Health inspection·March 22, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 1 of 5 residents (Resident #7) reviewed for right to be informed about consents. Residents Affected - Few The facility failed to ensure Resident #7 had signed psychotropic consent for Lorazepam (antianxiety). This failure could place residents at risk of receiving medications without their prior knowledge or informed consent, or that of their responsible party. The findings included: Record review of Resident #7's face sheet, dated 03/23/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with the diagnoses which included Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), atrial fibrillation (extremely fast heartbeat), anxiety (feeling of stress) and dementia(impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of Resident #7's annual MDS assessment, dated 02/15/23, indicated Resident #7 was usually understood and usually understood others. Resident #7's BIMs score was 02, which indicated he was cognitively severely impaired. The MDS did not indicate Resident #7 rejected care or had behavior problems. The MDS indicated Resident #7 required total assist with toileting, extensive assistance with bed mobility, dressing, personal hygiene, transfers, and eating. Resident #7 had 7 days of antianxiety medication during the look back period. Record review of Resident #7's medication administration record report, dated 03/22/23, indicated the resident had an order, dated 12/16/22, for Lorazepam 0.5 mg, give one tablet daily three times a week for anxiety. Record review for Resident #7's medication administration record, dated 03/22/23, indicated he received Lorazepam as ordered over last 22 days. Record review of the comprehensive care plan, dated 10/26/22 and updated 02/10/23, indicated Resident #7 had the potential for complications related to psychotropic drug use of Clonazepam and Celexa. The intervention of the care plan indicated staff would give medication as ordered, have consent on Page 1 of 8 676167 676167 03/22/2023 Buckner Westminster Place 2201 Horseshoe LN Longview, TX 75605

F 0552 Level of Harm - Minimal harm or potential for actual harm chart, staff would monitor for side effects, staff would monitor for behavior, pharmacy consultant would monitor for reduction needs as needed. The care plan did not address lorazepam. Record review for Resident #7 consents for use of psychotropic medication, Lorazepam was not documented in his chart. Residents Affected - Few During an interview on 03/21/23 at 3:11 p.m., LVN C said consents should be obtained for all psychotropic medication prior to being given. LVN C said Resident #7 was given Lorazepam for anxiety but did not know his consent was not done until mentioned by the State Surveyor. LVN C said psychotropic medications could change a resident's demeanor and this was why their responsible party should be aware of all medications and the possible side effects from the medications. During an interview on 03/22/23 at 10:18 a.m., the ADON said Resident #7 took Lorazepam 3 x a week since December 2022. The ADON said she was on vacation during the new order and the DON was out sick with COVID and this was how the consent was missed. The ADON said she and the DON usually reviewed new medication or changes in the daily morning meetings and this was their process to ensure consents or other new changes were reviewed and updated. The ADON said they normally got consents for all psychotropic medication because these types of medications could alter the mind and could cause other risks. The ADON said the nurse who received the order was responsible to get the consents. The ADON said it was important for family to know about potential side effects and what medication their loved ones were taking. The ADON said failure to get consents could lead to a side effect and the family would not know why. During an interview on 03/22/23 at 12:04 p.m., LVN D said consents should be obtained for all psychotropic medication prior to being given. LVN D said the family should be notified prior to medications given for potential side effects. LVN D said failure to notify the family could lead them to not knowing about their loves one care or lead to side effects they would not be aware of. During an interview on 03/22/23 at 12:39 p.m., the DON said consents should be signed prior to medication being administered. The DON said one reason consents were obtain was to inform the family about the risk and benefits prior to receiving medications. The DON said the charge nurse who received the order was responsible to obtain consents and the ADON was the overseer. The DON said the pharmacist when at facility would also look for consents. The DON said failure to obtain consents could cause families not to have a choice about resident's care. During an interview on 03/22/23 at 1:21 p.m., the ADM said consents should be done to inform families of risk and/or benefits of medication or a choice to decline. The ADM said the ADON was the overseer of this process. The ADM said failure to get consents could lead to families not having a voice in resident care. During an interview on 03/22/23 at 2:19 p.m. Resident #7's Responsible Party said a staff member came to her house around 1:00 p.m. on 03/22/23 to sign a consent for Lorazepam. The responsible party said she signed the consent. She said she was not aware of Resident #7's Lorazepam medication or side effects prior to consent. During an interview on 03/22/23 at 2:30 p.m., the DON indicated she did not have a policy on consents. She stated they followed state and federal regulations. The DON provided a policy on Medication Management, but it did not reference medication consents. 676167 Page 2 of 8 676167 03/22/2023 Buckner Westminster Place 2201 Horseshoe LN Longview, TX 75605

