Health inspection·September 29, 2022

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 interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming, and personal hygiene, for one of six residents (CR #1) reviewed for activities of daily living. Residents Affected - Few -The facility failed to ensure CR #1 was provided a bath for 4 days. This failure could place all residents receiving ADLs at risk for hygiene neglect and diminished quality of life. Findings included: Record review of CR#1's, face sheet, revealed CR#1 was 70 years-old and was admitted to the facility on [DATE]. CR#1 was discharged on 07/27/22. CR#1's diagnoses included, Vascular Dementia without behavioral disturbance, cerebral atherosclerosis (thickening and hardening of the walls of the arteries in the brain), major depressive disorder etc. Record review of CR#1's baseline care plan dated 7/22/22 stated ADL focus was Eating, Grooming, toileting, personal hygiene, bathing, dressing, bed mobility, transfers, locomotion. Interventions include assist with ADL (Activities of daily living) care as needed. Record review of the ADL record for CR #1 dated 7-22-22 thru 7-27-22 revealed no showers provided on July 22nd, 23rd, 24th, 25th, and 27th. In an Interview with a family member for CR#1 on 09/27/22 at 8:00a.m. , stated CR #1 went to facility for respite care for 5 days July 22nd - 27th. The FM stated CR #1 smelled of a foul odor from the private areas. The FM stated CR #1 stated the facility treated him like an animal and his neck was hurting. The FM stated CR #1 stated he was not bathed or repositioned while at the facility. The FM stated she spoke to the Social Worker and the Administrator the day after CR #1 was discharged from the facility, who stated it would be investigated? On August 3rd she was contacted by the Social Worker, who was apologetic and stated it was due to new employees. She stated she was sent a letter by the facility stating that it appears that the resident did not have a shower during his stay at the facility. The letter also stated, we apologize that CR #1's stay did not meet yours or the facilities standards. In an interview on 09/28/22 at 2:30 p.m., the DON stated residents are showered depending on what rooms they are in. The shower schedule is Monday, Wednesday, Friday and Tuesday, Thursday, Saturday depending on rooms. Facility policy stated residents have the right to shower more if requested or to Page 1 of 10 676381 676381 09/29/2022 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few decline. When residents refuse showers, they are asked again. He stated he doesn't know if refusals are documented. He states the Director and managers are responsible for ensuring showers are given and facility policy/procedures are followed. One way the facility ensures this is by doing spot checks which are done daily by the managers, and randomly. During a spot check the facility is looking at the resident to ensure they are clean, dry, groomed, there is no foul odor etc. He stated residents not offered or given showers can be prone to infection or skin problems. In an Interview with the Social Worker on 9/29/22 at 10:33 AM, he stated the relative of Resident #1 contacted him via phone call on July 27th, 2022, one day after CR #1 discharged from the facility. The relative stated she was concerned about CR #1's stay at the facility and dissatisfied that he was discharged from respite care at the facility without receiving a bath. She stated she was informed by her father as well as his odor that he did not receive a bath while in the facilities care. The social worker stated he did not know if the resident received a shower while in the facilities care and that he understands CR #1's relative being upset if he did in fact not receive a shower. The relative requested a letter of apology in Spanish for CR #1. He stated that he forwarded the concerns to the administrator verbally and in writing. He stated he translated a letter of apology written by the administrator and emailed the relative. He stated the relative contacted him stating she was dissatisfied with the letter as it was vague and did not address her concerns in depth. He stated he then informed the administrator, and he doesn't know what happened after this. He stated he is confident that the administrator followed up with the relative. In an interview with the Administrator on 09/29/22 at 12:37 PM, he stated he sent a letter to the relative of CR #1 stating no shower was given and apologizing initially. He stated the preliminary findings and after research the facility found record of one shower being provided on July 26th. He stated that it is a facility expectation that showers be provided to residents as assigned on the resident's shower day or upon resident request. He stated it is the responsibility of the