Health inspection·April 25, 2023

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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 16 residents (Resident #4) reviewed for care plans. The facility failed to ensure Resident #4's care plans accurately reflected residents' dialysis status. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings include: Record review of a facility face sheet dated 4/25/23 for Resident #4 revealed that she was a [AGE] year-old female originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: end stage renal disease (kidney failure) and dependance on renal dialysis (a way to treat advanced kidney failure and help patient carry on an active life despite failing kidneys). Record review of a comprehensive MDS dated [DATE] for Resident #4 revealed that Section O, question 00100J was answered indicating that resident had received dialysis treatments in the previous 14 days and while a resident of the facility. Record review of Resident #4's medical record revealed the comprehensive care plan with a last revision date of 10/10/22 and a close date of 1/13/23 did not address resident's dialysis status nor address if dialysis services were being received. During an interview with a dialysis center staff member on 4/24/23 at 12:15 p.m. staff member said that Resident #4 was receiving dialysis services on Tuesdays, Thursdays, and Saturdays. Resident's last dialysis treatment was received on 12/15/22 due to resident request and admission to hospice. During an interview with the Administrator on 4/25/23 at 1:30 p.m. he said that he had been here for 3 weeks and was unable to comment on why the dialysis was not care planned for Resident #4. Resident #4 was no longer in facility. He said that going forward, he would like to discuss care plans in their morning stand up meetings and update them accordingly. He also said that he would like to involve the CNAs in care planning as well. He said that residents could be at risk of not receiving the care they needed if their care plans were inaccurate or not updated as needed. Page 1 of 8 676147 676147 04/25/2023 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DON on 4/25/23 at 1:55 p.m. she said that she had only been here since 3/1/23 and was unable to say why the dialysis was not addressed on Resident #4's care plan. She said that the MDS nurse was responsible for doing the care plans, but that she would update them with interventions for falls only. She said going forward that they plan to meet with family and update the care plans accordingly and ensure their accuracy. She said that she could think of no harm that could come to residents by not having an accurate care plan. During an interview with the MDS nurse on 4/25/23 at 2:05 p.m. she said that she had been here about 3 months. She said she was unable to say why dialysis was not included on Resident #4's care plan. She said when she did a care plan, the information would flow over from the MDS to the care plan and she would also go through the resident's face sheet, medication list, orders, and diagnoses to see what needed to be included on the care plan. She said that she reviewed care plans at least quarterly and more often if needed such as a change in condition. She said that she cannot think of any harm that may come to resident's by not having an accurate care plan. She said that going forward she would like to have more help in doing the care plans as it was hard at times to keep up with it all. During an interview with the DON on 4/25/23 at 4:30 p.m. she said that she was unsure who had been signing the care plans prior to her arrival, but that going forward she would be signing them and would be responsible for ensuring care plan accuracy. Record review of facility policy titled Care Planning - Interdisciplinary Team dated September 2013) stated .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . Record review of facility policy titled End-Stage Renal Disease, Care of a Resident with dated September 2010 stated .The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care . 676147 Page 2 of 8 676147 04/25/2023 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision with assistive devices to prevent accidents for 1 of 16 residents (Resident #6) reviewed for accidents and hazards. CNA A transferred Resident #6 from her bed to a wheelchair without using a Hoyer lift. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: Record review of an admission record for Resident #6 dated 4/25/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following cerebrovascular disease (paralyzed on one side along with weakness following a stroke) major depressive disorder (a persistent depressed mood and loss of interest), anxiety disorder (feeling restless, wound up or on edge) and personal history of a traumatic fracture (significant or extreme force caused a broken bone). Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated she had moderate impairment with thinking with a BIMS score of 11. She was totally dependent with transfers and required two-person physical assistance. Record review of an Annual MDS assessment dated [DATE] for Resident #6 indicated she had moderate impairment with thinking with a BIMS score of 12. She was totally dependent with transfers and required two-person physical assistance. Record review of a care plan for Resident #6 dated 12/7/2021 indicated a focus of an adl self-care performance deficit related to CVA with interventions she required (Hoyer lift, mechanical aid, sling, etc.) for transfers. Record review of a physician order for Resident #6 dated 4/25/2023 for the month of 4/1/2023-4/30/2023 indicated an order for Hoyer lift x2 for transfers every shift with a start date of 12/17/2021. Record review of a signed witness statement undated by CNA A indicated: Resident #6 asked to get up to go outside to smoke. I CNA A and my coworker went in her room [ROOM NUMBER] to get her up and she began to stand and start leaning to one side. I gently pulled her by the pants to help her sit in her chair. She yelled out that I was pulling on her pants and said that I yank her down which I did not. Record review of a facility self-report for Resident #6 dated 1/6/2023 indicated an incident occurred with Resident #6 and CNA A. Resident #6 reported to the SW on 1/6/2023 that CNA A was transferring her from the bed to the wheelchair and Resident #6 was dropped into her wheelchair onto her left hip where she had an old fracture. Record review of an X-ray report for Resident #6 dated 1/6/2023 indicated an x-ray was conducted of her left hip which revealed that there were 3 screws keeping her left femur (thigh bone) fracture 676147 Page 3 of 8 676147 04/25/2023 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0689 in good alignment. Level of Harm - Minimal harm or potential for actual harm Record review of a signed witness statement dated 1/6/2023 by CNA D indicated: entered the room late, CNA A was already helping Resident #6 as I walked to the other side to help, CNA A told me she had it, Resident #6 then told me and aide to let her do it, then I started picking up trash as she was getting in her chair. Resident #6 almost fell, and CNA A grabbed the back of her pants and helped her in the chair and Resident #6 got upset. Residents Affected - Few Record review of an in-service attendance record dated 1/6/2023 indicated the facility conducted an in-service on proper techniques and safety during all transfers. CNA A and CNA D were both in attendance as evidenced by their signatures. During an observation/interview on 4/24/2023 at 10:12 AM, Resident #6 was lying in bed awake and said she had been at the facility for 2 months. Resident #6 was alert and oriented x3. She said CNA A was helping her to get up on the day of the incident and she had her foot and was pushing it all bad, and asked CNA A to stop and she went back and did it again. She said CNA A did not use a Hoyer lift to get her out of the bed. She said she reported it to the Administrator, and they said they would talk to CNA A. She said they were all in the conference room discussing the incident and CNA A was missing for a few days after and does not work on her hall anymore. A fall mat was observed on the floor by the bed. During an interview on 4/25/2023 at 10:38 AM, CNA A said she had been employed at the facility for 3 years and worked hall 200 and 300 on the 6 am-2 pm shift. She said Resident #6 was trying to get in her chair and wanted to do it on her own but was going over too far, and she caught her by her pants and Resident #6 said she pulled her down too hard. CNA A said Resident #6 did not want any assistance from anyone that day. CNA A said she was supposed to be using a Hoyer lift on Resident #6, but that day transferred Resident #6 the way she wanted to be transferred. She said she had not been getting Resident #6 up with a Hoyer lift because the resident did not like the Hoyer lift and said it hurts her legs. She said after that incident she did not provide any more care to Resident #6. She said she was suspended for a few days following the incident. She said following the incident the staff had in-services on how to transfer and to look at ADLs on the computer to see how residents were to be transferred. During an interview on 4/25/2023 at 12:15 PM, CNA B said she had been employed at the facility for 4 years and worked 6 am-2 pm on hall 100. She said Resident #6 required a Hoyer lift for transfers. She said it was in Resident #6's care plan that the CNA's had access to at the nurse station in the charting system which would indicate how a resident was care planned for transfers. She said a care plan was there for a reason and they must follow the care plan and if they did not it would be completely wrong. She said a resident could fall and staff would not be able to handle the resident. She said the care plan was there to prevent accidents. She said following the incident with Resident #6 and CNA A, the facility conducted in-services