Health inspection·March 22, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, 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, mental, and psychosocial needs that are identified in the comprehensive assessment for 3 of 19 residents reviewed for care plans. (Residents #15, #65 and #72) *The facility failed to care plan Resident #15 as having a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder. The tube is inserted into the bladder through a cut in the stomach , a few inches below the navel. *The facility failed to care plan Resident #65 for the use of Duloxetine (a medication used to treat depression). *The facility failed to care plan Resident #72 for the use of Eliquis (a medication used to prevent blood clots) and his use of an AutoPAP (a continuous positive airway pressure device that delivers effective sleep therapy catered to the individual's immediate needs. and automatically adjusts pressure levels in real-time). These failures 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: Resident #15 1. Record review of the face sheet dated March 2023 indicated Resident #15, was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included retention of urine (Difficulty urinating and completely emptying the bladder) and paraplegia (Paralysis of the legs and lower body). Record review of urologist notes dated 02/06/23 indicated Resident #15 had a suprapubic catheter surgically placed. Record review of Treatment Administration Record (TAR) dated March 2023 indicated Resident #15 was receiving daily care to the insertion site of his suprapubic catheter and it was being changed monthly by nurses. Record review of an annual MDS assessment dated [DATE] indicated Resident #15 had moderate Page 1 of 8 676011 676011 03/22/2023 Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575

F 0656 cognitive impairment, required extensive assistance with most ADLs, and had an indwelling catheter. Level of Harm - Minimal harm or potential for actual harm Record review of the care plans last updated 10/26/22 indicated Resident #15 did not have a care plan indicating he had a suprapubic catheter surgically placed on 02/06/23. Residents Affected - Some During an observation and interview on 03/20/23 at 9:49 AM, Resident #15 was sitting up in a wheelchair in his room. His catheter bag was attached to the bottom of his wheelchair below the level of his bladder and was draining a light-yellow urine into a privacy bag. Resident #15 said he used to have a different catheter but the one he now has was better. 2. Record review of physician orders dated March 2023 indicated Resident #65, was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of persistent depressive disorder (a mild but long-term form of depression). Resident #65's orders indicated she was prescribed duloxetine HCL 60 mg at bedtime for persistent depressive disorder with a start date of 09/01/22 and duloxetine HCL 30 mg daily for persistent depressive disorder with a start date of 09/01/22. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #65 had a BIMS score of 13, (mental status cognitively intact) a diagnosis of depression and received an antidepressant medication 7 of 7 days. Record review of care plans updated 2/20/23 indicated Resident #65 did not have a care plan for duloxetine or antidepressant medication. Record review of MARS indicated Resident #65 received duloxetine 30 mgs at 8:00 am daily with a start date of 9/1/22 and duloxetine 60 mg at 10:00 p.m., daily with a start date of 9/1/22. During an observation and interview on 03/20/23 at 11:30 a.m., Resident # 65 was lying in bed. She said the staff treated her well and she received needed care. 3. Record review of physician orders dated March 2023 indicated Resident #72, was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of persistent depressive disorder (a mild but long-term form of depression). Resident #72's orders indicated he was prescribed autopap to be worn at bedtime for obstructive sleep apnea (a sleep disorder characterized by repeated obstruction to the airway during sleep) with a start date of 10/17/22 and Eliquis 5 mg two times a day for atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) with a start date of 10/13/22. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #72 had a BIMS score of 2, (mental status severely impaired) diagnoses of atrial fibrillation and obstructive sleep apnea and received an anticoagulant medication 7 of 7 days. Record review of care plans updated 03/14/23 indicated Resident #72 did not have a care plan for his Eliquis or AutoPAP machine. Record review of a MAR dated March 2023 indicated Resident #72 received Eliquis 5 mgs twice a day with a start date of 10/12/22. The MAR indicated Resident #72 received AutoPAP at bedtime daily with a start date of 10/17/22. 676011 Page 2 of 8 676011 03/22/2023 Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575

