Health inspection·May 10, 2023

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. 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 assess each resident quarterly (every 3 months) using the Minimum Data Set (MDS) specified by the state and approved by CMS for 1 of 4 resident (Resident #18) reviewed for quarterly assessments. Residents Affected - Few The facility failed to ensure Resident #18's MDS assessment was completed within three months of her last assessment. This failure could place residents at risk for not having their assessments completed timely and not having their individually assessed needs met. The findings included: Record review of Resident #18's face sheet, dated 05/10/2023, revealed Resident #18 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of unspecified fracture of lower end of right humerus, subsequent encounter for fracture with routine healing (broken arm near the elbow that was healing with no complications). Record review of Resident #18's electronic medical record, accessed on 05/10/2023, revealed an admission MDS assessment with an ARD of 12/20/2022. The electronic medical record further revealed Resident #18 had a discharge return not anticipated MDS assessment dated [DATE] with no quarterly assessment completed prior to discharge. This was more than 3 months between MDS assessments. During an interview on 05/10/2023 at 5:18 PM, MDS Nurse C stated quarterly MDS assessments should have been completed every 3 months. MDS Nurse C stated Resident #18 should have had a quarterly MDS assessment completed prior to discharge. MDS Nurse C stated a quarterly MDS assessment was not completed for Resident #18 because of human error. MDS Nurse C stated completing quarterly MDS assessments was important because it was regulatory and to capture Resident #18's current status. During an interview on 05/10/2023 at 6:14 PM, the Administrator stated she expected the MDS Nurses to complete quarterly MDS assessments in a timely manner. The Administrator stated MDS assessments were monitored in the electronic charting system by pulling reports. The Administrators stated completing quarterly MDS assessments was important for timely payment of services. Record review of the CMS RAI Version 3.0 Manual, last revised in October 2019, revealed that the ARD must be ARD of previous OBRA assessment of any type + 92 calendar days. Page 1 of 16 676235 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 an encoded, accurate, and complete annual comprehensive MDS assessment was transmitted to the CMS System within 14 days after completion for 2 of 5 residents (Residents #24 and #49) reviewed for MDS assessments transmissions. Residents Affected - Few The facility did not ensure Resident #24's and Resident #49's discharge MDS assessments were transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. The findings included: 1. Record review of Resident #24's face sheet, dated 05/10/2023, revealed Resident #24 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of nondisplaced fracture of first metatarsal bone, right food, subsequent encounter for fracture with routine healing (fracture of a bone in the foot with normal healing). Record review of Resident #24's discharge MDS assessment, dated 02/17/2023, revealed the MDS assessment was signed completed by the RN on 03/03/2023, which indicated the assessment was transmitted 12 days late. Record review of the MDS 3.0 NH Final Validation Report, completed on 03/28/2023, revealed for Resident #24 Record Submitted Late: The submission date is more than 14 days after Z0500B [RN sign date] on this new (A0050 equals 1) assessment. 2. Record review of Resident 49's face sheet, dated 05/10/2023, revealed Resident #49 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of acute embolism and thrombosis of left popliteal vein (blood clot behind the knee). Record review of Resident #49's discharge MDS assessment, dated 01/07/2023, revealed the MDS assessment was completed on 01/19/2023, which indicated the assessment should have been transmitted by 02/01/2023. Record review of the MDS 3.0 NH Final Validation Report, from January 2023 - May 2023, revealed Resident #49's discharge MDS assessment had not been transmitted. During an interview on 05/10/2023 at 5:18 PM, MDS Nurse C stated she was responsible for ensuring MDS assessments were transmitted. MDS Nurse C stated discharge MDS assessments should have been transmitted regardless of payor source. MDS Nurse C stated Resident #49's discharge MDS assessment had been pulled over from a previous assessment that was not required to be transmitted because of his payor source. MDS Nurse C stated she forgot to ensure that the discharge MDS was not marked so it would be transmitted. MDS Nurse C stated Resident #24's MDS assessment was transmitted late due to human error. MDS Nurse C stated she referred to the RAI Manual for timeframes for transmitting MDS assessments. MDS Nurse C stated transmitting MDS assessments were important because it was a regulatory requirement. 676235 Page 2 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/10/2023 at 6:14 PM, the Administrator stated she expected the MDS Nurses to ensure MDSs were transmitted timely. The Administrator stated it was monitored by reports in the electronic charting system and validation reports. The Administrator stated it was important to ensure MDS assessments were transmitted and transmitted timely for timely payment of services. Review of the CMS RAI Version 3.0 Manual, dated October 2019, revealed that discharge assessments 676235 Page 3 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

