Health inspection·October 4, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 9 residents (Resident #1) reviewed for ADL's. Residents Affected - Some The 2:00 p.m. - 10:00 p.m. shift failed to consistently provide showers/bed baths and daily clothing changes for Resident #1, who was physically impaired, for at least two months and resulted in body odors. This failure could place ADL dependent residents at risk of experiencing embarrassment from odors, infection, and skin breakdown. Findings include: Record review of Resident #1's face sheet dated 09/05/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (when the blood supply to part of the brain is blocked or reduced), morbid obesity (when a person has a body mass index of 40 or higher), urinary tract infection (bacterial infection that affects the urinary tract), muscle weakness, acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), diabetes (a group of diseases that result in too much sugar in the blood), dementia (a group of thinking and social symptoms that interfere with daily functioning), and depression (a group of conditions associated with the elevation or lowering of a person's mood). Record review of Resident #1's quarterly MDS dated [DATE] revealed she was usually able to express ideas and wants and she was usually able to understand others; Resident #1 had a BIMS score of 7 (severe cognitive impairment); Resident #1 did not reject care; she was wheelchair bound; she was totally dependent on staff for toileting, showers/bathing and lower body dressing and she was substantially/maximally dependent on staff for assistance with upper body dressing, oral hygiene, and personal hygiene; Resident #1 was incontinent of bowel and had an indwelling urinary catheter. Record review of Resident #1's care plan revised on 09/02/2024 revealed the following care areas: * Resident #1 requires extensive - total assistance with ADL's. Goal included: Will maintain a sense of dignity by being clean, dry, odor free, and well groomed. Interventions included: Encourage independence, praise when attempts are made. Provide set-up, assist, give shower, shave, oral, hair, nail care scheduled and PRN. Provide set-up, assist with dress according to climate and monitor Page 1 of 8 676207 676207 10/04/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0677 appearance. Level of Harm - Minimal harm or potential for actual harm * Residents Affected - Some Resident #1 requires extensive - total assistance with ADL's. Goal included: Will maintain a sense of dignity by being clean, dry, odor free, and well groomed. Interventions included: Assist with ADL functional mobility as needed. Provide up to 1:2 assistance with transfers as needed. Assist with repositioning as appropriate. Offer tray set-up, assist with verbal cueing/feeding as needed. Record review of the facility's undated document titled, Shower Schedule revealed Resident #1's was to receive showers on Mondays, Wednesdays, and Fridays during the 2:00 p.m. - 10:00 p.m. shift. Record review of Resident #1's computer generated shower documentation for 07/01/2024 - 08/31/2024 revealed the following days were checked Yes for bathing: 07/08/2024, 07/30/2024, 07/31/2024, 08/03/2024, and 08/16/2024. Record review of Resident #1's shower sheets for July 2024, August 2024, and September 2024 revealed there were no sheets available for review prior to 09/05/2024. In an interview with the Administrator on 09/05/2024 at 12:35 p.m., she stated Resident #1 had missed a few shower days, but staff gave the showers the next day. She stated Resident #1's family voiced a few grievances about missed showers, but the showers were given on the next day. She said to her knowledge, Resident #1 never missed a shower that was not given the next day. She stated she could not give the dates Resident #1's family voiced grievances because she had already erased the text messages. Observation and interview with Resident #1 on 09/05/2024 at 1:15 p.m. revealed she was in bed, asleep. She woke up to verbal stimuli but was still very sleepy. Resident #1 was alert and oriented and did not exhibit any odors. She stated she did not always get her shower or bed bath like she was supposed to. She said her family spoke to staff about her showers and not changing her clothes because they said she sometimes had an odor. She stated she did not really know how she felt about not getting showers/bed baths and not having her clothes changed daily. Observation of Resident #1's room at that time revealed there was a sign over her bed that read, Please Change Clothes Every day!!! RP's name and number. Shower Days: M-W-F 2-10 Shift!!! In an interview with LVN C on 09/05/2024 at 1:37 p.m., she stated she always worked the 6:00 a.m. - 2:00 p.m. shift. She stated they have designated CNAs, so they know each other's routines. She said as a nurse, she did rounds room to room, she knew if her residents had been touched (been given showers or provided incontinent care). She said Resident #1 was alert and oriented x 3-4 (indicates level of awareness and orientation. 