Health inspection·December 9, 2022

F 0567 Honor the resident's right to manage his or her financial affairs. 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 manage the personal funds of the resident deposited with the facility for 2 (Resident #29 and Resident #46) of 2 residents reviewed for with resident rights. Residents Affected - Few The facility failed to ensure Resident #29 and Resident #46 trust fund accounts were spent down to avoid being over the amount allowed to have Medicaid Insurance benefits. This failure could place 2 residents, whose funds are managed by the facility, of losing their Medicaid insurance benefits Findings Included: Resident #29 An interview on 12/8/22 at 8:48 am with the CFO (Chief Financial Officer), he said he handled trust funds spending down trust fund balances and the remaining monies were from the Covid Relief money for Resident #29 and Resident #46, by sending out emails notifying Activities/ Management that the money is over or close to the 2,000-dollar limit. Residents #29 and Resident #46 that have over 2, 000 they investigated pre planned burial plans, but he thought they already had them, but their money will be spent down in the next couple of months. An interview on 12/8/22 at 10:41 am with the Administrator, she said that she was aware of the trust fund balances for Resident #29 and Resident #46 exceeding the amount limit requirements for trust funds with residents with Medicaid. She said that the money is from the Covid Relief funds and the facility have made and continue to make efforts to spend the money down. She said the facility has been in contact with the responsible parties and Medicaid regarding the trust fund accounts and spending. An interview on 12/8/222 at 10:46 am with the Activities Director, she said that the CFO will send emails to management when a trust fund account requires spending down. She said she would then purchase items for residents based on their likes and needs. An interview on 12/8/22 at 11:25 am with the former DON/Contract RN, he confirmed receiving emails from the CFO to spend down monies from the trust fund and would approve spending on items needed by the resident. Review of Resident #29's face sheet dated 12/8/22 revealed she was [AGE] years old year old, admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included traumatic Page 1 of 8 676170 676170 12/09/2022 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0567 amputation and dysphagia (medical term for swallowing difficulties). Level of Harm - Minimal harm or potential for actual harm Review of Resident #29''s Annual MDS assessment dated [DATE] revealed her BIMS (Brief Interview for Mental Status) score was 8 (minimaly impaired cognitively). Residents Affected - Few Review of Resident #29's care plan dated 7/31/2019 revealed she was care planned for areas of care including confusion due to dementia and swallowing. Review of the facility patient fund balances report dated 11/30/22 revealed Resident #29 had a trust fund balance of $2,844.05. Resident #46 Review of Resident #46's face sheet dated 12/8/22 revealed she was [AGE] years old, admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Dementia and muscle weakness. Review of Resident # 46's Annual MDS dated [DATE] under section C-Cognitive Patterns revealed she was severely impaired cognitively. Review of Resident #46's care plan dated 3/12/19 revealed a care plan in the area of Cognitive loss/Dementia. Review of the facility 's patient fund balances report dated 11/30/22 revealed Resident #46 had a trust fund balance of $3,538.9. Review of the facility's policy and procedure entitled Resident Trust Funds' dated revised July 2017 read in part . The CFO will monitor the trust funds and will work to spend down the resident's balance to keep the trust fund under the Medicaid approved asset limits. . 676170 Page 2 of 8 676170 12/09/2022 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure assessments accurately reflected resident's status for 1 of 7 residents (CR #105) reviewed for their MDS. Residents Affected - Few - The facility failed to prevent CR #105 from being inaccurately assessed for being hospitalized when she was instead discharged to community. These failures placed residents at risk for receiving unnecessary services or inadequate care. Findings included: Record review of CR #105's MDS, Section A, dated 10/25/2022, revealed the resident was discharged due to hospitalization. Record review of the CR #105's medical records revealed a medication list and discharge summary on file indicating resident was being discharged home with home health services. In an interview on 12/09/22 at 10:06AM, MDS Nurse A said he incorrectly selected hospitalization on the drop-down list for CR #105, instead of discharge to community due to human error. He said she was a skilled resident. So CR#105's discharge was planned as a scheduled discharge. Review of MDS for CR #105 revealed she had a Return Not Anticipated, dated 10/25/22, which in section A indicated she had been discharged to hospital instead of the community. He said that he did submit the admission and discharge assessments, both original and corrected, to CMS. He said that he used the RAI Manual to complete MDS assessments and for submission of MDS assessments. Record review of the facility's healthcare planning policy, dated September 2012, revealed the purpose of the policy is, . to develop and implement a comprehensive health care plan on each individual resident that summarizes the needs of the resident and the potential and actual problems the resident presents. The RAI Manual, dated October 2019, stated, . The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident ' s status . . 