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 observation, interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 1 of 21 residents reviewed for MDS accuracy. (Resident #40) Residents Affected - Few The facility failed to accurately document Resident #40's bladder status of having an indwelling urinary/foley catheter (tube inserted into the resident's bladder to drain urine) on the MDS. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #40's face sheet dated 5/09/23 revealed she was a [AGE] year-old female, who readmitted to the facility on [DATE]. Resident #40 had diagnoses of urinary retention (difficulty urinating or emptying the bladder) and history of a cerebral infarction (stroke-parts of the brain die due to a lack of adequate blood supply to the brain cells). Record review of Resident #40's quarterly MDS dated [DATE] did not indicate the resident had a urinary catheter. Record review of Resident #40's comprehensive care plan with a last review date of 5/09/23 revealed there were no care areas to address the care of the foley catheter. Record review of Resident #40's Order Summary Report dated 5/09/23 revealed orders to change foley catheter every 24 hours as needed for blockage or dislodgement and foley catheter care every shift with start date of 3/20/23. Record review of Resident #40's Nursing Progress Note dated 3/20/23 revealed the resident was readmitted to the facility from the hospital with a foley catheter. During an observation on 5/08/23 at 11:26 AM Resident #40 observed to have an indwelling foley catheter with yellow urine noted in the catheter bag hanging on side of the bed below the bladder level. During an interview on 5/10/23 at 3:52 PM MDS Coordinator E said she had worked at the facility for 2 years, but she had been training for two weeks as the second MDS Coordinator. MDS Coordinator E said when a resident came back from the hospital the MDS Coordinator would review the hospital records, orders, medication list, nursing assessments, diagnoses, and any changes in condition to have an accurate assessment of the resident on the MDS. MDS Coordinator E said if a resident did not have a foley catheter when they went into the hospital but came back to the facility with a foley catheter, then it would need to be included on the MDS assessment completed after the resident returned to the facility. MDS Coordinator E said if the foley catheter was not captured on the MDS assessment, then it would most likely not be included on the care plan. MDS Coordinator E said Resident #40's 3/24/23 quarterly MDS did not include her foley catheter she returned to the facility with from the hospital, therefore it was not an accurate assessment of the resident. MDS Coordinator E said it was important the MDS assessment was accurate to make sure the facility received proper reimbursement and to make sure the care plan reflected what care the resident needed. During an interview on 5/10/23 at 4:08 PM MDS Coordinator F said the facility's census almost 676235 Page 4 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0641 Level of Harm - Minimal harm or potential for actual harm doubled in a short time and she just received help recently. MDS Coordinator F said she must have just missed Resident #40 had a foley catheter when she returned to the facility from the hospital. MDS Coordinator F said it was the responsibility of the MDS Coordinator to ensure the MDS assessment was an accurate assessment of the resident. MDS Coordinator F said if the MDS assessment was not accurate, the care plan would not be updated and could affect the care the resident received. Residents Affected - Few During an interview on 5/10/23 at 4:20 PM the DON said he had worked at the facility since March 20th, 2023. The DON said he would expect the MDS assessment to be accurate to capture new changes, such as a new foley catheter, so it could be care planned appropriately to meet the care needs of the resident. During an interview on 5/10/23 at 4:41 PM the Administrator said the MDS Coordinator was responsible for the accuracy of the assessments. The Administrator said she would expect the MDS assessments to be an accurate assessment of the resident to reflect the needed care areas for the resident. Record review of the facility's undated policy titled, Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy, indicated . purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who were familiar with his/her physical, mental, and psychosocial well-being . each individual responsible for a portion of the MDS assessment must sign and certify that their portion of the assessment was accurate and complete . 676235 Page 5 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0642 Ensure a qualified health professional conducts resident assessments. 