Health inspection·February 22, 2024

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 ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #74) of 8 residents reviewed for comprehensive care plans. The facility failed to create and implement a care plan that reflected the Resident's preference to speak Spanish. This failure could put the Resident at risk of not being able to communicate effectively with staff, which could result in isolation, reduced psychosocial well-being, and of not getting her needs met in a timely manner. Findings included: Review of Resident #74's face sheet undated reflected a [AGE] year-old female admitted to the facility on [DATE] and diagnosis of unspecified dementia (loss of cognitive functioning), unspecified severity, , insomnia (sleep disorder), unspecified anxiety disorder (a condition in which a person has excessive worry and feelings of fear or unease), hypertension (high blood pressure), muscle weakness (generalized), muscle wasting and atrophy, other abnormalities of gait (manner of walking) and mobility, history of falling. Record Review of Resident #74's admission document titled dated 05/23/23 revealed Resident #74 was Spanish speaking only. Record review of Resident #74's Admissions MDS assessment dated [DATE] and Quarterly MDS dated [DATE] and 11/14/23 revealed Resident #74 resident preferred speaking Spanish and needed an interpreter to communicate with doctors and staff. Record review of Resident #74's Quarterly MDS dated [DATE], 11/14/23, and 08/14/23 revealed Resident #74 preferred language was Spanish and she did not want or need an interpreter. Record Review of Resident #74's care plan dated 02/13/24 revealed there was no care plan for Resident's preferred language of Spanish. Record Review of Resident #74's progress note date 12/5/23 by Previous Activities Director: Every time I go in the room now she closes her eyes and pretends to be asleep. I'm not sure it is a good Page 1 of 5 676390 676390 02/22/2024 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few idea to continue one to one visits with her. The language barrier is an issue and she is not interested in having me visit. Record Review of Resident #74 progress note dated 1/11/24 by Previous Activities Director: there aren't adequate materials in the file for Spanish Resources. Everything in the file folder is in Spanish. I pointed this out to my supervisor and she told me to do my best and figure it out. Observation of Resident #74 on 02/20/24 at 11:08 AM revealed the resident was laying in bed watching television in Spanish with call light and water cup within reach. Resident #74's room had the lights on low and pictures were on nightstand next to the resident's bed with additional pictures on top of furniture underneath the television. Surveyor attempted an interview and resident raised her hand and indicated she only spoke Spanish. Interview on 02/21/24 at 11:54 AM with Resident #74 with translation by CNA D revealed resident laying in bed with television on a Spanish channel, with a blanket, call light within reach, and water cup on bed side tray. Resident #74 stated that she did not have concerns with abuse or neglect and staff were kind to her. Resident #74 stated that she did not know what a communication board was and did not remember anyone asking her about a communication board. Interview 02/21/24 at 11:57 AM with CNA D revealed a communication board that Resident #74 could point to show what she needed such as water or if she were in pain, would be helpful for Resident #74. CNA D stated that, if needed, staff could also get the Spanish-speaking housekeeping staff to translate for Resident #74. Interview on 02/21/24 at 2:00 PM with the Speech Therapist revealed she was aware that Resident #74 was Spanish-speaking only and there were no interventions to use for resident. The Speech Therapist stated she did not speak Spanish. Speech Therapist stated she did not do care plans. The Speech Therapist stated that if a resident had a communication deficient then it should be care planned. The Speech Therapist stated that when residents needed interventions, she was responsible for training staff on what resident needs. The Speech therapist stated she did not do care plans and would report to charge nurse if there was an issue or a resident needed an issue care planned. Interview with the MDS Coordinator on 02/21/24 at 2:16 PM revealed she was aware that Resident #74 spoke Spanish but thought she was able to make her needs known by saying yes or no and indicating with body language. The MDS Coordinator stated Resident #74's language limitation was not care planned. The MDS Coordinator stated he spoke with her everyday by asking her how she was and she always said she was good, and anytime he asked if he can check her fridge for expired food she tells him yes. The MDS Coordinator stated that communication deficits should be care planned. Interview on 02/21/24 at 2:20 PM with LVN B revealed she that had been at facility about 5 years PRN (as needed). LVN B stated she spoke Spanish and communicated in Spanish with Resident #74 because that was her preferred language. LVN stated that Resident #74 communicated in English a little with examples of: yes, no, a little bit. LVN B stated that residents with communication deficits should be care planned. LVN B stated that staff could also get housekeeping to assist if they needed translation assistance. LVN B stated that something like a communication board would be helpful for Resident #74. Interview on 02/21/24 at 2:30 PM with CNA E revealed she was responsible for scheduling staff. CNA E stated that she did not purposely schedule Spanish-speaking CNA's and nurses for Resident #74 hall 676390 Page 2 of 5 676390 02/22/2024 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and that they just happen to have Spanish speakers on every shift. CNA E provided a highlighted list of Spanish speaking staff. CNA E stated that she communicated with Resident #74 and resident would say yes and no and sometimes more than that. CNA E stated she probably could schedule Spanish speakers for that hall, and that housekeepers are usually available if staff needed someone to translate in Spanish for resident or staff. CNA E agreed that a communication board would probably be helpful for Resident #74. CNA E stated that resident arrived to facility able to communicate fairly well in English and perhaps she had a decline. Interview with the Personal Care Assistant (PCA) on 02/22/24 at 8:40 AM revealed Resident #74 mainly spoke Spanish and a little bit of English like Yes, No, or Wet to indicate she needed to be changed and that he can usually communicate with her. The PCA