676170 Page 3 of 8 676170 12/09/2022 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for 1 of 6 residents (Resident #12) reviewed for weight loss. 1. The facility failed to ensure Resident #12 had monthly weights documented, as care planned, for the month of July. 2. The facility failed to ensure Resident #12's meal intake records were not being documented as care planned. These failures placed residents with nutrition-related risks at risk of not having their nutritional needs addressed in a timely manner. Findings included: Record review of Resident #12's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with atrial fibrillation and Alzheimer's disease. Record review the physician orders revealed Resident #12 had an active order for pureed diet and fortified food plan starting 11/16/2022. Resident #12's care plan, dated 12/08/2022, revealed the resident was at risk for weight loss related to aging dementia, variable nutritional intake and limited mobility with a goal of maintaining a weight between 150lbs to 160lbs over the next 90 days. Listed interventions for her weight loss included, weekly weight after admission or until stable; monthly thereafter, monitoring and recording amount of meals consumed, and staff are to notify charge nurse if resident persistently leaves 25% or more on meal trays. Record review of Resident #12's vitals revealed resident's weights for the past 6 months were as follows: 6/13/22 - 164.2lbs 8/3/22 - 127.2lbs 9/6/22 - 132.6lbs 10/10/22 - 126.4lbs 11/3/22 - 123lbs Record review of Resident #12's meal intake for the month of December, revealed the resident's meal intake was not recorded on 12/1/2022 - 12/4/2022, 12/7/2022 for breakfast and lunch, and 12/8/2022 for breakfast. Observation on 12/08/2022 at 10:25AM revealed Resident #12 lying with breakfast tray at bedside her 676170 Page 4 of 8 676170 12/09/2022 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0656 with 25-50% of her pureed breakfast meal consumed. Level of Harm - Minimal harm or potential for actual harm In an interview with Charge Nurse D on 12/08/2022 at 10:30AM, he stated all residents were to have their meal intake documented and they were documented for Resident #12 as well. He stated Resident #12 was ordered nutritional shakes, fortified food plan, and supplements to help with her weight loss that has been an ongoing issue for the past few months. Residents Affected - Few In an interview with CNA V on 12/08/2022 at 10:45AM, she stated she assisted Resident #12 with feeding and that day, she ate 50% of her breakfast meal. In an interview with RNA on 12/09/2022 at 10:24AM, she said she knew Resident #12 had not been eating well, received supplements, needed assistance with feedings, and experienced significant weight loss a couple of months ago. She said her process for documenting monthly weights included her printing reports listing all residents in need of monthly weights, weighing the residents, and documenting the weights. She stated she printed a report for weekly weights. She said she worked on the floor as an aide, while doing her best to complete her workload of monthly weights and asked for help when needed. However, if the monthly weight for Resident #12 were not completed in July, then it meant she dropped the ball. In an interview on 12/09/22 at 11:29AM, Unit Manager A ([NAME] RN) said RNA was responsible for obtaining resident weights in the weight loss program and she was the only restorative aide right now with a CNA assigned to assist her. She said that the DON was responsible for the oversight of the weight program at the facility. She said the DON kept a log of who was being weighed and tracked weights. She said the system for meal intake documentation involved the charge nurses reviewing the meal intake records after the CNAs documented thee meal intake percentage and if there was an issue with meal consumption, the charge nurses were to notify the unit managers. She said that she was familiar Resident #12's weight loss and eating habits. She said that she did not update care plans and would have to ask the MDS person about care plans. In an interview on 12/09/22 at 12:33PM, the former DON said RNA was responsible for taking the weight and reporting any discrepancies to the Unit Manager. He stated if Resident 12's care plan calls for the weights to be checked weekly or monthly, then it should be followed and all residents are to have the percent meal intake recorded for every meal per facility policy. In a phone interview on 12/09/22 at 01:04 PM, the Dietitian said she was familiar with Resident #12 and was aware of resident's decline in intake and said the resident often refused most food and supplements. She said that she always asked the restorative and nursing aides for more recent weights to use for her nutrition assessments on residents. In an interview on 12/09/2022 at 1:40 PM, CNA V stated meal intake percentage should have been documented for all