Health inspection·February 8, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 13 residents (Resident #6, Resident #27) reviewed for reasonable accommodations. Residents Affected - Few The facility failed to ensure Resident #6 had access to a call light. The facility failed to ensure Resident #27's call light was within reach. These failures could place residents at risk for unmet needs, injuries, and decreased quality of life. Findings included: 1. Record review of a face sheet dated 02/08/23 indicated Resident #6 was [AGE] years old and was initially admitted on [DATE] with diagnoses including need for assistance with personal care, chronic pain, and history of falling. Record review of a care plan dated 01/05/23 indicated Resident #6 had potential for decline in ADL function related to terminal illness, decline in health. There was a goal for Resident #6's needs to be met by staff. There was an intervention to encourage the resident to call for assistance. To leave the call bell within reach while in bed or chair and to answer the call bell promptly. Record review of the MDS dated [DATE] indicated Resident #6 was understood and understood others. The MDS indicated a BIMS score of 5 indicating severe cognitive impairment. The MDS indicated Resident #6 required supervision to extensive assistance with ADLs. Record review of a Maintenance Request Log dated 01/25/23 - 02/08/23 kept near the nurse's station did not indicate any request for repair of Resident #6's call light. During an observation on 02/06/23 at 9:59 a.m., Resident #6 was asleep in bed. There was no call light near the resident. At the call light outlet there was a call light leading to the roommate's bed. The other call light outlet had a plastic plug inserted with no cord. During an observation on 02/06/23 at 10:29 a.m., Resident #6 was provided incontinent care. There was no call light from the call light outlet to Resident #6's bed. Only one call light noted in room, and it was attached to the roommate's bed. Page 1 of 29 676154 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 02/06/23 at 1:42 p.m., there was no call light leading to Resident #6's bed. At the call light outlet there was a call light leading to the roommate's bed. The other call light outlet had a plastic plug inserted with no cord. During an observation 02/07/23 at 8:00 a.m., Resident #6 was asleep in bed. There was no call light near the resident. At the call light outlet there was a call light leading to the roommate's bed. The other call light outlet had a plastic plug inserted with no cord. During an observation on 02/07/23 at 9:10 a.m., Resident #6 was asleep in bed. There was no call light near the resident. At the call light outlet there was a call light leading to the roommate's bed. The other call light outlet had a plastic plug inserted with no cord. During an observation 02/07/23 at 10:34 a.m., Resident #6 was asleep in bed. There was no call light near the resident. At the call light outlet there was a call light leading to the roommate's bed. The other call light outlet had a plastic plug inserted with no cord. During an interview on 02/08/23 at 8:40 a.m., Resident #6 said she did not know how long she was without a call light. She said she could not remember if she needed assistance when she did not have one. She said without a call light she would have to yell for assistance. I can get pretty loud. During an interview on 02/08/23 at 8:55 a.m., CNA E said Resident #6 was not without a call light for very long. She said the call light had kept going off by itself. She said she verbally reported the call light not working on the morning of 2/7/23 to maintenance and the call light was replaced. She said she did know that Resident #6 did not have a call light on 2/6/2023. She said she did not report it to maintenance because it just slipped her mind. During an interview on 02/08/23 at 9:11 a.m., the Maintenance Supervisor said he normally found out about maintenance issues from the maintenance logbook that was kept near the nurse's station. He said maintenance was told by a CNA on 2/7/2023 that Resident #6's call light was not working. He said he was not sure how long there had not been a call light. He said he did weekly rounds on Wednesdays to check each call light. He said he last did rounds on 2/1/2023 and there were no issues with the call light. He said there has been a huge amount of move ins and it may have fell through the cracks. During an interview on 02/08/23 at 9:37 a.m., Maintenance Assistant said he was told by an aide on 2/7/23 that the call light for Resident #6 was shorted out. He said he put in a new call light immediately. During an interview on 02/08/23 at 10:44 a.m., the DON said any staff should report a malfunctioning call light immediately so it could be replaced. He said if a CNA found a call light not working appropriately it should have been reported immediately to a nurse and a new call light should be placed in the room. He said a resident without a functioning call light might not have their needs met. 2. Record review of the face sheet dated 02/06/23 revealed Resident #27 was [AGE] year-old male and admitted on [DATE] with diagnoses including focal (confined to one area of the brain) traumatic brain injury (damage to the brain) with loss of unconsciousness and nondisplaced comminuted fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of right fibula (is a small bone that runs along the outside of the lower leg). 676154 Page 2 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the quarterly MDS dated [DATE] revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS of 06 which indicated severe cognitive impairment. The MDS revealed Resident #27 was independent for bed mobility, transfer, dressing, toilet use, and bathing but needed supervision for personal hygiene. Record review of the care plan dated 12/28/22 revealed Resident #27 had a history and was at risk for increased falls and injury as evidence by actual fall. Interventions included fall 1/10/23, Resident #27 encouraged to use assistive rollator when going to restroom, evaluate the need for further intervention for increased falls, fall 12/28/22, fall star program initiated. Record review of the care plan dated 07/20/21, edited 01/10/23 revealed Resident #27 has potential for decline in ADL function related to history of traumatic brain injury and progressive decline in cognition. Intervention dated 04/13/22 included encourage to call for assistance. Leave call bell within reach while in bed or chair. Answer promptly. During an observation and interview on 02/06/23 at 10:24 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. Resident #27 said he did not know where his call light was and did not help getting out of the bed. He said he did not use the call light often but would use it if it was available. He said if fell and the call light was not within reach, he would have to holler for help, and someone would eventually show up to help him. During an observation on 02/07/23 at 9:10 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. During an observation on 02/08/23 at 9:10 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. During an interview on 02/08/23 at 11:29 a.m., CNA A said she had worked at the facility for 3 years. She said she was the aide assigned to Resident #27's hall. She said Resident #27 did not use the call light because he was independent, but he would use it if he really needed something. She said he did have two falls recently and broke his right leg the last fall. She said she mainly monitored the hall by making rounds but knew call lights needed to be always in reach to prevent falls. During an interview on 02/08/23 at 11:46 a.m., the ADON said Resident #27 was on the fallen star program which a yellow star was placed by his name on the door letting staff know he had fallen within the last 4 weeks. She said she did not know if Resident #27 used his call light for assistance. The ADON said his call light should be within reach when he was in the bed or chair to encourage him to call for assistance. She said it was the CNAs responsibility to ensure call lights were within reach when they made rounds. The ADON said call lights needed to be in reach so residents could get assistance and prevent falls or injuries. During an interview on 02/08/23 at 2:16 p.m., the DON said Resident #27 was on the fall prevention program due to recent falls with an injury. He said Resident #27 was independent with his ADLs so did not know how much he used the call light. The DON said the call light should at least be in the bed not behind it. The DON said it was aides and nurses' responsibility to ensure call lights were within reach. He said a lot of things could happen if a resident call light was not within reach, so he 676154 Page 3 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0558 did not want to speculate. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/08/23 at 11:17 a.m., the Administrator said he would expect all residents to have working call light. He said CNAs should report malfunctioning call lights without delay before it has time to slip their mind. He said a resident not having a call light could interfere with them getting assistance with something they want or need. Residents Affected - Few Review of a facility Answering the Call Light policy dated 10/2010 indicated, .The purpose of this procedure is to respond to the resident's requests and needs .be sure that the call light is plugged in at all times .when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .report all defective call lights to the nurse supervisor promptly . 676154 Page 4 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

