Health inspection·August 30, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 residents, who were unable to carry out activities of daily living, received the necessary services to maintain good grooming, and personal hygiene for 1 of 28 residents reviewed for ADL care. (Resident #15) Residents Affected - Few The facility did not shave Resident #15's upper lip and chin hairs. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of psycho-social well-being. Findings included: Record review of physician's orders dated August 2023 indicated Resident #15 was admitted to the facility on [DATE], was an [AGE] year old female, and had diagnoses of anxiety, muscle weakness and macular degeneration. Record review of the most recent MDS dated [DATE] indicated Resident #15 was alert and, oriented with a BIMS of 13 (score of 13 to 15 indicates the resident is cognitively intact) and required extensive assistance of one person for personal hygiene. Record review of a care plan updated 06/11/23 indicated Resident #15 had ADLs and preferences that needed staff attention, understanding, and possible assistance for her deficits. The care plan indicated the resident required extensive assistance with ADL care needs. The goal was to maintain the resident's dignity and needs. There was no care plan to indicate the resident resisted care or refused care. During observation and interview on 08/28/23 at 8:52 a.m., revealed Resident #15 was lying in bed. The resident had multiple hairs on her upper lip and chin approximately 3/4 inch in length. She said the facility staff usually shaved her but had not shaved her recently. She said she wanted to keep the facial hair shaved. She denied concerns related to dignity. During observation and interview on 08/28/23 at 12:15 p.m., revealed Resident #15 had multiple hairs to upper lip and chin approximately ¾ inch in length. During observation and interview on 08/29/23 at 12:26 p.m., revealed Resident #15 had long hairs to her upper lip approximately ¾ inch in length. HerThe chin had been shaved. The resident said one of the staff shaved her chin but did not shave her upper lip. She said she wanted her upper lip shaved but did not feel it was a dignity issue. CNA A entered the resident's room. She said Page 1 of 6 676008 676008 08/30/2023 Silsbee Oaks Health Care LLP 920 E Ave L Silsbee, TX 77656

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #15 did have multiple long hairs on herthe upper lip. She said the resident sometimes told them she didn't want to be shaved. The resident said she always wanted to keep her facial hair shaved. The CNA said it was her responsibility to keep the resident's facial hair shaved. She said it could be a dignity concern if the resident's facial hair was not shaved. During an interview on 08/29/23 at 2:38 p.m., LVN B said it was the direct care staff's responsibility to ensure the residents received the necessary ADL care. She said Resident #15's daughter family member usually shaved her. She said it was ultimately the facility's responsibility to ensure the resident's facial hair was shaved. She said the department heads were supposed to monitor the halls and report to the charge nurse if the residents needed to be shaved. She said the possible negative outcome of the resident's facial hair not being shaved would be they might feel negative about their appearance. During an interview on 08/29/23 at 2:34 p.m., the Accounts Payable person said she was the Hall 100 monitor for the month of August 2023. She said she did observation rounds every morning to check oxygen, nebulizers, hazards and to check resident's care needs. She said she did not notice Resident #15 had facial hair because usually the resident was sleeping 9 times out of 10 when she did her rounds and she did not want to be bothered, so she left her alone. She said it was her responsibility to report Resident #15's facial hair to the charge nurse, but she had not. She said the possible negative outcome of the resident not being shaved could be she would feel bad about herself. She said knowing the resident, the resident did not care if she was shaved. During an interview on 08/29/23 at 3:23 p.m., the a dministrator said her expectations were for the staff to keep the residents shaved. She said even if Resident #15's family shaved the resident at times,; it was the staff's responsibility to ensure Resident #15 was shaved. She said the residents not being shaved could be a dignity concern. Record review of an Activities of Daily Living Policy dated 06/28/2003 indicated: . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and, personal and oral hygiene. 676008 Page 2 of 6 676008 08/30/2023 Silsbee Oaks Health Care LLP 920 E Ave L Silsbee, TX 77656

