Health inspection·July 17, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (CR #1 and Resident #1) reviewed for supervision. - CNA A failed to provide adequate supervision for CR #1 by leaving the resident on the toilet alone and going to break. - The facility failed to provide adequate supervision to Resident #2 by leaving the resident on the toilet alone making the resident feel unsafe. These failures could place residents at risk for falls and injury. Finding included: CR #1 Record review of CR #1's Face Sheet dated 07/17/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, muscle weakness, need for assistance with personal care, unsteadiness on feed, other reduced mobility and aftercare following explanation of knee joint prosthesis. CR #1 discharged from the facility on 03/03/23. Record review of CR #1's MDS dated [DATE] revealed, intact condition as indicated by a BIMS score of 13 out of 15, use of a wheelchair, limited assistance with most ADLs (transfer, toilet use and personal hygiene) and not steady, only able to stabilize with staff assistance for moving on and off the toilet as well as surface-to-surface transfer. Toileting hygiene and transfer required partial/moderate assistance at admission. Record review of CR#1's Interim Care Plan dated 02/16/23 revealed, no related focus areas, goals or interventions. Record review of CR #1's OT Evaluation & Plan of Treatment signed 02/23/23 revealed, sitting balance- fair (minimal weight shifting to same side of body/front, difficulty crossing midline). Functional Skills Assessment: toileting- total, toilet/commode transfers minimal. Impression- pt displays decreased strength, endurance, balance, transfers, toilet transfers, toileting ADL performance and safety awareness. Skilled justification- CR #1 would benefit from continued OT services for strengthening, endurance training, toilet transfer training, toileting, ADL retraining and safety awareness Page 1 of 3 676236 676236 07/17/2023 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0689 training. Focus of POT- restoration. Level of Harm - Minimal harm or potential for actual harm Record review of CR #1's undated MDS Report printed 07/17/23 revealed, CR #1 was not steady during transitions/walking and needed one-person physical assist with toilet use. Residents Affected - Some Record review of a witness statement dated 03/13/23 and signed by LVN B revealed, CNA A notified her that CR #1 was on the toilet, and she would be going on break on an unspecified date. She said when CNA A was on break she heard the call light and assisted the patient with toileting hygiene and helped him back in bed. She wrote I do not recall the exact date of the event or exactly how long the call light was going off but she didn't feel I was very long. She wrote It had only been around 10-12 minutes since aide (CNA A) told me she would be leaving for break. She wrote she did not remember the patient being upset about a long wait. Resident #2 Record review of Resident #2's Face Sheet dated 07/17/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with spinal stenosis (pressure on the spinal cord and nerves as a result of the space inside the backbone being too small), muscle weakness and Sciatica (pain, weakness, numbness, or tingling in the leg) Record review of Resident #2's undated Care Plan revealed, focus- risk of falls related to impaired balance. Record review of Resident #2's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 13 out of 15 and limited assistance with all ADLs. Record review of Resident #2's OT Evaluation & Plan of Treatment signed 06/23/23 revealed, Sitting balance- sitting during ALDS=fair - (reach to same side of the body and unable to weight shift). Functional Skills Assessment- toileting minimal and commode transfers- moderate. Impression- Pt displayed decreased strength, endurance, balance, transfers, toilet transfers, toileting. Skilled Justification- Resident #2 would benefit from continued skilled OT services for strengthening, endurance, training, toilet transfer training, toileting, ADL retraining and safety awareness training. Focus of POT=restoration. Record review of Resident #2's Progress Notes dated 06/25/23 at 12:34 AM revealed, Resident #2 was found sitting in on the floor in front of her wheelchair. Resident #2 stated she was trying to get in her chair to go to the bathroom. An observation and interview on 07/17/23 at 09:45 AM revealed, Resident #2 sitting in her wheelchair folding clothes by her dresser. She said that she didn't feel safe in the facility because the staff leave her in the restroom, unattended, for prolonged periods in time. Resident #2 said on multiple occasions the staff have transferred her to the restroom and told her to pull the call light and when she does pull the call light it takes them over 10 to come in so they clearly left the room. Resident #2 said the long wait forces her to transfer herself off the toilet and since she had a fall recently it made her feel really unsafe. In an interview on 07/17/23 at 10:10 AM, LVN B said nursing staff are expected to not leave the resident room once they have been assisted to the restroom. She said some resident's require extensive assistance due to poor balance requiring staff to be inside the bathroom with them, while with 676236 Page 2 of 3 676236 07/17/2023 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some others who had better balance/cognition staff could stay outside of the bathroom door. LVN B said nursing staff cannot leave a resident on the toilet unattended and leave the room because leaving resident's unsupervised places them at risk for falls. In an interview on 07/17/23 at 12:12 PM, CNA A said that on an unspecified date she helped CR #1 to the restroom because he had to have a bowel movement. She said she checked on the resident a few times but he was still using the restroom and it was time for her break, so she left the resident in the bathroom with the door closed, notified an unnamed nurse that the resident was in the restroom and he would pull the call light when he was done. CNA A said some residents can be left on the toilet unsupervised depending on the assessment by PT while others required supervision at all times. CNA A said if a resident cannot self-transfer from the toilet then staff must stay in the room right outside the door for safety reasons, but CR #1 was able to transfer himself to and from the toilet. She said multiple occasions when she placed CR#1 on the toilet by the time she returned to the room he had transferred himself and was already in his room. In an interview on 07/17/23 at 12:42 PM, the PT Director said at the time of the incident CR #1's sitting balance during ADLs was fair and her interpretation of fair was that the resident could sit on the toilet but he shouldn't be left alone because it was fair it wasn't good. She said based on the documentation on CR #1's chart he was not safe to be left alone on the toilet unattended. The PT director said on 06/23/23 Resident #2 was assessed as requiring moderate assistance with commode transfers but on 06/29/23 she was assed as moderate assistance with transfer and ass time passed (07/03/23, 07/04/23) she would not transfer due to back and knee pain. She said after Resident #2 had a fall she complained of knee pain that was limiting and Resident #2 was assessed as requiring total assistance with toileting staring 07/04/23. The PT director said based on this change in Resident #2 she should not be left unattended. In an interview on 07/17/23 at 01:10 PM, the Administrator said nursing staff are expected to stay within the vicinity of the resident room to ensure the safety of the resident. In an interview on 07/17/23 at 03:00 PM, the Administrator said the facility did not have a policy addressing supervision and quality of care. Record review of facility policy titled Supporting Activities of Daily Living (ADL) revised 03/2018 revealed, 2appropriate care and services should be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and/or resident representative and in accordance with the plan of care, including appropriate support and assistance with: c- elimination(toileting). 676236 Page 3 of 3