Health inspection·February 14, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 Observation, interview and record review, the facility failed to complete a comprehensive, accurate, standardized reproducible assessment for 3 (Resident #11, #29, & #50) of 18 residents reviewed for comprehensive assessment. 1 The facility failed to accuretly assess Resident #11's lack of teeth and no dentures. 2 The facility failed to accurately assess Resident # 29 for her hearing deficit. 3 The facility failed to accurately assess Resident #50 for his oral cavity. These failures could place the residents at risk of not having all medical needs assessed and met. Findings included: 1.Record review of Resident # 11's electronic face sheet on 02/13/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, hypertension, muscle wasting, abnormal weight loss, diabetes, schizophrenia, anxiety, and depression. Review of Resident #11's Annual MDS dated [DATE] revealed a BIMS score of 7, indicating she was severely impaired on cognition. Her Functional Status indicated she required limited assistance with her ADLs. Her Dental Status did not note any broken or loosely fitting dentures. Section L (B) no natural teeth or tooth fragment(s) (edentulous) was left blank. L (Z) was coded as no problem. Observation on 02/12/23 at 11:00AM revealed Resident #11 was on her wheelchair alert and oriented. She was observed snaking on chips. Observation on 02/13/24 at 12:20PM revealed Resident #11 had lunch in the dining room she was served mechanical altered diet. She had hard time with the meat and requested for soup which was provided. Observation of her oral cavity revealed she had no teeth in her oral cavity. 2.Record review of Resident # 29's electronic face sheet on 02/13/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Peripheral neuropathy (nerve damage caused by several different conditions) hypertension, muscle wasting, hearing loss ear, and heart failure. Review of Resident #29's Annual MDS assessment dated [DATE] revealed she had a BIMS score of 12 Page 1 of 7 676360 676360 02/14/2024 The Shoal 1011 Mainland Center Dr Texas City, TX 77591

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that indicated she was cognitively intact. Her Functional Status indicated she required limited assistance with her ADLs. Record review of section B of the MDS hearing, speech, and vision, were all coded as adequate. Record review of Resident 29's care plan initiated on 10/14/22 updated 10/27/23 read in part the resident has a communication problem related to hearing deficit. . Intervention The resident will be able to make basic needs known daily basis through the review target date of 12/27/23. . communication: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off television\radio to reduce environmental noise, Ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. . Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. . Monitor/document frustration level. Wait 30 seconds before providing resident with . Monitor/document residents' ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend. Observation and interview on 02/12/24 at 9:40AM revealed Resident #26 was on wheelchair in front of her room. During an interview, Resident #29 said come closer and speak louder I can't hear you. 3.Record review of Resident # 50's electronic face sheet on 02/13/24 revealed a [AGE] year-old male admitted to the facility on initially on 12/13/2017 and readmitted on [DATE]. His diagnoses included muscle weakness, hypertension, type 2 diabetes mellitus with diabetic neuropathy, adult failure to thrive, depressive episodes, vitamin deficiency, heart disease, chronic kidney disease, and liver cirrhosis. Review of Resident #50's Annual MDS dated [DATE] revealed a BIMS score of 12 indicated he was cognitively intact. Record review section L (A) Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) was left blank section L(Z) was coded 0 no oral dental problem. 676360 Page 2 of 7 676360 02/14/2024 The Shoal 1011 Mainland Center Dr Texas City, TX 77591

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview on02/13/24 at 1:0PM revealed Resident #50 was up on his bed eating his lunch which was mechanical diet. During an interview he open his mouth and said his lower teeth are grounded to his gum and he had three on his upper cavity. He said he had no dentures and had not seen any dentist. He continued with his meal. During an interview on 02/14/23 at 1:30PM, MDS coordinator A said she started at the facility sometimes in June of 2023 and there was back flow of MDS that needed to be done. She said would look at Resident # 11, #29 and 50 to see what was wrong. During an interview on 02/14/24 at 2:00PM, MDS coordinator A stated Resident #11 had no teeth in her oral cavity, Resident #29 had hearing loss and Resident #50 had few teeth on his upper cavity and all his lower teeth are grounded down to his gum. She said she would reassess all residents and update their MDS as pointed out. She said an inaccurate assessment would result in needed services not being provided to residents. Policy on accuracy of MDS assessment was requested from the MDS coordinator A on 02/14/24 at 2:15PM. No policy was provided prior to exit on 02/14/24 at 5:00pm 676360 Page 3 of 7 676360 02/14/2024 The Shoal 1011 Mainland Center Dr Texas City, TX 77591

