Health inspection·May 9, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident, for 1 of 6 residents (Residents #2) reviewed for baseline care plan, The facility failed to ensure Resident #2's baseline care plan included information related to the resident's full code status and the use of a Hoyer lift. This failure could affect newly admitted residents and place them at risk of not receiving appropriate interventions to meet their current needs and communication among nursing home staff to ensure their immediate care needs were met. The findings included: Record review of Resident #2 ' s face sheet, dated [DATE] revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Acquired Absence of Right Leg above Knee, Orthopedic aftercare following Surgical Amputation, End Stage Renal Disease (kidney failure), Dependence on Renal Dialysis, Malignant Neoplasm of Pancreas (Caner in the Pancreas), Type 2 Diabetes Mellitus without Complications, Hypertension (high blood pressure), Liver Cell Carcinoma (Liver Cancer), Other Acute Osteomyelitis (inflammation in the bone) Right Ankle and Foot, and Muscle wasting and Atrophy. Record review of Resident #2 ' s MDS Record dated [DATE] revealed Resident #2 had a BIM Score of 13 indicating cognition was intact. Record review of Resident #2 ' s physician order summary dated [DATE] revealed CPR (Full Code) order date [DATE]. Record review of Resident #2 ' s care plan reviewed on [DATE] revealed that there was no code status or hoyer lift on the baseline care plan available. In an interview on [DATE] at 01:36pm with LVN H stated when a resident comes from the hospital, the hospital would send the orders and it would have the code status. The social worker will then go in and confirm with the resident/family of status. The social worker would then input the order into the computer. LVN H stated that she would look in the computer at the top of the resident ' s chart, in the binder on the crash cart, and in the care plan. She stated MDS was responsible for entering Page 1 of 6 676125 676125 05/09/2024 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the hoyer lift in the baseline care plan. Resident #2 used a hoyer lift, but therapy would help at times with the sliding board. In an interview on [DATE] at 01:49pm Social Services stated that the nurses get the physician orders. She then speaks to the resident and/ or family, whoever was the responsible party, to confirm code status, and get the required signatures. She was responsible for entering the code status in the care plan. She does her own audits. She does not know why the code status was not entered in the baseline care plan. In an interview on [DATE] at 02:02pm CNA I stated Resident #2 used a hoyer lift. She stated the nurse would tell them how residents transfer, if not they look in the computer in the [NAME]. In an interview on [DATE] at 02:06pm MDS J stated that he was not responsible for the baseline care plans. He was responsible for the comprehensive care plans. He over looks the initial baseline care plan. If something was missing, then he corrected it. In an interview on [DATE] at 02:11pm the DON stated that the person responsible for entering code status in the baseline care plan was social services. She stated this was entered immediately. The DON stated the negative outcome of not developing a baseline care plan for the code status was that staff would not be following the resident ' s rights whether a full code or DNR. She stated the hoyer lift needed to be in the baseline care plan because that was how staff communicate and care for the residents amongst themselves. Record review of the facility's policy titled, Baseline Care Plan date Reviewed/Revised [DATE], reflected, Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders 2.The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. b. Interventions shall be initiated that address the resident ' s current needs including: 676125 Page 2 of 6 676125 05/09/2024 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0655 Level of Harm - Minimal harm or potential for actual harm i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. Residents Affected - Few 676125 Page 3 of 6 676125 05/09/2024 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1), reviewed for care plans. Resident #1's comprehensive care plan dated 01/24/2024 incorrectly indicated she was a dialysis patient. The facility failed to ensure Resident #1's comprehensive care plan dated 01/24/2024 indicated she required a mechanical lift to transfer to and from bed. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. The Findings included: Record review of Resident #1's face sheet dated 05/06/2024 revealed the resident was a [AGE] year-old female with an admission date of 02/21/2024, an initial admission date of 01/24/2024 and an original admission date of 12/31/2019. Resident #1's relevant diagnoses included: infection and inflammatory reaction due to internal right knee prostheses, sepsis, pain in right knee, abnormalities of gait and mobility, need for assistance with personal care, acute embolism (a blocked in an artery caused by blood clots or other substance), thrombosis of deep veins of right lower extremity, and presence of right artificial knee joint. Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 08 indicating moderately impaired cognition. The MDS also reflected Resident #1 required partial/moderate assistance with chair/bed-to-chair transfer. Record review of Resident #1's comprehensive care plan dated 01/24/2024 revealed: Problem: [Resident #1] needs hemodialysis r/t acute renal failure, dated 01/24/2024, revised on 02/09/2024. Interventions: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, and Friday 10:30am. Date Initiated: 01/24/2024, revision on: 02/09/2024. Problem: [Resident #1] has an ADL self-care performance deficit r/t metabolic encephalopathy. Date initiated 01/24/2024 and revised on 02/09/2024. Interventions: Functional Performance: chair/bed-to-transfer: [Resident #1] requires substantial/maximal assistance to transfer to and from a bed to a chair (wheelchair). Date initiated/revised: 02/09/2024. 