Health inspection·June 2, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition for one (Resident #1) of five residents reviewed for activities of daily living. Residents Affected - Few The facility failed to provide Resident #1 assistance with feeding. This failure affected all residents who require feeding assistance at risk of not receiving the necessary services to maintain good nutrition and decline in health. Findings included: Record review on 06/02/23 of Resident #1's face sheet revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE]. Her diagnoses included: metabolic encephalopathy (chemical imbalance of blood in the brain), traumatic amputation at level between live here in Type 2 diabetes mellitus, retinopathy without macular (damage to tissue in the back of the eye), edema end-stage renal disease (Kidneys cease function on a permanent basis), peripheral vascular disease (narrowing of blood vessels reducing blood flow), hyperlipidemia (high levels of fats in the blood), hereditary and idiopathic neuropathy (illness of sensory and motor nerves in the peripheral nervous system are affected) hypertensive heart disease without heart failure(long term high blood pressure), iron deficiency anemia (fewer healthy red blood cells), necrosis of amputation (death of most of the cells), sepsis (chemicals released in the blood system to trigger inflammation), gastroesophageal reflux disease without esophagitis pain (acid or bile flows into the food pipe and irritates the lining), blindness in right eye category three, low vision left eye category one, hypotension (low blood pressure) glaucoma (eye disease that cause vision loss and blindness), cognitive communication, deficient, anxiety disorder, and insomnia. Review of Resident #1's Quarterly MDS Assessment, dated 05/01/23, revealed a BIMS score of 15 indicating the resident was cognitively intact. The submitted MDS Assessment further revealed Resident #1 required set-up assistance with meal trays. The edited and revised MDS dated [DATE] reflected Resident #1 needed total dependency with eating upon anticipated return from discharge. Review of Resident #1's Care Plan, dated 05/09/23, revealed she refused her meals and has impaired vision related to Glaucoma. Blindness one eye and low vision one eye , but the care plan did not specify the level of assistance needed. Review of Resident #1 progress notes revealed the resident was in the hospital from [DATE] to 05/26/23 due to complications of an amputated leg healing poorly and 05/30/23-06/02/23 due to low blood Page 1 of 5 676326 676326 06/02/2023 Edgewood Rehabilitation and Care Center 1101 Windbell Dr Mesquite, TX 75149

F 0677 sugar readings. Level of Harm - Minimal harm or potential for actual harm Review on 06/02/23 of Resident #1's EHR revealed the following weights: 5/18/23 150.92 pounds Residents Affected - Few 5/16/23 154 pounds 5/13/23 151.8 pounds 5/11/23 157.3 pounds 5/09/23 152.68 pounds 5/06/23 154.22 pounds 5/02/23 159.9 pounds 4/29/23 161.7 pounds Record review revealed 05/18/23 was the most current weight in the resident chart. The resident had lost 6.8%. Resident #1 weight loss appeared to be appropriate. The resident goes to dialysis 3 days a week, and some days she would refuse dialysis which would cause her weight to fluctuate. The resident had refused to be weighed at the time of the visit. Interview on 06/02/23 at 9:57 AM with Resident #1 revealed she needed assistance. She stated staff came in the room and set up her tray and sometimes the tray was out of her reach. She stated she always needed help with her feedings because she cannot see out of both eyes. She said no one had offered her assistive devices to find her food or to assist her with feeding herself. She stated she would eat when her family member visits because he assists her with eating. She stated it gets frustrating when one cannot see and does not know where the items are on the tray, so she did not eat. The resident stated if she had assistance with her feedings then she would eat the food provided by the facility. Resident #1 stated she had informed the staff that was in charge she needed assistance with feedings, but the resident could not recall the names of the staff members. She stated no one addressed concerns. Observation on 06/02/23 at 12:10 PM revealed Resident #1 was sitting up in bed. Her right eye (listed as the blind eye on the face sheet) would open periodically and her left eye (listed as low vision) did not open. CNA B assisted with setting up the meal tray in front of the resident. The lunch tray comprised of crunchy fish sandwich, tartar sauce, green beans, mac and cheese, strawberry cream pie, iced tea, and water. The resident started to search for silverware. Resident #1 was moving the tray as she attempted to use her hands to guide her and because she was unable to see the silverware located in the upper left corner. The resident had begun to use her fingers to scoop out the cream pie. Each time the resident reached for her meal the tray would slide out of its original placement. The resident had eaten the items that where easy to locate and closes to her. She had eaten the crunchy fish and strawberry cream pie, which was 50% of her meal. Interview on 06/02/23 at 12:10 PM with CNA A revealed she had been assisting with Resident #1's care since her admission on [DATE]. She stated Resident #1 could feed herself and did not need 676326 Page 2 of 5 676326 06/02/2023 Edgewood Rehabilitation and Care Center 1101 Windbell Dr Mesquite, TX 75149

