Health inspection·October 19, 2022

F 0610 Respond appropriately to all alleged violations. 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 all alleged violations were thoroughly investigated for 3 of 4 residents (Resident #s 2, 15 and 35) reviewed for investigation of incidents of alleged neglect and injuries of unknown origin. Residents Affected - Some The facility failed to thoroughly investigate allegations of neglect and injury of unknown origin for Resident #s 2, 15 and 35. This failure could place the residents at risk for further abuse, neglect, exploitation and mistreatment. Findings included: 1. Record review of the face sheet dated 10/19/22 for Resident #2 indicated the resident, admitted [DATE], was [AGE] years old with diagnoses of Alzheimer's disease (progressive mental deterioration) and adjustment disorder with mixed disturbance of emotions. Record review of the TULIP [(Texas Unified Licensing Portal) the state on line reporting website] facility case #372177, PIR (provider incident report) for Resident #2 dated 8/22/22 indicated the interim DON conducted in-services on observation and reporting for nursing staff and in-services on change in the resident's condition or status for LVN, RN staff. The allegation was made 08/21/22. The facility classified the incident as an Injury of unknown origin. MD (medical director) notified and received orders to monitor for worsening condition. Record review of the facility incident investigation #372177 for Resident #2 indicated the investigation included the incident report and the PIR submission confirmation sheet dated 08/22/22. There was no documentation to indicate the staff had been in-serviced on observation and reporting or change in condition, the resident had been monitored or the staff and/or alert residents had been interviewed regarding the incident. 2. Record review of the face sheet for Resident #15 dated 10/19/22 indicated the resident, admitted [DATE], was [AGE] years old with diagnoses of Alzheimer's disease and anxiety disorder. Record review of the TULIP (Texas Unified Licensing Portal) facility case #370038, PIR (provider incident report) for Resident #15 dated 8/15/22 indicated the staff would be in-serviced on fall prevention. The allegation was made 08/11/22. Orders from hospice indicated to transfer the resident to emergency room. The facility classified the incident as an unwitnessed fall with head injury. Page 1 of 6 676055 676055 10/19/2022 Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the facility incident investigation #370038 for Resident #15 indicated the investigation included the incident report and an in-service dated 08/12/22 titled, Assessing Falls and Their Cause. There was no documentation to indicate the resident had been monitored or the staff and/or alert residents had been interviewed regarding the incident. 3. Record review of the face sheet for Resident # 35 dated 10/19/22 indicated the resident, admitted [DATE], was [AGE] years old with a diagnosis of dementia without behavioral disturbance. Record review of the TULIP (Texas Unified Licensing Portal) facility case #372237, PIR (provider incident report) for Resident #35 dated 8/15/22 indicated the staff would be in-serviced on observation and reporting to all nursing staff. The allegation was made 08/21/22. The facility classified the incident as an injury of unknown origin. The investigation summary indicated injury believed to be caused by wheelchair. The report indicated resident put on close monitoring. Record review of the facility incident investigation #372237 for Resident #35 indicated the investigation included the incident report dated 08/21/22. There was no documentation to indicate the staff had been in-serviced, the resident had been monitored or the staff and/or alert residents had been interviewed regarding the incident. During an interview and record review of the facility investigation reports for Resident #s 2, 15 and 35 on 10/19/22 at 10:27 a.m., the Interim DON providedhanded the surveyor 3 incident reports and said those were histhe facility investigations of the incidents that occurred for Resident #s 2,15, and 35. He said he did not have any other documentation to provide and that he had not conducted interviews with staff or residents regarding the incidents. He said he should not have documented on the PIR for the staff to monitor the residents; that was the wrong word to use because he did not imply the staff were going to assess the residents at routine intervals and document it. When asked where the in-services regarding the incidents were, he said he would have to look for them. During an interview on 10/19/22 at 2:45 p.m., the Interim DON said his expectations of investigating unwitnessed falls or injuries of unknown origin were for the residents to have neuro checks completed, interview the resident if able, interview the CNAs to see if they knew what happened, interview the nurses, look in the area the incident occurred for safety concerns, and look at medications for new/changed medications or side effects of