Health inspection·August 11, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Residents have the right to formulate an advance directive for 1 of 9 resident (Resident # 73) reviewed for advanced directive in that: The facility failed to have the physician's signature recorded on the Out of Hospital Do Not Resuscitate (OOHDNR), which made the advanced directive invalid. This deficient practice could place residents at risk of not having their wishes known, which could affect whether they receive emergency medical treatment. Findings: Record review of Resident #73 face sheet, dated 08/10/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to the following: cerebral infarction (stroke) due to unspecified to occlusion or stenosis of right middle cerebral artery, acute respiratory failure with hypoxia, type 2 diabetes (high blood sugar), hyperlipidemia (high cholesterol), pneumonia, dysphagia following a cerebral infarction, muscle wasting and atrophy, lack of coordination, and aphasia (loss of ability to understand or express speech, caused by brain damage). Record Review of Resident #73's care plan with a print date of 08/10/2023 revealed a DNR status, additional review of the Resident's chart revealed an incomplete DNR signed on 06/29/2023 by spouse and on 06/30/2023 by two witnesses, (one unidentified in relationship to the Resident and the second signature was that of the Social Services Director. The OOHDNR was not signed by a physician. Record Review of the facility order summary report with a print date of 08/10/2023 revealed an active DNR (Do Not Resuscitate Order) dated 06/29/2023. Interview on 08/10/2023 at 3:57 p.m. with the Social Services Director, revealed the Social Services Director was aware Resident # 73's OOHDNR had not been signed by the physician. The Social Services Director, stated the OOHDNR must be signed by a physician for a OOHDNR to be valid, I was told by the corporate social worker that if we have the family's signature or POA on the OOHDNR form and a doctor's verbal order then the patient is considered a DNR, I present the OOH DNR's to the physician however sometimes it takes a while to get them back even with multiple follow ups requesting the document, it should be signed and in the EHR but it is not. Program, updated 12/2020, accessed 08/22/2023 revealed, Out-of-Hospital Do-Not-Resuscitate Form Page 1 of 10 676133 676133 08/11/2023 Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852

F 0578 Level of Harm - Minimal harm or potential for actual harm section D requires the patient's attending physician to sign and date the form, print or type his/her name and give his/her license number. No policy was provided regarding OOHDNR's prior to exit. Residents Affected - Few 676133 Page 2 of 10 676133 08/11/2023 Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that its activities program was directed by a qualified professional. Residents Affected - Some The Activity Director was not currently qualified to direct the activities program. This failure could result in not meeting the assessed activity needs of each resident. The findings were: Review of the staff roster on 08/11/2022 revealed the current Activity Directors hire date was 09/25/2015. Interview on 08/11/2023 at 03:25 p.m. with the Activity Director revealed the Activity Director had been in the current position since January 2022, stating I was the Activity Assistant before, when the Activity Director left I took over the position. The Activity Director stated, I am not a certified Activity Director, I haven't had any classes, they haven't ever told me that I need a certificate or anything, I do good at my job, and I don't think I need any training . The Activity Director further stated, if I need help I just as the Regional Nurse. Interview on 08/11/2023 at 03:29 p.m. the Interim Administrator stated, the facility does not have a certified activity director, I am aware it is a deficiency. The Interim Administrator further stated, I have been here a short period and I was unaware the Activity Director was not certified, I am aware that is a requirement. 676133 Page 3 of 10 676133 08/11/2023 Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 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 for 1 or 2 residents (#73). Residents Affected - Few Resident #73's oxygens was administered at 2 Liters Per Minutes instead of 1 Liter Per Minute via nasal cannula as ordered by the physician. This deficient practice could affect 2 residents who received oxygen continuously and result in residents receiving incorrect or inadequate oxygen support and could result in decline in health. The findings were: Record review of Resident #73 face sheet, dated 08/10/2023, revealed the resident was admitted the facility on 06/29/2023 with diagnoses that included but not limited to the following: cerebral infarction due to unspecified to occlusion or stenosis of right middle cerebral artery, acute