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 a registered nurse signed and certified that the MDS assessment was completed for 1 of 5 residents (Resident # 36) reviewed for MDS completion. Residents Affected - Few The facility failed to ensure the RN signed Resident #36's discharge MDS assessment as completed. This failure could place residents at risk for incomplete or inaccurate documentation that does not completely reflect the resident's current status. The findings included: Record review of Resident #36's face sheet, dated 05/10/2023, revealed Resident #36 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of COVID-19 (acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions). Record review of Resident #36's MDS assessment, dated 01/06/2023, revealed no RN signature in section Z. Record review of the MDS 3.0 NH Final Validation Report, submitted on 01/17/2023, revealed Resident #36's MDS was rejected for Z0500B Invalid Date: This item must contain a valid date in YYYYMMDD format or allowable special character(s). During an interview on 05/10/2023 at 5:18 PM, MDS Nurse C stated an RN should have signed Resident #36's MDS assessment as completed. MDS Nurse C stated during the month of January 2023, RN K was responsible for ensuring the MDS assessments were signed as completed. During an interview on 05/10/2023 at 5:30 PM, RN K stated she was responsible for signing the MDS assessments during the month of January 2023. RN K stated she was unsure why Resident #36's MDS assessment was missed. RN K stated she was notified of MDS assessments that were ready to have been signed verbally, via e-mail, or on a post-it note. RN K stated it was important to ensure MDS assessments were signed as completed to ensure accuracy of the services that were provided. During an interview on 05/10/2023 at 6:14 PM, the Administrator stated she expected the RN to sign when MDS assessments were completed. The Administrator stated it was important to ensure timely payment of services. Record review of the MDS 3.0 RAI Manual, dated October 2019, revealed that Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete. 676235 Page 6 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

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, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 21 residents reviewed for care plans. (Resident #40). The facility failed to develop and implement a care plan for Resident #40 having a urinary/foley catheter (tube inserted into the resident's bladder to drain urine). This failure could place residents at risk for not receiving necessary care and services or having important care needs identified. Findings included: Record review of Resident #40's face sheet dated 5/09/23 revealed she was a [AGE] year-old female, who readmitted to the facility on [DATE]. Resident #40 had diagnoses of urinary retention (difficulty urinating or emptying the bladder) and history of a cerebral infarction (parts of the brain die due to a lack adequate blood supply to the brain cells). Record review of Resident #40's quarterly MDS dated [DATE] did not indicate the resident had a urinary catheter. Record review of Resident #40's comprehensive care plan with a last review date of 5/09/23 revealed there were no care areas to address the care of the foley catheter. Record review of Resident #40's Order Summary Report dated 5/09/23 revealed orders to change foley catheter (urinary catheter) every 24 hours as needed for blockage or dislodgement and foley catheter care every shift with start date of 3/20/23. There was an order to keep the foley catheter in place for chronic urinary retention and neurogenic bladder with a start date of 4/05/23 and an order to empty the drainage bag every shift for urinary tract infection with a start date of 4/24/23. Resident #40 also had an order for ciprofloxacin (antibiotic used to treat infections) 500 MG by mouth two times daily for 10 days for a urinary tract infection with a start date of 5/05/23. Record review of Resident #40's Nursing Progress Note dated 3/20/23 revealed the resident was readmitted to the facility from the hospital with a foley catheter and had a urinary tract infection. Resident #40's Nursing Progress Note dated 4/05/23 revealed the resident had gone to the urologist and had orders to keep the foley catheter due to chronic urinary retention. During an observation on 5/08/23 at 11:26 AM Resident #40 observed to have an indwelling foley catheter with yellow urine noted in the catheter bag hanging on side of the bed below the bladder level. During an interview on 5/10/23 at 1:49 PM RN D said the MDS coordinator was responsible to update the care plan when a resident returned from the hospital. RN D said the nurses could update the care plan as needed for any changes in the resident's care needs. RN D said she had just recently received training to update the care plan in the software, but she was not sure how to update the care plan and needed additional training. RN D said a resident with a foley catheter should have a care plan to let all staff know how to care for the catheter. RN D said the purpose of the care plan was so 676235 Page 7 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0656 staff would know how and what care the resident required to meet their needs. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/10/23 at 3:52 PM MDS Coordinator E said she had worked at the facility for 2 years, but she had been training for two weeks as the second MDS Coordinator. MDS Coordinator E said when a resident came back from the hospital the MDS Coordinator would review the hospital records, orders, medication list, nursing assessments, diagnoses, and any changes in condition to have an accurate assessment of the resident on the MDS. MDS Coordinator E said if a resident did not have a foley catheter when they went into the hospital but came back to the facility with a foley catheter, then it would need to be included on the MDS assessment completed after the resident returned to the facility. MDS Coordinator E said if the foley catheter was not captured on the MDS, then it would not be included on the care plan. MDS Coordinator E said the purpose of the care plan was to let staff know what care the resident required to meet their needs. MDS Coordinator E said there needed to be a specific care plan for a foley catheter so everyone would know what care the resident required to meet their needs. MDS Coordinator E said Resident #40's 3/24/23 quarterly MDS did not include her foley catheter she returned to the facility with from the hospital. Residents Affected - Few During an interview on 5/10/23 at 4:08 PM MDS Coordinator F said the facility's census almost doubled in a short time and she just received help recently and she must have just missed Resident #40 had a foley catheter when she returned to the facility from the hospital. MDS Coordinator F said she did not feel that the MDS not being accurate affected the resident, but if the care plan was not updated, it could affect the care the resident received. During an interview on 5/10/23 at 4:20 PM the DON said he had worked at the facility since March 20th of this year. He said the MDS Coordinator was responsible for updating the long-term care plans and the nurses were responsible for updating the care plans for acute care changes or needs. The DON said the care plans were something he was working on with training nursing staff on how, when, and what should be care planned to meet the needs of the resident. The DON said Resident #40's foley catheter should have been care planned with the problems that go with having a foley catheter and should have interventions for the nurses/staff to be checking and care to be provided. The DON said not having the foley catheter care planned could result in the resident having a lack of appropriate care for the foley catheter. The DON said he would expect the MDS assessment to be accurate to capture new changes, such as a new foley catheter, so it could be care planned appropriately to meet the needs of the resident. The DON said he planned to audit all the resident's care plans to ensure their accuracy, but the care plans were a work in progress. During an interview on 5/10/23 at 4:41 PM the Administrator said she would expect the care plans to be complete to meet the needs of the resident. The Administrator said if the care plan did not include interventions for a foley catheter, the resident could receive inadequate care. Record review of the facility's undated policy titled, Comprehensive Care Planning, indicated . the facility will develop and implement a comprehensive person-centered care plan for each resident . to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . the comprehensive care plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . the resident's care plan would be reviewed after each admission, quarterly, annual and/or significant change MDS assessment, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions . 676235 Page 8 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

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 respiratory care was provided consistent with professional standards of practice for 1 of 5 residents (Resident #7) reviewed for respiratory care and services. Residents Affected - Few The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #7. This failure could place residents who receive respiratory care at risk for developing respiratory complications. Findings include: Record review of Resident 7's order summary report, dated 05/10/2023, indicated Resident #7 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included chronic respiratory failure (not enough oxygen in the blood), COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure (the heart does not pump blood as well as it should). The order summary report indicated Resident #7 received oxygen at 2 liters per minute via nasal cannula every shift with a start date 02/18/2023. Record review of Resident #7's quarterly MDS, dated [DATE], indicated Resident #7 usually understood others and usually made herself understood. The assessment indicated Resident #7 was cognitively intact with a BIMS score of 14. The assessment indicated Resident #7 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #7 was receiving oxygen therapy. Record review of Resident #7's care plan with an initiated date of 11/08/2019 indicated Resident #7 received oxygen therapy. The care plan indicated Resident #7 received oxygen at 2 liters per minute via nasal canula. During