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 interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 2 of 5 residents (Residents #7 and #12) reviewed for care plan timing and revisions. 1. The facility failed to ensure Resident #7's care plan was updated to include psychotic medication of lorazepam. 2. The facility failed to ensure Resident #12's care plans was updated to reflect a problem for diuretic and interventions. These deficient practices could place residents at risk of not receiving appropriate care to meet their current needs. Findings included: 1. Record review of Resident #7's face sheet, dated 03/23/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), atrial fibrillation (extremely fast heartbeat), anxiety (feeling of stress) and dementia(a term for several diseases that affect memory, thinking, and the ability to perform daily activities). Record review of Resident #7's annual MDS assessment, dated 02/15/23, indicated Resident #7 was usually understood and usually understood others. Resident #7's BIMs score was 02, which indicated he was cognitively severely impaired. The MDS did not indicate Resident #7 rejected care or had behavior problems. The MDS indicated Resident #7 required total assist with toileting, extensive assistance with bed mobility, dressing, personal hygiene, transfers, and eating. Resident #7 had 7 days of antianxiety medication during the look back period. Record review of Resident #7's medication administration record report dated 02/22/23 indicated resident had an order dated 12/16/22 for Lorazepam 0.5 mg, give one tablet daily three times a week for anxiety. Record review of Resident #7's comprehensive care plan, dated 10/26/22 and updated 02/10/23, indicated Resident #7 had the potential for complications related to psychotropic drug use of Clonazepam and Celexa. The intervention of the care plan indicated staff would give medication as ordered, staff would monitor for side effects, staff would monitor for behavior, pharmacy consultant would monitor for reduction needs as needed. The care plan did not address lorazepam. 2. Record review of Resident #12's face sheet, dated 03/23/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included fracture of the femur, dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), edema (swelling), and atrial fibrillation (extremely fast heartbeat). 676167 Page 3 of 8 676167 03/22/2023 Buckner Westminster Place 2201 Horseshoe LN Longview, TX 75605

F 0657 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #12's quarterly MDS assessment, dated 12/27/22, indicated Resident #12 was usually understood and understood others. Resident #12's BIMs score was 05, which indicated she was cognitively severely impaired. Resident #12 required total care with bathing, extensive assistance with bed mobility, dressing, personal hygiene, transfers, toilet use and eating. Resident #12 had 7 days of diuretic medication during the look back period. Residents Affected - Few Record review of Resident #12's comprehensive care plan dated 09/07/22 and revised 12/30/23 did not address Resident #12 being on a diuretic. Record review of Resident #12's physician order report, dated 02/23/23, indicated the resident had an order, dated 09/14/22, for Lasix (furosemide), give one tablet daily for edema. During an interview on 03/21/23 at 2:01 p.m., the ADON said the DON is responsible for care plans but felt someone on a diuretic and or a psychotic medication should have a care plan. During an interview on 03/21/23 at 3:29 PM, the Administrator said she did not feel all medications or diagnoses needed to be on the care plan. The administrator said Resident #12 diuretic did not need to be on the care plan because this resident was not having any edema issues. The Administrator said the DON was responsible for the care plan but the doctor saw all the residents weekly and if they had a change in condition the care plan would be updated. During an interview on 03/22/23 at 12:39 p.m., the DON, who was also the MDS nurse said she was responsible for all care plans. The DON said she did not feel all medications needed to have a care plan if they were stable and there were no problems because the NP saw them weekly. The DON said Resident #12 did not have any problems with edema therefore she did not care plan the medication of Lasix. The DON said if they had any concerns then she would update the care plan. The DON said if she did all medications and or diagnoses, staff would not read the care plan because it would be too much. The DON said the care plans were done to alert staff of resident's current problems. During an interview on 03/22/23 at 2:19 p.m., the NP said she was not sure of nursing home care plans but she would expect a plan of care for Resident #7 because of the swelling in her legs related to her fracture and history of deep vein thrombosis (blood clot). The NP said although she had not seen Resident #12 in a while, she would expect him to have a plan of care if he received Lorazepam. The NP said this needed to be done so staff would be aware of the plan of care. During an interview on 03/22/23 at 12:39 p.m., the DON said they did not have a policy on care plans. She stated they followed state and federal regulations. 676167 Page 4 of 8 676167 03/22/2023 Buckner Westminster Place 2201 Horseshoe LN Longview, TX 75605

