Health inspection·September 15, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 18 residents (Resident #6) reviewed for advanced directives, in that: Resident #6's OOH-DNR form was improperly executed via family member's signature, not Resident #6. This deficient practice could place residents at-risk of having their end of life wishes dishonored and of having CPR performed against their will. The findings were: Record review of Resident #6's face sheet, dated [DATE], revealed an [AGE] year-old female admitted to facility on [DATE] with diagnosis that included: [Insomnia] is a sleep disorder in which you may have trouble falling asleep, staying asleep, or getting good quality sleep, [Chronic obstructive pulmonary disease] a group of diseases that cause airflow blockage and breathing-related problems, and [Alzheimer's Disease] a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Record review of Resident #6's quarterly MDS, dated [DATE], revealed a BIMS of 15, indicating intact cognition. Record review of Resident #6's care plan, reviewed [DATE], revealed [Resident #6] DNR code status. Record review of Resident #6's physician orders revealed an order dated [DATE], Code Status: DNR. Record review of Resident #6's OOH-DNR form, dated [DATE], revealed, Section B. Declaration by legal guardian, agent, or proxy on behalf of the adult person who is in competent or otherwise incapable of communication. Based upon known desires of the person or a determination of the best interest of the person, direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardia pacing, defibrillation, advanced airway management, artificial ventilation had been signed by the resident's responsible party. Further review revealed Section B of Resident #6's OOH-DNR form had been signed by the resident's family member. An attempted interview with Resident #6's Responsible Party was conducted on [DATE] at 10:36 a.m. The resident's responsible party failed to answer the phone and did not return Surveyor's voicemail Page 1 of 9 676250 676250 09/15/2023 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0578 prior to the end of survey. Level of Harm - Minimal harm or potential for actual harm During an interview with Resident #6 on [DATE] at 11:00 a.m., the resident stated she was unaware that her family member had signed her DNR, she was ok with the decision but would have liked to be included in the conversation. Residents Affected - Few During an interview with the Social Worker on [DATE] at 11:16 a.m., the Social Worker confirmed Resident #6's OOH-DNR form was invalid because the form had been signed by Residents #6's family member. The Social Worker stated she was responsible for ensuring advanced directives were executed correctly and stated she was not on staff at the facility when Resident #6's OOH-DNR was created and would not have completed the form in that manner. The Social Worker further stated she reviewed advance directives with the resident and their responsible party during quarterly care plan meetings. The Social Worker stated she would immediately initiate a review of every resident's advance directive to ensure the forms had been properly executed. Record review of the facility policy, Advance Directives or associated documentation, revised [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy. 676250 Page 2 of 9 676250 09/15/2023 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, not less than once every 12 months, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 18 residents (Resident #34) reviewed for comprehensive assessments and timing, in that: The facility failed to ensure an MDS Annual Assessment for Resident #34 was completed every 12 months. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings include: Record Review of Resident #34's face sheet, dated 9/14/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: [Atrial fibrillation] is an irregular and often very rapid heart rhythm, [diabetes mellitus] is a disease in which the body's ability to produce or respond to the hormone insulin is impaired, and [Osteoarthritis] occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates. Record review of Resident #34's Quarterly MDS dated [DATE] revealed a BIMS score of 5, indicating severe cognitive impairment. Record review of Resident #34's medical record revealed as of 09/15/2023, no Annual Assessment MDS had been completed since 8/12/2022. During an interview with the MDS Coordinator A on 9/14/23 at 3:52 p.m., MDS Coordinator A stated the time frame for an Annual MDS was to be completed not less than once every 12 months from admission. MDS Coordinator A stated due to staffing shortages, she had been working the floor and had gotten behind on her MDS assessments which could possibility affect residents negativity. MDS Coordinator A stated she used the RAI manual as a reference, and she had electronic access to the manual. During an interview with the Administrator on 09/14/2023 at 4:44 p.m., the Administrator stated he was unaware the MDS Coordinator needed help with the assessments for the facility and the facility was trying to hire more floor nurses. During an interview with the DON on 09/14/2023 at 5:00 p.m., the DON stated she was unaware the MDS Coordinator was late on her assessments due to staffing shortages. The DON stated she was in the process of hiring more nurses. The DON stated the risk of not completing MDS on time placed residents at risk of not receiving services needed due to prompt reimbursement. Record review of the mds-3.0-rai-manual-v1.17.1_October_2019 revealed . Comprehensive MDS includes admission and Annual Assessments. 