Health inspection·April 14, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 ensure residents received services in the facility with reasonable accommodations of resident needs and preferences for 3 (Residents #1, #2, and #3) of 5 residents reviewed for call light placement. Residents Affected - Some The facility failed to ensure Resident #1's, #2's, and #3's call light were within reach on 04/14/25. This failure could place residents at risk of needs not being met. Findings included: Review of Resident #1's Face Sheet, dated 04/14/25, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had medical diagnoses that included dementia (a decline in memory, thinking, and other cognitive abilities severe enough to interfere with daily life), venous insufficiency (a condition where the veins in the legs have difficulty returning blood back to the heart, causing blood to pool in the legs), right shoulder pain, unsteadiness on feet, bacterial pneumonia (a lung infection caused by bacteria, leading to inflammation and fluid buildup in the air sacs (alveoli)), localized edema (swelling that is confined to a specific area of the body, as opposed to affecting the entire body), delusional disorders, insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early, leading to daytime impairments), moderate protein-calorie malnutrition, other abnormalities of gait and mobility, general muscle weakness, cognitive communication deficit, pain and weakness. Review of Resident #1's Annual MDS Assessment, dated 03/08/25, reflected a BIMS score of 8, which indicated he had moderate cognitive impairment. Resident #1 had two falls with no injury since admission. Resident #1 required set up help/clean up help with eating, toileting, personal and oral hygiene, bed mobility, transferring, and upper body dressing and supervision with lower body dressing. Review of Resident #1's Care Plan, revised 04/10/25, reflected CNAs and nursing staff were required to keep Resident #1's call light in reach at all times because he was at risk for falling and experienced bladder incontinence mainly at night. Review of Resident #1's POC History from 04/08/25 through 04/14/25 reflected Resident #1 was most recently checked on and assisted with ADLs by CNA A on 04/14/25 at 1:13 a.m. and CNA B on 04/14/25 at 1:06 p.m. Review of Resident #1's Progress Notes from 02/28/25 through 04/14/25 reflected Resident #1 was Page 1 of 5 676308 676308 04/14/2025 San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some most recently checked on and reminded to use his wheelchair by LVN C on 04/14/25 at 9:05 a.m. Resident #1 was also most recently checked on and assessed for wounds by RN D on 04/14/25 at 9:09 a.m. Review of Resident #2's Face Sheet, dated 04/14/25, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #2's had medical diagnoses that included chronic obstructive pulmonary disease (lung and airway diseases that make it difficult to breathe), other abnormalities of gait and mobility, unsteadiness on feet, weakness, cutaneous abscess of chest wall (a collection of pus beneath the skin of the chest, often caused by a bacterial infection), edema (the swelling of body tissues caused by an accumulation of fluid), cognitive communication deficit, shortness of breath, general muscle weakness, repeated falls, right shoulder muscle wasting and atrophy, other lack of coordination, overactive bladder, hypertension (a condition where the force of your blood against your artery walls is consistently too high), hyperlipidemia (a high concentration of fats or lipids in the blood), and dementia. Review of Resident #2's Quarterly MDS Assessment, dated 02/04/25, reflected a BIMS score of 12, which indicated she had moderate cognitive impairment. Resident #2 had no falls since readmission. Resident #2 required set up help/clean up help with eating, oral and personal hygiene, toileting, upper and lower body dressing, bed mobility and transferring and supervision with showering. Review of Resident #2's Care Plan, revised 04/13/25, reflected CNAs, nursing staff, and all other staff were required to keep Resident #2's call light in reach at all times and teach Resident #2 about safety measures of using the call light for help because she was at risk for visual decline, experienced occasional bladder and bowel incontinence, at risk for injuries related to her seizure diagnosis and at risk for falls. Review of Resident #2's POC History from 04/08/25 through 04/14/25 reflected Resident #2 was most recently checked on and assisted with ADLs by CNA on 04/14/25 at 1:07 a.m. and CNA B on 04/14/25 at 1:10 p.m. Review of Resident #2's Progress Notes from 07/15/24 through 04/14/25 reflected Resident #2 was most recently checked on by LVN E on 04/04/25 at 1:40 p.m. Review of Resident #3's Face Sheet, dated 04/14/25, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had medical diagnoses that included a left femur (thigh bone) fracture, shortness of breath, gas pain, anxiety disorder, other chronic pain, nausea with vomiting, and constipation (a condition where bowel movements become infrequent and stools become hard and difficult to pass). Review of Resident #3's admission MDS Assessment, dated 03/10/25, reflected a BIMS score of 5, which indicated she had severe cognitive impairment. Resident #3 had one fall with no injury since admission. Resident #3 was always incontinent with her urine and bowel movements and had constipated bowel patterns. Resident #3 required substantial/maximal assistance with eating, oral and personal hygiene, toileting, showering, lower body dressing, bed mobility, and transfers and partial/moderate assistance with upper body dressing. Review of Resident #3's Care Plan, revised on 04/13/25, reflected nursing staff and all other staff were required to keep Resident #3's call light in reach at all times because she experienced bowel and bladder incontinence, was at risk for falling, 676308 Page 2 of 5 676308 04/14/2025 San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665