residents per the facility's policy. She stated it was important to track how well the patient was eating. She stated the reason for missing documentation in the meal intake record was likely due to the reason of the staff on duty not having the time to fill in the intake records. When asked if she has ever missed the opportunity to document the resident's meal intake for that reason, she did not answer the question and stated she tried to take the meal intake sheet in the residents' rooms with her or sometimes wrote the percentage eaten down on the bottom of the meal ticket to document on the meal intake form later at the end of her shift. In an interview on 12/09/22 at 03:19 PM, Charge Nurse D who said that he reviewed documentation of 676170 Page 5 of 8 676170 12/09/2022 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meal intake records and said that he was not aware of any missing documentation for that week or the month of December. When asked if the CNAs did not complete the documentation as instructed, he did not answer the question but stated they should be reprimanded if they did not. He said negative outcomes or a decline in a resident could be missed if the documentation was not completed and that he would be the first person to reprimand the CNAs and then escalate it up to the unit manager and so on. He said that he did not hear regularly from his CNAs that residents were consuming less than 50% of their meals. Record review of the facility's weight policy, dated August 2021, stated, . all residents are weighed monthly and more often as order by a physician. Record review of the facility's meal intake policy, dated November 2008, stated . 1) The staff responsible for assisting the resident with meals, or the staff member picking up the resident's tray at the end of a meal shall record the meal intake of the resident after each meal. 2) all resident will have documentation daily. 3) Nurses are responsible for ensuring that the meal intake sheets are filled out each shift and are also responsible for having them filled out if is not done . Record review of the facility's healthcare planning policy, dated September 2012, revealed the purpose of the policy is, . to develop and implement a comprehensive health care plan on each individual resident that summarizes the needs of the resident and the potential and actual problems the resident presents. . 676170 Page 6 of 8 676170 12/09/2022 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable for 2 ( Hall 2-B and Hall 3 Medication Carts) out of 3 hall medication carts, reviewed for medication storage. - The facility failed to ensure the Hall 2-B and Hall 3 Medication Cart stored protein supplements had an open date. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: Hall 2-B Medication Cart In an observation and interview on 12/07/22 at 07:38 AM, inventory of the Hall 2-B Medication Cart with MA A revealed: - an open and in use bottle of Pro-Stat, a protein supplement, with no open date and manufacturer's instructions to discard 3 months after opening. MA A said that when a bottle of Pro-Stat was opened it must be labeled with the date in order to track the expiration date and nursing staff checked their carts daily for expired medications. She said she did not know that the protein supplement expired after 3 months and since there was no open date it should be treated as expired. MA A said the bottle of Pro-Stat must be discarded in the trash because its use could place residents at risk for side effects and GI upset. Hall 3 Medication Cart In an observation and interview on 12/07/22 at 07:56 AM, inventory of the Hall 3 Medication Cart with LVN A revealed: - an open and in use bottle of Pro-Stat, a protein supplement, with no open date and manufacturer's instructions to discard 3 months after opening. LVN A said when multidose bottles like Pro-Stat are opened they must be labeled with the date in order to track the expiration and nursing staff are expected to check their carts for expired and inappropriately labeled medications daily as used. She said since the bottle of protein supplement did not have an open date it could not be used and must be discarded. She said the use of expired protein supplement could no longer be used because it could place residents at risk for GI upset. In an interview on 12/07/22 at 11:43 AM, the DON said nursing staff were expected to check their carts daily as used for loose pills and expired or inappropriately labeled medications. He said multi-dose protein supplement bottles should be labeled with the date opened in order to track the expiration date. The DON said he didn't know the shelf life of Pro-Stat and if there is no open date, it should be treated as expired and could no longer be used. He said expired or inappropriately labeled 676170 Page 7 of 8 676170 12/09/2022 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications should be discarded in the drug disposal bin located in the medication room because its use could place resident's at risk for intoxication or GI upset. Record review of the facility policy titled Medication Administration revised September 2018 revealed, General Statements: . 14- All multi-use containers must be labeled with opening date. If container is found to be opened and not labeled, it must be discarded. . 676170 Page 8 of 8