Health inspection·June 16, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans in that: - Resident #1's [NAME] hose were not applied according to the physician's order on 06/16/23. - Resident #1's did not receive health shake for breakfast on 06/16/23 as ordered by the physician. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. Finding include: Record review of the admission sheet for Resident # 1 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) Type 2 diabetes mellitus without complication ( a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and heart failure, unspecified (a condition that develops when your heart doesn't pump enough blood for your body's needs). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognition. She required extensive assistance from staff with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Record review of Resident #1's Care Plan initiated 4/13/21 and revised on 4/4/23 revealed the following care plan: Focus: Resident#1 has edema and is at risk for alteration in fluid/electrolyte imbalance. Goal: Resident#1 will be able to maintain current ADLs and no injuries will occur through the next review. Interventions: Encourage\assist to elevate extremities when in bed or chair. Give medications per Page 1 of 4 676381 676381 06/16/2023 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0656 order, monitor labs-report abnormal to MD. Monitor and report increasing signs of edema to MD. Level of Harm - Minimal harm or potential for actual harm Focus: Resident#1 has a potential nutritional problem r/t Therapeutic Diet and Dementia. Residents Affected - Few Goal: will maintain adequate nutritional status as evidenced by maintaining weight within 5% of IBW, no s/sx of malnutrition and dehydration daily through review date. Interventions: Monitor/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Observe, document, report to MD prn s/sx of dehydration: Decreased urine output Poor skin turgor Dry mucous membranes Confusion Hypotension Tachycardia Headache Fatigue/weakness Dizziness Fever Thirst Weight loss Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. OT to screen and provide adaptive equipment for feeding as needed. Provide, serve diet as ordered. Monitor intake and record q meal. RD to evaluate and make diet change recommendations PRN. Record review of Resident #1's physician's orders dated 10/7/2021 revealed an order for HEALTH SHAKE-three times a day for Supplement. Give with meals at 9:00am, 1:00pm and 5:00pm. Record review of Resident #1's physician's orders dated 7/25/2022 revealed an order to [NAME] hose to BLE, start in AM, take off at bedtime. One time a day for Feet swelling Apply in AM, then take off at bedtime and remove per schedule. Apply at 8:00am and remove 8:00pm. Record review of Resident #1's MAR for the month of June 2023 revealed LVN A documented [NAME] hose were applied on June 16, 2023. Record review of Resident #1's nurses notes revealed no documentation of resident's refusal to apply/remove [NAME] hose. Record review of Resident #1's Dietary notes dated 6/13/23 at 8:52am read in part: . please continue to encourage Po intake of >/=75% most meals, offering res po sup/shakes . In an interview and observation on 06/16/23 at 8:50 am revealed Resident #1 lying in bed. She did not have her [NAME] hose applied. A breakfast tray was sitting across from her bed, untouched. The breakfast ticket revealed read in part: Feed instruction: shakes with all meals The breakfast tray did not have health shake. Resident#1 said, I am hungry. I am supposed to eat breakfast at 7am but they feed me at different times sometime 8am or 9am. Observation and interview on 06/16/23 at 8:55a.m., with CNA QQ said she Resident#1 required assistance with feeding. She said she was now getting around to feed Resident#1. CNA QQ said Resident#1 only ate grits for breakfast and drank her health shake but the kitchen did not send health shake today. Resident#1 said, I am supposed to get shake each meal. In an interview and observation with CNA QQ on 6/16/23 at 11:30 a.m., Resident #1 was observed sitting on the recliner. She did not have her [NAME] hose applied. CNA QQ said she gave shower to resident this morning and applied pink sock on the resident. CNA QQ said she was an agency aide but had worked with Resident #1 at least three time a week for the last one month but was not aware that 676381 Page 2 of 4 676381 06/16/2023 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident had orders for [NAME] hose, and she needed to apply them on. Resident #1 said, I need to have my stockings. My feet swell up. CNA QQ asked Resident #1 if she knew where the [NAME] hose was kept. The Resident replied it was kept in her drawer. CNA QQ tried to locate the [NAME] hose in resident's drawers but was unable to locate them. In an interview on 06/16/23 at 11:53p.m., with LVN A, she said Resident#1 received health shakes three times a day. Shakes came with each meal from the kitchen. She said Resident# 1 needed health shake for nutrition. Resident had weight loss. Shakes were meal supplement. Observation and interview on 06/16/23 at 12:10 p.m., with LVN A and CNA QQ Resident #1 was observed sitting on a recliner. She did not have her [NAME] hose applied. Resident #1 had pink sock on. LVN A said CNAs were responsible for applying the [NAME] hose on the residents, but the nurses documented the presence of [NAME] hose in the MAR. She said she documented the resident had her [NAME] hose on assuming the CNA had applied them. At this time LVN A asked Resident#1 where the [NAME] hose was kept. Resident #1 pointed to her drawer across from her bed. LVN A searched for the [NAME] hose but was unable to find them. LVN A said, Resident does not like facility's [NAME] hose. She has her own but it's dirty. Daughter does laundry. LVN A said Resident needed [NAME] hose because she sits on chair for long period of time . In an interview on 06/16/23 at 2:21p.m., with the DON, shared observation from earlier. She said it was the CNAs responsibility to apply the [NAME] hose. She said before staff signed the MAR to reflect completion of the task, the nurses were to assess the residents to ensure the [NAME] hose had been applied according to the physician's orders. The DON said it was error on nurse's part for documenting when the [NAME] hose was not available. she said, 'moving forward we will make sure there is a pair on the resident and one pair on the cart and supply room. She said [NAME] hose help with circulation. She said the Health Shake came from dietary. She said if the shake was not on the tray the staff needed to go to dietary and get the shake. She said health shakes were ordered to meet nutrition caloric need. In an interview on 06/16/23 at 3:45p.m., with the Dietary Director, she said dietary put the shakes on the tray if it was mentioned on the meal ticket. She said nursing staff could also come to the kitchen door to get the shake if it was missing from the tray. In an interview on 06/16/23 at 4:22p.m., with the DON, she said the facility did not have a policy on following physician order. Record review of 1 on 1 in-service record for LVN A conducted by DON dated 06/16/23 revealed read in part: .Topic: Documentation. Comments: Documentation is to be completed at the time of service. Documentation should be factual and objective. False information should not be documented. Documentation must be detailed about the resident care. Failure to do so will result in re-education and up to termination . Record review of facility's in-service dated 06/16/23 conducted by Dietary Director to kitchen staff revealed read in part: .Course title: Supplements and tray items. Subject: Ensuring that all items including shakes are on the tray . Record review of facility's Documentation in Medical Record policy (Dated reviewed/revised: 02/2023) read in part: .Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the 676381 Page 3 of 4 676381 06/16/2023 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0656 residents progress through complete, accurate, and timely documentation . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676381 Page 4 of 4