Health inspection·November 17, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to coordinate assessments for the PASARR program for 2 of 7 residents (Residents #20 and #14) reviewed for PASARR. The facility failed to re-screen Residents #20 and #14 for specialized mental disorder services after the residents received new diagnoses of major depressive disorder, and schizoaffective disorder and, bipolar disorder respectively. This failure could place residents with mental illness at risk for not receiving appropriate services and a decreased quality of life. Findings included: A face sheet dated 11/17/22 indicated Resident #20 was an [AGE] year-old female admitted on [DATE] with a diagnosis of schizophrenia and anxiety disorder. On 09/07/22, a new diagnosis of major depressive disorder, recurrent severe without psychotic features was added. PASARR Level 1 Screening dated 08/18/21 Section C was answered No for mental illness, intellectual disability and developmental disability. A face sheet dated 11/17/22 indicated Resident #14 was an [AGE] year-old female admitted on [DATE] with an original admit date of 12/29/2009 with a diagnosis anxiety disorder. On 09/13/22 a new diagnosis schizoaffective disorder, bipolar type was added. PASARR Level 1 Screening dated 04/01/2018 Section C was answered No for mental illness, intellectual disability and developmental disability. During an interview on 11/17/2022 at 09:52 a.m., the DON said the conference he was at was covering the psychosocial and PASARR. He said he realized that the PASARR 2 had not been done . He said going forward, he would be focusing more on PASARR and the evaluations for the residents and would make sure they were complete. He said he was responsible along with the MDS in making sure the PASARR screening was done correctly. During an interview on 11/17/22 at 11:03 a.m., the MDS Nurse said every resident must be screened for PASSAR when admitted . She said if the resident's PASARR was positive, it triggered in the portal. She said she then notified the DON, the Administrator, and the PASSAR Ccoordinator with LMHA. An email is also sent to the PASARR Coordinator. She said in a perfect world, she would have alerted the Page 1 of 5 676229 676229 11/17/2022 Trucare Living Centers-Columbus 1511 Montezuma Street Columbus, TX 78934

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PASARR Coordinator that a PASARR Level 2 was needed, and an assessment needed to be done due to new diagnosis. During an interview on 11/17/22 at 12:36 p.m., the DON said they did not have a policy and procedure for PASARR. He said they followed CMS guidelines. He said he had also received information from the PASARR Coordinator with LMHA. On 11/17/22 at 12:38 p.m., an unsuccessfil attempt was made, by phone made to contact the PASARR Coordinator. A voice message was left. 676229 Page 2 of 5 676229 11/17/2022 Trucare Living Centers-Columbus 1511 Montezuma Street Columbus, TX 78934

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 under sanitary conditions in 1 of 1 kitchen. Residents Affected - Some 1. The facility did not keep baking sheets free of carbon build-up. 2. The facility did not keep steam pans clean. These failures could place residents who receive meals from the kitchen at risk for food borne illnesses. Findings included: During an observation and interview on 11/15/22 at 10:55 a.m. there were 5 large cookie sheets stacked together. Two had a dark brown substance build up on the outside and inside of the pans. There were two 1/2 sized cookie sheets stacked together. One had a dark brown substance build up inside the corners and along the outer edge. There were 4 large deep steam table pans stacked together. Two of the pans had a brown sticky substance and build up on the outer edge. The DM said she was not aware of the condition of the pans and would get them cleaned or replaced. DM said she did not realize the cookie sheets had the carbon build up on them. She said she would clean them. During an interview on 11/16/22 at 11:27 p.m., the DM said she was not able to get the cookie sheets and pans clean, so she was ordering new ones. According to the Texas Food Establishment Rules revised October 2015 §228.113. Cleaning of Equipment and Utensils. Equipment, food-contact surfaces, nonfood-contact surfaces, and utensils. (1) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (2) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations 676229 Page 3 of 5 676229 11/17/2022 Trucare Living Centers-Columbus 1511 Montezuma Street Columbus, TX 78934

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 1 resident (Resident# 65) reviewed for dialysis and for 4 of 5 months reviewed for in-room and one on one activities. 1. The facility did not have an order for Resident #65's dialysis 2. The facility AD did not keep records of in-room and one on one activities for June, July, August, September, and October 2022. The AD did not have the records scanned into the EMRs. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 11/17/22 indicated Resident #65 was a [AGE] year-old male admitted on [DATE]. His diagnoses included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension (high blood pressure), and type 2 diabetes (an impairment in the way the body regulates and uses sugar). Record review of a care plan dated 04/01/22 indicated Resident #65 had end stage renal disease and received dialysis. Record review of an admission MDS assessment dated [DATE] indicated Resident #65 received dialysis. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #65 received dialysis. Record review of the physician orders for November 2022 had no indication Resident #65 had an order for dialysis. During an interview on 11/16/22 at 07:23 a.m. Resident #65 indicated he received dialysis three times a week on Tuesday, Thursday, and Saturday. He said he had no issues with his transportation to and from dialysis. During an interview on 11/17/2022 at 11:40 LVN A indicated she was unsure if there were supposed to be an order for dialysis in the chart. During an interview on 11/17/22 at 11:45 a.m. the DON indicated that there should have been an order in the batch orders for dialysis for any resident on dialysis. He indicated the order should include what days dialysis took place and his chair time. He indicated that the process for physician orders was the nurse receives the orders, the orders were entered into the EMR, and then QA ensured received orders were entered. He indicated the nurse who received the resident at the time of reentry would have been responsible for obtaining an order for dialysis and entering the order into the EMR. 676229 Page 4 of 5 676229 11/17/2022 Trucare Living Centers-Columbus 1511 Montezuma Street Columbus, TX 78934

F 0842 Level of Harm - Minimal harm or potential for actual harm 2. Record review of the in-room and one on one activities documentation indicated there was no documentation for July, August, September, and October 2022. During an interview on 11/15/22 at 10:30 a.m. the AD said she did not have the documentation of the In-Room and One on One Activity except for November 2022. Residents Affected - Some During an interview on 11/17/22 at 11:16 a.m. the AD said she did not realize her documentation of one-on-one and in-room activities were part of the resident clinical record, so she did not keep copies. She said there were 8 residents who received one-on-one or in-room activities. Record review of the policy provided was not relevant to the lack of documentation. A policy for physician orders was not provided prior to exit. 676229 Page 5 of 5