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 interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 13 residents reviewed for assessments. (Resident #27) Residents Affected - Few The facility failed ensure Resident #27 was not improperly coded for limb restraints and chair alarms on the MDS. This failure could place residents at risk of not having individual needs met. Findings included: 1. Record review of the face sheet dated 02/06/23 revealed Resident #27 was [AGE] year-old male and admitted on [DATE] with diagnoses including focal (confined to one area of the brain) traumatic brain injury (damage to the brain) with loss of unconsciousness and nondisplaced comminuted fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of right fibula (is a small bone that runs along the outside of the lower leg). Record review of the quarterly MDS dated [DATE] revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS of 06 which indicated severe cognitive impairment. The MDS revealed Resident #27 was independent for bed mobility, transfer, dressing, toilet use, and bathing but needed supervision for personal hygiene. The MDS revealed Resident #27 used limb restraint less than daily in the bed and chair alarm less than daily. During an interview on 02/06/23 at 10:24 a.m., Resident #27 said he never had a restraint used on his body or a device in his wheelchair that alarmed when he got up. During an interview on 02/08/23 at 1:23 p.m., the MDS coordinator said she incorrectly coded Resident #27 for restraints and alarms. She said the facility did not use either for residents. The MDS coordinator said it was her responsibility to ensure MDSs were accurate. She said the inaccurate MDS made discrepancy on the resident's chart and did not provide an accurate assessment of Resident #27. During an interview on 02/08/23 at 2:16 p.m., the DON said he expected the MDSs to be accurate and reflect the resident's status. He said the MDS coordinator was responsible for MDS input and accuracy. The DON said he did not know Resident #27 had been incorrectly coded for restraints and alarms. He said himself and the corporate MDS coordinator were responsible for overseeing the MDS coordinator input and accuracy. During an interview on 02/08/23 at 2:51 p.m., the Administrator said he expected residents to have accurate assessments or MDSs. Record review of an undated facility Certifying Accuracy of the Resident Assessment policy revealed .all personnel who complete any portion of the resident assessment (MDS) must sign and certify the accuracy of that portion of the assessment . 676154 Page 5 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

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 interview and record review, the facility failed to ensure the baseline care plan included the instructions for resident care needed to provide effective and person-centered care was provided to the resident and/or their representative for 3 of 12 residents reviewed for new admissions (Resident #139, #140, and #5). The facility did not provide Residents #139, #140, and #5 and/or their representative with a summary of the baseline care plan. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of the admission Face Sheet dated 02/08/2023, for Resident #139 revealed an [AGE] year-old male. Resident #139 was admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). Record review of the admission MDS dated [DATE] documented a BIMS score of 12, which indicated moderate memory impairment. Resident #139 required extensive assistance x 2 staff assistance for bed mobility, transfer, and toileting. Resident #139 required limited assistance x1 staff assistance for eating. Record review of the 01/08/2023 to 02/08/2023 Active Physician Orders revealed Resident #139 received Eliquis 2.5 mg twice daily (blood thinner), Lexapro 20 mg once daily (antidepressant), Lantus 15 units at bedtime (insulin), and was on Hospice. Resident #139 had an order to cleanse deep tissue injury (DTI) to right buttock with normal saline, pat dry and apply a hydrocolloid dressing every other day. Resident #139 had an order to cleanse deep tissue injury to left buttock with normal saline, pat dry and apply a hydrocolloid dressing every other day. The orders revealed Resident #139 had an order for supplemental oxygen at 2-4 liters via nasal cannula and an order of do not resuscitate. Record review of Resident #139's paper and online chart for the Baseline Care Plan revealed a baseline During an interview on 02/08/2023 at 9:30 a.m., Resident #139 stated no care plan meeting or review of a base line care plan had been done with him since admission. Resident #139 stated it was important to him to have his family involved in his care decisions. During an interview on 02/08/2023 at 10:00 a.m., the family member of Resident #139 stated no care plan meeting or review of care had been done with the family since admission. The family member of Resident #139 stated a care plan meeting would be beneficial to the resident to ensure all aspects of his medical condition were being addressed. 2. 676154 Page 6 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the admission Face Sheet dated 02/08/2023, for Resident #140 revealed a [AGE] year-old male. Resident #140 was admitted to the facility on [DATE]. His diagnoses included acute cerebrovascular accident (stroke), atrial fibrillation (irregular heartbeat), and dysphagia (difficulty swallowing). Record review of the admission MDS dated [DATE] documented a BIMS score of 03, which indicated severe memory impairment. Resident #140 required extensive assistance x 2 staff assistance for bed mobility and toileting. Resident #140 required dependent assistance for transfer x 2 staff and was independent for eating. Record review of the 01/08/2023 to 02/08/2023 Active Physician Orders revealed Resident #140 received amiodarone 200mg once daily (regulate heartrate), aspirin 81mg once daily (blood thinner), Eliquis 5mg twice daily (blood thinner), lacosamide 100mg once daily (antiseizure medication), losartan 25 mg once daily (hypertension), metoprolol 25 mg twice daily (regulate heartrate), and spironolactone (fluid pill). Resident #140 had an order for left lateral foot arterial wound to be cleansed with normal saline, barrier cream to be applied around wound, iodosorb gel to wound bed, absorbent pad, and change every other day. Resident #140 had an order for a low concentrated sweet, mechanical soft diet. Record review of Resident #140's paper and online chart for the Baseline Care Plan revealed a baseline During an interview on 02/08/2023 at 10:00 a.m., the family of Resident #140 stated no one contacted them about a care plan meeting and Resident #140 was admitted in the middle of January. Resident #140's family stated it was important to them and the resident to all be part of his care. Resident #140's family was unaware of the type of wound Resident #140 had and what was being used. 3. Record review of the admission Face Sheet dated 02/08/2023, for Resident #5 revealed an [AGE] year-old female. Resident #5 was admitted to the facility on [DATE]. Her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), diabetes mellitus type 2 (impairment in the way the body regulates and uses sugar (glucose) as a fuel), and chronic kidney disease (gradual loss of kidney function). Record review of the admission MDS dated [DATE] a BIMS score of 13, which indicated intact cognition. Resident #5 required extensive assistance x 2 staff assistance for bed mobility. Resident # 5 was dependent x 2 staff assistance for transfer and toileting. Resident #5 required supervision assistance x1 staff assistance for eating. Record review of the 01/08/2023 to 02/08/2023 Active Physician Orders revealed Resident #5 received aspirin 81mg once daily (blood thinner), hydrocodone 10/325mg as needed for pain, metoprolol 25mg once daily (regulate heartrate), midodrine 25mg as needed for low blood pressure, Neurontin 1250mg once daily (nerve pain), Plavix 75 mg once daily (antiplatelet), and Renvela 3200mg three times daily with meals (controls phosphorus levels in people with chronic kidney disease). Resident #5 had a diet order of renal low potassium with low phosphorus foods, and double meat portions. Resident #5 had an order for dialysis three times per week. Record review of Resident #5's paper and online chart for the baseline care plan revealed a 676154 Page 7 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0655 Level of Harm - Minimal harm or potential for actual harm During an interview on 02/07/2023 at 11:30 a.m., Resident #5 stated no care plan meeting or review of a base line care plan had been done with her since admission. Resident #5 stated it was important to her to have her family involved in his care decisions. Residents Affected - Few During an interview on 02/08/2023 at 10:15 a.m., the family member of Resident #5 stated no care plan meeting or review of care had been done with the family since admission. The family member of Resident #5 stated having input into Resident #5's care was very important to the family. During an interview on 02/08/2023 at 11:58 a.m., the MDS Coordinator stated the DON was responsible for completing the baseline care plan. The MDS Coordinator stated the process for baseline care plan completion was