Health inspection·May 22, 2024

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 interview and record review the facility failed to have assessments that accurately reflect the status of 1 of 2 residents (Resident #1) reviewed for resident assessments. Residents Affected - Few Resident #1's admission MDS assessment did not reflect her skin integrity issues, treatments and impairment in lower extremities accurately. This failure puts residents at risk of a decreased quality of care and not having their individualized needs met or communicated accurately to staff. Findings include: Record review of Resident #1's face sheet dated 05/22/2024, revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: Sepsis (infection in the bloodstream), cellulitis of right lower limb (bacterial skin infection on the right leg) and local infection of the skin and tissue. Record review of Resident #1's admission MDS assessment dated [DATE] revealed the following: Section C- Cognitive patterns reflected the following: BIMS score of 13 which indicated the resident was cognitively intact. Section GG- Functional Abilities and Goals: Resident did not have an impairment with her lower extremities. Section M- Skin Conditions reflected the following skin conditions: Resident #1 had an Unstageable - Slough and/or eschar pressure wound that was present upon admission. Resident #1 did not have moisture associated skin damage. Resident #1 did not have treatments that reflected pressure reducing devices for chair. Record review of Resident #1's Initial skin assessment, dated 05/03/2024 revealed the following: Page 1 of 11 675988 675988 05/22/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

F 0641 Site 1) Lymphedema wound on the right, lower calf. Level of Harm - Minimal harm or potential for actual harm Site 2) Stage 3 Pressure Wound Sacrum, full thickness. Site 3) Candidiasis rash of the abdomen, apply antifungal. Residents Affected - Few Record review of Resident #1's Skilled Evaluation dated, dated 05/05/2024 revealed the resident had Lower extremity ROM: Impairment on both sides. Record review of Resident #1's treatment record for May 2024 revealed the following order: May have pressure reducing device in wheelchair as tolerated. Monitor for placement every shift -Start Date05/03/2024. Record review of Resident #1's May 2024 TAR revealed the following wound care orders: 1) Clean left lower abdominal fold with n/s, pat dry with gauze, cover with dry dressing one time a day. Start date of 05/05/2024. 2) Clean RLE with N/S, pat dry with gauze, place xero-form dressing over wound bed, and wrap with bandage one time a day. Start date 05/05/2024. 3) Clean coccyx with n/s, pat dry with gauze, lay anti-sept cream and collagen. Cover with bordered dressing one time a day. Start date 05/05/2024. Interview with the Wound Care Nurse on 05/22/2024 at 2:49 PM, revealed that Resident #1 did not have an unstageable pressure ulcer. She revealed that based on her observations since admission the resident had the following skin integrity issues: Stage 3 pressure ulcer on her sacrum, a lymphademic wound on her right lower extremity and a candidiasis rash of the abdomen that was moisture associated. She revealed that the resident was using a pressure reducing device while in her chair. She stated that the resident did have an impairment in her lower extremities. Interview with the DON on 05/22/2024 at 3:00 PM, revealed that she delegated the wound care to the Wound Care Nurse and that she had received all of her training. She revealed that the wound care interview and observations were correct for Resident #1. She stated that Resident #1 did not have an unstageable pressure ulcer while in the facility. She revealed that Resident #1 had a pressure reducing device while in her chair. She revealed that she had signed off on Section Z of the MDS assessment for completion, but she had not completed the MDS. She stated that the MDS nurse that had completed the MDS was unavailable for an interview since she was no longer employed by the facility. She stated that they were opening the MDS assessment and correcting the inaccuracies to reflect an accurate depiction of Resident #1. She said that the MDS nurse's failure could cause issues with the careplan, but not the resident's care, since they were already completing that. Record review of the facility's policy and procedure covering Accuracy of Assessments was requested 675988 Page 2 of 11 675988 05/22/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

F 0641 on 05/22/2024. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675988 Page 3 of 11 675988 05/22/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