F 0656 During an observation and interview on 03/20/23 at 11:25 a.m., Resident #72 was sitting Level of Harm - Minimal harm or potential for actual harm in his wheelchair with his AutoPap machine sitting on his bedside table. Resident #72 said he uses his Auto pap every night, the nurses put it on him. Residents Affected - Some During an interview on 3/21/23 at 318 p.m., MDS nurse A said she was responsible for residents on Hall 400, 500 and 600's care plans. She said she and MDS nurse B were each other's back up and the DON spot checked MDS and care plans and double checked them. MDS nurse A said she was in-serviced on care plans, the most recent 4 to 6 months ago. During an interview and record review on 3/22/23 at 3:19 p.m., MDS nurse B said she was responsible for residents on Halls 100, 200 and 300's care plans. She said she had been in-serviced on care plans, the most recent 4 to 6 months ago. She said she was MDS nurse A 's back up. MDS nurse B said she was responsible for Resident #65's care plan, and the duloxetine was not care planned and should have been. MDS nurse B said she was responsible for Resident #72's care plan and the Auto PAP and Eliquis were not care planned and should have been. She said they were just missed. She agreed the potential negative outcome was a nurse potentially not knowing the side effects or adverse reactions to monitor for the medication. When asked by the surveyor if the staff may potentially not be aware a resident's needed services or care she agreed. During an interview on 3/21/23 at 3:22 p.m., the DON said MDS nurse A was responsible for care plans of residents on halls 400, 500 and 600, and MDS B was responsible for care plans of residents on Halls 100, 200 and 300. She said dietary, activities and the treatment nurse contributed to the care plan. The DON said she spot checks some MDS's and care plans during the IDT (interdisciplinary team) meetings and updates and changes made at that time. When asked what her expectations related to care plans were the DON said resident care, services, treatments, medication, status changes, should be care planned. She said the MDS nurses were in-serviced frequently on care planning and MDS. When asked about the risk of not care planning items the DON said she did not see a risk to the resident. She said the resident received the care and services, medication, medications were monitored for side effects. She said the staff were just not following their policy. During an interview on 3/21/23 at 3:30 p.m., the administrator when asked his expectation related to care plans; said anything the staff did for a resident must be care planned, including special items or services. He said the MDS nurses are responsible for care plans. When asked the potential negative outcome for the resident for items not care planned the administrator said he did not see a risk to the resident, the resident received the care and services he said the staff were just not following their policy. During an interview on 03/22/23 at 2:30 PM, MDS Nurse A said she was responsible for care plan for Resident #15. Nurse reviewed the care plan and said she had never written a care plan for his suprapubic catheter. She said nurses have been doing daily insertion site care and changing the catheter monthly and the suprapubic catheter should have been included in the care plan. She said she had worked at the facility for 17 years and had many in-service trainings on MDS and care plans. She said she had made a mistake by not adding the suprapubic catheter to Resident #15's care plan but he was 676011 Page 3 of 8 676011 03/22/2023 Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575

F 0656 receiving his ordered care. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/22/23 at 2:50 PM, the DON said that MDS Nurse A was responsible for completing care plans for Resident #15. DON said she expected care plans to include all resident problems or diagnosis, interventions, and goals. She said she spot checked care plans with the IDT meetings, and she was MDS Nurse A's direct supervisor. She said MDS Nurse A had received trainings on MDS and care plan completion. She said she saw no negative outcome for Resident #15's catheter not being included in his care plan because he was receiving care as ordered by his physician. Residents Affected - Some Record review of a policy titled, Comprehensive Care Plans dated 2022 indicated, .This facility's policy is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs are identified in the resident's comprehensive assessment. d. Resident-specific interventions that reflect the resident's needs and preferences. 676011 Page 4 of 8 676011 03/22/2023 Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 3 of 19 residents reviewed for respiratory care and services. (Resident #s 14, 30, and 76) Residents Affected - Some * The facility did not provide Resident #14's oxygen concentrator with a clean filter. The filter was covered with a thick layer of gray powdery substance. *The facility failed to administer the correct dose of oxygen to Resident #30. *The facility failed to administer the correct dose of oxygen to Resident #76. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. admission report indicated Resident #14 was a female [AGE] years old, admitted on [DATE] with diagnosis of COPD (Chronic Obstructive Pulmonary Disease) [chronic lung disease]. Physician orders March 2023 indicated Resident #14 orders included oxygen at 2 LPM via Nasal cannula or mask as needed with start date of 09/01/2022. Record review of the annual MDS assessment dated [DATE] indicated Resident #14 had severely impaired with cognition and received oxygen therapy during last 14 days while she was a resident at the facility. Record review of the care plan dated 03/15/23 for Resident #14 indicated she had altered respiratory status/difficulty related to COPD and she used continuous oxygen therapy per order. Record review of task flow sheet dated March 2023 for Resident #14 the task of cleaning or replacing air filter on concentrator had not been marked with initials, it was blank for last 21 days. During observation and interview on 03/20/23 at 9:03 a.m., Resident #14 was in bed and was receiving oxygen at 2 LPM and both filters on oxygen were covered with a gray powdery substance. Resident #14 said the staff take care of the oxygen machine for her, like the bottle and tubing. She said she did not know about the filters. During an observation on 03/21/23 at 9:30 a.m., Resident #14's oxygen concentrator filters were covered with a gray powdery substance. During an interview on 03/21/23 at 9:45 a.m., RN D said Resident #14's oxygen concentrator filters were dirty and should not be. RN D said it could cause the machine to not function properly. During an interview on 03/21/23 at 10:00 a.m., ADON said the hospitality aides were to change or clean the filters weekly and they report to the charge nurse. 676011 Page 5 of 8 676011 03/22/2023 Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/21/23 at 10:15 a.m., the DON said they had changed their policy and started having the hospitality aides clean the filters each week and the hospitality aides were trained. During an interview on 03/21/23 at 10:20 a.m., hospitality aide E said she did not clean Resident #14's concentrator's filters yesterday (Monday, 3/20/23) and forgot to tell the nurse. Hospitality aide E said she had been trained in cleaning the filters. During an interview on 03/21/23 at 3:50 p.m., the Administrator said he wanted the filters clean, and he was going to get more filters and rotate stock in and out while they were being cleaned. During an interview on 03/22/23 at 2:54 p.m., the Administrator said if the filters on concentrators were dirty that could cause the concentrator to overheat or cause mechanical issues. 2. Record review of physician orders dated March 2023 indicated Resident #30, admitted [DATE], was [AGE] years old with a diagnosis of chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty in breathing). The orders indicated the resident received oxygen at 3-5 liters per minute per nasal cannula continuously effective 11/19/22. Record review of the most recent MDS assessment dated [DATE] indicated Resident #30 was alert, oriented with a BIMS of 15 (score of 13 to 15 intact cognition) and received oxygen therapy in the last 14 days. Record review of a care plan updated 01/22/23 indicated Resident #30 had difficulty breathing because of chronic obstructive pulmonary disease and required oxygen. The interventions indicated the resident would receive continuous oxygen therapy per orders. There was no care plan to indicate the resident adjusted the oxygen dosage outside of ordered parameters. During observations the oxygen was not administered to Resident #30 and the oxygen concentration machine was turned off and sitting against the back wall as follows: *on 03/20/23 at 9:56 a.m.; and *on 03/21/23 at 3:08 p.m. During an interview on 03/21/23 at 3:10 p.m., Resident #30 said she did not always wear oxygen. She said she had the oxygen on earlier that morning and used the oxygen as needed. During observation and interview on 03/21/23 at 3:15 p.m., LVN C said Resident #30 was not wearing oxygen and the orders for Resident #30 indicated she was supposed to wear the oxygen continuously. She said she did not require continuous oxygen. She said she would have to clarify the orders with the physician. She said the possible negative outcome of not administering the oxygen as ordered was the resident could experience respiratory distress. 