the DON filled out the medical information and he passed it to the other departments. When all departments were done with the baseline care plan, the DON gave it back to the MDS Coordinator to file in the soft file and use as reference for the comprehensive care plan. The MDS Coordinator stated the family was not contacted during the process. The MDS Coordinator stated she was not aware a copy of the baseline care plan needed to be given to the family or the resident. The MDS Coordinator stated including the family in the base line care plan process could affect continuity of care. During an interview on 02/08/2023 at 12:00 p.m., the DON stated he completed the nursing portion of the baseline care plan when a new resident admitted . The DON stated he then passed the baseline care plan to the other departments like dietary, social services and activities. The DON stated he expected the completed baseline care plan to be back to him within one to two days and for the most part the baseline care plans were completed within 48 hours. The DON stated it was the responsibility of the MDS nurse to coordinate with the family and discuss the plan of care and set up care plan meetings. The DON stated he was not sure if the family or resident was getting a copy of the baseline care plan. The DON stated he was ultimately responsible for ensuring the base line care plan process was followed in the facility. During an interview on 02/08/2023 at 3:00 p.m., the Administrator stated he expected the policy for baseline care plans to be followed. The Administrator stated not involving the family or resident in the baseline care plan process could result in a disruption in continuity of care. Record review of the undated facility Care Plans Baseline Policy revealed The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: initial goals of the resident, a summary of resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and any updated information based on the details of the comprehensive care plan, as necessary. 676154 Page 8 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 5 of 12 residents (Resident #19, Resident #29, Resident #27, Resident # 32, and Resident #15) reviewed for comprehensive person-centered care plans. The facility failed to implement fall care plan interventions for Resident #19. The facility failed to care plan Resident #29's use of psychotropic medications. The facility failed to care plan Resident #15's admission to hospice. The facility failed to implement care plan intervention on call bell within reach for Resident #27. The facility failed to develop a care plan problem to address Resident #32's hearing loss and use of communication/writing board. These failures could place residents at risk of not having their individualized needs met, falls and a decline in their quality of care and life. Findings included: 1. Record review of a face sheet dated 02/08/2022 revealed Resident #19 was an [AGE] year-old female and admitted on [DATE]. Her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), repeated falls, lack of coordination, and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Record review of the annual MDS dated [DATE] revealed Resident #19 was understood and understood others. The MDS revealed Resident #19 had a BIMS score of 14 which indicated no cognitive impairment. The MDS revealed Resident #19 required limited assistance x 1 staff member for bed mobility, extensive assistance x 1 staff member for transfer and toileting, and supervision x 1 staff member for eating. Record review of the Morse Fall Scale dated 01/06/2023 revealed a score of 80 for Resident #19, which indicated a high fall risk. Record review of the care plan for Resident #19, with a revision date of 01/23/2023 by the DON revealed a care plan titled Falls. The care plan problem revealed Resident #19 had a history of falls and was at risk for increased falls and injury. The care plan interventions listed for this problem included: encourage use of call light, bed in lowest position, falling star program, and fall mat at bedside. 676154 Page 9 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0656 Level of Harm - Minimal harm or potential for actual harm During an observation on 02/06/2023 at 9:45 a.m., Resident #19 was in bed with no fall mat at bedside and bed not in lowest position. Resident #19 had a falling star symbol located on the outside of her door. During an observation on 02/06/2023 at 11:45 a.m., Resident #19 was in bed with no fall mat at bedside and bed not in lowest position. Resident #19 had visitor at bedside. Residents Affected - Some During an observation on 02/07/2023 at 10:45 a.m., Resident #19 was in bed with no fall mat at bedside and bed not in lowest position. During an observation on 02/07/2023 at 4:45 p.m., Resident #19 was in bed with no fall mat at bedside and bed not in lowest position. During an observation on 02/08/2023 at 9:45a.m., Resident #19 was in bed with no fall mat at bedside and bed not in lowest position. No fall mat was in the room. During an interview on 02/07/2023 at 10:45 a.m., Resident #19 stated she had not had a fall mat in several months. Resident #19 stated she thought they needed it for someone else. Resident #19 stated the CNAs never lowered her bed to the floor. During an interview on 02/07/2023 at 10:45 a.m., CNA A stated she was unaware Resident #19 was supposed to have a fall mat. CNA A stated all residents in the bed should be left in lowest position to decrease distance to the floor if a fall occurred. CNA A stated a falling star symbol is put outside the doors of all residents that are high fall risks and these people need a fall mat and the bed in the lowest position. During an interview on 02/08/2023 at 10:45 a.m., the DON stated he was unaware Resident #19 did not have a fall mat at her bedside. The DON stated it was the floor nurse's responsibility to ensure all beds were in the lowest position when a resident was left in bed. The DON stated it was his responsibility to ensure the charge nurses were doing their jobs. The DON stated he could not speculate on what injuries could occur from a fall from the bed not in the lowest position with no fall mat beside the bed. 2. Record review of the face sheet dated 02/08/2023 revealed Resident #29 was a [AGE] year-old male admitted on [DATE] with diagnoses of left below the knee amputation, hypertension (high blood pressure), and depression. Record review of the quarterly MDS dated [DATE] revealed Resident #29 was understood and usually understood others. The MDS revealed Resident #29 had a BIMS score of 09 which indicated moderate cognitive impairment. The MDS revealed Resident #29 was independent for bed mobility and eating and required only supervision for transfer and toileting. The MDS revealed the daily use of antidepressants. Record review of the comprehensive care plan for Resident #29, revised 05/18/2022 by the MDS Coordinator revealed no care plan for psychotropic medication usage. During an interview on 02/08/2023 at 10:00 a.m. the MDS Coordinator stated the process for creating comprehensive care plans started with doing the MDS and care planning anything that triggered in the Care Area Assessment (CAA) area. The MDS Coordinator stated it was important to care plan these areas because the areas required the most monitoring and intervention to ensure good quality of care 676154 Page 10 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and life for each resident. The MDS Coordinator was not aware of why Resident #29 was not care planned for psychotropic medication usage for the 2 antidepressants taken daily. The MDS Coordinator stated it was her responsibility to make sure all psychotropic medications were care planned. The MDS Coordinator stated it was an oversight. During an interview on 02/08/2023 at 11:00 a.m., the DON stated it was important to care plan each triggered area on the MDS and was unaware Resident #29 did not have a care plan for the use of his Celexa and Remeron. The DON stated he could not speculate on what outcomes would develop from not care planning triggered MDS items. The DON stated it was the responsibility of the MDS Coordinator to ensure all psychotropic medications were care planned. 