F 0558 Level of Harm - Minimal harm or potential for actual harm Review of Resident #3's POC History from 04/08/25 through 04/14/25 reflected Resident #3 was most recently checked on and assisted with ADLs by CNA A on 04/14/25 at 12:26 a.m. Review of Resident #3's Progress Notes from 03/07/25 through 04/14/25 reflected Resident #3 was most recently checked on by LVN C on 03/10/25 at 10:01 a.m. Residents Affected - Some An observation of Resident #1's room on 04/14/25 at 10:47 a.m. revealed Resident #1 was sitting in his wheelchair across from his low bed. Resident #1's low bed was clean and made. Resident #1's call light was on the ground next to his bed. Resident #1 had a posting on his closet that indicated to push his call light for assistance. During an observation and interview on 04/14/25 at 10:47 a.m., Resident #1 stated he pressed his call light when he needed help. When asked if he could reach his call light on the ground next to his low bed, Resident #1 rolled his wheelchair to the call light on the ground, attempted to reach for the call light, and was unable to reach it. Resident #1 stated a nurse checked on him sometime today (04/14/25), but he could not recall when the nurse checked on him and who the nurse was. An observation of Resident #2's room on 04/14/25 at 11:04 a.m. revealed Resident #2 was sleeping in her bed. Resident #2's call light was on the ground underneath her bed. An attempt to interview Resident #2 was made on 04/14/25 at 11:04 a.m., but Resident #2 stated she did not want to answer any questions. An observation of Resident #3's room on 04/14/25 at 11:06 a.m. revealed Resident #3 was lying in her low bed. Resident #3's fall mat was next to her bed. Resident #3's call light was on the ground underneath her bed. An attempt to interview Resident #3 was made on 04/14/25 at 11:06 a.m., but Resident #3 stated she did not want to answer any questions. During an interview on 04/14/25 at 11:22 a.m., RN D stated she was conducting wound care rounds (checks) on Resident #1's, #2's and #3's hall. RN D stated she most recently checked on residents within the last hour (sometime between 10:22 a.m. through 11:22 a.m.). RN D stated CNAs and nurses checked on residents within two hours. RN D stated the ADON or DON in-serviced her on call light placement in March 2025 or April 2025. RN D stated all staff ensured call lights were within residents' reach. RN D stated she knew to always make sure call lights were within residents' reach when checking on and after a care or service is provided to a resident. RN D stated she knew the importance of ensuring call lights were within residents' reach and said, So the resident could notify staff for assistance. It was a patient right. Residents could be in distress and not be able to communicate with staff about that. During an interview on 04/14/25 at 11:32 a.m., CNA F stated she was not assigned to Resident #1's, #2's, and #3's hall. CNA F stated she most recently checked on residents around 10:30 a.m. CNA F stated CNAs and nurses checked on residents within two hours. CNA F stated the ADON or DON in-serviced her on call light placement in March 2025 or April 2025. CNA F stated CNAs and nurses ensured call lights were within residents' reach. CNA F stated she knew to make sure call lights were within residents' reach whenever a call light request was fulfilled and at least 2-3 times throughout a shift. CNA F stated she knew the importance of ensuring call lights were within residents' reach and said, Very important because if someone needed help, residents could push the call light anytime. It could 676308 Page 3 of 5 676308 04/14/2025 San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665

F 0558 be a problem if the call light was not within the resident's reach. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/14/25 at 11:42 a.m., LVN C stated she and CNA B were assigned to Resident #1's, #2's and #3's hall. LVN C stated there were no staff who were checking on Resident #1's, #2's, and #3's hall as CNA B was showering residents today (04/14/25). LVN C stated she most recently rounded (checked) on residents at the time of the interview. LVN C stated she could not recall when she most recently checked on residents prior to the time of the interview. LVN C stated ADON or DON in-serviced her on call light placement in March 2025 or April 2025. LVN C stated CNAs and nurses checked on residents and ensured call lights were within residents' reach. LVN C stated she knew to make sure residents' call lights were within reach every two hours. LVN C stated she knew the importance of ensuring call lights were within residents' reach and said, So residents