unit managers and the Director of Nursing to ensure showers are being given in accordance with facility policy and procedures. He stated rounds are conducted as well as a review of charting documentation to ensure that residents needs are being met regarding showers. He stated the consequences of residents not receiving showers could result in skin breakdown and infections. Record review Shower/Tub Bath policy dated 2001 (revised 2010) states the purpose of this procedure is to promote cleanliness, provide comfort to resident and to observe the condition of the resident's skin. 676381 Page 2 of 10 676381 09/29/2022 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #47) reviewed for indwelling catheters. -CNA ZZ did not clean Resident #47's indwelling urinary catheter during incontinent care. This failure could place residents at risk for discomfort, urethral trauma (injury to the duct which urine is transported out of the body from the bladder), and urinary tract infections. Findings included: Record review of the admission sheet for Resident #47 revealed he was [AGE] year-old male admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 4 (Stage 4 ulcers are deep wounds that may impact muscle, tendons, ligaments, and bon), sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues), type 2 diabetes mellitus without complications (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), pressure ulcer of other site, stage 3 (Full thickness tissue loss). Record review of Resident #47's admission MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognition. Further review of Section H0100. A. Indwelling catheter (including suprapubic catheter and nephrostomy tube) coded: yes. Record review of Resident #47's care plan initiated 9/8/22 and revised on 9/28/22 revealed the following: Focus: Resident has an Indwelling Catheter r/t Stage 4 pressure ulcer of sacrum and is at Risk for Increased Urinary Tract Infections. Goal: Foley Catheter will remain patent and resident will not develop increased incidence of UTI's through the next review. The resident will be/remain free from catheter-related trauma through review date. The resident will show no s/sx of Urinary infection through review date. Interventions: Monitor/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 9/28/22 at 10:01 a.m., CNA ZZ and CNA NN provided Resident #47 with foley catheter care/incontinent care for a bowel movement.CNA ZZ entered the room without washing/sanitizing his hands, donned (put) clean double gloves on his left hand and clean glove on his right hand. Resident #47 was laying on his right side, facing the window. CNA ZZ unfastened Resident #47's brief,the resident had a large bowel movement. CNA ZZ tucked the brief underneath the resident and started cleaning the resident. CNA ZZ had bowel continents on his gloves. CNA ZZ during care removed his gloves, did not wash, or sanitize his hands, donned new gloves, and continued with incontinent care. CNA NN assisted Resident #47 in a supine position. CNA ZZ did not retract the foreskin or clean the head of the penis. CNA ZZ wiped around the catheter but did not wipe the catheter at least 4 inches away. CNA ZZ completed incontinent care and with the same soiled gloves touched the resident's clean hospital gown, brief, draw sheet, top sheet and blanket. 676381 Page 3 of 10 676381 09/29/2022 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 9/28/22 at 10:11 a.m., with CNA ZZ, he said he had been working at this facility for the past couple of weeks (could not remember the exact date) as a floater (not assigned to a hall). He said he thought he did good when providing care for Resident #47. He confirmed he did not clean the head of the penis or retract the foreskin. He said he should have washed his hands resident had pooped. He said he had not been in serviced on hand washing/ infection control at this facility. He said he had received infection control training at his other job 6 months ago. CNA ZZ said he had worked as a CNA for a while at other places. He said it was important to sanitize hands and change gloves often during care to avoid infections. He said upon hire Lead CNA completed competency check off for both male and female residents with and without foley catheter with him. In an interview on 9/28/22 at 10:16 a.m., with CNA NN, she said she did good as far as assisting. She said she had been in serviced/trained on hand washing/ infection control sometime last week. She said she was shocked. CNA ZZ did bad. CNA ZZ did not perform hand hygiene while providing incontinent care, he had double gloves, started care from back instead the front. Resident had a large poop, and the poop was on CNA ZZ's gloves. CNA ZZ should have changed his gloves which was at risk for infection and cross contamination. She said Resident #47 was assigned to