3. Record review of the face sheet dated 02/08/23 revealed Resident #15 was [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), adult failure to thrive (is a decline seen in older adults), and moderate protein-calorie malnutrition (is the state of inadequate intake of food). Record review of Resident #15's consolidated physician order dated 12/07/22 revealed an order to admit to a hospice company under a medical doctor for terminal diagnosis of Alzheimer's disease. Record review of the significant change in status MDS dated [DATE] revealed Resident #15 was usually understood and usually understood others. The MDS revealed Resident #15 was unable to complete the BIMS due to being rarely/never understood. The MDS revealed Resident #15 required extensive assistance for ADLs. The MDS revealed Resident #15 had hospice care while a resident. Record review of Resident #15's care plan dated 01/13/23 did not reveal a care plan problem for hospice care. 4. Record review of the face sheet dated 02/06/23 revealed Resident #27 was [AGE] year-old male admitted on [DATE]. His diagnoses included focal (confined to one area of the brain) traumatic brain injury (damage to the brain) with loss of unconsciousness and nondisplaced comminuted fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of right fibula (is a small bone that runs along the outside of the lower leg). Record review of the quarterly MDS dated [DATE] revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS of 06 which indicated severe cognitive impairment. The MDS revealed Resident #27 was independent for bed mobility, transfer, dressing, toilet use, and bathing but needed supervision for personal hygiene. Record review of the care plan dated 07/20/21, edited 01/10/23 revealed Resident #27 has potential for decline in ADL function related to history of traumatic brain injury and progressive decline in cognition. Intervention dated 04/13/22 included encourage to call for assistance. Leave call bell within reach while in bed or chair. Answer promptly. During an observation and interview on 02/06/23 at 10:24 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. Resident #27 said he did not know where his call light was and did not help getting out of the bed. He said he did not use the call light often but would use it if it was available. He said if fell and the call light was not 676154 Page 11 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0656 within reach, he would have to holler for help, and someone would eventually show up to help him. Level of Harm - Minimal harm or potential for actual harm During an observation on 02/07/23 at 9:10 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. Residents Affected - Some During an observation on 02/08/23 at 9:10 a.m., Resident #27 was lying in his bed watching television. Resident #27 had an orthopedic boot/brace on his right leg. Resident #27's call light was on the other side of his bed, on the floor not within reach. During an interview on 02/08/23 at 11:29 a.m., CNA A said she had worked at the facility for 3 years. She said she was the aide assigned to Resident #27's hall. She said Resident #27 did not use the call light because he was independent, but he would use it if he really needed something. She said he did have two falls recently and broke his right leg the last fall. She said she mainly monitored the hall by making rounds but knew call lights needed to be always in reach to prevent falls. During an interview on 02/08/23 at 11:46 a.m., the ADON said Resident #27 was on the fallen star program which a yellow star was placed by his name on the door letting staff know he had fallen within the last 4 weeks. She said she did not know if Resident #27 used his call light for assistance. The ADON said his call light should be within reach when he was in the bed or chair to encourage him to call for assistance. She said it was the CNAs responsibilities to ensure call lights were within reach when they made rounds. The ADON said call lights needed to be in reach so residents could get assistance and prevent falls or injuries. During an interview on 02/08/23 at 2:16 p.m., the DON said Resident #27 was on the fall prevention program due to recent falls with an injury. He said Resident #27 was independent with his ADLs so did not know how much he used the call light. The DON said the call light should at least be in the bed not behind it. The DON said it was aides and nurses' responsibility to ensure call lights were within reach. He said a lot of things could happen if a resident call light was not within reach, so he did not want to speculate. 5. Record review of the face sheet dated 02/08/23 revealed Resident #32 was [AGE] year-old male admitted on [DATE]. His diagnoses included impacted cerumen, left ear (is an accumulation of cerumen that causes symptoms, such as hearing loss, fullness, otorrhea, tinnitus, dizziness, or other symptoms, and/or prevents a required assessment of the ear canal, tympanic membrane, or audiovestibular system) and hemiplegia (a severe or complete loss of strength) and hemiparesis (a relatively mild loss of strength) following cerebral infarction (stroke) affecting right dominant side. Record review of Resident #32's consolidated physician order dated 01/23/23 revealed Carbamide peroxide 6/5% solution, 5 drops, left ear, twice a day. Record review of Resident #32's consolidated physician order dated 01/31/23 revealed follow up appointment with an otolaryngologist (is a doctor that specializes in treating conditions that affect the ears, nose, and throat, as well as head and neck) on 01/31/23 at 1:15 p.m. Record review of the admission MDS dated [DATE] revealed Resident #32 was understood and understood others. The MDS revealed Resident #32 had minimal difficulty hearing without hearing aide. The MDS revealed Resident #32 had a BIMS of 06 which indicated severe cognitive impairment and required extensive assistance for bed mobility, transfer, dressing, and personal hygiene and total dependence for 676154 Page 12 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0656 toilet use and bathing. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #32's care plan dated 11/07/22 did not a reveal a care problem for hearing deficits with use of writing board. Residents Affected - Some Record review of a progress note for Resident #32 written by the activity director on 11/14/22 revealed .he is hard of hearing, so speak a little louder and very clear for him to understand . Record review of a progress note for Resident #32 written by the ADON on 01/05/23 revealed .report from hearing company sent to Ear, Nose, and Throat doctor for further evaluation and treatment .Resident #32 has an appointment in office January 17th at 10am . Record review of a progress note for Resident #32 written by LVN F on 01/17/23 revealed .Resident has started wanting staff to write on paper any questions because he is hard of hearing . During an observation and interview on 02/06/23 at 11:07 a.m., Resident #32 was sitting up in bed watching television. Resident #32 did not hear knock on door. Resident #32 noticed surveyor only when in line of vision. The surveyor started to speak but Resident #32 lifted a writing board with a pen. Resident #32 said he was hard of hearing and preferred using the board. During an interview on 02/08/23 at 10:56 a.m., Resident #32 responded to questions written on the writing board. He said when he admitted to the facility, he had hearing issues. Resident #32 said after he got COVID-19 (1/13/23) his hearing got worse. Resident #32 said he started asking staff to write questions of paper and pen then a staff member brought him the writing board. During an interview on 02/08/23 at 3:00 p.m., the MDS coordinator said she was responsible for updating residents care plan with new care problems. She said she did know Resident #32 was hard of hearing and was seeing a doctor for treatment. The MDS coordinator said she did not know he preferred communicating with staff using a writing board. She said she collected her information to implement or update care plan from the progress notes and orders. She said she missed the progress note mentioning his wishes to use writing tablet. She said it would be an important problem to care plan because aides can access the care plan and it would inform them on his communication needs. She said his needs could not get met or wishes not honored due to his care plan not being developed for hearing loss. The MDS coordinator said when Resident #15's significant change MDS was done for hospice admission, she should have developed a care plan problem. She said it was a change of condition and all staff needed to be on the same page. Record review of a policy named Care Conferences dated 07/14/2017 revealed, Make sure issues related to falls, restraints, skin breakdown, psychotropic medications, pain management, and weight loss are discussed, and effective interventions are implemented and documented. Compare the care plan to the MDS and make sure everything matches. 676154 Page 13 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to review and revise by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment for 1 resident (Resident #15) of 13 residents reviewed for comprehensive person-centered care plans in that: Resident #15's care plan was not revised after his anti-anxiety medication was discontinued and no longer was coded on his MDS. This failure could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in a decline in physical well-being and care needs not being addressed. Findings included: Record review of the face sheet dated 02/08/23 revealed Resident #15 was [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), generalized anxiety disorder and adult failure to thrive (is a decline seen in older adults). Record review of the significant change in status MDS dated [DATE] revealed Resident #15 was usually understood and usually understood others. The MDS revealed Resident #15 was unable to complete the BIMS due to being rarely/never understood. The MDS revealed Resident #15 required extensive assistance for ADLs. The MDS revealed Resident #15 did not have an active diagnosis of anxiety disorder. The MDS revealed Resident #15 did not receive an antianxiety medication during the last 7 days of the assessment. Record review on the care plan dated 01/13/23 revealed Resident #15 received antianxiety medication related to anxiety. During an interview on 02/08/23 at 1:23 p.m., the MDS coordinator said she should have revised the care plan to reflect Resident #15 was no longer receiving antianxiety. She said she must have forgotten to revise the care plan. She said the Resident #15's MDS reflected the change which should have prompted her the do the same for the care plan. She said it was important to have an accurate care plan so residents were monitored for the correct signs/symptoms and labs, and it was a change of condition to monitor for tolerance. During an interview on 02/08/23 at 2:16 p.m., the DON said he expected the MDS coordinator to update and revise the care plan with scheduled MDSs and changes. He said he was responsible for ensuring the care plans and MDS were revised and updated. He said it was important for the care plan to be revised to reflection the resident accurate status. Record review of a facility Care Conference policy dated 07/17/14 revealed .the DON will lead the care plan meeting .review recent changes in medications and physician's orders .review the nursing care plan, reading each problem statement .discuss with the care plan team if addition or changes need to be made to the resident's care plan .care plan do not need to be completely rewritten with each assessment .they can be edited each time . compare the care plan to the MDS and make sure everything 676154 Page 14 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0657 matches . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676154 Page 15 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