3. Record review of physician orders dated March 2023 indicated Resident #76, admitted [DATE], was [AGE] years old with a diagnosis of chronic obstructive pulmonary disease. The orders indicated the resident was to receive oxygen at 2 liters per minute per nasal cannula continuously effective 9/1/22. Record review of the MDS assessment dated [DATE] indicated Resident #76 was alert, oriented with a 676011 Page 6 of 8 676011 03/22/2023 Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some BIMS of 10 (score of 8 to 12 moderately impaired cognition), was independent for ADL care and received oxygen therapy in the last 14 days. The assessment indicated the resident did not have behaviors. Record review of a care plan updated 01/22/23 indicated Resident #76 had difficulty breathing because of chronic obstructive pulmonary disease and required oxygen. The interventions indicated the resident was to receive continuous oxygen therapy per orders date initiated: 08/03/2022. The care plans did not indicate the resident adjusted the oxygen dosage without staff knowledge and/or had behaviors. During observations Resident #76 received oxygen per nasal cannula at 5 liters per minute on: *03/20/23 at 9:33 a.m.; *03/21/23 01:53 p.m.; and *03/21/23 02:39 p.m. During observation and interview on 03/21/23 at 1:53 p.m., Resident #76 had oxygen at 5 liters per minute nasal cannula in progress. The resident said she did not touch or change the oxygen settings. She said she was not sure what dose of oxygen she was supposed to receive. She said she could get up to the bathroom by herself because she had long oxygen tubing however, she did not touch the oxygen concentrator settings. During observation on 03/21/23 at 2:39 p.m., Resident #76 had oxygen at 5 liters nasal cannula in progress. LVN A said the resident's oxygen was set at 5 liters nasal cannula and was not the correct dosage. She said physician orders were supposed to be followed and she would have to clarify the order with the physician. She said the resident did not adjust the oxygen concentrator and she should have caught the fact that it was not set on the ordered dose. She said the possible negative outcome of the resident's oxygen dosage being set higher than ordered could be the resident may not be able to manage the dose. During an interview on 03/22/23 at 9:33 a.m., the DON said the residents were to receive all medication, including oxygen therapy, as ordered. She said her expectations were for the residents to receive oxygen at the dosage ordered by the physician. She said the possible negative outcome of not administering oxygen as ordered would be the resident would not receive the correct amount and it could have a negative effect on the outcome of their treatment. A Oxygen Administration policy date 04/16/21 indicated . 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. The undated Maintenance of nebulizer, concentrators and equipment Policy indicated Policy: Nebulizer equipment maintenance and concentrator. Maintain cleanliness . Procedure 1. All maintenance of nebulizers and concentrators will be done on Mondays by Hospitality aides. 2 All machines are to be wiped down with disinfectant wipes and filter is to be cleaned with warm water, a mild soap rinsed and air dry. 676011 Page 7 of 8 676011 03/22/2023 Magnolia Place Health Care 1620 Magnolia St. Liberty, TX 77575

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 post information daily regarding registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. Residents Affected - Many The facility failed to post the total number of hours worked for licensed nurses and certified nurse aides with the daily census. This failure could place residents at risk of being unaware of the facility's daily staffing requirements. Findings include: During an observation on 3/20/23 at 9:00 a.m., there was not a Direct care daily staffing sheet posted in the building. During an observation on 3/21/23 at 10:30 a.m., there was not a Direct care daily staffing sheet posted in the building. During an observation on 3/22/23 at 12:45 p.m., there was not a Direct care daily staffing sheet posted in the building. During an interview on 3/22/23 at 12:50 p.m., the ADON said the Direct care daily staffing sheet was not posted and had not been posted in a very long time. During an interview on 3/22/23 at 1:23 p.m., the ADON said she was responsible for posting the Direct care daily staffing sheet. The ADON said she was not sure why the Direct care daily staffing sheet was not done and that it may have come down during covid. The ADON said the Direct care daily staffing sheet informs residents and families how many staff are available each day. During an interview on 3/22/23 at 1:50 p.m., the DON said she expected the Direct care daily staffing sheet to be completed and posted daily. The DON said the charge nurses were responsible for completing the Direct care daily staffing sheet and the ADON was responsible for monitoring the Direct care daily staffing sheet were completed. The DON said the ADON would be getting with charge nurses to in-service them. The DON said there is no P&P for posting the Direct care daily staffing sheet. During an interview on 3/22/23 at 2:05 p.m., the Administrator said he expected the Direct care daily staffing sheet to be completed and posted daily. The Administrator said the ADON was responsible for the Direct care daily staffing sheet. The Administrator said there is no P&P for posting the Direct care daily staffing sheet. 676011 Page 8 of 8