medications. He said he was responsible for investigating incidents/accidents. He said he did not have the in-services for all the incidents but he did find an in-service for Resident #15's incident. He said he did not have a neuro-check monitoring sheet for Resident #15, but he would try to find it. He said he did not have interviews with staff or residents regarding the incidents for Resident #s 2, 15 and 35. He said he was responsible for being the DON, ADON and investigating intakes and it was too much for one person to do. He said the information provided was all he had and it is what it is. . During an interview on 10/19/22 at 3:40 p.m., the administrator said his expectations regarding investigating injuries of unknown origin or unwitnessed falls was for the alleged violations to be thoroughly investigated to prevent further abuse, neglect, exploitation or mistreatment while the investigation is in progress and to take appropriate corrective actions as to the investigation findings. When asked if he thought the incidents had been investigated thoroughly, the administrator said he did not want to comment. 676055 Page 2 of 6 676055 10/19/2022 Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of an Accident and Incidents- Investigating and Reporting policy revised July 2017 indicated: . 2. The following data, as applicable, shall be included on the report of incident/accident form: e. The names of witnesses and their accounts of the accident or incident. m. other pertinent data as necessary or required; Record review of an Abuse Investigation and Reporting policy revised July 2017 indicated: . injuries of unknown origin source (abuse) shall be promptly reported to local, state and federal agencies (as defined by the current regulations) and thoroughly investigated by facility management. 676055 Page 3 of 6 676055 10/19/2022 Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 transmit a resident assessment within 14 days after a facility completes a resident's assessment 1 of 3 discharged residents (Resident #1) reviewed for data encoding and transmission in that: Residents Affected - Few Resident #1's discharge MDS dated [DATE] was not transmitted to CMS within 14 days of completion. This failure could place the residents at risk for MDS assessments not being transmitted and not receiving care and services as needed. Findings included: Record review of admission record for Resident #1 indicated Resident #1 was admitted on [DATE], [AGE] years old with diagnosis of fracture of his left leg and discharge date of 5/17/22. Record review of a list of the MDS assessments for Resident #1 indicated: the MDS assessment had been completed however had not been transmitted the discharge MDS dated [DATE] and was marked complete; and the admission MDS assessment for Resident #1 dated 05/17/22 was marked accepted. During an interview on 10/19/22 at 9:41 a.m., the MDS nurse said she would check why Resident #1's discharge MDS assessment on 5/17/22 was not transmitted within 14 days of completion. During an interview on 10/19/22 at 10:40 a.m., the MDS nurse said the MDS for Resident #1 discharge MDS was coded return not anticipated, and she said it was not transmitted to CMS but should have been transmitted. She said she was retrained recently and follows the RAI manual for the policy. She said the MDS assessments need to be transmitted within 14 days of completion, so the MDS would be accepted and to get care and services for the residents. During an interview on 10/19/22 at 10:45 a.m., The interim DON said the MDS should be transmitted as required. Reference obtained per Internet on 10/24/2022 at website https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf .OBRA-required non-comprehensive MDS assessments include a select number of MDS items, but not completion of the CAA process and care planning. The OBRA non-comprehensive assessments include: Quarterly Assessment, Significant Correction to Prior Quarterly Assessment, Discharge Assessment Return not Anticipated, Discharge Assessment - Return Anticipated . .Transmitting Data: Submission files are transmitted to the QIES ASAP system using the CMS wide area network. Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Discharge Assessment All values All values 10 or 11 Z0500B + 14 days. 676055 Page 4 of 6 676055 10/19/2022 Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 14 residents (Resident #20) reviewed for medication administration in that: The facility did not provide adequate monitoring or have parameters to monitor Resident #20's Midodrine (a medication to treat low blood pressure). This failure could place residents at risk of adverse effects or not receiving the intended therapeutic effect of medications. Findings included: Record review of Resident #20's face sheet, dated 10/18/22, revealed a [AGE] year-old female, re-admitted to the facility on [DATE]. She had diagnoses which included chronic atrial fibrillation(irregular heart rate), hypertension(high blood pressure), nonrheumatic aortic valve insufficiency(heart valve disease where the aortic