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 that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 3 of 13 residents reviewed for accidents. (Residents #11, #8, and #21) The facility failed to ensure CNA A and CNA E performed a safe mechanical lift transfer for Resident #11. The facility did not complete quarterly safe smoking assessments for Residents #8 and #21. These failures could place residents at risk of injury from accident and hazards. Findings included: 1. Record review of the face sheet dated 02/07/23 revealed Resident #11 was [AGE] years old and admitted on [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body caused by spinal injury or disease), need for assistance with personal care, and weakness. Record review of the quarterly MDS dated [DATE] revealed Resident #11 was understood and understood others. The MDS revealed Resident #11 had adequate hearing, clear speech, and adequate hearing. The MDS revealed Resident #11 had a BIMS of 14 which indicated intact cognition. The MDS indicated Resident #11 required extensive assistance with all ADLs. Record review of the care plan dated 02/06/23 revealed Resident #11 had a potential for decline in ADL function related to paraplegia. The care plan indicated Resident #11 was total care for transfers. Record review of an In-Service Training Report titled Transfers, Pocket Worksheets, and Care Plans dated 1/24/23 indicated, .Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents . The In-Service was signed by CNA A and CNA E. During an observation on 02/06/23 at 11:09 a.m., CNA A and CNA E used a mechanical lift to transfer Resident #11 from the wheelchair to the resident's bed. After lifting Resident #11 from the wheelchair CNA A moved the legs of the base of the lift from a wide position to a narrow position. CNA E then moved the lift across the room approximately 6 feet to the bed with the legs in the narrow position. The resident was then lowered into the bed. During an interview on 02/07/23 at 10:40 a.m., CNA E said after lifting Resident #11 from the wheelchair on 2/6/2023 the legs on the base were narrowed before moving the resident across the room to the bed. She said the legs should have been left in the wide position. She said the legs were supposed to be kept in the wide position to prevent the mechanical lift from tipping over while moving the resident. During an interview on 02/07/23 at 11:30 a.m., CNA A said she was the CNA that narrowed the legs on the base of the mechanical lift during the transfer of Resident #11. She said the reason she 676154 Page 16 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few narrowed the legs was because she did not feel there was enough room to maneuver the lift to the bed. She said she had received trainings in the past and she did know she was supposed to the leave the legs of base in a wide position. She said when the legs were narrowed, it could cause the lift to tip over. 2. Record review of the face sheet dated 02/08/23 revealed Resident #8 was [AGE] year-old male and admitted on [DATE]. His diagnoses included acute respiratory failure with hypoxia (is a condition in which your lungs have a hard time loading your blood with oxygen), chronic obstructive pulmonary disease (lung diseases that block airflow and make it difficult to breathe), lack of coordination, weakness, and nicotine dependence, other tobacco product, with withdrawal (occurs when you need nicotine and can't stop using it). Record review of the quarterly MDS dated [DATE] revealed Resident #8 was understood and understood others. The MDS revealed Resident #8 had adequate hearing, clear speech, and adequate hearing. The MDS revealed Resident #8 had a BIMS of 13 which indicated intact cognition and required supervision for dressing, toilet use, personal hygiene, and extensive assistance for bathing. The MDS revealed Resident #8 required oxygen therapy while a resident. Record review of the care plan dated 04/10/20 revealed Resident #8 was a current smoker and had a history of 25 years for smoking. Interventions included instruct on smoking risks and hazards. Promote smoking cessation. Instruct on facility's smoking protocol: location, times, cigarette disposal and safety concerns. Observe skin and clothes for signs of cigarette burns. Record review of an admission smoking assessment dated [DATE] revealed Resident #8's smoking risk score of 5 which indicated safe smoker (score of 0-9). No quarterly smoking assessment performed after Resident #8's admission assessment. During an observation and interview on 02/06/23 at 11:11 a.m., Resident #8 was lying in his bed with an oxygen nasal cannula on his face. A pack of cigarettes and lighter was on the bedside table and another pack on top of the oxygen concentrator. Resident #8 said he could keep his smoking material in the room, and he did not take his oxygen outside with him to smoke because it was dangerous. During an observation and interview on 02/07/23 at 3:00 p.m., Resident #8 was sitting in his wheelchair beside his bed with an oxygen nasal cannula on his face. A pack of cigarettes and lighter was on the bedside table, another pack of cigarettes on top of the oxygen concentrator, and open carton of cigarettes on the empty bed next to him. Resident #8 said he did not know he was supposed to have a smoking assessment done every 3 months. During an observation on 02/07/23 at 3:15 p.m., Resident #8 self-propelled himself in his wheelchair to the smoking area without oxygen. 3. Record review of the face sheet dated 02/07/23 revealed Resident #21 was [AGE] years old and admitted on [DATE] with diagnoses including diabetes, lack of coordination, and kidney failure. Record review of the quarterly MDS dated [DATE] revealed Resident #21 was understood and usually understood others. The MDS revealed Resident #21 had adequate hearing, clear speech, and adequate hearing. The MDS revealed Resident #21 had a BIMS of 12 which indicated moderate cognitive impairment. The MDS indicated Resident #21 required supervision to extensive assistance with ADLs. 676154 Page 17 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the care plan dated 01/05/23 revealed Resident #21 was an independent smoker who does not require supervision while smoking. The care plan indicated Resident #21 would follow smoking policy. There were interventions to allow resident to keep cigarettes and lighter and to review smoking assessments quarterly and as needed. Record review of an admission smoking Risk assessment dated [DATE] indicated Resident #21 had a smoking risk score of 2 which indicated the resident was a safe smoker. There were no other Smoking Risk assessments in Resident #21's electronic medical record or Resident #21's chart. During an observation on 02/06/23 at 1:50 p.m., Resident #21 was outside smoking in the designated smoking area unsupervised. No staff or other residents were present in the smoking area. During an interview on 02/07/23 at 2:22 p.m., the Social Worker Liaison said she normally completed safe smoking assessments annually. She said she began working at the facility after Resident #21 was admitted to the facility. She said nothing had triggered her to complete a safe smoking assessment for Resident #21. She said she had taken the residents who smoke outside at times and if she saw anything concerning, she would complete a safe smoking assessment then. She said Resident #21 smoked safely so she had not seen a reason to do another safe smoking assessment. She said since she started working at the facility in October 2022, she had completed smoking assessments for all new admits and if a current resident had shown a decline. During an observation and interview on 02/07/23 at 3:30 p.m. Resident #21 said she just came in from smoking. She said she took herself out to smoke and she kept all of her smoking material and lighter with her. She said she went out to smoke by herself 4 and 5 times a day. She said she was allowed to smoke unsupervised. She said she kept her smoking material in her bra. She pulled a pack of cigarettes and lighter out of her bra. During an interview on 02/08/23 at 8:55 a.m., CNA E said Resident #21 always took herself out to smoke and kept her smoking material with her. During an interview on 02/08/23 at 10:44 a.m., the