Health inspection·June 28, 2023

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 4 of 4 months reviewed. (January 2023, February 2023, March 2023, and June 2023) The facility did not have the required 8 consecutive hours of RN coverage during the months of January 2023 (4 days), February 2023 (2 days), March 2023 (2 days), and June 2023 (3 days). This failure could place residents at risk for not having their nursing care and medical needs met. Findings include: Record review of the January 2023 time sheets indicated no RN worked on Monday 01/02/23, Sunday 01/15/23, Monday 01/16/23 and Tuesday 01/17/2023. Record review of the February 2023 time sheets indicated no RN worked on Saturday 02/04/2023 and Sunday 02/19/2023. Record review of the March 2023 time sheets indicated no RN worked on Tuesday 03/14/2023 and Saturday 03/25/2023. Record review of the June 2023 time sheets indicated no RN worked on Saturday 06/10/2023, Sunday 06/11/2023, and Saturday 06/24/2023. During an interview on 06/28/2023 at 10:30 AM with the DON, she said she tried to cover any days that she did not have an RN charge nurse. During an interview on 06/28/2023 at 10:40 AM with the BOM, she said she reviewed the time sheets of the DON for the months of January, February, March, and June of 2023 and said the DON did not work on any of the days in question. During an interview on 06/28/2023 at 11:30 AM with the ADON, she said the DON made the nursing schedule. She said the facility has a daily nursing stand-up meeting but have not been reviewing RN nursing coverage needs during that meeting. During an interview on 06/28/2023 at 11:40 AM with the ADM, said the facility has a scheduler, which was the DON, to ensure RN coverage requirements were met and a system where staff can pick up open Page 1 of 3 676072 676072 06/28/2023 Corrigan Ltc Nursing & Rehabilitation 300 Hyde St Corrigan, TX 75939

F 0727 shifts. Level of Harm - Minimal harm or potential for actual harm A review of the facility's undated policy titled Staffing indicated the facility has an RN available for coverage 8 hours a day, 7 days a week. Residents Affected - Some 676072 Page 2 of 3 676072 06/28/2023 Corrigan Ltc Nursing & Rehabilitation 300 Hyde St Corrigan, TX 75939

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that the facility's Medical Director attended the Quality Assessment and Assurance/Quality Assurance and Performance Improvement Committee meetings, for 2 of 2 quarterly meetings (April, May, June 2022 and July, August, September 2022), reviewed for QAA/QAPI. Residents Affected - Some The facility failed to ensure the Medical Director attended their QAA and QAPI meetings for the months of April 2022 through September 2022. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented, and no appropriate guidance developed. Findings included: Review of the facility's QAA/QAPI meeting signature logs for the months of April 2022 through September 2022, revealed the Medical Director had not attended any of the meetings for the QAA/QAPI Committee, during those months. There were no notation indicating the Medical Director had attended any of the meetings by telephone or zoom. During an interview on 06/28/2023 at 1:35 PM, the Administrator said the QAA/QAIP met monthly, but no less than once per quarter. She said she realized the Medical Director was not in attendance for the QAA/QAIP meetings for the months of April 2022 through September 2022, but she could not say why he was not in attendance. She said she was not the Administrator at that time, she became the Administrator in February 2023 and could not speak to anything prior to that. She said there was no indication the Medical Director had attended any of the meetings between April 2022 and September 2022, by telephone or zoom. Review of the facility's Quality Assurance and Performance Improvement (QAPI Program - Governance Leadership (revised March 2020) revealed, Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI Plan that is focused on indicators of the outcomes of care and quality of life for our residents. Governance and Leadership: 1. The Administrator, weather a member of the QAPI Committee or not, is ultimately responsible for the QAPI Program . 6. The following individuals serve on the committee: Administrator, DON, Medical Director, Infection Preventionist and representative from various departments . 7. The committee meets at least quarterly . 676072 Page 3 of 3