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, in accordance with State and Federal laws, provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 storage area located in the DON's office of drugs for destruction reviewed for drug storage. The facility failed to ensure controlled drugs for destruction were stored in a separately locked, permanently affixed compartment for storage until destroyed. This failure could place residents at risk for possible drug diversion. The findings included: During observation and interview on 08/30/23 at 9:16 a.m., revealed the DON opened a cabinet drawer in her office using her key. She said the drawer contained all the discontinued drugs intended for destruction at the facility. Inside the drawer was a secured/affixed lock box that was closed and locked and lying across the bottom of the drawer were medication cards holding medications and control medication count sheets. Included in the medications lying in the bottom of the drawer outside the secured lock box were the following controlled medications: -Hydrocodone-Acetaminophen 5-325mg card and count sheet - 45 tablets -Acetaminophen-Codeine #3 card and count sheet - 28 tablets -Alprazolam 0.25mg card and count sheet - 27 tablets -Hydrocodone-Acetaminophen 5-325mg card and count sheet - 20 tablets The DON said all drugs for destruction should be kept under a double lock system with the drawer locked and all drugs secured into the lock box inside the drawer. She said she, the pharmacist, and the ADON planned to destroy the drugs on 08/29/23, but she got called away. She said she did not place all medications back into the affixed/secure box before she locked the drawer. She said the possible negative outcome of not keeping controlled medications under a double lock system could be drug diversion. During an interview on 08/30/23 at 9:32 a.m., the ADON said she shared the office with the DON where drugs for destruction were secured, but she did not have a key to the drawer or the lock box. She said only the DON had a key. The ADON confirmed that she, the pharmacist, and the DON had planned to destroy the medications on 08/29/23 but were interrupted and they did not destroy the drugs. During an interview on 08/30/23 at 10:10 a.m., the Pharmacist said he was at the facility on 08/29/23 and was about to destroy discontinued medications with the DON and ADON when the DON was called away. He said he saw the DON put the medications into the drawer without locking them all in the lock box. He said they did not complete the drug destruction and the medications were left in the drawer without being secured into the lock box. He said the possible negative outcome of medications not 676008 Page 3 of 6 676008 08/30/2023 Silsbee Oaks Health Care LLP 920 E Ave L Silsbee, TX 77656

F 0761 being stored/locked properly could be drug diversion. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy and procedure dated 06/28/23 and titled, Destruction of Unused Drugs indicated the following: All unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed. Residents Affected - Few 676008 Page 4 of 6 676008 08/30/2023 Silsbee Oaks Health Care LLP 920 E Ave L Silsbee, TX 77656

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 interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, complete and accurately documented medical records for each resident, for 1 of 27 residents (Resident #5) reviewed for accurate records. The facility failed to document Resident #5's baths for 08/01/23 - 08/29/23. This failure could place residents at risk for inaccurate and missing documentation in their records. Findings included: Record review of a face sheet dated 08/30/23 indicated Resident #5 admitted to the facility on [DATE] and was [AGE] years old with diagnoses including a seizure disorder and hemiplegia (paralysis of one side of the body). Record review of the MDS dated [DATE] indicated Resident #5 had no speech, was unable to express ideas and wants, and he rarely/never understood. The resident's cognitive skills for daily decision making were severely impaired and he required one staff member for grooming and personal hygiene. Record review of the care plan dated 08/29/23 indicated Resident #5 had a deficit with ADL self-care performance and he was totally dependent on staff for ADLs. It indicated for personal hygiene: He was dependent on (1) staff for personal hygiene and oral care; provide my care and notify nurse of any changes in my abilities. The CNA bathing/showering care plan indicated: He was dependent on (1-2) staff to provide bath/shower and as necessary. Record review of the August 2023 aide flowsheet in the electronic medical record indicated no documented evidence Resident #5 did not received his baths from 08/01/23 - 08/29/23. During an interview on 08/29/23 at 9:30 a.m., the DON said Resident #5's August 2023 ADL flowsheet with the bath record was incomplete and said the 2 p.m. - 10 p.m. aide did not chart the baths for him. The DON said she knew the bath had been given because she saw the CNA C perform the bath last week. She said the CNA C was the only CNA that bathed Resident #5 and should have charted the bath was given. The DON said the staff could look at the clinical record and ensure baths werewas given as required. The DON said Resident #5 should have been charted at least three times weekly for his bath. During an interview on 08/29/23 at 3:00 p.m., CNA C said she had given Resident #5 his bath every day she worked on the 2-10 shift Monday-Friday but did not chart the baths as being given during the month of August 2023. She said there was not a place for charting his baths and did not report to the nurse or the DON that she was unable to chart Resident #5's bath. During an interview on 08/30/23 at 7:45 a.m., the DON said she and the nurses were responsible for making sure the aide flowsheets were correct and completed. She said Resident #5 bath was put in the computer on night shift, but he received the bath on 2-10 and was given by CNA C. 676008 Page 5 of 6 676008 08/30/2023 Silsbee Oaks Health Care LLP 920 E Ave L Silsbee, TX 77656

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/30/23 at 7:55 a.m., the a dministrator said she expected the clinical electronic medical records to be correct and completed when the residents received their baths. She said they had given training on completing aide flowsheets and medical records in June 2023. Record review of the undated policy and procedure titled electronic charting and electronic signatures revealed . will maintain residents' charts through electronic charting using the .with only minimal paper charting. The direct care staff will enter their documentation . b. The staff member will complete their documentation as required 676008 Page 6 of 6