Health inspection·November 23, 2022

F 0641 Ensure each resident receives an accurate assessment. 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 assessments accurately reflected the residents' status for 1 of 7 residents (Resident #77) reviewed for accurate MDS assessments. Residents Affected - Few The facility failed to ensure Resident #77's MDS accurately reflected the resident's range of motion in upper and lower extremities. This failure could place residents at risk for not having individual needs identified, a decline in health status, and decreased feelings of well-being. The findings include: Record review of Resident #77's admission Record, dated 11/23/22, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #77 had diagnoses which included aphasia (loss of ability to understand or express speech caused by brain damage), cerebral hemorrhage (bleeding in the brain), high blood pressure, and dysphagia (inability to swallow). Record review of Resident #77's Quarterly MDS Assessment, dated 09/26/22, revealed she was assessed as having no impairment to range of motion in her upper extremities, and no impairment in range of motion in her lower extremities. Record review of Resident #77's care plan revealed documentation that the resident was at risk for contracture and had a goal of no contractures in the next 90 days. Interventions included assist with ADL's and mobility as needed, monitor for pain with ADL's and movement, monitor for stiffness of joints, range of motion per staff, reposition resident every 2 hours and as needed. In an interview on 11/21/22 at 3:43 PM, Resident #77's family member stated Resident #77 had contractures to her right and left arm, hands, her right and left foot and legs. In an interview and observation on 11/23/22 at 10:30 AM, Resident #77 was noted to have contractures to her upper and lower extremities. The ADON was present during the observation and stated Resident #77 had contractures to her upper and lower extremities. She stated it should have been documented in the EMR and it was the nurse's responsibility to ensure assessment findings were accurately documented. She stated she did not know why the resident contractures were not documented. In an interview on 11/22/22 at 11:00 AM, the DON stated she was aware of the contractures to the bilateral upper and lower extremities for Resident #77. She stated the person completing the MDS and the nurses were responsible for ensuring the EMR contained accurate information regarding the Page 1 of 9 676144 676144 11/23/2022 Senior Care Health & Rehabilitation Center - Wichi 910 Midwestern Pkwy Wichita Falls, TX 76302

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents' assessments. She stated the MDS assessment should reflect what the nurses observe, and this should be documented accurately in their medical record. In an interview on 07/07/22 at 4:05 PM, MDS Nurse B stated she did the MDS assessments for the Resident #77 and all the Medicaid and long-term care residents at the facility. She stated she needed to do a correction to the MDS for Resident #77 and document the contractures to her upper and lower extremities. She stated she was not aware the resident had limitations in Range of Motion in her upper and lower extremities. She stated she depended on the documentation by the nurses in the EMR to complete the MDS assessments. She stated the error occurred because she had looked in the medical record of Resident #77 and did not see any documentation of limited Range of Motion in the upper and lower extremities. Record review of the facility's, undated, policy Resident Assessment, stated: Purpose: To ensure consistent and accurate assessments of all residents. To identify resident strengths and potential areas of concern. Procedure: MDS Nurse will do an assessment on each resident within 14 days of initial admission, within 14 days of identified significant change per Health Care Financing Administration guidelines, and every 90 days thereafter using the quarterly MDS form. MDS Nurse will review resident record for further information and to locate supporting documentation. 676144 Page 2 of 9 676144 11/23/2022 Senior Care Health & Rehabilitation Center - Wichi 910 Midwestern Pkwy Wichita Falls, TX 76302