her hall, but resident required two people assistance that is why she asked for CNA ZZ's assistance. She said, if I knew he didn't know how to clean the resident properly I wouldn't have called him to help me. In an interview on 9/28/22 at 2:17 p.m., with the DON, the Surveyor shared incontinent care/foley catheter observation from earlier. He said his expectation was for the CNAs to provide foley catheter care/incontinent care as the procedure and policy indicated and use standard precaution. Seek help when needed. He said CNA ZZ was not a brand-new CNA. He was seasoned person not fresh out of school. He said upon hire he was mentored for 4 to 5 days on the floor. He said it was unfortunate he should have done his due diligent and put him with someone else. CNA ZZ should have been orientated and trained with better people for 3 to 4 days on the same hall with the same residents. He said ADON conducted infection control in services at least quarterly. He said CNA ZZ was lying he had received infection control training at this facility sometime this month. Could not remember the exact date. He said ADON was responsible for competency check off and spot checks. In an interview on 9/28/22 at 2:33 p.m., with the ADON, she said the Lead CNA was responsible for CNAs competency check off upon hire. She said she was the facility's infection preventionist. She said she tried to spot check CNAs once every other month. She said due to rotating unit manager duties she had fallen behind. She said sometime in July 2022 she had spot checked CNAs. She said Hand washing and PPE training were provided in orientation. She said she tried to spot check at least 3 people weekly for hand hygiene. In an interview on 9/29/22 at 10:32 a.m., with Lead CNA, she said new CNAs received orientation for 3 days on the floor and as needed depending on the individual. Competency check offs were done during orientation for transfers, hand washing, foley, peri care, showers, feeding and Hoyer lift. She said CNA ZZ was not a new CNA. He had worked as a CNA at another facility. He completed his 3 days on the floor with another CNA. She said she tried to spot check CNAs at least once a week. Record review of facility's Inservice conducted on 9/22/22 read in part: .Topic: Infection control-handwashing, proper PPE, universal precautions, contact precautions. Instructor: LVN/ADON . The in service was signed by CNA ZZ. Record review of facility's Perineal Care policy (Revised February 2018) read in part: . Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent 676381 Page 4 of 10 676381 09/29/2022 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure For a male resident: b. Wash perineal area starting with urethra and working outward. C. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. d. Retract foreskin of the uncircumcised male. e. Wash and rinse urethral area using a circular motion. f. Continue to wash the perineal area including the penis, scrotum and inner thighs. g. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. i. Gently dry perineum following same sequence. j. Reposition foreskin of uncircumcised male. m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks . 676381 Page 5 of 10 676381 09/29/2022 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 each resident's drug regimen was free from unnecessary drugs, to include adequate monitoring for 1 of 5 residents (Resident #74) reviewed for unnecessary medications. Residents Affected - Few - The facility failed to monitor Resident #74 for complications related to the use of the anticoagulant Apixaban (reduces risk of blood clots, Eliquis). This failure could place residents at an increased risk for adverse drug consequences and decline in their status. Findings Include: Record review of Resident #74's admission face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), heart failure (occurs when the heart muscle doesn't pump blood as well as it should), type 2 diabetes mellitus with unspecified complications(an impairment in the way the body regulates and uses sugar (glucose) as a fuel). Record review of Resident #74's comprehensive MDS assessment dated [DATE] revealed the resident had a BIMS score of 14 out of 15 indicating intact cognition. Further review of Section N0410 revealed resident received anticoagulant 7 days a week. Record review of Resident #74's care plan initiated 3/25/22 and revised on 4/5/2022 revealed the following: Focus: Resident is receiving Anticoagulant Therapy and is at risk for increased bleeding, bruising, etc. Goal: Resident will have no complications from use of anticoagulant medication until next review. Interventions: Attempt to avoid any injury causing bruising, cuts, or abrasions. Give meds per MD order. Report to family and MD any changes in condition, unusual bleeding, or bruising, dark brown or