAA information, she said she could either throw the invoices away or shred them. She then said the invoices were HIPAA information and needed to be shredded. She said the negative outcome would be nothing, then she said the resident's information could be exposed to the public. The BOM said she had been trained by corporate on HIPAA and resident rights. During interview and record review on 11/28/23 at 12:00 p.m., after reviewing Resident #70's invoices, the Administrator said the 5 invoices included the resident's private information and should be shredded. He said the information on the invoices did contain HIPAA information and should not be thrown in the garbage. He said not complying with HIPAA was against resident rights. He said his expectations were for the BOM to secure resident information. During observation and record review on 11/29/23 at 07:47 a.m., upon entrance into the facility, the surveyor entered the main door to the Administrator/HR/BOM's office with no staff present in the offices. The door to the BOM's office was open and there were 2 personal checks totaling $26,700 attached with a paperclip to Resident #20's Cash Receipt Report (a document indicating the amount received in payment for a resident's account) and Deposit Detail Report (a detail of the money to be deposited for a resident) lying on an overbed table near the open door. The 2 checks included the payer sources' name and address. One of the checks indicated the payment was for Resident #20. During observation, interview and record review on 11/29/23 at 08:00 a.m., after observing there were no staff present and the door to the BOM's office was open with checks and billing information lying on the table inside, the administrator said Resident #20's checks and billing information should 675975 Page 18 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not be on the table with the door open and unlocked. After reviewing Resident #20's information, he said the resident's billing documents and checks included private information and should be kept in a secure locked cabinet when it was not being utilized. He said he had trained the BOM on 11/28/23 regarding HIPAA and would have to retrain her today 11/29/23 and she would be counseled. During interview and record review on 11/29/23 at 08:08 a.m., after reviewing Resident #20's private billing information and checks, the BOM said she had left them on the table with the door to the BOM's open and unlocked so that staff could get to the supply closet. She said the information did contain HIPAA information and should not have been left out with the door open and unlocked. She said leaving the information out could put the resident's information at risk of being exposed to the public and the checks could be stolen. She said she had been trained on HIPAA violations and resident rights and did know leaving the information unsecured with the door open was against the resident's rights. Record review of a HIPAA Compliance H5MAPL0374 policy dated August 2007 indicated: It is the policy of this facility to protect resident information from unauthorized use, access to, or release. Our facility will not condone the unauthorized use, access to, or release of protected resident information as defined by current HIPAA rules and regulations. 675975 Page 19 of 20 675975 11/29/2023 Village Creek Rehabilitation and Nursing Center 705 N Main St Lumberton, TX 77657

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to maintain record of the required annual in-service records ensure the required in-service trainings for nurse aides were sufficient to ensure the continuing competencies of nurse aides, but must be no less than 12 hours per year and included abuse, neglect training for 5 of 5 staff, (CNA C, CNA E, CNA F, MA G and MA H), records reviewed for staff training. The facility failed to provide CNA C, CNA E, CNA F, MA G and MA H with Abuse/Neglect training and 12 hours of training per year. This failure could place residents at risk of being cared for by untrained staff. The findings included : Record review of training hours for CNA C, CNA E, CNA F, MA G and MA H revealed: CNA C had a hire date of 1/6/22 and the training transcript did not include evidence of training for 12 hours each year since hire date CNA E had a hire date of 10/28/22 and the training transcript did not include evidence of training for 12 hours each year since hire date. CNA F had a hire date of 06/28/22 and the training transcript did not include evidence of training for 12 hours each year since hire date. MA G had a hire date of 10/20/11and the training transcript did not include evidence of training for 12 hours each year since hire date. MA H had a hire date of 02/09/22 and the training transcript did not include evidence of training for 12 hours each year since hire date. During an interview on 11/29/23 at 3:00 p.m., the HR Director stated training and in-servicing records for direct care staff were completed by the staffing coordinator and she had quit on 09/29/23. The HR Director stated it was her own responsibility to place completed records in the computer of completed training for staff when the staffing coordinator would give her the records. She said the DON and ADON were in the previous staffing coordinator's office and they were trying to locate the training records. The HR Director stated that she was unaware of why the trainings were unable to be located in the computer or in the staffing coordinator's office. During an interview on 11/29/23 at 03:36 p.m., the Administrator said they were unable to find training transcripts that was reviewed. The Administrator said the staffing coordinator had quit, and she was responsible for tracking and ensuring all training required by the state and federal requirements were completed and at least 12 years annually. He said no one had been assigned to that task. He said his expectation was for the training records and trainings to be maintained so the residents would have well trained direct care staff as required . He said the risk to the residents was receiving care from incompetent staff. 675975 Page 20 of 20