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failedto ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents needs, as identified through resident assessments, and described in the plan of care for 1of 3 staff (Medication Aide C) reviewed for competency and proficiency of nursing staff.: The facility failed to ensure Medication Aide C reported and elevated pulse rate when Resident #59 had an elevated pulse of 154. This failure could place residents at risk of adverse effects, or inadequate therapeutic effect of medications and a decline in health status. The findings were: Record review of Resident #'59's face sheet, dated 11/23/22, indicated a [AGE] year-old male with an admission date of 10/21/21. Resident #59 had diagnoses which included chronic respiratory failure with low blood oxygen, shortness of breath, atrial fibrillation (rapid irregular heart beat the commonly causes poor blood flow) heart failure, kidney failure, syncope, and collapse (a temporary loss of consciousness caused by a drop in blood pressure). Record review of Resident #59's significant change MDS, dated [DATE], indicated a BIMS of 11, which indicated mild to moderate cognitive impairment. Record review of Physician Orders for Resident #59, dated 11/21/22, indicated the following, metoprolol tartrate 25 mg 2 times a day PO (Hold if pulse is less than 60 and notify physician), diltiazem capsule extended release 24-hour/300 mg give one capsule one time a day for hypertension by mouth (if systolic blood pressure is less than a hundred or diastolic blood pressure is less than 50 hold and notify physician, or if systolic blood pressure is greater than 180 or diastolic blood pressure is greater than 110 notify a physician). Record review of Resident # 59's vital sign readings for the month of 11/22 revealed the residents pulse readings had ranged from 60 to 115 beats/minute. In an observation and interview on 11/22/22 at 7:30 AM, Resident #59 was sitting on the side of his bed . Medication Aide C administered medications to Resident #59. She obtained his blood pressure and pulse, using a wrist type blood pressure cuff. The resident's blood pressure was 113/65 and his pulse was 154. The resident stated to Medication Aide C he had just taken a breathing treatment earlier and maybe that was why his pulse was higher than normal. Medication Aide C administered the resident's medications and did not report the elevated pulse to the charge nurse. On 11/22/22 at 8:30 AM an interview with LVN D revealed Medication Aide C had not reported to her that Resident #59 had a pulse rate of 154 during his medication administration. She stated it was her expectation the medication aide reported any vital sign which was out of range ( normal pulse range 60-100). She stated CNAs were taught in their training of the abnormal signs and symptoms to report to a licensed nurse which included the normal range for a resident's pulse. She stated a pulse rate of 154 would be abnormal and she would expect the pulse to be reported to the chare nurse. She also 676144 Page 3 of 9 676144 11/23/2022 Senior Care Health & Rehabilitation Center - Wichi 910 Midwestern Pkwy Wichita Falls, TX 76302

F 0726 stated she would assess the resident if an abnormal pulse rate was reported to her. Level of Harm - Minimal harm or potential for actual harm In an interview on 11/22/22 at 8:40 AM LVN D stated that she had assessed the resident and pulse was regular and within normal limits. Residents Affected - Few During an interview the ADON on 11/23/22 at 8:35 AM, she said she would expect a pulse of 154 to be reported to the nurse. She stated Resident #59 had an unstable cardiac and respiratory status and he could go downhill quickly. She stated his pulse should be re-checked by the charge nurse an if it was still elevated it should be reported to his physician by the charge nurse. On 11/23/22 at 8:55 AM an interview with Medication Aide C revealed she did not report the elevated pulse of Resident #59 because the resident did not seem alarmed and stated he had just had a breathing treatment which might have caused his heart rate to increase. She stated there were low parameters for 2 of the medications but no instructions to report a pulse higher than a certain rate. She stated she would have reported a reading outside of the stated parameters if there had been a high parameter on the physician orders. She stated she had been trained to take a pulse in her training and to report abnormal readings but she though the pulse rate was higher because the resident said it was due to his breathing treatment. Record review of Medication Aide C's employee file revealed she had been observed for competency while administering medications on 07/06/22 and 11/17/22. The observation form revealed she had met the expectation of obtaining vital signs for residents with parameters before administering the medication. There was no documentation of training in recognizing abnormal pulse rates in the competency checks. The DON provided an employee corrective action form dated 11/23/22 which stated: [C.M.A.C] obtained vital signs per medication regimen requirements; resident pulse noted to be 154. CMA failed to directly relay abnormal pulse to Charge Nurse directly instead of relying on the EMR clinical alert to notify the charge nurse. Record review of the Texas Curriculum for Certified Nurse's Aides In Long Term Care Facilities published by Procedural Guideline for Manual Pulse: Locate the radial pulse by placing the tips of your first 3 fingers on the thumb side of the resident's wrist. Do not press hard. Count the pulse for one minute. Report to the nurse pulse rate below 60 or above 100/minute (normal is about 76 and regular). 676144 Page 4 of 9 676144 11/23/2022 Senior Care Health & Rehabilitation Center - Wichi 910 Midwestern Pkwy Wichita Falls, TX 76302