DON said staff should follow the facility policy when performing a mechanical lift. He said he just held an in-service on mechanical lift transfers. He said if policy said the base should be kept wide then it should be kept wide. He said he could not say what could happen if the base was not kept wide. He said he could not speculate what could happen. He said the social worker completed all of the safe smoking assessments. He said he would have expected for the smoking policy to have been followed. He said he could not speculate what could happen if safe smoking assessments were not completed per policy. During an interview on 02/08/23 at 11:17 a.m., the Administrator said he would have expected safe smoking assessments to have been completed quarterly per policy. He said completing a safe smoking assessment should be triggered by the quarterly MDS. He said the social worker liaison was new to her position and had a lot to learn. He said if a resident had a change in condition and they were no longer a safe smoker there could be negative outcome such as burns in clothes and other negative outcomes. He said he would have expected CNAs to follow the rules and trainings concerning mechanical lift transfers. He said anytime there was a body weight on the lift, the base should be in the wide position. He said the base not being in the wide position could lead to a fall. Review of a facility Transfers, and Lifts policy dated 07/14/17 indicated, .lock wheels of bed and lift before using, widen base of lift to transfer . 676154 Page 18 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of an undated facility Smoking Policy indicated, .Smoking assessments will be conducted on admission and updated quarterly. Those residents deemed safe to smoke independently may manage their own lighters/matches and tobacco products, and smoke independently. Those residents deemed unsafe to smoke independently will be taken to smoke at the specified times. Smoking times will be limited to 15 minutes for unsafe smokers . Residents Affected - Few 676154 Page 19 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0692 Provide enough food/fluids to maintain a resident's health. 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 maintained acceptable parameters of nutritional status when there was a nutritional problem for 1 of 13 residents (Resident #27) reviewed for nutritional problems. Residents Affected - Few The facility failed to serve Resident #27 double portion with all meals prescribed by the MD. This failure could place residents at risk for poor intake, weight loss, and unmet nutritional needs. Findings included: Record review of the face sheet dated 02/06/23 revealed Resident #27 was a [AGE] year-old male admitted on [DATE]. His diagnoses included focal (confined to one area of the brain) traumatic brain injury (damage to the brain) with loss of unconsciousness and nondisplaced comminuted fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of right fibula (is a small bone that runs along the outside of the lower leg). Record review of Resident #27's consolidated physician order dated 10/28/22 revealed an order for double portion with each meal plus health shake with each meal. Record review of the quarterly MDS dated [DATE] revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS of 06 which indicated severe cognitive impairment. The MDS revealed Resident #27 was independent for bed mobility, transfer, dressing, toilet use, and bathing but needed supervision for personal hygiene. Record review of the care plan problem dated 1/10/23 revealed nutritional status: Resident #27 is at risk for nutritional problems related to depression, traumatic brain injury, and adjusting to facility. Interventions included monitor weights per facility protocol, provide diet per orders, and provide verbal cues as needed to complete meals. Record review of Resident #27's meal ticket dated 02/08/23 revealed Breakfast-Regular, Large Portion at Lunch ONLY, Lunch- Regular, Large Portion at Lunch ONLY, and Dinner- Regular, Large Portion at Lunch ONLY. Record review of Resident #27's weights dated 05/01/22-02/07/23 revealed 12/07/22 181.2 lbs., 01/04/23 176.6 lbs., 02/01/23 181 lbs. Record review of the nutritional recommendation for Resident #27 dated 12/31/22 revealed Resident #27: continue plan of care (on appetite stimulant, double portion, health shake with each meal) During an observation on 02/07/23 at 12:10 p.m., Resident #27 portion size was not double on his meal tray. During an observation on 02/08/23 at 12:25 p.m., Resident #27 was eating lunch in the dining room. Resident #27's portion size was not double. Resident #27's meal ticket stated, large portion for lunch only. 676154 Page 20 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/08/23 at 11:29 a.m., CNA A said she thought Resident #27 was supposed to have double meat for all meals and could not recall seeing a health shake. She said the nurses verified the meal tickets were correct and CNAs documented the meal intake. During an interview on 02/08/23 at 11:46 a.m., the ADON said Resident #27 had double portions with all meals and health shakes added in October. She said Resident #27 had weight loss but not significant loss, so this intervention was attempted. The ADON said Resident #27 refused the double portion and did not see a difference in his weight. She said an appetite stimulant was added on 11/1/22 but the diet order was not modified or discontinued. The ADON said the dietary supervisor received a communicate note to inform her of diet orders and changes. She said the nurses should be looking at the meal ticket to ensure the resident received the right diet ordered. During an interview on 02/08/23 at 1:16 p.m., the dietary supervisor said Resident #27 was on a regular diet with health shakes. She said she was notified of diet orders with communication slips from the nursing staff. The dietary supervisor said she thought Resident #27 requested only large portions at lunch. She said normally if a resident request something not ordered, she asked the nurses to ask for order or modify current order. She said she did not know if anyone notified nursing staff Resident #27 only wanted large portion at lunch. During an interview on 02/08/23 at 2:00 p.m., LVN D said she did not know Resident #27's diet order had changed to double portion for all meals in October 2022. She said because she did not know about the order change, she would not question his meal ticket with a different order. She said when nursing staff received a diet order, a communicate slip was written and given to the dietary supervisor. LVN D said if a resident requested a diet order different then what was ordered then the doctor would have to be called. During an interview on 02/08/22 at 2:16 p.m., the DON said the diet order was printed out then given to the dietary supervisor. He said then the nurse documents the order on the 24-hour report to communicate to all nursing staff the change. The DON said the nurses should always be checking meal tickets at meal service to ensure physician orders were being followed. He said he would not speculate the risk to the resident, but physician orders were not being followed. The DON said it was the nursing staff and dietary supervisor responsibility to ensure diet orders were being followed. During an interview on 02/08/23 at 2:51 p.m., the ADM said he expected physician's orders to be followed by nursing staff and dietary supervisor. Record review of a facility Care Conference policy dated 07/17/14 revealed .review recent changes in medications and physician's orders .make sure issues .and weight loss are discussed and that effective interventions are implemented and documented . 676154 Page 21 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

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 observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 12 resident reviewed for respiratory care. (Resident #14) Residents Affected - Few The facility failed to properly store Resident #14's nasal cannula when not in use. This failure could place residents at risk for respiratory infections. Findings included: Record review of the face sheet dated 02/08/23 revealed Resident #14 was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), history of acute respiratory disease (a serious and widespread infection of the bloodstream), emphysema (a lung condition that causes shortness of breath), and chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #14's consolidated physician orders dated 02/08/23 revealed oxygen at 3 liters per minute via nasal cannula, twice a day (08/17/20) and oxygen at 2 liters per minute via nasal cannula at hour of sleep as needed, oxygen saturation less than 90%, or shortness of breath (01/18/23). Record review of the quarterly MDS dated [DATE] revealed Resident #14 was understood and understood others. The MDS revealed Resident #14 had adequate hearing, clear speech, and impaired vision with corrective lenses. The MDS revealed Resident #14 had a BIMS of 15 which indicated intact cognition and independent for ADLs. The MDS revealed Resident #14 had oxygen therapy while a resident. Record review of the care plan problem dated 04/05/18 revealed Resident #14 had diagnosis of COPD/emphysema and had a potential risk for complications. Resident #14 wears oxygen at night while sleeping and during day wears it as needed. Resident #14 will remove and replace oxygen per self. Interventions change oxygen tubing/clean filter