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistance. She stated the resident's family member brought food most of the time because the resident did not eat what the facility provided. She stated Resident #1 can see out of her right eye because it opens. CNA A stated Resident #1 had never ask her for assistance with feedings. CNA A stated she did not have access to the MDS and relies on the nurse to give her updates on the resident care. She stated she was unsure if she had access to the care plan. She stated if the nurse did not notify her any changes, then she did not change the care the resident is receiving. Interview on 06/02/23 at 1:05 PM with the DON revealed Resident #1 did not have motivation to eat and she needed constant motivation. He stated the resident had deficient vision and did not believe she is blind. The DON stated the care plan information is based on the information from the MDS. He stated the care plan is pulled over to the kiosk (computer on the resident hall) located in the hall of the residents rooms on the wall. He stated the CNAs have access to the care the plan and the nurses have accesses to the MDS and the care plans. He stated the MDS Nurse is responsible for updating the care plan and MDS. He stated the level of assistance the resident need with feedings should be care planned but if we do not see the information on the care plan then her feeding assistance is not care planned. The DON stated sometimes Resident #1 would want help and sometimes she would wait on her family member to bring her food. He stated the expectation for his staff is to follow orders and report change in conditions. The DON stated the risk of Resident #1 not eating food provided by the facility can lead to poor wound healing. The DON stated Resident #1 had never informed him of concerns regarding her needing assistance with feedings. Interview on 06/02/23 at 1:21 PM with the MDS Nurse revealed care plans were devised based on information from the MDS, so any updates to the MDS Assessments should be reflected in the care plan. She stated Resident #1 level of assistance should have been on the care plan, but she was unable to locate the resident feedings on the care plan. The MDS Nurse stated she had done an observation on Resident #1 on 5/26/23 and based on Resident #1's scoring a three, she stated it was in her professional opinion that the resident required moderate assistance. She stated a score of three meant the resident needed assistance with setting up her tray and feedings. The MDS Nurse stated section G of the MDS Assessment, which assessed for functional status, was based on point of care documentation provided by the CNAs and section GG, which assessed functional abilities and goals, was based on a physical assessment and observation of the resident by the MDS Nurse. She stated it was her opinion that section GG more accurately reflected resident's needs. Interview on 06/02/23 at 1:51 PM with the Director of Physical Therapy revealed she had evaluated Resident #1 on 05/01/23. She stated she stayed at Resident #1's bedside and encouraged her to eat. She stated the resident needed a lot of encouragement feed herself, because she wanted to be fed. The Director of Physical Therapy stated her position was just to determine if the resident can physically feed herself, she does not determine if resident is capable based on cognitive or behavioral reasons. She stated nursing determines the cognitive and behavioral reasons. She stated Resident #1 is physically capable, but she might still need assistance per the nursing assessments. She the resident is minimal assist, which means she need tray assist only. Observation on 06/02/23 at about 2:00 PM revealed the resident started Physical Therapy on 05/06/23-5/20/23. The document revealed the resident is minimal assist. Interview on 06/02/23 at 2:30 PM with the resident's family member revealed she had a need for assistance with feedings because she was blind and could not see where her food items were on the food tray. He stated he would bring the resident food and feed and guide her to her food items. The family member stated he was not able to be at the facility for all mealtimes because he had to work. He 676326 Page 3 of 5 676326 06/02/2023 Edgewood Rehabilitation and Care Center 1101 Windbell Dr Mesquite, TX 75149

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident #1 do not appear to be losing weight, because he would not let that happen. He stated he would try to feed Resident #1 to prevent her from losing too much weight and help her amputated leg heal. Interview on 06/02/23 at 4:00 PM with Director of Physical Therapy revealed, after each hospitalization Resident #1 progressively declined. She stated in her professional opinion Resident #1 would benefit from adaptive equipment like a divider plate, built up eating utensils to allow her to hold food items easily, and a non-slip mat under her tray so it would not move. Director of Physical Therapy stated she and her colleagues had discussed the use of adaptive equipment upon initial admission to the facility in 04/27/23, but they did not implement the adaptive equipment for no specified reason. She was unable to find the note of the meeting in the EMR and she stated she had written documentation of the meeting in her daily logs but was unable to locate the logs at the time of the facility visit. She stated she noticed a decline in the resident's emotional state and there had not been any improvements but did not discuss or implement the use of adaptive equipment with the resident. Review of the facility's policy titled Nursing Policies and Procedures, revised May 5, 2023, revealed in part the following: .SUBJECT: ACTIVITIES OF DAILY LIVING, OPTIMAL FUNCTION DEFINITION: Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. POLICY: The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. PROCEDURES: 1. Facility staff recognize and assess an inability to perform ADLs, or a risk for decline in any ability to perform ADLs by reviewing the most current comprehensive or most recent quarterly assessment . 2. Facility staff to monitor conditions which may cause an unavoidable decline in the resident's ability to perform ADLs: D. Signs and symptoms of depression and pain even if not indicated on his/her MDS 3. Facility staff develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences and recognized standards of practice that address the identified limitations in ability to perform ADLs . 4. Facility staff provides assistive devices to maximize independence, including but not limited to the following: D. Eating- Built-up utensils, plate guard, nosey cup, three-compartment dish, scoop plate/bowl, weighted or swivel utensils, cup with lid and handles, Dycem mats . 676326 Page 4 of 5 676326 06/02/2023 Edgewood Rehabilitation and Care Center 1101 Windbell Dr Mesquite, TX 75149

F 0677 7.Facility staff revises the approaches and interventions as appropriate . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676326 Page 5 of 5