676250 Page 3 of 9 676250 09/15/2023 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident, for 2 of 9 residents (Residents #187 and #81) reviewed for baseline care plan, in that: 1. Resident #187's baseline care plan did not include the resident's code status, diet order, need for care of multiple wound sites, need for sternal precautions due to surgery, or need for isolation due to an infectious disease diagnosis. 2. Resident #81's baseline care plan did not include the resident's need for a gluten free diet due to a diagnosis of celiac disease. This deficient practice could affect all residents who require staff assistance and interventions to maintain the highest practicable level of health and well-being. The findings were: 1. Record review of Resident #187's face sheet, dated 09/12/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Cardiomegaly, and Zoster Without Complications. Record review of Resident #187's clinical record revealed the resident's admission MDS had not yet been completed due to her status of having been newly admitted to the facility. Record review of Resident #187's order summary report, dated 09/12/2023, revealed physician orders with a start date of 09/02/2023 and no end date which included: [Low concentrated sweets/no added salt] diet REGULAR texture, THIN LIQUIDS consistency, FULL CODE: USE AED (Automated External Defibrillator) WITH [cardiopulmonary resuscitation] DURING SUDDEN CARDIAC ARREST. Further review revealed physician orders with a start date of 09/04/2023 and no end date which included: Monitor donor surgical incision sites to [bilateral lower extremities] for [signs and symptoms] of infection or dehiscence every shift, Stage II Pressure Ulcer to Sacrum: Cleanse are wound cleanser, pat dry then apply Medi-honey gel to wounds and cover with calcium alginate and secure with foam dressing daily and as needed. as needed for Stage II Pressure Ulcer to Sacrum, STERNAL PRECAUTIONS: Do not lift, push or pull anything more than 10 lbs. Do not [sic] bar any body weight on your arms. hold pillow and use rocking motion to go from sitting to standing position. Do not raise elbows higher than [sic] you shoulders unless you move baith arms in front of your face only. DO not reach behind you. every shift, Surgical Incision Left Upper Thigh (superior):Cleanse with wound cleanser, pat dry, then apply Xeroform dressing and cover with island dressing daily and as needed [sic] as needed, Surgical Incision Left Upper Thigh (superior):Cleanse with wound cleanser, pat dry, then apply Xeroform dressing and cover with island dressing daily and as needed every day shift for Surgical Incision to Left Thigh (superior), Surgical Incision Mid Chest: Cleanse with wound cleanser, pat dry, then pack with Iodoform strips, cover with calcium alginate dressing and secure with island dressing daily and as needed as needed for Surgical Incision Mid Chest, Surgical Incision Right Upper Thigh (superior): Cleanse with wound cleanser, pat dry, then apply Xeroform dressing and cover with island dressing daily and as needed every day shift for Surgical Incision right upper thigh (superior), Surgical Incision Right Upper Thigh Medial: Cleanse with wound cleanser, pat dry, then apply Xeroform dressing and cover with 676250 Page 4 of 9 676250 09/15/2023 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some island dressing daily and as needed as needed for SI Right Upper Thigh Medial, Surgical Incision to Left calf: Cleanse with wound cleanser, pat dry, then apply Xeroform dressing and cover with island dressing daily and as needed as needed for Surgical Incision to left calf, Surgical Incision to Left Thigh (medial site #1) Cleanse with wound cleanser, pat dry, then apply Xeroform dressing and cover with island dressing daily and as needed as needed for Surgical Incision to L thigh (medial), Surgical Incision to Left Thigh (medial site #2) Cleanse with wound cleanser, pat dry, then apply Xeroform dressing and cover with island dressing daily and as needed as needed, Surgical Incision to Right Inner Knee (Site 1): Cleanse with wound cleanser, pat dry, then apply Xeroform dressing and cover with island dressing daily and as needed as needed for Surgical Incision to Right Inner Knee (Site 1), Surgical Incision to Right Inner Knee (Site 2): Cleanse with wound cleanser, pat dry, then apply Xeroform dressing and cover with island dressing daily and as needed as needed for Surgical Incision to Right Inner Knee (Site 2). Further review revealed a physician order with a start date of 09/08/2023 and no end date, Contact [isolation] for shingles every shift. Record review of Resident #187's care plan as of 09/12/2023, revealed it did not include the resident's code status, diet order, need for care of multiple wound sites, need for sternal precautions due to surgery, or need for isolation due to a diagnosis of shingles. During an interview with MDS Coordinator A and MDS Coordinator B on 09/15/2023 at 9:56 a.m., MDS Coordinator A and MDS Coordinator B confirmed Resident #187's care plan did not include the resident's code status, diet order, need for care of multiple wound sites, need for sternal precautions due to surgery, or need for isolation due to a diagnosis of shingles. MDS Coordinator A and MDS Coordinator B confirmed there were jointly responsible for ensuring the accuracy of residents' care plans and stated the deficient practice was an oversight. 2. Record review of Resident #81's face sheet, dated 09/12/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Malignant Neoplasm of Unspecified Site of Right Female Breast, Secondary Malignant Neoplasm of Bone, and Celiac Disease. Record review of Resident #81's comprehensive MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #81's order summary report, dated 09/12/2023, revealed a physician order with a start date of 08/04/2023, GLUTEN FREE diet CHOPPED MEAT texture, THIN LIQUIDS consistency, related to UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION (E43); CELIAC DISEASE (K90.0). Record review of Resident #81 care plan as of 09/12/2023, revealed the resident's physician order for gluten free, chopped meat diet was not included. During an interview with MDS Coordinator A and MDS Coordinator B on 09/15/2023 at 9:56 a.m., MDS Coordinator A and MDS Coordinator B confirmed Resident #81's care plan did not include the resident's physician order for gluten free, chopped meat diet. MDS Coordinator A and MDS Coordinator B confirmed there were jointly responsible for ensuring the accuracy of residents' care plans and stated the deficient practice was an oversight. During an interview with the DON on 09/15/2023 at 11:20 a.m., the DON confirmed residents' care plans should be accurate. Record review of the facility policy, Comprehensive Person-Centered Care Planning, revised 01/2022, 676250 Page 5 of 9 676250 09/15/2023 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0655 Level of Harm - Minimal harm or potential for actual harm revealed, Procedure: Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. The baseline care plan will include he minimum healthcare information necessary to properly care for a resident including, but not limited to a) Initial goals based on admission orders, b) Physician orders, c) Dietary orders, d) Therapy services, e) Social Services . Residents Affected - Some 676250 Page 6 of 9 676250 09/15/2023 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 reviews the facility failed to provide or obtain laboratory services for 1 of 18 residents (Resident #18) reviewed for laboratory services, in that: Residents Affected - Few Resident #18's Depakote levels were not checked every three months while prescribed Depakote as ordered by Resident #18's physician. This failure placed residents at risk for not having lab services completed resulting in delayed treatment or residents' needs not being met. The findings included: Record review of Resident #18's face sheet dated 09/14/2023 revealed an admission date of 07/28/2018 with diagnoses which included dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), heart failure, hypertension (high blood pressure), chronic kidney disease, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #18's care plan, dated 03/01/2023, revealed, Resident #18 receives anti-convulsant medications related mood disorder. Date initiated: 07/18/2022. Revision: 07/18/2022. Goal: Will have no complications related to anticonvulsant medication use through review date. Revision on: 05/17/2023. Interventions: Anticonvulsants: Tremor, abdominal pain, dizziness, drowsiness, blurred vision, nausea, vomiting, increased confusion and increased sedation. NOTIFY PROVIDER IF PRESENT. Date initiated: 07/20/2022. - Administer medication as ordered. Monitor/document side effects and effectiveness. - Discuss with MD, family re ongoing need for use of medication. Date initiated: 7/18/2022. Record review of Resident #18's quarterly MDS, dated [DATE], revealed Resident #18 was assessed as a 5 out of 15 for the BIMS which indicated severe cognitive impairment. Record review of Resident #18's physicians orders, dated 02/21/2023, revealed: Depakote levels every three months every night shift every 3 month(s) starting on the 15th for 29 