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 10 residents (Residents #8 and #4) reviewed for infection control practices. Residents Affected - Few 1. CNA A failed to change her gloves and sanitize her hands after performing peri care to Resident #8. 2. LVN C failed to change gloves and sanitize his hands after cleaning Resident #4's wound and before applying treatment as ordered during wound care. These failures could place residents at risk for infections. Findings include: 1. A record review of Resident #8's, undated, face sheet indicated she was83-years-old who was admitted to the facility on [DATE], with diagnoses which included: fracture of left femur (broken hip), pain in left hip, Alzheimer's Disease (progressive mental deterioration), and acute cystitis (inflammation or infection of the bladder.) A record review of the MDS, dated [DATE], indicated Resident #8 had no speech, was sometimes understood by others, and sometimes understood others. She had short- and long-term memory problems with an altered level of consciousness that fluctuated in severity. She required the extensive assistance of two or more staff for bed mobility, transfer, and toilet use. She was always incontinent of bowel and urine. A record review of Resident #8's care plan, dated 3/9/23, indicated Resident #8 had impaired cognition due to dementia, and impaired communication. The care plan indicated she was incontinent of bowel and bladder. Resident #8 required 1-2 staff for ADL's and 2 staff for transfer. During an observation on 03/21/23 at 10:49 AM, incontinent care was performed by CNA A and CNA B for Resident #8. CNA A did not change her gloves after cleaning Resident #8's peri area that had urine. She touched Resident #8's right hand, shoulder, buttock, knee, clean brief, pants, wheelchair and bed pad with the same gloves. CNA A used the same gloves and never changed her gloves during incontinent care. She washed her hands before and after peri care. During an interview on 3/21/23 at 11:15 AM, CNA A said she should have changed her gloves after cleaning Resident #8's front. She said she did not change her gloves and she touched Resident #8 and items on the bed with her dirty gloves and could have spread infection. She said she realized she had not changed her gloves but felt it was too late to change them once she realized. She said she was taught in CNA school and was taught in the facility that you should change your gloves and sanitize your hands after completing a dirty procedure then put on clean gloves to continue to finish the procedure to prevent the spread of infection. During an interview on 3/21/23 at 11:18 AM, CNA B said she realized CNA A had not changed her dirty gloves but she said it was too late to tell her once she realized it. She said she realized CNA A 676167 Page 5 of 8 676167 03/22/2023 Buckner Westminster Place 2201 Horseshoe LN Longview, TX 75605

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few touched Resident #8's bed, wheelchair and other items with dirty gloves. She said that could have spread germs and CNA A should have changed her gloves after performing peri care. She said they were taught in school and at the facility to take off dirty gloves and sanitize or wash your hands before putting on clean gloves. During an interview and record review, on 3/21/23 at 11:46 AM, LVN C said CNA's who provided incontinent care should always take off their dirty gloves and sanitize or wash their hands before touching anything clean. He said if a staff did not take their dirty gloves off there was a risk of cross-contamination and the spread of infection. He said CNA A and CNA B both were in-serviced on incontinent care while working at the facility. He provided a Proficiency Assessment for CNA A dated 10/25/22 and CNA B dated 11/22/22. The assessments he provided indicated both CNAs were proficient in incontinent care and handwashing. During an interview on 03/21/23 at 12:20 PM, the DON said they did not have a policy on Incontinent Care. She said they used the CNA curriculum. During an interview on 3/21/23 at 1:01 PM, the DON said CNA A and CNA B told her they made a mistake during incontinent care for Resident #8. She said they told her CNA A did not change her dirty gloves. She said not changing gloves could cause cross-contamination and spread infection. She said they used the CNA curriculum for the CNA's. She said it was a book but she could print the page(s) out regarding dirty gloves. She said both CNAs were checked off for incontinent care and handwashing with a demonstration. She said CNA A was checked off by the corporate nurse and CNA B was checked off by the ADON. During an interview on 03/21/23 at 3:29 PM, the Administrator said she expected staff to change their gloves after a dirty procedure. She said touching clean items or a resident with dirty gloves could transmit infection to that resident or other residents through the environment. During an interview on 03/21/23 at 4:12 PM, the ADON said staff should always change gloves after a dirty procedure. She said she always told them they should change gloves at least 3 times when providing incontinent care. She said touching a resident or items with dirty gloves could cause infection transmission that could make someone very sick. Record review of training for CNA A and CNA B revealed computer training, which indicated CNA A had an Infection Control computer-based training on 5/26/22 and she was successful with completion. She provided computer training for CNA B which indicated CNA B had training on Personal Protective Equipment and Cleaning and Disinfecting on 11/17/22 and was successful with both. 2. Record review of Resident #4's face sheet, dated 03/23/23, indicated Resident #4 was an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included diabetes (excess sugar in the blood), high blood pressure and osteoporosis (weak bones). Record review of Resident #4's significant change MDS assessment, dated 01/18/23, indicated Resident #4 was understood and usually understood others. Resident #4's BIMs score was 12, which indicated she was cognitively moderately impaired. Resident #4 required extensive assistance with, transfer, dressing, toilet use, bathing, and limited assistance with bed mobility. The MDS did not indicate during the 7 days prior Resident #4 had wounds. Record review of Resident #4's comprehensive care plan, dated 03/07/23, indicated Resident #4 had 676167 Page 6 of 8 676167 03/22/2023 Buckner Westminster Place 2201 Horseshoe LN Longview, TX 75605