respiratory failure with hypoxia, type 2 diabetes (high blood sugar), hyperlipidemia (high cholesterol), pneumonia, dysphagia following a cerebral infarction, muscle wasting and atrophy, lack of coordination, and aphasia (loss of ability to understand or express speech, caused by brain damage). Record of review of Resident #72's August 2023 Order Summary Report revealed Resident #73 ordered Oxygen at 1 L in Place Connected, originally ordered on July 25, 2023. Observation on 08/10/2023 at 11:34 a.m. of Resident #73 revealed she was lying in bed with the oxygen concentrator was turned on and was being worn by the Resident while she was lying in the bed oxygen administered at 2 liters per minute instead of 1 liter per minute. Interview and Observation with LVN C at 08/10/2023 at 11:40 a.m. revealed Resident #73 was lying in bed while wearing the nasal canula and utilizing the oxygen at 2 liters per minute. LVN stated, it is my responsibility to make sure the oxygen was set at 1 liter per minute as directed by the doctor's order and it was not at that time. LVN C said she did not think there were any negative consequences for Resident's oxygen being set at 2 liters per minute but would let the DON know to make sure. Interview with Interim DON, on 08/10/2023 at 3:23 p.m., the DON stated, staff made me aware Resident #73 was receiving Oxygen at 2 liters per minute and the physician's order indicated the oxygen was to be administered at 1 liter per minute. The Interim DON, further stated, The physician's order should have been followed but I do not think it had any negative effect on the Resident in my opinion. When asked for a policy during this interview, the Interim DON stated she was not sure if there was a policy for oxygen administration, that is a general nursing practice to follow physician orders. 676133 Page 4 of 10 676133 08/11/2023 Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #44) reviewed for dialysis in that: Residents Affected - Some The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #44. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of Resident #44's face sheet, dated 8/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] and 7/17/23 with diagnoses that included hypoglycemia (low blood sugar), hyperlipidemia (elevated cholesterol), cognitive communication deficit, end stage renal disease (condition in which the kidneys cease functioning on a permanent basis) and dependence on renal dialysis. Record review of Resident #44's most recent admission MDS assessment, dated 7/19/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required dialysis treatments. Record review of Resident #44's comprehensive care plan, revision date 7/11/23 revealed the resident had end stage renal disease and was provided dialysis on Tuesday, Thursday, and Saturday. Record review of Resident #44's Order Summary Report, dated 8/11/23 revealed the following: -Dialysis provided Tuesday, Thursday, and Saturday at 6:00 a.m. with order date 7/19/23 and no end date. Record review of Resident #44's Dialysis Communication Form, Resident Assessment and Observation Post-Dialysis revealed incomplete documentation by the facility for 7/20/23, 8/5/23 and 8/8/23. The Post-Dialysis section of the Dialysis Communication form for the aforementioned dates were blank. The facility failed to provide Daily Communication Forms for Resident #44 for the following dates: 7/18/23, 7/22/23, 7/25/23, 7/27/23, 7/29/23, 8/3/23 and 8/10/23 During an interview on 8/11/23 at 10:42 a.m., ADON A revealed Resident #44 received dialysis treatments on Tuesdays, Thursdays, and Saturdays. ADON A further revealed, the facility provided the Dialysis Communication Form to the dialysis clinic and the form was given to the transportation driver or to the resident if the resident was competent. ADON A revealed it was the facility nurse's responsibility to ensure the Dialysis Communication Form's top portion was completed by the facility nurse prior to dialysis and the middle portion was filled out by the dialysis staff. ADON A revealed, after the resident returned from dialysis, the facility nurse was supposed to fill out the bottom portion, Resident Assessment and Observation Post-Dialysis section of the Dialysis Communication Form. ADON 676133 Page 5 of 10 676133 08/11/2023 Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A revealed it was important the Dialysis Communication Forms were completed and filed because Resident #44 needed to be monitored for possible adverse effects from dialysis treatments. During an interview on 8/11/23 at 11:01 a.m., LVN B revealed Resident #44 received dialysis treatments on Tuesdays, Thursdays, and Saturdays. LVN B revealed, the facility nursing staff were responsible for completing the top portion of the Dialysis Communication Form, the dialysis clinic staff were responsible for completing the middle portion of the Dialysis Communication Form and upon return to the facility, the