an observation on 05/09/23 at 09:43 AM, Resident #7 was sitting up in her chair wearing oxygen at 3 liters per minute via nasal canula. During an observation and interview on 05/10/23 at 09:27 AM, Resident #7 was sitting in her chair wearing oxygen at 3 liters per minute via nasal canula. Resident #7 stated she had been wearing her oxygen at 3 liters per minute for as long as she could remember. Resident #7 stated she could breathe better with her oxygen set a 3 liters per minute and she did not want to change it. During an observation and interview on 05/10/23 at 2:01 PM, RN D stated Resident #7 was wearing her oxygen at 2.5 liters per minute via nasal cannula. RN D stated it was the nurse's responsibility to check the oxygen settings and oxygen saturations every shift and she had checked Resident #7's today and did not notice the setting. RN D stated the importance of receiving the correct amount of oxygen was to make sure the resident got the correct amount of oxygen ordered by the physician. RN D stated if Resident #7 received too little oxygen she could have been hypoxic (not enough oxygen in the tissues) and if she received too much oxygen, it could have resulted in Resident #7's overall breathing not being adequate or poor profusion (large quantity of oxygen). 676235 Page 9 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/10/23 at 2:12 pm, the DON stated the charge nurses were responsible for making sure the oxygen settings were correct and they were following the physician orders. The DON stated the charge nurses were responsible for making rounds on their residents at least twice a shift. The DON stated if oxygen settings were too low then it could have resulted in hypoxia (not enough oxygen in the tissues) and if the setting were too high it could have resulted in Resident #7 losing respiratory drive (intensity of respiratory output) potentially. During an interview on 05/10/23 at 3:20 pm, the Administrator stated she expected the charge nurses to follow the physician orders on oxygen settings and receive clarification to make sure the settings were correct. The Administrator stated too little oxygen could cause the patient to pass out. Record review of the facility's policy titled, Oxygen Administration, revised 02/13/2007 indicated, .The administration, monitoring of responses, and safety precautions associated with oxygen are performed by the nurse. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician . 676235 Page 10 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #56) Residents Affected - Few The facility failed to keep ongoing communication with the dialysis facility and did not ensure the post-dialysis assessments were completed for Resident #56. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #56's face sheet, dated 05/10/2023, revealed Resident #56 was an [AGE] year-old-female who admitted to the facility on [DATE], with diagnoses of end stage renal disease (condition where the kidney reaches advanced state of loss of function) and anemia (low amount of red blood cells that carry oxygen to all parts of the body). Record review of the order summary report, dated 05/10/2023, revealed Resident #56 had an order, which started on 01/30/2023, for Effective 1/20/23: Hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) every M-W-F . Record review of the MDS assessment, dated 04/13/2023, revealed Resident #56 had clear speech and was understood by staff. The MDS revealed Resident #56 was usually able to understand others. The MDS revealed Resident #56 had a BIMS score of 7, which indicated severe cognitive impairment. The MDS revealed Resident #56 had no behaviors or refusal of care. The MDS revealed Resident #56 received dialysis while a resident during the 14-day look-back period. Record review of the comprehensive care plan, dated 04/04/2023, revealed Resident #56 needed dialysis related to renal failure. The interventions included: Resident received dialysis 3 days per week (M-W-F). Record review of the Dialysis Communication Form for Resident #56, from March 2023, April 2023, and May 2023, revealed Resident #56 had missing dialysis communication forms for the following dates: 03/03/23, 03/08/23, 03/15/23, 03/17/23, 03/24/23, 03/27/23, 03/31/23, 04/12/23, 04/17/23, 04/28/23, 05/3/23, and 05/05/23. The dialysis communication forms further revealed there was no post-dialysis assessment on 03/16/23 and 04/14/23. During an interview on 05/10/2023 at 4:58 PM, LVN B stated the charge nurses were responsible for ensuring the dialysis communication forms were filled out before dialysis and when Resident #56 returned from dialysis. LVN B stated he was unaware Resident #56 had missing dialysis communication forms or forms that were not completely filled out. LVN B stated dialysis communication forms were important to monitor Resident #56's vital signs and change of conditions. During an interview on 05/10/2023 at 5:53 PM, the DON stated dialysis communication forms should have been completed every time Resident #56 goes to dialysis. The DON stated the post-dialysis section of the communication form should have been completed when she returned from dialysis. The DON 676235 Page 11 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the charge