Health inspection·November 22, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 received care, consistent with professional standards of practice, to prevent pressure ulcers for one of three residents (Resident #1) reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #1 was turned or repositioned for 12 hours the night of 11/21/23 to the morning of 11/22/23. This failure placed residents at risk of developing avoidable pressure ulcers, pain, and infection. Findings included: Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of multiple sclerosis (a disease that affects central nervous system making it difficult for the brain to send signals to rest of the body), paraplegia (paralysis of the legs and lower body), muscle weakness, need for assistance with personal care, joint contracture (condition in which a joint becomes very stuff and has limited movement), dementia, muscle wasting and atrophy, lack of coordination, malaise (feeling uncomfortable, ill or lack of energy), and bed confinement status. Review of the quarterly MDS assessment for Resident #1 dated 08/26/23 reflected a BIMS score of 13, indicating an intact cognitive response. The section that assessed for functional status reflected that she required the extensive assistance of two people during bed mobility (how resident moved to and from lying position, turned side to side, and positioned body while in bed or alternate sleep furniture). Review of the care plan for Resident #1 with a target date of 02/10/24 reflected the following: I have an ADL self-care performance deficits r/t MS, paraplegia, PVD, and polyosteoarthritis (when five or more joints are affected with joint pain). BED MOBILITY: the resident requires extensive assistance to turn and position in bed. Resident needs weight-bearing assistance most of the time. May need additional assistance at times. Encourage resident to ask for and provide assistance to turn and position every two hours and PRN comfort. Provide verbal queue and simple 1-2 steps instructions as needed. The care plan also reflected the following: I have a potential for pressure ulcer development and impaired skin. Integrity related to immobility, incontinence, and staff assistance with all ADLs. I will have intact skin free of redness, blisters, or discoloration through review date. Follow facility protocols for the prevention/treatment of skin breakdown. I need assistance to Page 1 of 4 676093 676093 11/22/2023 Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567

F 0686 turn/reposition at least every two hours, more often as needed or requested. Level of Harm - Minimal harm or potential for actual harm Review of video camera footage from Resident #1's AEM from 06:00 PM on 11/21/23 to 06:00 AM on 11/22/23 reflected Resident #1 was not repositioned after 06:24 PM until her private caregiver arrived at 06:55 AM. Residents Affected - Few Review of CNA-documented bed mobility for Resident #1 from 10/23/23 through 11/22/23 reflected it was documented once per day on 10/24/23, 10/28/23, 10/29/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/08/23, 11/09/23, 11/11/23, 11/12/23, 11/14/23, and 11/18/23; twice on 10/23/24, 10/27/23, 11/07/23, 11/10/23, 11/15/23, 11/16/23, 11/17/23, 11/19/23, and 11/20/23; and three times on 11/13/23. During an interview on 11/21/23 at 10:40 AM, the PCG for Resident #1 stated the staff did not turn Resident #1 at night. The PCG stated Resident #1 had some blisters that the PCP had told them were the result of an autoimmune response, but there was no actual skin breakdown or pressure ulcers. She stated Resident #1 did not move on her own at all and completely relied on assistance to reposition. She stated Resident #1 was not feeling well that day and had not been waking up at all to interact, but she could assist in revealing the skin on Resident #1's back and arms. Observation on 11/21/23 at 10:50 AM revealed Resident #1 had creases on the skin on her back and the backs of her arms from an impression of the cloth of her nightgown but no signs of skin breakdown or maceration and no rashes or pressure ulcers. There were five areas that were healing, previously-ruptured blisters, none of which had any redness, irritation, or drainage and were nearly resolved. Her brief was dry with no leakage or unpleasant odor emanating from within. During an interview on 11/20/23 at 03:07 PM, the PCP for Resident #1 stated Resident #1 could not move on her own and was completely reliant on staff to position her due to the advanced state of her multiple sclerosis. The PCP stated Resident #1 had no pressure ulcers or skin breakdown. The PCP stated she had done an exam on Resident #20 the day before and had looked at the blisters on the back of her left arm and trunk. The PCP stated the blisters were not pressure-related, moisture-related, or the sign of skin breakdown. The PCP stated she was still trying to determine the etiology of the blisters but was monitoring them and the facility had