blood-tinged bodily secretions, injury, trauma, dizziness, abnormal pain, swelling, back pain, severe headache, or increased joint pain. Observation and interview on 9/27/22 at 8:45 a.m., she stated she was given her medications daily. She stated she took medication for a few reasons, but she could not name her diagnosis or medications. Record review of Resident #74's physician orders dated 3/20/22 revealed an order for Eliquis Tablet (Apixaban) Give 5 mg by mouth two times a day for blood clots give 1 tab twice daily. Record review of Resident #74's MAR and TAR flow sheets for September 2022 revealed no documentation of nursing staff monitoring Resident #74 for possible side effects of anticoagulant administration to include bruising. Record review of Resident #74's medical records revealed the following orders after surveyor's interventions: 676381 Page 6 of 10 676381 09/29/2022 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0757 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #74's Physician's order dated 9/28/22 revealed an order to monitor resident for abnormal bruising and/or bleeding from nose gums, blood in urine or stool every shift. In an interview on 9/28/22 at 1:23 p.m., with Medication Aide AAA, she said nurses were responsible to document presence or absence of medication side effects. Residents Affected - Few In an interview on 9/28/22 at 2:00 p.m., with LVN A, she said nurses monitored for possible side effects of anticoagulant therapy. She said some signs of side effects included bleeding and bruising. She said nurses documented presence or absence of side effects on the MAR for complications and monitoring. In an interview on 9/28/22 at 2:14 p.m., with the ADON, she said the nurse who entered the order into the system should have added the order to monitor for the drug side effects. Observation and interview on 9/28/22 at 2:17 p.m. with the DON, he said the facility monitored for side effects through standard monitoring to check for bruising. He said he expected nursing staff to document anticoagulant side effect monitoring in the MAR/TAR. Record review of facility's Anticoagulation-Clinical protocol (Revised November 2018) read in part: .Assessment and Recognition: 1a. Assess for any sign or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. 2. In addition, the nurse shall assess and document/report the following: a. Current anticoagulation therapy, including drug and current dosage; b. Recent labs, including therapeutic dose monitoring; c. Other current medications; and d. All active diagnosis . 676381 Page 7 of 10 676381 09/29/2022 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #2 and #47) and 3 (Surveyors A, B, and C) of 3 visitors reviewed for daily screening for COVID-19/infection control, in that: Residents Affected - Few -The facility failed to screen visitors for temperature, signs and symptoms of COVID-19 before allowing them into the facility for Surveyors A, B, and C. - Wound Care Nurse failed to perform hand hygiene when moving from a dirty to clean site while performing Resident #2's wound care. These failures could place residents at risk for COVID-19 exposure and/or infection. Findings included: Observation on 9/27/22 at 8:30 a.m., revealed upon entry into the facility Surveyors A, B and C's temperatures were not taken and they were not asked any screening questions related to COVID-19. Telephone interview on 9/29/22 at 11:23 a.m., with Receptionist A was unsuccessful. In an interview on 9/29/22 at 12:10 p.m., with Receptionist B, she said every visitor that entered the facility needed to be scanned for temperature and were verbally asked three screening questions for signs and symptoms of COVID-19 by the Receptionist. If no sign and symptoms of COVID-19 were present they could enter the facility. She said it was important to screen the visitors because the residents were suspectable to COVID. In an interview on 9/29/22 at 12:35 p.m., the Administrator said all visitors were to be screened for COVID-19 upon entering the facility, including temperature checks and screening questions for signs and symptoms of COVID-19. He said it was important to screen employees and visitors for the safety of the residents. He said the Receptionist had received training on infection control/screening process. Resident #2 Record review of the admission sheet for Resident #2 revealed he was [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia with behavioral disturbance. Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed his staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. He was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. He was totally dependent on two persons physical assist for dressing, toilet use, and personal hygiene. He was always incontinent of bowel and bladder. Section M0150 revealed: is this resident at risk of developing pressure ulcers/injuries? Coded yes. Does this resident have one or more unhealed 676381 Page 8 of 10 676381 09/29/2022 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0880 pressure ulcers/injuries? Coded No Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's Care plan initiated 10/31/2018 revised on 9/27/22 revealed the following: Focus: Resident has a venous wound of the right lateral ankle. Residents Affected - Few Goal: Areas will heal without complications through the next review. Interventions: Monitor areas for increased breakdown, s\s of infection--report to M.D. Perform treatments per order, if no improvement x2 weeks--report to M.D. Record review of Resident#2's Physician order dated 9/28/22 revealed an order for Type of wound Venous Wound Location of wound Right lateral ankle Irrigate or cleanse wound bed with Normal saline or wound cleanser, pat dry and apply Santyl and Calcium alginate gauze once daily. Cover with Gauze Island with border. Observation on 9/28/22 at 11:14 a.m., revealed the Wound Care Nurse performing wound care on Resident #2 assisted by Lead CNA. Prior to start of the treatment, Resident #2 was assisted onto his left side. Observation revealed a dressing dated 9/27/22 on a wound to Right lateral ankle approximately 1 cm in diameter. The Wound care nurse did not clean the Right lateral ankle wound from the inside to out. The Wound Care nurse then removed her soiled gloves, without sanitizing/washing her hands, donned new gloves and continued the wound care treatment. Wound Care Nurse applied the Santyl, Calcium Alginate and dry dressing. In an interview on 9/28/22 at 11:22 a.m., with the Wound Care nurse, she said she started 3 months ago at this facility as a wound care nurse. She said she received no wound care training upon hire. She said she learned from watching [youtube videos]. She said the ADON spot checked her last Thursday (9/22/22). She said she was nervous, overwhelmed. She should have performed hand hygiene before donning (putting) clean gloves as it placed the risk for cross contamination and infections to the wound. In an interview on 9/28/22 at 2:17 p.m., with the DON, he said he expected staff to follow standard infection control techniques. To perform handwashing before the treatment, if hands become soiled and after as it placed risk for infections. He said staff were provided training on infection control and hand hygiene quarterly by the ADON. He said staff were monitored to ensure they are following infection control precautions by ADON spot checking during care. He said the potential risk to resident due to this failure was cross contamination. In an interview on 9/28/22 at 2:33 p.m., with the ADON, she said she did the competency check off with the Wound care nurse upon hire. Wound Care nurse never worked as a Wound Care Nurse before, so she gave her policy and procedure for this company. She said the Wound Care Nurse had worked as a nurse for few years. But had not been a Wound Care Nurse. She said she expected the staff to follow standard precautions while providing care and treatments. At this time Wound Care Nurse competency check off was requested. Record review of facility's Dressing, Dry/Clean policy (Revised June 2005) read in part: .Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Steps in the Procedure: 16. Cleanse the wound. Use a syringe to irrigate the wound, if ordered. If 676381 Page 9 of 10 676381 09/29/2022 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). 20. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. 21. Reposition the bed covers . Record review of facility's Skilled Services Treatment Competency Check off (Momentum 2018) read in part: .WOUND CARE: 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands or sanitize as appropriate. 6. Put on gloves . Wound Care Nurse competency check off was not provided on exit. Record review of the facility's Nursing Home Visitation policy (not dated) did not mention screening visitors for COVID-19. Record review of facility's Handwashing/Hand Hygiene policy (Revised August 2019) read in part: .Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene . Record review of facility's Infection Control Protocol (not dated) read in part: .Standard Precautions: Treating all residents with the same basic level of standard precautions involves work practices that are essential to provide a high level of protection to patients, health care workers and visitors. Gloves: Change gloves between tasks/procedures on the same resident to prevent cross-contamination between different body sites. Such as: If you are preforming peri-care on a resident change glove when soiled with body fluids and change gloves when moving from area to the next, so forth. Wash hands immediately after removing gloves . 676381 Page 10 of 10