facility nurse was supposed to complete the bottom portion, Resident Assessment and Observation Post-Dialysis section of the Dialysis Communication Form. LVN B revealed, once the Dialysis Communication Form was completed, it was placed in a file bin at the nurse's station where the medical records clerk picked it up and uploaded it into the resident's electronic record. During an observation and interview on 8/11/23 at 1:23 p.m., Resident #44 revealed she received dialysis treatments on Tuesdays, Thursdays and Saturdays and had last been to the dialysis clinic on Thursday, 8/10/23. Resident #44 revealed the area on the right upper arm was the access for dialysis treatments. Resident #44 revealed she was not aware of any paperwork when she went to the dialysis clinic. During a follow up interview on 8/11/23 at 1:31 p.m., LVN B revealed she had completed a general assessment of Resident #44 when she returned from her dialysis treatment on Thursday, 8/10/23. LVN B revealed she had obtained Resident #44's vital signs, wrote them down on a piece of paper, but did not document the results in the electronic record. LVN B revealed Resident #44 was provided with the Dialysis Communication Form, but the resident did not come back with the form on 8/10/23. LVN B stated, we were pretty busy, and when Resident #44 came back from dialysis I did the general head to toe (assessment), Resident #44 looked stable and comfortable, then we got real busy and the (Dialysis Communication Form) was overlooked. During an interview on 8/11/23 at 1:43 p.m., the Interim DON revealed it was the expectation of the facility nurses to ensure the Dialysis Communication Forms were completed because we gotta know if something happened to the resident while at dialysis. Record review of the facility policy and procedure titled, Hemodialysis, revision date 7/2015 revealed in part, .Purpose .Hemodialysis devices may only be accessed by the dialysis center by medical personnel who have received training and demonstrated clinical competency regarding use of these devices .Documentation .The general medical nurse should document in the resident's medical record as follows .4. Any pertinent information from dialysis nurse post-dialysis being given .5. Observations post-dialysis . 676133 Page 6 of 10 676133 08/11/2023 Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 for at least 8 consecutive hours a day, 7 days a week, on 5 days during the look back period from April 1, 2023, to August 8, 2023 (99 calendar days). The facility failed to maintain RN coverage on: April 1,2023, April 2, 2023, April 5, 2023, May 12, 2023, and May 13, 2023. This failure could affect all 82 residents of the facility by placing them at risk for not having their nursing and medical needs met. Findings included: Review of the 'Timecard Review (Department Report)' for all of the facility's RNs from 04/01/2023 08/08/2023 revealed there was no RN coverage on the following dates: April 1, 2023 April 2, 2023 April 5, 2023 May 12, 2023 May 13, 2023 During an interview on 08/11/2023 at 8:38 a.m. the Interim Administrator stated, I began my employment at this facility on July 13, 2023, I was not here on any of the days reported as not having the required RN coverage, I did check with the Regional Nursing Consultant to make sure she was not in the building and she was not. I have not been able to find any information to support there was an RN in the building for 8 hours on April 2, April 5, or May 13 of 2023. All of the information I have researched shows there was not 8 hours of RN coverage on those days. I am aware that is a requirement, however I do not feel that affected resident care because there were qualified staff in the building and the Regional Consultant was on call for the facility in case, they needed her assistance. Review of the form CMS-672 dated 08/07/2023 revealed a census of 82 residents. 676133 Page 7 of 10 676133 08/11/2023 Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852

F 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 18 residents (Resident #55 and #64) reviewed for infection control practices, in that: Residents Affected - Few During the medication pass, LVN B: -placed clean gloves in her pocket -did not perform hand hygiene prior to care and between glove changes -did not sanitize the digital wrist blood pressure cuff between resident use These failures could place residents at risk for infection, transmission for communicable diseases and/or a decline in health. The findings included: 1. Record review of Resident # 55's face sheet, dated 8/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included muscle wasting and atrophy (wasting or thinning of muscle mass), hypertension (high blood pressure), hyperlipidemia (elevated cholesterol) and gastrostomy status (a tube inserted through the wall of the stomach; can be used to give drugs and liquids.). Record review of Resident #55's most recent quarterly MDS assessment, dated 6/29/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and required a feeding tube. Record review of Resident #55's comprehensive care plan, revision date 8/9/23 revealed the resident had impaired tissue perfusion (lack of oxygenated blood flow to areas of the body) related to hypertension with interventions that included to administer anti-hypertensive medications as ordered and to monitor for side effects of medication and the resident was at risk for narrowing of arteries related to hyperlipidemia with interventions that included to give all cardiac medications as ordered by the physician and to monitor blood pressure. 