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 observation, interview and record review the facility failed to provide pharmaceutical services which included procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for Resident #121 reviewed for pharmaceutical services. 1. The facility failed to ensure LVN F administered medications to Resident #121 according to physician's orders. 2. The facility failed to ensure LVN-F did not leave Resident #121's medication with her at her bedside to take at a later time. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. The findings included: Record review of the Resident #121's face sheet, dated 11/21/22, revealed the resident was admitted to the facility on [DATE]. Her diagnoses included: Chronic Pulmonary Disease with Acute Exacerbation (chronic inflammatory lung disease that causes obstructed airflow flow the lungs), Pneumonia (fluid in the lungs), Acute/Chronic Respiratory Failure (inadequate gas exchange, lungs cannot get enough oxygen to the blood), Acute Pulmonary Edema (excessive liquid accumulation in the tissue and air space of the lungs) and shortness of breath. Record review of Resident #121's, physicians' orders, dated 11/22/22, documented an order for Budesonide Suspension 0.5 MG/2ML inhale orally two times a day for shortness of breath. In an observation and interview on 11/21/22 at 9:27 AM, Resident #121 was sitting up in her bed watching her television She stated earlier that morning LVN F went into her room and gave her morning nebulizer treatment but set it on her nightstand to take when she was finished eating. Resident #121's nebulizer was out, and medication was in the nebulizer cup for treatment. Treatment had not been done by the resident or LVN F. Resident stated the nurse always left her medicine for her to take when she was ready and she takes it after she ate her food Record review of the medication administration record revealed Resident #121's Budesonide Suspension 0.5 MG/2ML inhale orally two times a day for shortness of breath, was initialed as treatment being administered when the medication remained in the nebulizer machine at her bedside. In an interview on 11/21/22 at 9:40 AM with LVN F, who was assigned med pass during the observation, stated she left the medication for the resident to take after she was finished eating breakfast. She stated residents should be observed to ensure the medication was taken by the correct resident at the correct time. She stated the medication should not be documented as taken unless the nurse actually watched them take the medication. LVN F observed the medication was still in the nebulizer, and she discarded the medication. In an interview on 11/22/22 at 2:20 PM, the DON stated the person who administered the medication 676144 Page 5 of 9 676144 11/23/2022 Senior Care Health & Rehabilitation Center - Wichi 910 Midwestern Pkwy Wichita Falls, TX 76302

F 0755 Level of Harm - Minimal harm or potential for actual harm should always verify medication with the resident, date, time, and route with medication being given. When medication is given to a resident the nurse who provided the medications should always witness the medication taken by the resident for whom it was ordered and taken per the orders given. She stated the nurse was not a new nurse and was trained to watch and stay with the resident until the medication treatment was completed . Residents Affected - Few Record review of the facility policy statement on Administration of Drugs stated Proceed with cart to resident's room and identify the resident, read medication orders on medication sheet and have medication ready, remove prescribed liquid medication from appropriate place and pour prescribed amount into calibrated cup, make appropriate entry on the electronic medical records, wash hands and leave resident who is to receive medication. [sic] 676144 Page 6 of 9 676144 11/23/2022 Senior Care Health & Rehabilitation Center - Wichi 910 Midwestern Pkwy Wichita Falls, TX 76302