on abuse/neglect, falls and transfers. During an interview on 4/25/2023 at 2:05 PM, LVN C said he had been employed at the facility for 5 years. He said Resident #6 required transfers with a Hoyer lift x2 staff. He said the aides would ask the nurses about residents if they were unfamiliar with the resident about how to transfer them. He said if staff were not aware of the resident's care plan for transfers or orders there could be a risk of fall or injury. During an interview on 4/25/2023 at 3:45 PM, the SW said the incident that occurred with Resident 676147 Page 4 of 8 676147 04/25/2023 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0689 Level of Harm - Minimal harm or potential for actual harm #6 and CNA A was reported to her by Resident #6. She said Resident #6 reported to her that CNA A and another aide were getting her up and her bottom hit the arm of the wheelchair and she wanted to complain that they had abused her. She said she immediately reported it to the Administrator at that time. She said the resident would report anything that was not right to her. She said the DON at that time assessed her. She said from then on, Resident #6 was a Hoyer lift transfer. Residents Affected - Few During an interview on 4/25/2023 at 4:20 PM, the DON said she had only been employed at the facility since 3/1/2023. She said she was not aware of an incident that was reported to the state agency with Resident #6 and CNA A. She said the CNAs were supposed to check the [NAME] in the charting system to look at the resident's care plans to see how a resident should be transferred. She said the CNAs should be updated by the charge nurse if they were unfamiliar with a resident and how they were to be transferred. She said she would provide oversight to ensure staff received trainings and in-services on transfers and if the care plan stated a Hoyer lift must be used, then that is what would be used. She said there are things that could have been done before transferring a resident without assistance. She said there was a potential risk of danger, harm, injury or fall to the residents. Record review of a facility policy titled Lifting Machine, Using a Portable with a revised date of April 2007 indicated, .The purpose of this procedure is to help lift residents using a manual lifting device. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. General Guidelines: The portable lift can be used by one nursing assistance if the resident can participate in the lifting procedure. If not, two (2) nursing assistants will be required to perform the procedure. Reporting: 1. Notify the supervisor if the resident refuses the care . 676147 Page 5 of 8 676147 04/25/2023 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents received respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 10 residents (Resident #5) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #5 had a physician order for her Cpap. (Continuous positive airway pressure) This deficient practice could place residents at risk of respiratory failure, respiratory infections, and complications. Findings include: Record review of an admission record for Resident #5 dated 4/24/2023 indicated she admitted to the facility initially on 1/8/2020 with an admission date of 12/22/2022 and was [AGE] years old with diagnoses of acute respiratory failure with hypoxia (lungs cannot get enough oxygen into your blood to remove the carbon dioxide form the body), chronic obstructive pulmonary disease (a group of lung disorders that constricts the airways and cause difficulty in breathing), sleep apnea (a sleep disorder when breathing stops and starts) and ESRD (end stage kidney disease). She discharged to the hospital on [DATE] and did not return to the facility. Record review of the physician's orders dated 12/1/2022-12/31/2022 indicated Resident #5 did not have an order for a cpap. Record review of a care plan for Resident #5 dated 5/26/2020 indicated a focus that she had chronic respiratory failure, COPD with Chronic bronchitis and sleep apnea related to history of smoking with interventions to change O2/Cpap tubing/water every week on Sunday and prn, Cpap pressure range from 4-16 cm water, mask type ResMed [NAME] full mask medium size on at bedtime nightly. Record review of an Annual MDS assessment dated [DATE] for Resident #5 indicated she did not have any impairment in cognitive thinking with a BIMS score of 15. She had active diagnoses of respiratory failure and asthma, COPD, or chronic lung diseases. Record review of a 24-hour report for hall 400 and right side of halls 200 and 300 indicated Resident #5 was listed on the 24-hour report dated 12/7/2022 with remarks/change of condition for amoxicillin with diagnosis of increased white blood cells and additional comments bipap (bilevel positive airway pressure) at night. Record review of a nurse progress note dated 12/22/2022 at 11:10 PM, written by LVN C indicated, .Resident #5 returned to the facility at 4:00 PM from the hospital with