3 is the highest level of orientation but situational questions would make highest level 4). She said Resident #1 made her needs known, but you would have to ask yes and no questions. She said Resident #1 knew what was going on. She said Resident #1 was bed bound since she had a stroke (when blood flow to the brain is disrupted). She said Resident #1 did not refuse care and should have showers on the 2:00 p.m. - 10:00 p.m. shift. She said sometimes, her 6:00 a.m. - 2:00 p.m. CNA took the initiative and gave Resident #1 a shower on their shift. She said when Resident #1 missed a shower day, she had a urine or yeasty smell. She said Resident #1's left hand was closed (contracted) due to stroke, so staff must get inside her hand and clean it. She said Resident #1 did not get showers on the 2:00 p.m. - 10:00 p.m. shift often. She stated the staff did document showers on shower sheets and they were supposed to document when any resident refused. She said if 676207 Page 2 of 8 676207 10/04/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a resident refused a shower, the nurse went and talked to the resident to see if they could get them to take the shower. She stated Resident #1's family complained about the odors several times within the past month or so and they have been very patient. She said on her hall (100 hall), there should be five showers on each shift. She stated her CNA (on the 6:00 a.m. - 2:00 p.m.), CNA D has been giving Resident #1 showers because they tried to accommodate Resident #1's family as best they could, but it was not fair that the 2:00 p.m. - 10:00 p.m. shift had not been held accountable. She said they all had a job to do and some days, it was hard to get Resident #1 her shower and she had to miss those days. She stated Resident #1's family requested that staff change her gown daily and the 2:00 p.m. - 10:00 p.m. shift should be the ones to change her gown on her off-shower days. She said they let the next shift know during report if they did Resident #1's shower or if they changed her gown. In an interview with CNA D on 09/05/2024 at 1:50 p.m., she stated she always worked the 6:00 a.m. - 2:00 p.m. shift. She stated Resident #1 was easy to get along with. She said Resident #1 was alert and you only had to ask her what she wanted. She stated she gave Resident #1 showers/bed baths on Mondays, Wednesdays, and Fridays during her shift because the family had concerns about the 2:00 p.m. - 10:00 p.m. shift not doing it. She said when she works on those days, she does Resident #1's showers. She said she did not know if any other CNAs from the 6:00 a.m. - 2:00 p.m. shift did Resident #1's showers when she was on at work. She said Resident #1 never refused care because she liked to be clean. She said Resident #1 got bed baths. She said she could tell Resident #1 was not getting showers because of the yeast odor from her body. She said she smelled the odor after she returned to work after Resident #1's scheduled shower days. She said depending on who worked the hall, Resident #1's shower would not get done. She said the other shift was not doing what they were supposed to do and Resident #1's family had been patient. She said when she arrived to work in the mornings, she could tell if Resident #1 had been touched or not because she had the same thing on when she left day before. She said frequently when Resident #1 did not get changed (clothing change), she found feces stains and odors on her gown and her family complained. She said she confronted staff from the 2:00 p.m. - 10:00 p.m. shift and they said they did bathe Resident #1. She said she knew they were not bathing Resident #1 because of how she smelled. She said she did not know if the other shift documented the showers/bed baths. She said LVN C often tells the other shift they had to bath Resident #1. She said her shift was not responsible for changing Resident #1's gown daily. In an interview with the Administrator and the DON on 10/04/2024 at 1:01 p.m., the Administrator stated Resident #1's family complained twice about her not receiving showers/bed baths and not being changed (clothing changes), but she received the showers/bed baths and had her clothes changed right after the Administrator was notified by the family. The Administrator said they investigated the complaints on both occasions, which prompted them to do a PIP related to showers and clothing changes. The Administrator said the PIP was initiated after the state surveyor's visit on 09/05/2024. She said based on the PIP, they started making staff document showers on shower sheets because the shower documentation staff entered into the computer system did not always capture that showers were given. The Administrator stated after the state brought the issue to their attention on 09/05/2024, they started doing shower sheets. The Administrator said after each shower, the shower sheet and validated and signed by the charge nurse, then given to the unit manager. The Administrator said the shower sheets are brought to the morning meetings and discussed to ensure each resident received their scheduled showers. The Administrator said each department head was assigned to a hall, so each resident had a guardian angel to check on them daily and share their concerns. The DON said Resident #1's family never voiced concerns opposing bed baths instead of showers. The Administrator said not having showers/bed baths 676207 Page 3 of 8 676207 10/04/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0677 and clothing changes could lead to psychosocial affects, a mental decline, and infection. Level of Harm - Minimal harm or potential for actual harm In a telephone interview with Resident #1's RP on 10/04/2024 at 3:45 p.m., she stated she visited the resident daily throughout the