nurses were responsible for ensuring the communication forms were filled out and sent with the resident. The DON stated he was responsible for ensuring the charge nurses completed the communication forms from dialysis. The DON stated it was important for good communication and the monitoring of Resident #56's status. During an interview on 05/10/2023 at 6:14 PM, the Administrator stated she expected the charge nurses to completely fill out and send the dialysis communication forms to the dialysis center. The Administrator stated she expected the post dialysis communication section to be filled out unless the resident went to the hospital before returning to the facility. The Administrator stated it was important for monitoring the residents' conditions. Record review of the Dialysis policy, revised November 2013, revealed 19. The facility will monitor departures and returns from the dialysis center. The facility will document the resident's vital signs, general appearance, orientation, and additional baseline data as needed . 676235 Page 12 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 provide food that was palatable and served at an appetizing temperature for 3 of 17 residents (Resident #53, Resident #5 and Resident #282) reviewed for dietary services. Residents Affected - Some The facility failed to provide palatable food served at an appetizing temperature and taste to Resident #53, Resident #5, and Resident #282. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: 1. Record review of a face sheet dated 05/10/2023 revealed, Resident #53 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive memory loss), type 2 diabetes mellitus (too much sugar in the blood) and hypertension (high blood pressure). Record review of the MDS assessment dated [DATE] revealed, Resident #53 was usually understood by others and sometimes made herself-understood. The MDS assessment revealed Resident #53 had a BIMS score of 12, which indicated she was moderately impaired. Record review of the Order Summary Report dated 05/10/2023 revealed Resident #53 had an order for a regular diet regular texture, regular consistency, with a start date of 09/29/2022. During an interview on 05/10/23 at 9:56 AM, Resident #53 stated, The food was served cold in the dining room, and it did not taste good. Resident #53 stated the food does not look appealing most days and the chicken looks and feels pasty (texture of paste). Resident #53 stated she often requested alternate trays and they looked a little better. Resident #53 stated, she would not feed most of the meals to a dog, so then why would she eat it. 2. Record review of a face sheet dated 05/10/2023 revealed Resident #5 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (diabetes with low blood sugars), hypertension (high blood pressure), and Alzheimer's (progressive memory loss). Record review of the MDS assessment dated [DATE] revealed Resident #5 was usually understood by others and usually made herself-understood. The MDS assessment revealed Resident #5 had a BIMS score of 13, which indicated her cognition was intact. Record review of the Order Summary Report dated 05/10/2023 revealed Resident #5 had an order for a diet with regular texture, regular consistency, with start date of 01/20/2023. During an observation and interview on 05/09/23 at 1:19 PM, a lunch tray was sampled with the cook and DM H. The tray consisted of roast beef, potatoes, carrots, pineapple cake and a roll. The cook and DM H stated the potatoes and carrots were bland and did not have any flavor. DM H stated they did not heat the rolls and the rolls were cold. 676235 Page 13 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 05/8/23 at 10:50 AM, Resident #5 stated the food did not taste good and it did not have any flavor. Resident #5 stated, The food tasted like it came out of a box most days and it was not always warm. 3. Record review of Resident #282's face sheet, dated 05/10/2023, revealed Resident #282 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus without complications (high blood sugar). Record review of the order summary report, dated 05/10/2023, revealed Resident #282 had an order, which started on 04/24/2023, for Regular diet, regular texture, regular consistency. Record review of the MDS assessment, dated 04/30/2023, revealed Resident #282 had clear speech and was usually understood by staff. The MDS revealed Resident #282 was usually able to understand others. The MDS revealed Resident #282 had a BIMS score of 15, which indicated no cognitive impairment. During an interview on 05/08/2023 at 10:46 AM, Resident #282 stated the food was awful. Resident #282 stated he was not a picky eater, but the food served was often bland and tasted badly. Resident #282 stated when he ate in his room, the food was cold when the facility staff served it to him. Resident #282 stated the spaghetti and meatballs they had the previous night (05/07/2023) looked like they came straight out of the can. During an interview on 05/10/23 at 4:24 PM, DM G stated she had only received a couple of food complaints from residents, and it was because they did not like a certain food or wanted specific things. DM G stated she was also working as the cook because the previous cook