day(s) related to UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE. Order date: 06/20/2022; start date: 07/15/2022. Review of Resident #18's EHR on 09/12/2023 revealed laboratory tests for Valproic Acid (Depakote/Depakene) had been completed on 10/17/2022 and on 1/17/2023. During an interview on 09/14/2023 at 3:03 p.m. with the DON, the DON provided documentation of a laboratory test that had been taken the previous night, on 09/13/2023 at 6:26 p.m., was received by the laboratory at 9:30 p.m. and the result was listed as pending. The DON acknowledged Resident #18's valproic acid level had not been checked every three months as ordered by the resident's physician and should have been. During an interview on 09/14/2023 at 4:00 p.m. with the facility's Resource RN she clarified the physician's order, stating this particular lab test was to be drawn every three months by a nurse on the night shift. This night shift nurse has from the 15th through the 29th to click on the reminder 676250 Page 7 of 9 676250 09/15/2023 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few set up to appear in a banner on the resident's EHR., so the nurse knows to go to the lab book and verify it will be drawn. This way the doctor does not need to keep putting in the order. The lab has a portal whereby the nurse can go into the resident's name and see what laboratory tests need to be drawn and what has been drawn to ensure nothing is missed. The facility does not have a policy that specifically explains this process; the flagging in the EHR should be an alert the lab is due to be drawn. This process functions well in other facilities but there was clearly a failure in this one as Resident #18's labs were not drawn in a timely manner. During an interview on 09/15/2023 at 11:23 a.m. with the administrator he stated there was no follow-through to ensure Resident #18's lab tests for Depakote levels were drawn in a timely manner. The administrator further stated the DON is responsible for making sure the prompts in the residents' EHR are addressed and the DON is also supposed to monitor the residents' dashboard for incomplete tasks. Record review of facility policy Diagnostic Test Results Notification, Revised 01/2022, revealed: It is the policy of this facility to obtain laboratory and radiology services when ordered by a Physician, Physician Assistant (PA), Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS) and to promptly notify the ordering provider of test results. Procedure: 1. Laboratory and radiology services will be arranged as ordered. 2. Results of lab, radiology & diagnostic services shall be made a part of the resident's medical record. Record review of facility policy Medication Review by Physician: Following orders, undated, revealed: It is the policy of this facility to ensure that all orders are to be carried out as per physician orders. 676250 Page 8 of 9 676250 09/15/2023 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 medical records on each resident that were complete and accurately documented for 1 (Resident #187) of 29 residents reviewed, in that: Resident #187's medical diagnoses were not reflected on her face sheet. This deficient practice could place residents at risk of improper care due to inaccurate medical records. The findings were: Record review of Resident #187's face sheet, dated 09/12/2023, revealed the resident was admitted to the facility on [DATE]. Further review revealed a single diagnosis was listed: Encounter for Surgical Aftercare Following Surgery on the Circulatory System. Record review of Resident #187's clinical record revealed the resident's admission MDS had not yet been completed due to her status of having been newly admitted to the facility. Record review of Resident #187's care plan as of 09/15/2023, revealed a focus, Anticoagulant therapy (Apixaban) [related to]: post-surgical [coronary artery bypass surgery] and an intervention, Monitor and report [signs and symptoms] of thromboembolism: acute onset of shortness of breath, pleuritic chest pain, cough, coughing up blood, syncope and anxiety. Record review of Resident #187's Order Summary Report, dated 09/12/2023, revealed physician orders addressing twelve medical conditions. During an interview with MDS Coordinator A and MDS Coordinator B on 09/15/2023 at 9:56 a.m., MDS Coordinator A and MDS Coordinator B confirmed Resident #187's clinical record and face sheet did not accurately reflect the resident's status, stated the responsibility for accuracy of records was shared among all the nurses, and indicated this deficient practice was an oversight. During an interview with the DON on 09/15/2023 at 11:20 a.m., the DON confirmed residents' clinical records should be accurate and complete. Record review of the facility policy, Medical Records, undated, revealed, It is the policy of this [sic] Facility to ensure every resident has a record that contains those items required by state regulation. 676250 Page 9 of 9