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 complete and transmit an MDS for 1 of 3 (CR #90) residents reviewed for closed records. Residents Affected - Few The facility failed to complete and transmit a discharge MDS for CR #90 This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes. Finding included: Record review of CR #90's electronic face sheet, on 02/14/24 revealed a [AGE] year-old male, initially admitted to the facility on [DATE] readmitted on [DATE], readmitted on [DATE], 03/09/23, and discharged from the facility on 09/06//23. His diagnoses included, heart diseases, chronic kidney disease, end stage renal disease, hypertension, anemia, diabetes, Arthritis, lack of coordination, pain, and muscle wasting. Record review of CR #90' last completed MDS was dated ARD 09/06/23 was sign as completed on 02/05/24, 5 months after being discharge from the facility. Record review of nurse's notes dated 09/12/23 undated, unsigned read in part Patient with elevated BUN 113 CR 4.7, unable to obtain IV access. VSS. Patient AOX#, no c/o voiced. Received order to send to local hospital ER for further evaluation. Record review of nurses note dated 9/21/2023 14:12 (2:12PM) unsigned read in part COMMUNICATION with POA: Tried to LVM for Resident #90's POA to check on CR #90. Was told CR #90 was sent to another facility so I wanted to follow up with POA to discuss why. During an interview with MDS Coordinator B on 02/14/24 at 2: 10PM, stated she was new to the position of MDS and was still in training. She said she could not explain why it was not done but she would complete the MDS and transmit it. Policy on MDS completion was requested from the MDS coordinator. The policy was not provided prior to exit on 02/14/24 at 5:00PM 676360 Page 4 of 7 676360 02/14/2024 The Shoal 1011 Mainland Center Dr Texas City, TX 77591

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the comprehensive care plan was completed and reviewed and revised by the Interdisciplinary team after each assessment for 1 of 18 residents reviewed for care plan accuracy (Resident # 96). --Resident # 96 comprehensive care plan was not completed by the review date and did not contain goals and interventions as coded in the baseline care plan. This failure placed residents at risk of not receiving proper care and services according to their individual status. Finding include: Record review of Resident # 96's face sheet dated 1/15/24 revealed admission date 1/15/24 with diagnoses including dementia (loss of cognitive functioning, memory, reasoning), heart disease (conditions affecting the vessels, arteries, structure of the heart), hypertension (high blood pressure), arthritis inflammation or swelling of joints), depression (feeling sad, irritable, empty), and Diabetes (elevated blood glucose levels). Observation and interview of Resident # 96 on 2/12/24 at 9:15 am revealed he was in his room, resting in bed, and was easily awakened. He said he was fine and just came here last month for rehab, which was going well and he was getting stronger. He said he needed the therapy so he could get strong enough to walk after his health decline. Record review of the admission MDS dated [DATE] revealed triggered care areas of functional abilities, cognitive loss/dementia, urinary incontinence, dehydration/fluid maintenance, nutritional status, pressure ulcer, and return to community referral Record review of the Baseline Care Plan dated 1/16/24 revealed the following sections were completed on the following dates: functional abilities and goals (1/16/24), health conditions (1/16/24), dietary/nutritional status, therapy, and social services (1/24/24), and plan of care. . Record review of Resident #96's comprehensive care plan revealed date initiated 1/15/24, and next review date 2/4/24. The comprehensive care plan had not been reviewed by the review date of 2/4/24 and did not contain goals/interventions for MDS triggered care areas of functional abilities, cognitive loss/dementia, urinary incontinence, dehydration/fluid maintenance, nutritional status, pressure ulcer, and return to community. In an interview with the MDS nurse on 2/14/23 at 1:40 pm, she said she just took over this job in January 2024 and had been busy. She said they have 21 days to complete the care plan, and knew it was late, but she did not have time to complete it. She said the other nurses and managers would give her input for the care areas for the residents and she would complete the care plan. She said the risk of having an incomplete care plan would be the resident not receiving correct care, but she would hope the CNAs would ask someone about the care for a certain resident if it was not on the Kiosk. 676360 Page 5 of 7 676360 02/14/2024 The Shoal 1011 Mainland Center Dr Texas City, TX 77591

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with the DON on 2/14/23 at 1:55 pm, she said they have had some changes in staff recently, which could be why the comprehensive care plan was late. She said if she revised the [NAME], her name would be listed as reviewer. She said the resident would not receive proper care if the care plan was incomplete. The facility policy on Care Plans was requested from Administration on 2/14/24 but had not been received by the exit. 676360 Page 6 of 7 676360 02/14/2024 The Shoal 1011 Mainland Center Dr Texas City, TX 77591

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that expired food products was not used in food preparation and served to resident. The facility failed to ensure that dented cans of food were stored separately. These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings included: Observation and interview of the facility kitchen on 02/12/24 at 8:40 AM revealed the dietary Manager opened a 4 oz carton of milk to use in food preparation. Observation of the carton revealed a used by date of 02/09/24. Further observation revealed two boxes of milk each with 25 cartons of 4oz milk all labeled used by 02/09/24. During an interview with the Dietary Manager at 8:48AM, the Dietary Manager said she did not notice the dates on the boxes because, the facility had just received the supply last week. Observation and interview of the dry good storage room revealed 4-7Ibs of dented can of banana pudding all stored together with undented cans. The Dietary Manager took out the dented can off the shelve and said they are supposed to be stored separately and returned to the supplier. She said the dented cans would be returned for credit. In an interview with the dietary Manager on 02/12/24 at 9:00AM, she said the expired milk products and dented can goods, could lead to food born illness. She said she would have an in-service to address all concerns. She said she was off over the weekend and did not have time to go over all the food that were received last week. Record review of facility's policies and procedures for food and safe handling revised December 2024, titled Refrigerators and Freezers read in part, . #8 Supervisors will be responsible for ensuring food items in pantry. Refrigerator and freezers are not expired, or pass perish dates. Supervisor should contact vendors or manufacturers when expiration dates are in question. Further review of the policy did not address dented cans. 676360 Page 7 of 7