per protocol or scheduled on Sunday and maintain oxygen flow per nasal cannula per MD orders. During an observation and interview on 02/06/23 at 10:39 a.m., Resident #14 was sitting in his recliner watching television. Resident #14 said he wore he oxygen when he needed. The nasal cannula was noted to be in his recliner, underneath his bottom not in a bag. During an observation on 02/07/23 at 9:13 a.m., Resident #14 was sitting in his recliner watching television. The nasal cannula was noted to be in his recliner, underneath his bottom not in a bag. During an observation on 02/07/23 at 11:43 a.m., Resident #14 was sitting in his recliner watching television. The nasal cannula was wrapped around the flowmeter (an equipment used to control oxygen flow delivery in patients undergoing oxygen therapy) attached to the oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe), not in a bag. 676154 Page 22 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/08/23 at 10:49 a.m., Resident #14 was sitting in his recliner watching television. The nasal cannula was noted to be in his recliner, underneath his bottom not in a bag. Resident #14 said he would use a bag to store his nasal cannula when he was not using it. Resident #14 said he could not recall anyone offering him a bag to store his nasal cannula when not in use. During an interview on 02/08/23 at 11:29 a.m., CNA A said she had been employed at the facility for 3 years. She said was the aide assigned to Resident #14. CNA A said Resident #14 normally only wore his nasal cannula when he was in bed. CNA A said Resident #14 was independent for ADLs and removed/replaced his nasal cannula. She said she had not noticed the nasal cannula stored in bag when not in use. CNA A said Resident #14's nasal cannula should probably not be in his recliner uncovered because the recliner may not clean. During an interview on 02/08/23 at 1:48 p.m., the ADON said Resident #14's nasal cannula should be stored in a bag. She said the nasal cannula not being stored in a bag and Resident #14 sitting on it was an infection control risk and potential damage the tubing. She said respiratory equipment stored unsanitary could lead to respiratory infection which may require antibiotics, increased oxygen need, or hospitalization. The ADON said it was nursing staff responsibility to ensure respiratory equipment was store in a sanitary manner. During an interview on 02/08/23 at 2:00 p.m., LVN D said Resident #14 used his oxygen as needed. She said Resident #14's nasal cannula should be stored in a plastic bag for infection control. LVN D said it was the nursing staff responsibility to ensure correct storage of Resident #14's nasal cannula. She said Resident #14 was at risk for respiratory infection. During an interview on 02/08/23 at 2:16 p.m., the DON said Resident #14's nasal cannula should be stored in a bag when not in use to minimize contamination. The DON said he did not want to speculate on the risk of using contaminated respiratory equipment. He said it was the nursing staff responsibility to ensure respiratory equipment was store in a sanitary manner. The DON said he was responsible for overseeing the nursing staff in ensuring proper storage of respiratory equipment. During an interview on 02/08/23 at 2:51 p.m., the ADM said he could not comment on nursing equipment. Record review of a facility Cleaning, and Disinfection of Resident-Care Items and Equipment policy dated 07/14 revealed .semi-critical items consist of items that may come in contact with mucous membranes on non-intact skin (e.g. respiratory equipment) .critical and semi-critical items will be sterilized/disinfected .stored appropriately until use . 676154 Page 23 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. Residents Affected - Many The facility failed to ensure that all staff members wore hairnets appropriately. This failure could place residents at risk of food contamination. Findings included: During an observation on 02/07/2023 at 11:45 a.m., Transportation aide #B entered the kitchen to deliver a package with no hair net on during meal service. During an observation on 02/07/2023 at 11:48 a.m., a sign on each entrance door to the kitchen stated kitchen personnel only. During an observation and interview on 02/07/2022 at 11:51 a.m., Business Office Worker # C walked into the kitchen and asked for foam plates and plastic forks to eat her personal lunch with no hair net on. Business Office Worker #C did not leave the kitchen when she was told by the Dietary Manager that the state was in the kitchen watching meal service. Business Office Worker #C stated she thought employees could come into the kitchen with no hair net on as long as they were not standing directly in front of the food. The Dietary Manager informed Business Office Worker #C, she was required to have a hair net on if she entered the kitchen. During an interview on 02/08/2023 at 10:00 a.m., the Dietary Manager said hair nets were required to enter the kitchen no matter if food was being served or not because food was always being prepared. She said residents could be negatively affected by hair contaminating food and the residents might not want to eat the food. During an interview on 02/08/2023 at 11:00a.m., the DON stated he was shocked people came into the kitchen at all because the Dietary Manager was known to run people out of the kitchen that did not belong there. During an interview on 02/08/2023 at 2:16 p.m., the Administrator said anyone in the kitchen should be wearing a hair net and the hair net should be covering all their hair. He said wearing a hair net inappropriately could cause hair to get into the food and cause contamination of the food item. Review of a facility Employee Hygiene and Sanitary Practices policy dated 2021 revealed, hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. 676154 Page 24 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0881 Implement a program that monitors antibiotic use. 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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 4 of 5 residents reviewed antibiotic use. (Resident #7, Resident #26, Resident #85, Resident #86) Residents Affected - Some The facility failed to add a diagnosis to support antimicrobial use for prescribed antibiotics for Resident #7, Resident 26, Resident #85, and Resident #86. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of an undated facility Antimicrobial Stewardship Policy and Procedure revealed the facility will establish a multidisciplinary stewardship program that defines and provides for optimal antimicrobial use .the consultant pharmacist should review antimicrobial orders during interim and monthly medication regimen review to ensure proper ordering .will develop, endorse and adopt established guidelines for use by facility staff for appropriate identification and assessment of infections and treatment guidelines . 1. Record review of a face sheet dated 02/08/23 revealed Resident #7 was an 80- year -old male admitted on [DATE]. His diagnoses included elevated white blood cell count (may be high because your body is fighting an infection), chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe), and acute respiratory disease (a serious and widespread infection of the bloodstream). Record review of the Resident #7's MDS dated [DATE] did not reveal active diagnosis of infection or use of antibiotics. Record review of Resident #7's care plan dated 01/05/23 did not reveal care problem addressing use of antibiotics. Record review of Resident #7's physician order dated 12/30/22 revealed Rifampin capsule 300mg 1 capsule BID x 10 days. No diagnosis noted on order. Record review of the antimicrobial stewardship recommendation created between 01/01/23-01/09/23 written by the Pharmacist revealed for Resident #7 . Please consider adding a diagnosis to the computer to support antimicrobial use to the active order for: Rifampin 300mg BID x10 days. 2. Record review of the face sheet dated 02/08/23 revealed Resident #26 was an 89 -year-old male admitted on [DATE] with diagnoses including pneumonia (is an infection that inflames the air sacs in one or both lungs) and infection following a procedure. Record review of the significant change in status MDS dated [DATE] revealed Resident #26 was usually understood and understood others. The MDS revealed Resident #26 had a BIMS of 13 which indicated intact cognition. The MDS revealed Resident #26 had an active diagnosis of pneumonia and received 676154 Page 25 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0881 antibiotic in the last 3 days of the assessment period. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #26's care plan dated 02/08/23 did not reveal care problem addressing use of antibiotics. Residents Affected - Some Record review of Resident #26's physician order dated 12/12/22 revealed Amoxicillin-Potassium Clavulanate tablet; 875-125mg; 1 tablet twice a day. No diagnosis noted on the order. Record review of the antimicrobial stewardship recommendation created between 12/1/22-12/14/22 written by the Pharmacist revealed for Resident #26 . Please consider adding a diagnosis to the computer to support antimicrobial use to the active order for: Augmentin 875mg BID x 7 days. 3. Record review of the face sheet dated 02/08/23 revealed Resident #85 was a [AGE] year-old female admitted on [DATE] with diagnosis including urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). Record review of the quarterly MDS dated [DATE] revealed Resident #85 was understood and understood others. The MDS revealed Resident #85 had a BIMS of 02 which indicated severe cognitive impairment. The MDS revealed Resident #85 had urinary tract infection in the last 30 days. The MDS revealed Resident #85 had 0 days of antibiotics during the assessment period. Record review of Resident #85 care plan dated 07/27/22 revealed history of infection as evidence by actual infection. Intervention included administer antibiotic as prescribed. Record review of Resident #85's physician order dated 12/08/22 revealed Clindamycin capsule; 300mg; 1 capsule oral; three times a day x 7 days. No diagnosis noted on the order. Record review of Resident #85's physician order dated 12/22/22 revealed Bactrim tablet; 800-160mg; 1 tablet; twice a day. No diagnosis noted on the order. Record review of the antimicrobial stewardship recommendation created between 12/1/22-12/14/22 written by the Pharmacist revealed for Resident #85 . Please consider adding a diagnosis to the computer to support antimicrobial use to the active order for: Clindamycin 300mg TID x 7 days. 4. Record review of the face sheet dated 02/08/23 revealed Resident #86 was an [AGE] year-old female admitted on [DATE] with diagnosis including urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). Record review of the admission MDS dated [DATE] revealed Resident #86 was sometimes understood and sometimes understood others. The MDS revealed Resident #86 was unable to complete the BIMS due to being rarely/never understood. The MDS revealed Resident #86 had short-and-long term memory loss. The MDS revealed Resident #86 had a urinary tract infection within the last 30 days and received antibiotic in the last 4 days of the assessment period. Record review of Resident #86's care plan dated 02/17/22 revealed resident has a urinary tract infection. Intervention administer antibiotic as ordered. Record review of Resident #86's physician order dated 03/13/22 revealed Cipro tablet; 250mg; 1 tablet; twice a day. No diagnosis noted on the order. 676154 Page 26 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the antimicrobial stewardship recommendation created between 03/01/22-03/13/22 written by the Pharmacist revealed for Resident #86 . Please consider adding a diagnosis to the computer to support antimicrobial use to the active order for: Cipro 250mg BID x 7 days. During an interview on 02/08/23 at 10:20 a.m., the DON said he was the Infection Control Preventionist for the facility. He said the antibiotic stewardship program met monthly. The DON said the ADON was responsible for reviewing and completing pharmacy recommendation. The DON said diagnosis for the use of the antibiotic should be on the order. The DON said the ADON was responsible for verifying orders which included diagnosis. The DON said he should be overseeing the process. He said it was important to have an appropriate diagnosis for antimicrobial use to ensure medications were giving for the right reason. The DON said he did not want to speculate on the risk of not having a diagnosis for antimicrobial usage. During an interview on 02/08/23 at 11:46 a.m., the ADON said she was responsible for pharmacy recommendations. She said the pharmacy recommendations were sent monthly by the pharmacist. The ADON said she printed the recommendations then faxed and delivered recommendation requiring MD approval. She said she completed the recommendations for nurses. The ADON said she was responsible for ensuring orders had an appropriate diagnosis and did not know why Residents #7, #26, #85, and #86 were not done. She said the original copy was in the antibiotic stewardship program binder and she signed the pharmacy recommendations when completed so if it was not signed, she had not added the diagnoses. The ADON said she ran a report of physician orders, but the report only looked at the end dates and correctly inputted. The ADON said she would have to start running a more involved report to monitor diagnoses of orders. She said it was important to have appropriate diagnosis for antibiotics to ensure medication was susceptible to the infection, make sure medication appropriate for diagnosis, watch for correct symptoms/reactions, and verify pharmacy accuracy. Record review of the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes accessed on 02/12/23 at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-b-508.pdf .other important data elements can be useful for tracking antibiotic use at the facility level .these data elements help identify the reason for inappropriate antibiotic prescribing .indication .tracking antibiotic use by the reason for treatment . 676154 Page 27 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 2 of 13 residents (Resident #10 and Resident #27) reviewed for a homelike environment. The facility failed to ensure Resident #10 and Resident #27's room door stayed closed when latched. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: 1. Record review of the face sheet dated 02/08/23 revealed Resident #10 was [AGE] year-old male admitted on [DATE] with diagnoses including need for assistance with personal care, generalized anxiety (is a feeling of fear, dread, and uneasiness), and insomnia (persistent problems falling and staying asleep). Record review of the quarterly MDS dated [DATE] revealed Resident #10 was understood and understood others. The MDS revealed Resident #10 had a BIMS of 15 which indicated intact cognition and only required supervision for bed mobility. 2. Record review of the face sheet dated 02/06/23 revealed Resident #27 was [AGE] year-old male and admitted on [DATE] with diagnoses including focal (confined to one area of the brain) traumatic brain injury (damage to the brain) with loss of unconsciousness and nondisplaced comminuted fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of right fibula (is a small bone that runs along the outside of the lower leg). Record review of the quarterly MDS dated [DATE] revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS of 06 which indicated severe cognitive impairment. The MDS revealed Resident #27 was independent for bed mobility, transfer, dressing, toilet use, and bathing but needed supervision for personal hygiene. During an observation and interview on 02/06/23 at 10:24 a.m., Resident #27 was lying in bed watching television. This surveyor went to shut the door to conduct interview and the door would not stay latched. Resident #27 said the door had been broken for a while but could not remember how long. He said it did not bother him unless other resident's televisions got too loud. During an interview on 02/06/23 at 11:33 a.m., Resident #10, roommate to Resident #27 said his door did not latch. He said it had been broken at least 6 months. He said maintenance was aware of the issue. Resident #10 said it bothered him that he could not completely shut his room door. During an interview on 02/08/23 at 11:29 a.m., CNA A said Resident #10 and Resident #27's room door did not stay latched when closed. She said she had verbally notified the maintenance assistance of the broken door about 4 months ago. She said the facility did have a maintenance logbook and the facility preferred staff placed issues in the book. She said the door had been broke at least 4 months. 676154 Page 28 of 29 676154 02/08/2023 Capstone Healthcare of Hughes Springs 215 Fm 161 Business South Hughes Springs, TX 75656

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA A said she could not recall Resident #10 complaining about the door being broken. She said neither Resident #10 and Resident #27 required assistance with incontinent care, but Resident #27 was particular about his privacy when he dressed himself. During an interview on 02/08/23 at 1:45 p.m., the maintenance supervisor said Resident #10 and #27's room door was kicked in and broken by the police. The maintenance supervisor said he could not recall the timeframe of the incident. He said he fixed the door and handle but has not been able to fix the striker plate (is a metal plate that is affixed to the doorjamb and has a hole (or holes) that accommodate the lock bolt) that hold the handle in place. The maintenance supervisor said the business office manager was going to look online to find the part because it was hard to find parts in the area. During an interview on 02/08/23 at 2:16 p.m., the DON said he was not aware of how Resident #10 and #27's door gotten broken or that it was broken. He said the facility was working on getting it fixed. During an interview on 02/08/23 at 2:51 p.m., the ADM said the maintenance supervisor had been working on a backlog of work orders. He said the maintenance supervisor was prioritizing worker orders by working on safety issues first. He said the residents deserved a functioning door to provide privacy and the facility was working on getting it fixed. Record review of the maintenance log dated 06/22-02/23 did not reveal work order for Resident #10 and #27's striker plate needing repair. Record review of a facility Maintenance service policy dated 12/00 revealed .maintenance service shall be provided to all areas of the building, grounds, and equipment .the maintenance department is responsible for maintaining the building .in a safe and operable manner .maintain the building in good repair and free from hazards .the maintenance director is responsible for developing and maintaining service to assure that the buildings .are maintained in a safe and operable manner 676154 Page 29 of 29