week and another family member visited on Saturdays and Sundays. She stated since she started having problems with Resident #1 getting showers and clothing changes several months ago (she could not recall exactly when the problem started), she and other family members started visiting at night as well. She stated the problem was on the 2:00 p.m. - 10:00 p.m. shift. She stated CNA D from the 6:00 a.m. - 2:00 p.m. shift treated Resident #1 very well and made sure she had showers on that shift. She stated Resident #1 did not get showers unless CNA D gave them. She stated she sent the Administrator a text message on 07/30/2024, saying Resident #1 had not been bathed and she had on the same gown for multiple days. She stated she could smell Resident #1 as she entered her room when she did not receive showers. She stated Resident #1 was found with the same gown on for multiple days several times, so she started taking pictures of her. She said some of the dates included: 08/03/2024 08/04/2024, 08/16/2024 - 08/17/2024, 09/06/2024 - 09/08/2024, and 09/14/2024 - 09/16/2024. She stated Resident #1 was transported to a local ER on [DATE] and the staff in the ER had to change the resident's gown because it smelled sour. She said Resident #1 returned to the facility on [DATE] and still had the same gown she had on in the ER on [DATE]. Residents Affected - Some Record review of the facility's policy titled, Activities of Daily Living dated May 2016 revealed, 1. Every effort must be made to assure that assignments of nurses and nurse aides to patients are as consistent as possible . 5. CNA ADL Tracking Record must be maintained in accordance with the MDS coding guidelines and specific to the patient's individual needs. CNA ADL Tracking Records must be regularly monitored by the DON or designee to ensure that tasks are being performed as scheduled. 6. The Monthly Quality Assurance and Performance Improvement Meeting must include a review of consistency in providing assistance to patients in activities of daily living . Record review of facility document titled, Performance Improvement Plan dated 09/05/2024 revealed, . Problem Area Identified: 2-10 showers not being documented . Changes Implemented to reach Baseline: 1. DON, ADON, UM will make shower sheets for each day/shift and give them to charge nurse. 2. Charge Nurse will provide CNA with shower sheet for their scheduled showers for that day. 3. CNA will complete shower sheet and give back to charge nurse to validate prior to end of their shift. 4. Shower sheets will be given back to the nurse management team in clinical stand up for the previous day. 5. Nurse management will validate that all showers were completed by verifying shower sheets with schedule. 6. Any missing showers will be given that day. 7. All shower sheets will be kept in a binder in the DON's office . 676207 Page 4 of 8 676207 10/04/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 of 3 residents (Resident#1) reviewed for incontinent care and for indwelling urinary catheters. -The facility failed to ensure Resident #1's catheter stabilizer was in place on 09/20/2024. This failure could place residents with urinary catheters at risk for accidental dislodgement of the catheter and trauma to the bladder and urethra. Findings included: Record review Resident #1's (undated) face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (when the blood supply to part of the brain is blocked or reduced), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and retention of urine (difficulty urinating and completely emptying the bladder). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS score 6 out of 15 which indicated she had severe cognitive impairment. She required substantial/maximal assistance with personal hygiene and dependent on staff with toileting hygiene, shower/bathe, upper body dressing and lower body dressing. Further review of section H0100 revealed she had an indwelling catheter. Record review of Resident#1's care plan initiated 03/08/2024 and revised on 04/01/2024 revealed the following: Problem: (Resident #1) is dependent on an indwelling catheter, potential for complications such as recurrent UTIs' DX: Urinary retention. 9/2/24-Candida Auris per E.R. visit (contact isolation). Goals: (Resident #1) will remain free of urinary tract infection during period of catheterization in the next 90 days. Interventions: Change foley catheter tubing and bag per order. Ensure leg strap or other method to secure catheter is in place unless contraindicated. Observation and interview on 09/20/2024 at 3:31p.m., revealed CNA/Activity and CNA B provided Resident#1 with foley catheter/incontinent care. Resident#1 had an indwelling catheter draining yellow urine to a catheter bag on the left side of her bed. The catheter tubing was not secured to Resident's leg with an anchor. CNA/Activity said the adhesive of the stabilizer was not sticking to the resident's leg after she attempted to reapply it. CNA/Activity said the stabilizer was used to prevent the catheter from being pulled on or out of place. She said nurses were responsible for ensuring the stabilizer was in place. In an interview on 09/20/2024 at 4:02p.m., LVN AA said he had not seen Resident #1 when he rounded. He said Resident #1's catheter stabilizer was used to keep the catheter in place to prevent it from being pulled out and/or injury. He said he relied on the CNAs to inform him if the catheter 676207 Page 5 of 8 676207 10/04/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0690 Level of Harm - Minimal harm or potential for actual harm stabilizer was not secured. He said nurses and CNAs were responsible for monitoring resident catheters. He said they should have made more frequent rounds. In an interview on 09/20/2024 at 4:36p.m., DON said it was nursing responsibility to ensure a resident's indwelling catheter was anchored in place to keep the tubing in place so it would not pull taut. Residents Affected - Few Record review of facility's Catheter Care, Urinary policy (Revised September 2014) read in part: .Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note. Catheter tubing should be strapped to the resident's inner thigh) . 676207 Page 6 of 8 676207 10/04/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

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 observations, interviews, 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 infection for 1 of 3 residents (Resident #1) reviewed for infection. Residents Affected - Few -The facility failed to ensure CNA B performed hand hygiene after removing soiled gloves and before applying new gloves while providing Resident #1 incontinence care. CNA B touched items in Resident #1's environment including the resident's bedside drawer, container of barrier cream, dress, clean brief, and sheets, while wearing soiled gloves. This failure could place residents at risk for the spread of infection Findings included: Record review of Resident #1's (undated) face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (when the blood supply to part of the brain is blocked or reduced), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and retention of urine (difficulty urinating and completely emptying the bladder). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS score 6 out of 15 which indicated she had severe cognitive impairment. She required substantial/maximal assistance with personal hygiene and dependent on staff with toileting hygiene, shower/bathe, upper body dressing and lower body dressing. Further review of section H0100 revealed she had an indwelling catheter. Record review of Resident #1's care plan initiated 03/08/2024 and revised on 04/01/2024 revealed the following: Problem: (Resident #1) is dependent on an indwelling catheter, potential for complications such as recurrent UTIs' DX: Urinary retention. 9/2/24-Candida Auris per E.R. visit (contact isolation). Goals: (Resident #1) will remain free of urinary tract infection during period of catheterization in the next 90 days. Interventions: Change foley catheter tubing and bag per order. Ensure leg strap or other method to secure catheter is in place unless contraindicated. Observation on 09/20/2024 at 3:31p.m., revealed CNA/Activity and CNA B provided Resident#1 with foley catheter/incontinent care. CNA/Activity entered the room, washed her hands applied double gloves, unfasten the resident's brief and tucked it under the resident's buttocks. CNA/Activity provided foley catheter care. Removed one pair of soiled gloves and assisted Resident #1 turn to onto her right side to clean her buttocks. Resident had a small bowel movement. CNA B removed the soiled brief and discarded it into the clear bag sitting near resident's foot of bed. Removed soiled gloves and without sanitizing/washing her hands applied clean gloves wiped x3. CNA B with the same soiled gloves looked for the barrier cream in the resident's side drawer. Applied barrier cream and completed incontinent care and with the same soiled gloves touched the Resident's clean dress, brief, and sheets. CNA/Activity picked up trash, removed the 2nd pair of soiled gloves and left the room without 676207 Page 7 of 8 676207 10/04/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0880 sanitizing or washing her hands. Level of Harm - Minimal harm or potential for actual harm In an interview on 09/20/2024 at 3:57p.m., with CNA/Activity, CNA B and the Administrator. CNA B said not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-services on infection control last month but could not recall the exact date. CNA B said CNA/Activity should not have double gloved. CNA/Activity said she applied double gloves to prevent infections. Administrator said, we don't double glove. Residents Affected - Few In an interview on 09/20/2024 at 4:36p.m., with the DON, she said CNAs should have either washed or sanitized their hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said these failures were risk for infection control. DON said CNA/Activity should not have double gloved she needed to use standard precautions. She said staff received in-service on infection control monthly. Record review of the Infection Control Policy (Reviewed & Revised [DATE]) revealed read in part: .1. The facility must establish an infection prevention and control program (IPCP) that must include: a. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all patients, under a contractual agreement based upon the facility assessment. b. Staff, volunteers, visitors, and other individuals providing services will not be allowed to work if a communicable disease is diagnosed . Record review of the facility's Hand Hygiene policy (Revised August 2015) revealed read in part: . Policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care; m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . 676207 Page 8 of 8