diagnoses of COPD, heart failure and hypoglycemia (low blood sugar). Resident wears a Bipap at bedtime, lying in bed at this time with fluids and call light within reach . Record review of a 24 hour report for halls 400 and right side of hall 200 and 300 indicated Resident #5 was listed on the report dated 12/23/2022 with remarks/change of condition of readmit with diagnosis of COPD and heart failure, O2 at 2 L prn, Cpap at hs, cpap mask missing a port, need another mask with additional remarks found missing piece to cpap. 676147 Page 6 of 8 676147 04/25/2023 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a phone interview on 4/24/2023 at 4:07 PM with a nurse from the pulmonologist (lung doctor) office for Resident #5 said Resident #5 had an order for a cpap that started on 5/25/2021 with settings to be from 4-12 cm of water to be applied every night at bedtime. She said they did not have an order to discontinue the cpap. During a phone interview on 4/24/2023 at 5:58 PM, LVN E said she worked at the facility prn and had worked with Resident #5 in the past. She said Resident #5's health status was wheelchair bound and transfer with a Hoyer lift. She said Resident #4 started declining towards the end and was in and out of the hospital for respiratory issues. She said she was dependent on O2 and wore a cpap at night. She said Resident #5 would refuse to wear it most of the time. She said there should be documentation in the charting system for each shift with nurse documentation on when the nurse would put the cpap on Resident #5. She said if a resident came back from a hospital, the nurses would go by the discharge summary report from the hospital to see if they would resume current orders or if there were any changes. During a phone interview on 4/25/2023 at 9:41 AM, LVN F said she worked at the facility prn but was full time until July 2022. She said Resident #5 had a cpap and occasionally would refuse to allow staff to put it on her. She said when she worked at night, she would fill up the water bottle for Resident #5. She said the nurses would document in progress notes about the cpap and not on the TAR. She said she not aware there was not an order for the cpap for Resident #5. During an interview on 4/25/2023 at 2:05 PM, LVN C said he had been employed at the facility for 5 years. He said he worked with Resident #5 often and was assigned to her hall. He said she had a cpap and would wear it every night and sometimes would put it on herself. He said the nurses would document in the charting system and on the nurse MAR about her cpap and would answer yes/no if it were applied and could also indicate if she refused it. He said the admitting nurse was responsible for entering orders from the discharge summary orders from hospital visits. During an interview on 4/25/2023 at 4:20 PM, the DON said she had only been employed at the facility since March 1, 2023. She said she was not aware that Resident #5 did not have an order for her cpap while a resident at the facility. She said orders were the responsibility of the nurse on duty and they were responsible for entering the orders in the system initially, then the ADON or DON would go in after to check for accuracy. She said orders were put in when they were received. She said she was not able to find record of a TAR or nurse MAR with orders for the cpap for Resident #5. She said she did find an old TAR from 2020 and the cpap order was discontinued at that time. She said there could be a risk of harm to residents who have to wear a cpap/bipap and it does not go away and would require testing and titration before being discontinued. She said she was going to conduct an audit for residents with cpaps/bipaps which would include their orders, care plans, and MDS assessments. She said not having active orders or following orders could put a resident at risk for harm. She said going forward she would be looking at the 24-hour report sheets in their morning meetings with nursing and ensure everything was followed through. Record review of a facility policy titled CPAP/BiPAP Support with a revised date of March 2015 indicated, .Purpose. 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. Preparation: 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, IPAP, and EPAP) for the machine. Documentation: Document the following in the resident's medical record: 1. General assessment (including vital signs, oxygen saturation, 676147 Page 7 of 8 676147 04/25/2023 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0695 Level of Harm - Minimal harm or potential for actual harm respiratory, circulatory and gastrointestinal status) prior to procedure; 2. Time CPAP was started and duration of the therapy; 3. Mode and settings for the CPAP/IPAP/EPAP; 4. Oxygen concentration and flow, if used; 5. How the resident tolerated the procedure; and 6. Oxygen saturation during the therapy. Reporting: 1. Notify the physician if the resident refuses the procedure . Residents Affected - Few 676147 Page 8 of 8