676125 Page 4 of 6 676125 05/09/2024 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation on 05/06/2024 at 8:40 a.m., Resident #1 was observed lying in bed. Her bed was set to the lowest position and her call light within reach. An interview on 05/06/2024 at 8:45 a.m., Resident #1 said she had not received dialysis since she was admitted on 01/2024. She said she had been a dialysis patient before prior to 01/2024. She said her doctor told her she no longer needed dialysis because her lab results were good. Resident #1 said she had right knee surgery sometime in 2020 and was admitted to the facility for therapy at that time. She said after she received physical therapy she was allowed to be discharged back home. Resident #1 said she ended up being re-admitted this year because she had no one to care for her and she had sustained several falls at home causing her to reinjure her right knee. She said since her most recent admission, she required a hoyer lift to be transferred to and from the bed because she was not able to bear weight on her knee. She said her knee swells and was in constant pain, requiring pain medication. An interview on 05/06/2024 at 1:07 p.m., CNA A said Resident #1 was not a dialysis patient. She said Resident #1 was a 2- person assist for transfer and required a mechanical lift for transfers to and from the bed because she was not able to bear weight on her right leg. CNA A said she knew Resident #1 required to be transferred with a mechanical lift to and from the bed because she had been told by her charge nurse regularly. An interview on 05/07/2024 at 1:20 p.m. CNA B stated Resident #1 was not a dialysis patient. She said Resident #1 was a 2 person assist for transfer and required a mechanical lift for transfers to and from the bed because she was not able to bear weight on her right leg. CNA B said she knew Resident #1 required to be transferred with a mechanical lift to and from the bed because she had been told by her charge nurse regularly. An interview on 05/07/2024 at 1:41 p.m., CNA C said Resident #1 was not a dialysis patient. She said Resident #1 was a 2 person assist for transfer and required a mechanical lift for transfers to and from the bed because she was not able to bear weight on her right leg. CNA C said she knew Resident #1 required to be transferred with a mechanical lift to and from the bed because she had been told by her charge nurse regularly. An interview on 05/07/2024 at 2:01 p.m., LVN D stated Resident #1 was not a dialysis patient. She said Resident #1 was on pain medication for her right knee pain. She said Resident #1 required a hoyer lift to be transferred to and from the bed because she was not able to assist with transfers and due to right knee pain. She said at the end of their shift, the Charge nurses would notify incoming charge nurse of the resident's needs and they would relay that information to the CNA's. An interview on 05/08/2024 at 10:57 a.m., RN E said Resident #1 was not a dialysis patient. She said Resident #1 was on pain medication due to having chronic pain to her right knee. She said she also required a hoyer lift for transfers to and from the bed. She said at the end of their shift, the Charge Nurse's would notify incoming charge nurse of each resident's needs and they would relay that information to the CNA's. An interview on 05/08/2024 at 1:55 p.m., LVN-MDS F said Resident #1 was not a dialysis patient. She said she corrected her care plan on 05/07/2024 and deleted that she was a dialysis patient. She said she did not know why Resident #1's care plan indicated she was a dialysis patient. LVN-MDS F stated she had also included on Resident #1's care plan that she required to be transferred with a mechanical lift. She said did not know when it had not been included in the past. She said there was no 676125 Page 5 of 6 676125 05/09/2024 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few negative outcome for Resident #1's care plan not included she required to be transferred by a hoyer lift because she was already being transferred by one. LVN-MDS said there was no negative outcome for Resident #1 having in her care plan that she was a dialysis patient (not able to say why). An interview on 05/08/2024 at 2:15 p.m., the DON stated when Resident #1 was re-admitted (from home) for the second time on 01/24/2024, she was pending lab results from her doctor to determine if she would need to continue dialysis. The DON said after her doctor read the results which was after her admission, he had decided Resident #1 no longer needed dialysis. The DON said that was the only explanation she had for Resident #1's care plan that indicated she was a dialysis patient. She said it should have been removed when it was determined Resident #1 no longer needed dialysis. The DON said the care plan was updated on 05/07/2024 and removed that she was a dialysis patient. The DON said Resident #1 had a bad surgery in December 2019 to her right knee. She said Resident #1 was admitted to the facility for therapy to her right knee and eventually was discharged to her residence. She said even though Resident #1's care plan did not indicate she required a mechanical lift to be transferred to and from the bed, staff were using a mechanical lift to transfer her because they were familiar with her right knee complications. The DON said there were no negative outcome for Resident #1's care plan not indicating she required a mechanical lift for transfer because she was still being transferred to and from with a hoyer lift. Record review of facility's Comprehensive Care Plan policy dated 10/24/22 reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the residence strengths and needs and will incorporate the residents personal and cultural preferences in developing goals of care. Service is provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 3. The comprehensive care plan will describe. At a minimum. The following: a) The services that are to be furnished to attain or maintain the residence highest practicable physical, mental, in psychosocial well-being. b) Any services that would otherwise be furnished but are not provided due to the residents exercise of his or her right to refuse treatment. 676125 Page 6 of 6