could let us know that they need something. Residents could fall and could not get in touch with staff. Residents Affected - Some During an interview on 04/14/25 at 11:54 a.m., CNA B stated she was assigned to Resident #1's, #2's and #3's hall. CNA B stated she most recently rounded on residents sometime between 8:30 a.m. and 9:00 a.m. CNA B stated she was showering seven residents while LVN C and CNA G were checking on residents' call lights. CNA B stated ADON or DON in-serviced her on call light placement in March 2025 or April 2025. CNA B stated all staff checked on residents and ensured call lights were within residents' reach. CNA B stated CNAs and nurses checked on residents within two hours. CNA B stated she knew to make sure residents' call lights were within reach anytime she went into residents' rooms. CNA B stated she knew the importance of ensuring call lights were within reach and said, Because that was the only way residents could reach out to CNAs and nurses. Some of them cannot really talk and use it as a tool unless they scream. Anything could happen to the resident. They could end up on the floor. During an interview on 04/14/25 at 12:12 p.m., CNA G stated she was working on Resident #1's, #2's and #3's hall and one other hall. CNA G stated she most recently rounded on residents around 9:00 a.m. CNA G stated ADON or DON in-serviced her on call light placement in March 2025 or April 2025. CNA G stated all staff were responsible for ensuring call lights were within residents' reach anytime they checked on residents. CNA G stated CNAs and nurses checked on residents within 1-2 hours. CNA G stated she believed most residents she oversaw on Resident #1's, #2's and #3's hall were out of bed and understood call lights should be within reach. CNA G stated she knew the importance of ensuring call lights were within reach and said, In case residents need help and could call staff whenever they needed help regardless of the situation. Residents could end up falling out their bed and chair or get up without assistance. During an interview on 04/14/25 at 12:24 p.m., the ADON stated her or the DON in-serviced the CNAs and nurses on call light placement sometime in March 2025 or April 2025. The ADON stated she reviewed with staff about ensuring call lights were within residents' reach at all times regardless of if they were in bed or not in bed. The ADON stated she expected the staff to ensure residents' call lights were within reach in the morning, throughout the shift and anytime they walked down the hall. The ADON stated CNAs and nurses checked on residents at least every two hours. The ADON stated she knew the importance of ensuring call lights were within reach and said, So we can meet residents' needs and make sure if a resident needed something and did not get up unassisted and harm themselves. During an interview on 04/14/25 at 12:44 p.m., the DON stated her and the ADONs in-serviced staff on call light placement often. The DON stated the ADONs performed guardian angel rounds in the morning, which included to check on residents. The DON stated she expected all staff to ensure call lights were within reach before leaving residents' rooms. The DON stated she expected staff to round on 676308 Page 4 of 5 676308 04/14/2025 San Gabriel Rehabilitation and Care Center 4100 College Park Dr Round Rock, TX 78665

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents every two hours and PRN. The DON stated she knew the importance of ensuring call lights were within reach and said, Safety and make residents' needs known. If not in reach, residents could not make needs known. During an interview on 04/14/25 at 12:55 p.m., the ADM stated her, the DON and ADONs in-serviced staff on call light expectations. The ADM stated she expected guardian angel rounds to be conducted one time throughout management team's shift daily. The ADM stated she expected all staff to ensure the call lights were within reach at least every two hours. The ADM stated knew the importance of ensuring call lights were within reach and said, So that we can meet residents' needs and so they don't have falls and stuff like that. Review of the facility's Guardian Angel Program, undated, reflected, Our facility has a customer service program in place called 'The Guardian Angel Program.' The goal of the program is to ensure that our residents and patients are cared for in a dean, caring, comfortable environment and have the most positive experience possible while living in our facility . Guardian Angel Program connects a staff member with each resident to provide extra attention and support. Guardian angels are available to assist residents with all aspects of their stay . The Guardian Angel will make regular visits to talk to residents and to address any concerns. Review of the facility's Responding to Call Lights policy and procedure, revised 05/05/23, reflected, Procedures: .6. When leaving the patient or resident room, ensure the call light is placed within the patient's/resident's reach. Review of the facility's Patient/Resident Rights policy and procedure, revised on 06/09/23, reflected, Resident Rights: The resident has a right to .communication with and access to persons and services inside and outside the facility .The facility must protect and promote the rights of residents. 676308 Page 5 of 5