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 interview and record review, the facility failed to develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of the resident's admission for 1 of 2 residents (Resident #1) whose records were reviewed in that: 1. Resident #1 did not have a Baseline Care Plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. This failure could place the residents at risk for not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility. The findings included: Record review of Resident #1's face sheet dated 05/22/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: Sepsis (infection in the bloodstream), cellulitis of right lower limb (bacterial skin infection on the right leg) and local infection of the skin and tissue. Record review of Resident #1's admission MDS assessment dated [DATE] revealed the following: Section C- Cognitive patterns reflected the following: BIMS score of 13 which indicated the resident was cognitively intact. Section GG- Functional Abilities and Goals: Resident did not have an impairment with her lower extremities. Section M- Skin Conditions reflected the following skin conditions: Resident #1 had an Unstageable - Slough and/or eschar pressure wound that was present upon admission. Resident #1 did not have moisture associated skin damage. Resident #1 did not have treatments that reflected pressure reducing devices for chair. Review of Resident #1's clinical record revealed a baseline care plan had not been completed within 48 hours following the resident's initial admission to the facility on [DATE]. In an Interview with the DON on 05/22/2024 at 3:00 PM, she stated the form titled Baseline care plan in the Resident's EMR's were not completed. She stated that she was responsible for delegating the task, but she was unsure who was assigned to complete it for Resident #1. She stated the failure could put residents at risk for not getting needed care. Review of the facility's policy and procedure titled Care Plans- Baseline dated - November 14,2023, 675988 Page 4 of 11 675988 05/22/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

F 0655 revealed the following [in part]: Level of Harm - Minimal harm or potential for actual harm Policy Statement Residents Affected - Few A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. Policy Interpretation and Implementation 1) To assure that the residents immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the residence admission. 2) The interdisciplinary team will review the health care practitioner's orders and implement a baseline care plan to meet the residents immediate care needs including but not limited to: a. Initial goals based on admission orders. b. Physician orders. c. Dietary orders. d. Therapy services. e. Social services. 3) The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 4) The resident and the representative will be provided a copy of the baseline care plan that includes but is not limited to: 675988 Page 5 of 11 675988 05/22/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

F 0655 a. Level of Harm - Minimal harm or potential for actual harm The initial goals of the resident. b. Residents Affected - Few The summary of the residence medication and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility and, d. Any updated information based on the details of the comprehensive care plan, as necessary. 675988 Page 6 of 11 675988 05/22/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to ensure that the daily nurse staffing information, including the facility name, current date, total number and actual hours worked by Registered Nurses, Licensed Practical Nurses or Licensed Vocational Nurses, Certified Nurse Aides, and the resident census, was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors for 1 of 1 facility. Residents Affected - Many The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings included: Observation on 05/22/2024 at 8:45 AM, revealed the daily staffing pattern was posted on the wall by the copier room and the DON's office, however the date was for 05/16/2024. During an interview with the DON on 05/22/2024 at 9:00 AM, She stated, that the staffing had not been updated or posted and that the last posting was for 05/16/2024. She stated that she was responsible for putting the staffing sheets out. She said that it had not been posted outside of the door, but it was in a binder book. She stated that someone had been removing that and the schedule, so they put it in a binder that was supposed to have been located at the front desk. She further stated, the failure could cause confusion on staffing and resident care issues. During an interview with the ADON on 05/22/2024 at 10:00 AM, she stated that the staffing sheets were being placed in a binder book and that it was supposed to have been kept at the front desk. She said that anyone can request or view the staffing sheets. She stated that it was not posted. She stated that employee time schedule was also taken over the weekend and she had to come up and reprint it. A copy of the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers dated July 2016 revealed the following: Policy Statement: Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residence. Policy interpretation and implementation. 1) Within two hours the beginning of each shift, the number of licensed nurses (RN's LPN's and LVN's) and the number of unlicensed nursing personnel (CNA's) directly responsible for resident care it will be posted in a prominent location accessible to residence and 2visitors and in a clear and readable format. 2) 675988 Page 7 of 11 675988 05/22/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