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few skin impairment to the bilateral toes and right heel. The goal of the care plan indicated Resident #4 areas would resolve within the next 90 days. The interventions of the care plan were for the wound care doctor to monitor and update orders as needed, do treatments as ordered, do weekly skin assessments and to monitor for healing. Record review of Resident #4's physician's orders, dated 03/01/23 thru 03/22/23, indicated cleanse wound to right distal 1st toe with normal saline, pat dry and apply Skin Prep (a type of treatment) daily, cleanse wound to left distal 1st toe with normal saline, pat dry and apply skin prep daily and cleanse wound to right posterior medial heel with normal saline, pat dry and apply skin prep daily. During an observation and interview on 03/21/23 at 02:43 PM., LVN C provided wound treatment for Resident #4. LVN C washed his hands, applied gloves, and cleaned wound #1 with normal saline, patted dry, then applied treatment. LVN C proceeded to do wound #2 without washing his hands or applying new gloves. LVN C completed wound care to wound #2 and afterwards he washed his hands and applied new gloves before he performed wound care to wound #3. LVN C said he did not realize he had not washed his hands or changed his gloves between treatment #1 and treatment #2. LVN C said not washing his hands or changing his gloves could lead to infection issues. During an interview on 03/21/23 at 2:01 PM, the ADON said she expected nurses before doing wound care to wash their hands and apply gloves. The ADON said then they should clean the wound, remove dirty gloves, wash their hands, apply new gloves then apply treatment. The ADON said she expected nurses to change their gloves from dirty to clean when doing treatments. The ADON said failure to wash hands or change gloves could lead to infection. During an interview on 03/21/23 at 3:29 PM., the Administrator said she expected staff to change their gloves after a dirty procedure. She said the DON was the overseer for nursing. The Administrator said failure to wash hands or change gloves during care could lead to residents having an infection. During an interview on 03/22/23 at 12:39 PM, the DON said any time anyone went from dirty to clean she expected them to wash their hands and apply new gloves. The DON said LVN C had been trained and completed his competency on wound care sometime last year by the Corporate Nurse. The DON said she was the overseer of the nurses for wound care. The DON said failure to wash hands or change gloves could lead to infection. Record review of LVN C revealed wound care competency was completed and dated 10/27/22. During an interview on 03/22/23 at 2:30 p.m., the DON indicated she did not have a policy on infection control other than covid and tranmission-based precautions. She stated they followed state and federal regulations. The DON provided a policy on Procedural Guidelines #20. A record review of the 2.7.3 Procedural Guideline #20 - Perineal Care/Incontinent Care - Female, dated 1/2022, indicated: a. Wash hands. Wear gloves and follow Standard Precautions . B. Handwashing should be done at the following times . 676167 Page 7 of 8 676167 03/22/2023 Buckner Westminster Place 2201 Horseshoe LN Longview, TX 75605

F 0880 e. After contact with blood, body fluids and contaminated items Level of Harm - Minimal harm or potential for actual harm f. before moving from work on a soiled body site to a clean body site on the same resident . 3. Rules for Standard Precautions Residents Affected - Few A Handwashing: Thoroughly wash your hands or any other skin surfaces that have come into contact with blood or body fluids. Wash hands before and after each resident contact and before applying and after removing gloves. B. Gloves b. Remove and discard gloves (and wash hands) promptly after use . 3. before touching non-contaminated environmental items/surfaces. This may require that you change gloves several times during the care of a single resident 676167 Page 8 of 8