been instructed to take a culture as soon as a new blister emerged. The PCP stated she had no concerns about skin breakdown or other neglect of Resident #1. During an interview on 11/22/23 at 05:55 AM, CNA A stated she and her colleague tried to reposition Resident #1 every two hours during the overnight shift and sometimes sooner if she said she was uncomfortable. CNA A stated her colleague was the primary person to work with Resident #1, but she helped with the repositioning sometimes. During an interview on 11/22/23 at 06:12 AM, CNA B stated she turned/repositioned Resident #1 every two hours during her shift, which was from 06:00 PM to 06:00 AM. CNA B stated she always had time to reposition her that frequently, because there were always two aides in the secure unit where Resident #1 lived. During an interview on 11/22/23 at 07:04 AM, the PCG for Resident #1 stated she had already seen on the AEM that Resident #1 had not been repositioned since the overnight CNA came in and repositioned her at 06:24 PM. The PCG stated the camera did not film constantly but was activated when there was movement or sound in the room and recorded as long as movement or sound was occurring. She stated 676093 Page 2 of 4 676093 11/22/2023 Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no video that showed Resident #1 being repositioned, and the wedge pillow was in exactly the same place where it was put during the repositioning at 06:24 PM. She stated the video camera on the AEM was very sensitive and activated with the slightest sound or movement. Observation on 11/22/23 at 07:05 AM of a dry erase board on Resident #1's bedside wall revealed CNA B had noted she turned Resident #1 at 06:30 PM, 09:30 PM, and 12:30 AM. Resident #1 was in the same position in which she had been seen in the video recorded at 06:24 PM the night before, 11/21/23. During an interview on 11/22/23 at 07:16 AM, the DON stated it was her expectation that immobile residents be repositioned every two hours at least and as needed. She stated she was not sure how often the CNAs documented repositioning, but she could tell by looking that there were gaps in the documentation, but it also looked like the CNAs were only documenting each shift at the most. The DON stated she expected the CNAs to document every time they repositioned. The DON stated the point of care documentation did not reflect any repositioning completed during the night shift 11/21/23 to 11/22/23. The DON stated the nurses should have monitored for repositioning, and they were responsible for overseeing to ensure it happened according to their policies. She stated a potential negative outcome for not repositioning an immobile resident was skin breakdown and pressure ulcers. During an interview on 11/22/23 at 07:31 AM, the ADM stated residents should have been repositioned every two hours to avoid skin breakdown and bedsores. He stated it was also an important aspect of quality of life for residents because they needed to be touched. The ADM stated the overnight CNAs claimed they had repositioned Resident #1 throughout the night, and he watched videos of them going into the rooms several times throughout the night. He stated the videos did not show what they did inside the rooms. The ADM stated the facility had no residents with facility-acquired pressure ulcers, and that was evidence that the staff was repositioning them frequently enough. Review of facility in-services from September 2023 to November 2023 reflected an in-service conducted on 10/23/23 about pressure injury prevention and management. Review of facility policy dated 01/01/23 and titled Turning and Repositioning reflected the following: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for returning and repositioning. Policy explanation and compliance guidelines: 1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. In this case, small shifts and repositioning will be employed. 2. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning. 3. A routine turn schedule includes using both sideline and back positions, alternating from the right, back, and left side. It also includes assisting the resident to stand or making small shifts of position in chair. A resident's condition will determine whether or not a specialized turn schedule is warranted. 676093 Page 3 of 4 676093 11/22/2023 Rockdale Estates & Rehabilitation 1350 W. Highway 79 Rockdale, TX 76567

F 0686 4. The frequency of turning and repositioning will be documented in the resident's plan of care, and will be determined by the resident's: Level of Harm - Minimal harm or potential for actual harm A. Tissue tolerance Residents Affected - Few B. Level of activity and mobility C. Skin condition D. Overall medical condition E. Treatment goals. F. Type of pressure read distribution support surface and use (turning and positioning is still required on specialty surfaces, but frequency may be reduced) G. Comfort levels H. Resident preferences. 676093 Page 4 of 4