had quit. DM G stated she was scheduled to start working as the full time cook on 05/09/2023 and would step down from being the DM. DM G stated the importance of preparing warm, palatable, and attractive food was so the residents would eat healthy meals and received the nutrition they needed. DM G stated if residents did not like the meals, it could result in weight loss. During an interview on 05/10/23 at 2:12 PM, the DON denied having any food complaints in general. The DON stated all residents were offered alternate trays prior to their meals and they always had soup, sandwiches, and salad available. During an interview on 05/10/23 at 3:20 pm, the Administrator stated she expected the food to be palatable, attractive and the correct temperature. The Administrator stated the dietary staff was responsible for making sure the food was good and warm when it left the kitchen. Record review of the facility's Dietary Services Policy & Procedure Manual dated 2012, titled, Preparation of Foods, revealed, We will establish safe and nutritional preparation of food. Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value . 676235 Page 14 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

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 for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure: food items were dated, labeled, and sealed appropriately. expired food items were discarded. Temperature checks were completed on the salad bar These failures could place residents at risk for foodborne illness. Findings included: During an observation on 05/08/2023 starting at 9:00 AM with DM G: Freezer 2 flat buffet hams not dated 1 opened southern biscuit box with no open date Refrigerator Box of onions with no date or label 2 bags of coleslaw with best by date 05/04/23 1 box of cabbage dated 04/19/23 with brown discoloration on the leaves 3 bags of a green substance with no label or date Dry Storage 2 unopened loaves of bread with best by date 04/16/23 1 open bottle of welches jelly with no date During an observation and interview on 05/09/23 at 11:30 AM, DM H did not check the temperatures on the salad bar for the: lettuce, peaches, ranch dressing, shredded cheese, and Italian dressing until surveyor intervention. DM H stated she was, just filling in at the facility and she thought the activity director was responsible for temperature checks on the salad bar because they did not have a salad bar at the facility she worked at. DM H stated it was important to temperature check the food on the salad bar to prevent residents from getting sick. 676235 Page 15 of 16 676235 05/10/2023 Rock Creek Health and Rehabilitation 1414 College Street Sulphur Springs, TX 75482

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 05/09/23 at 1:37 PM, the activity director stated she never checked the temperatures on the salad bar because she was not the one who prepped the items. The activity director stated she was only responsible for serving residents the salad. During an interview on 05/10/23 at 4:24 PM, DM G stated she was responsible for labeling, dating, and throwing away expired items in the kitchen. DM G stated she had been busy and worked as the cook and aide on several days because several staff members had called in. DM G stated there was no check off sheet for making sure the food items had been monitored and there was no process in place for other staff members to make rounds. DM G stated it was a safety hazard not to make sure the kitchen items were dated, labeled, and expired items were thrown out. DM G stated the cooks were responsible for checking the temperatures on the salad bar. DM G stated it was important to check the salad bar temperatures to prevent bacteria growth and it would be a safety hazard. DM G stated her last day to be the DM was on 05/08/23 and she stepped down to be the cook and kitchen aide. During an interview on 05/10/23 at 3:20 pm, the Administrator stated she expected the kitchen items to be labeled, dated, and expired items to be thrown away. The Administrator stated dietary was responsible for making sure it was done and there was no process in place for anyone to make rounds or double check. The Administrator stated if the food items were not labeled, dated, and thrown out, then residents could get sick. The Administrator stated she expected temperature checks to be done on the salad bar and the kitchen staff was responsible. The Administrator stated if temperature checks were not done on the salad bar, then the residents might not want to eat the salad because it was not the right temperature. Record review of the facility's Dietary Services Policy & Procedure Manual dated 2012, titled, Food Storage and Supplies, revealed, Food items such as loaves of bread with stamped best-by or use-by dates should be observed prior to the best-by date. If food spoilage is observed prior to the best by date, the product will be discarded .open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened. Record review of the facility's Dietary Services Policy & Procedure Manual dated 2012, titled, Appetizer Temperature Log, revealed, Before serving appetizers, cold foods will be held at 41 degrees Fahrenheit or below while holding and serving. 676235 Page 16 of 16