valve no longer functions adequately to control the flow of blood) and heart failure(heart does not pump blood as well as it should). Record review of Resident #20's electronic clinical record revealed the quarterly MDS with ARD 08/19/22, her BIMS was 6, which suggests she was severely impaired cognitively. Record review of Resident #20's undated care plan revealed Focus: Resident has congestive heart failure . Interventions: .give cardiac medications as ordered . Record review of Resident #20's Order Summary Report, dated 10/17/2022, revealed an order start date 08/08/20 for Midodrine 10 mg give 1 tablet by mouth three times a day. The orders did not address blood pressure parameters. Record review of Residents #20's MAR dated, October 2022, revealed from 10/01/22 to 10/17/22 Resident #20 did receive Midodrine 10 mg 1 tablet by mouth three times a day (9am, 1pm and 9pm) and no vital signs were recorded. Record review of Resident #20's medical record revealed there was no indication of physician notification, follow up assessment or medication being held for the Midodrine. During an interview on 10/19/22 at 3:14 p.m., LVN A said the midodrine for Resident #20 was administered and should have had physician ordered parameters when to hold. LVN A said she was not aware that the order did not have a parameter ordered of when to hold. She stated SBP readings should be recorded on the MAR and there was no assigned area on the MAR for SBP or DBP readings for the Midodrine. LVN A stated monthly reconciling of orders was the responsibility of the DON. LVN A stated giving midodrine outside of doctor order parameter could cause the resident to have high blood pressure and the resident already has an diagnosis of hypertension and if the medication were held the documentation would be on the MAR. During an interview on 10/19/22 at 3:24 p.m., CMA B said she had administered Midodrine to Resident 676055 Page 5 of 6 676055 10/19/2022 Shady Acres Health and Rehabilitation Center 405 Shady Acres Lane Newton, TX 75966

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #20 earlier at 9am and 1pm and did not take her blood pressure. CMA B said all B/P medications had parameters or should have parameters. CMA B said she did not know the Midodrine was a medication that affected the blood pressure. CMA B said as a medication aide she was responsible for knowing the medication usage and side effects before administering. She acknowledged Resident #20's B/P recordings were not recorded for Midodrine and there should have been parameters for administration of Midodrine. CMA B stated she was trained during orientation and annually on medication administration. CMA B said giving Resident #20 Midodrine without taking the blood pressure or having parameters puts her at risk for stroke because the blood pressure could go higher. During an interview on 10/19/22 at 3:41 p.m., Interim DON said he had been in the role since 9/13/22 and was not aware of exactly how to conduct monthly reconciling of physician order and relied on the MDS C to help him with that task. Interim DON said he was not aware Resident #20's midodrine was administered when the blood pressure was not taken. Interim DON said the order should have had parameters of when to hold and stated it is important to follow the parameters the doctor has set to avoid any adverse reactions like stroke symptoms of hypertension. Interim DON said the person giving the medication was responsible for checking parameters before giving the medication and documenting the reading on the MAR. During an interview on 10/19/22 at 4:00 p.m., MDS C said she did not know how it(Midodrine parameters) got missed that Resident #20 did not have parameters for her midodrine. She stated the Nursing Administration is responsible of monitoring documentation related to administering medications. MDS C said she has been helping the Interim DON reconcile monthly orders looking for parameters and monitoring documentation by looking a MARs for anything that is missing from the MAR or orders. MDS C stated she did this by looking daily at the order summary report for new orders and checking to see if the order was put in correctly and documentation was there. MDS C said not checking the blood pressure before taking midodrine puts the resident at risk for stroke and higher blood pressure. Record Review of Drugs.com at https://www.drugs.com/mtm/midodrine.html on 10/20/22 indicated . Midodrine hydrochloride is a vasopressor/antihypotensive. Administration of Midodrine hydrochloride results in a rise in standing, sitting, and supine systolic and diastolic blood pressure in patients with orthostatic hypotension of various etiologies . Record review of the facility's policy revised dated April 2019, titled Administering Medications: Medications are administered in a safe and timely manner and as prescribed . 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions . 11. The following information is checked/verified for each resident prior to administering mediations: . b. Vital signs, if necessary . 676055 Page 6 of 6