F 0732 Level of Harm - Potential for minimal harm Directly responsible for resident care means that individuals are responsible for resident's total care or some aspect of the residence care including, but not limited to, assisting with activities of daily living (ADL's) performing gastrointestinal feeds, giving medication, supervising care given by CNA's, and performing nursing assessments to admit residents or notifying physicians of change of condition. Residents Affected - Many 675988 Page 8 of 11 675988 05/22/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain clinical records that were complete and accurate for 1 of 3 (Resident #1) residents reviewed for clinical records in that: The facility did not maintain accurate and current nursing documentation related to wound treatments. The facility did not maintain accurate and current shower records. The facility did not maintain accurate and current bladder records. This failure could place residents at risk for inaccurate records. The findings were: Record review of Resident #1's face sheet dated 05/22/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: Sepsis (infection in the bloodstream), cellulitis of right lower limb (bacterial skin infection on the right leg) and local infection of the skin and tissue. Record review of Resident #'1s admission MDS dated [DATE] revealed the following: Section C- Cognitive patterns reflected the following: BIMS score of 13 which indicated the resident was cognitively intact. Section GG- Functional Abilities and Goals: Resident did not have an impairment with her lower extremities. Section H- Bowel and bladder reflected resident was occasionally incontinent with bladder. Section M- Skin Conditions reflected the following skin conditions: Resident #1 had an Unstageable - Slough and/or eschar pressure wound that was present upon admission. Resident #1 did not have moisture associated skin damage. Resident #1 did not have treatments that reflected pressure reducing devices for chair. Record review of Resident #1's May 2024 TAR revealed the following wound care orders that were not completed on May 7, 2024: 1) Clean left lower abdominal fold with n/s, pat dry with gauze, cover with dry dressing one time a 675988 Page 9 of 11 675988 05/22/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

F 0842 day. Start date of 05/05/2024. Level of Harm - Minimal harm or potential for actual harm 2) Residents Affected - Few Clean RLE with N/S, pat dry with gauze, place xero-form dressing over wound bed, and wrap with bandage one time a day. Start date 05/05/2024. 3) Clean coccyx with n/s, pat dry with gauze, lay anti-sept cream and collagen. Cover with bordered dressing one time a day. Start date 05/05/2024. Record review of Resident #1's daily Skilled Nursing Evaluation, dated 05/04/2024 revealed the following: Urostomy intact. Resident is always incontinent (no episodes of continent voiding). Record review of Resident #1's electronic record dated May 2024 did not show showers scheduled in their point of care. Record review of the facility's paper shower sheets for May 2024 revealed that Resident #1 was scheduled for showers on Tuesday, Thursday, and Saturday. Record review of the facility's individual paper shower sheets for May 2024, revealed that Resident #1 did have showers completed on the opposite days that were given on Monday, Wednesday, and Fridays. Interview on 05/22/2024 at 2:45 PM, The Wound Care Nurse stated that she did complete Resident #1's Wound Care on 05/07/2024, once she returned from wound care at 2:30 PM. She said that she had forgotten to document it in the electronic treatment record. She said this failure could result in inaccurate documentation. Interview on 05/22/2024 at 3:00 PM, the DON stated that upon her review there was electronic documentation reflecting the resident's showers being completed. She said that it should have been scheduled in the point of care records for the CNA's, but somehow it got missed. She said that it was scheduled on the paper sheets for Tuesday, Thursdays, and Saturdays, but that the resident was not there on those days due to dialysis. She said that they just did it on the other days and the CNA's put in on paper but did not ever document it electronically or notify her that it was not triggering or scheduled on their electronic documentation records. She said that the resident was occasionally incontinent but was never always incontinent. She stated that the Daily Skilled Evaluation from 05/04/2024 was inaccurate and not documented correctly. She stated that Resident #1 received wound care every day, and that the 05/07/2024 documentation that showed it was missed was inaccurate and incomplete documentation. She said that all nursing staff has been trained on documentation and following orders. She revealed that she was responsible for ensuring that documentation was entered and that she will be working with staff on this. She revealed this failure could result in inaccurate documentation. A record review of the facility's policy titled; Charting and Documentation dated 07/2017 revealed the following: 675988 Page 10 of 11 675988 05/22/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

F 0842 Level of Harm - Minimal harm or potential for actual harm All services provided to the resident, progress toward the care plan goals, or any changes in the residence medical, physical, functional, or psychosocial condition, shall be documented in the residence medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Residents Affected - Few 675988 Page 11 of 11