2. Record review of Resident #64's face sheet, dated 8/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hyperlipidemia (elevated cholesterol), hypertension (high blood pressure), muscle wasting and lack of coordination. Record review of Resident #64's most recent quarterly MDS assessment, dated 5/9/23 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #64's comprehensive care plan, revision date 5/16/23 revealed the resident had hypertension related to lifestyle choices with interventions that included to administer anti-hypertensive medications as ordered and to monitor for side effects and effectiveness. 676133 Page 8 of 10 676133 08/11/2023 Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 8/10/23 at 7:24 a.m., during the medication pass revealed LVN B took a digital wrist blood pressure cuff from the medication cart and took several disposable gloves from the glove box and placed the gloves in her pocket. LVN B then went into Resident #55's room, took out a pair of gloves from her pocket and put them on without performing hand hygiene. LVN B then obtained Resident #55's blood pressure with the digital wrist blood pressure cuff. LVN B, after obtaining Resident #55's blood pressure and after checking Resident #55's feeding tube, washed her hands and returned to the medication cart. LVN B then prepared Resident #55's medications by crushing each medication and returned to Resident #55's bedside. LVN B then removed a pair of gloves from her pocket and put them on without performing hand hygiene. LVN B, after completing medication pass to Resident #55 was summoned to Resident #64's room because the resident had been complaining of pain. LVN B took the digital wrist blood pressure cuff used on Resident #55, did not sanitize the digital wrist blood pressure cuff, and obtained Resident #64's blood pressure. During an interview on 8/10/23 at 10:46 a.m., LVN B revealed the digital wrist blood pressure cuff was her own personal blood pressure cuff and the only one used during the shift. LVN B revealed she realized after she was made aware by the surveyor that she had not been performing hand hygiene between glove changes and putting the gloves in her pocket could potentially result in cross contamination and was considered an infection control issue. LVN B stated, it is cross contamination, and the resident could get sick. LVN B revealed she had forgotten to sanitize the digital wrist blood pressure cuff between Resident #55 and Resident #64 and stated, that is also cross contamination, and I could be passing an infection from one resident to the other. During an interview on 8/10/23 at 3:43 p.m., the Interim DON revealed, staff must wash or sanitize hands between glove changes because you don't know what's in your hands and what if that glove breaks. What if you coughed in your hand, your hands brushed up against something and it could be passed to the resident and cause them to become ill. The Agency DON revealed it was not good nursing practice to place gloves in pockets. The Agency DON revealed, no hand hygiene between gloves changes, putting gloves in pockets and not sanitizing the blood pressure cuff between residents was considered an infection control issue and cross contamination. Record review of the competency training for LVN B, dated 5/2/23 revealed LVN B had satisfied the requirements for hand hygiene and infection control procedures. Record review of the facility policy and procedure titled, Hand Hygiene, date implemented 10/24/22 revealed in part, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .This applies to all staff working in all locations within the facility .Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub .The use of gloves does not replace hand hygiene .If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Record review of the facility policy and procedure titled, Infection Prevention and Control Program, date implemented 5/13/23 revealed in part, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services .All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and 676133 Page 9 of 10 676133 08/11/2023 Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852

F 0880 sterilization of soiled or contaminated equipment . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676133 Page 10 of 10