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 2 residents (Residents #66 and #276) reviewed for infection control. Residents Affected - Some The facility failed to ensure Occupational Therapist E, the Maintenance Director, and visitors donned Personal Protective Equipment (PPE) as required for residents who were on transmission-based precautions (TBP). This failure could place residents at risk for infections. The findings include: 1. Record review of Resident #66's face sheet, dated 11/22/22, revealed a [AGE] year-old male, who was admitted to the facility on [DATE]. He had a diagnosis that included Enterocolitis due to Clostridium Difficile (C-Diff, an infection of the large intestine). Record review of physician orders, dated 11/22/22, revealed Resident #66 had an order for: Isolation Transmission-based precautions (contact, droplet, and/or airborne) were in effect every shift, with a start date of 11/07/22. Record review of Resident #66's Care Plan, initiated on 11/07/22, revealed a care plan for Clostridium Difficile and isolation due to infection. In an observation on 11/21/22 at 11:16 AM revealed, Resident #66's door was closed, there were PPE supplies hanging in the doorway, and signage which informed the resident was on Transmission Based Precautions and full PPE was required. In an observation and interview on 11/21/22 at 3:27 PM, Resident #66's family member was in the room visiting the resident, she did not don PPE. She said she was given the choice by the facility if she wanted to wear PPE. Record review of Resident #276's face sheet, dated 11/22/22, revealed an [AGE] year-old female, initially admitted to the facility on [DATE]. She had a diagnosis which included Enterocolitis due to Clostridium Difficile (C-Diff / infection of the large intestine (colon) caused by the bacteria Clostridium difficile) after returning from the hospital on [DATE] and place on Transmission Based Precautions (TBP). Record review of physician orders, dated 11/22/22, revealed Resident #276 had an order for: Isolation Transmission-based precautions (contact, droplet, and/or airborne) were in effect every shift, with a start date of 11/15/22. Record review of Resident #276's Care Plan, initiated on 11/16/22, revealed a care plan for Clostridium Difficile and isolation due to infection. In an observation on 11/21/22 at 10:26 AM, Resident #276's door was closed and had PPE supplies 676144 Page 7 of 9 676144 11/23/2022 Senior Care Health & Rehabilitation Center - Wichi 910 Midwestern Pkwy Wichita Falls, TX 76302

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hanging on the doorway, and signage which informed the resident was on Transmission Based Precautions and full PPE was required. In an observation and interview on 11/21/22 at 2:30 PM, Resident #276 was receiving occupational therapy in her room. Occupational Therapist E was not donned in full PPE, she did not have a gown on . Resident #276's family member was also in the room and did not don PPE. Occupational Therapist E said she should have had a gown on but did not put one on. Occupational Therapist E donned a gown after she was asked about it. Resident's #276's family member said she was given the choice by the facility of donning PPE and didn't have to wear any PPE if she did not want too. In an interview on 11/21/22 at 2:35 PM, LVN A said Occupational Therapy was aware Resident #276 was on transmission-based precautions and they should be in full PPE when they provided therapy. She said family members who visited residents on Transmission Based Precautions should be in full PPE and were not given the choice if they wanted to wear PPE. She said family members had not been compliant and she had educated them about wearing PPE. In an interview on 11/21/22 at 2:44 PM, the DON said if a resident was on Transmission Based Precautions, visiting family members should be donned in full PPE and were not given the choice if they wanted to wear PPE. She said the occupational therapists should be donned in full PPE when they provided services. She said staff received education on Transmission Based Precautions and the need to wear full PPE. In an observation, on 11/21/22 at 3:44 PM, the Maintenance Director was observed going into Resident #276's room without donning PPE. In an interview on 11/21/22 at 4:20 PM, the DON said Resident #276's daughter has been educated about the need to wear PPE. She said the Maintenance Director should have donned PPE before going into Resident #276's room. The DON said, I educate, what else can I do?. In an interview on 11/23/22 at 8:58 AM, the Director or Rehabilitation, said she expected staff who provided services to be in full PPE if a resident was on Transmission Based Precautions. She said Occupational Therapist E knew she should have been in full PPE. She said the reason Occupational Therapist E did not have on full PPE was the family member is very demanding and that she forgot to put a gown on. In an interview on 11/23/22 at 9:14 AM, the Maintenance Director said he should have put on PPE but was not paying attention as he was looking at his work order and just walked into the resident's room. Record review of the facility's, undated, policy Isolation, Contact, revealed the following: Purpose: 1. To prevent the spread of infection. 2. To reduce the risk of transmission. Equipment: 676144 Page 8 of 9 676144 11/23/2022 Senior Care Health & Rehabilitation Center - Wichi 910 Midwestern Pkwy Wichita Falls, TX 76302

F 0880 1. Gloves, 2. Gowns, 5. Mask. Level of Harm - Minimal harm or potential for actual harm Procedure: 8. Wear gloves, gown and mask when coming into direct contact with resident or linens. Residents Affected - Some 676144 Page 9 of 9