stated that if he needed a translator, he could get a housekeeper to translate. The PCA stated he had to get a housekeeper to translate, before, when she was refusing to shower. The PCA stated that Resident #74 had never spoken more English than she had today. The PCA stated that a communication board would be helpful to ensure Resident #74's needs were addressed and did not know why they did not have one for resident. Interview on 02/22/24 at 11:40 AM with the Current Activities Director (CAD) revealed that she had only worked at facility for 3 weeks and she was not aware they had any Spanish speaking residents. The CAD could not recall Resident #74. The CAD stated that she was aware they have Spanish resources and was able to produce a printed booklet in Spanish only. The CAD stated she couldn't read them because they were in Spanish and she did not speak Spanish so she did not know what kind of resources they were. The CAD also produced a communication board but when asked what the paper was, the CAD replied she did not know and said that the words on the document were in Spanish and the CAD could not read it. The CAD stated if resident preferred Spanish or only spoke Spanish it would be difficult to communicate with resident because the CAD doesn't speak Spanish. Interview on 02/22/24 at 11:53 AM with the DON revealed she did not think they had any residents that couldn't speak English. DON stated she did not speak Spanish. The DON stated that resident #74 does speak some English, and while she had not had full blown conversations with her, she could communicate her needs. The DON stated that they care planned for residents with communication deficits and coordinated with Speech to develop a communication board for things like pain or other issues. Interview with the Social Worker on 02/22/24 at 12:13 PM revealed she worked at facility for 3 months and wasn't sure who their Spanish-speaking residents were. The Social worker did not recall speaking with Resident #74. The Social worker stated that if a resident did not speak English it would be challenging to communicate and ensure basic needs. Interview with the Administrator on 02/22/24 at 12:15 PM revealed he was aware that Resident #74 spoke Spanish and a little English. The Administrator stated that he did not know if Spanish-speaking staff were scheduled purposefully for Resident #74's hall. The Administrator stated that residents with communication deficits should be care planned. The Administrator stated a communication board would be a good idea and would work on getting that for Resident #74. Record review of facility's Comprehensive Care Plan Policy, undated, revealed (i) the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being. 676390 Page 3 of 5 676390 02/22/2024 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

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 observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #55) of two residents reviewed for catheter care. 1. The Facility failed to ensure Resident #55's foley catheter was secured prior to transferring Resident #55 from the bed to his wheelchair. 2. The facility failed to ensure CNA B and CNA C maintained the foley catheter drainage bag below Resident #55's bladder during a mechanical lift transfer. This failure placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter. Findings included: Record review of Resident #55's face sheet dated 02/20/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. Primary diagnoses included diabetes, and obstructive uropathy (disorder of the urinary tract due to obstructed urinary flow). Record review of Resident #55's Quarterly MDS assessment dated [DATE] reflected he had a BIMS of 15 which indicted he was cognitively intact, required extensive to total assistance with toileting and personal hygiene and was always incontinent of bowel and had a foley catheter. Record review of the Resident #55's care plan initiated on 07/10/23 reflected, The resident has an indwelling catheter related to obstructive uropathy. Interventions included .Position catheter bag and tubing below the level of the bladder .Goal .The resident will be/remain free from catheter-related trauma . Review of Resident #55's Order Summary report dated 02/20/24, reflected, Catheter Care-Catheter drainage bag to gravity. Secure catheter. Check every shift .Change catheter secure device every Wednesday With a start day of 07/07/23. Observation on 02/20/24 at 9:30 a.m. revealed CNA B and RN B entered Resident #55's room to get the resident up for the day. CNA B unhooked the catheter bag from the bed rail and passed it to CNA C, who then then hooked it to the top bar of the mechanical lift, above resident's bladder. The catheter tubing was not strapped to the resident's leg. The staff raised the resident from the bed with the Foley catheter bag hanging above the resident's head. Urine was observed flowing back toward the resident's bladder. The staff then positioned him over his wheelchair and lowered him into his chair and unhooked the catheter bag from the mechanical lift and onto the back of his wheelchair. In an interview with CNA B on 02/20/24 at 09:45 a.m., she stated she had worked at the facility for 3 years. She stated she was trained to make sure the catheter bag was always in a privacy bag, make sure the tubing was not kinked and make sure they emptied the drainage bag each shift. She stated the catheter tubing was supposed to be secured to the resident's leg and it was the nurse who secured it. She stated she was not sure why Resident #55's was not secured and would let the nurse know. 676390 Page 4 of 5 676390 02/22/2024 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few When asked about keeping it below the bladder, the CNA was not sure where the catheter bag should have been positioned during the transfer. She stated having it above the bladder could possibility cause blockage and then she stated the urine could run backwards, which could cause an infection. In an interview with CNA C on 02/20/24 at 09:50 a.m. she stated Resident #55's catheter tubing was supposed to be taped to his leg, and stated she was not sure why it was not secured. She stated it was the nurse who took care of that. When asked about the positioning of the foley catheter bag, she stated they should have placed it in his lap, but then stated it would still be above his bladder and stated they should have held the drainage bag below the resident while they transferred him. She stated failing to do this could cause the urine to back up and might cause an infection. In an interview with Staff Development on 02/20/24 at 02:15 a.m., she stated the facility did skills checks on all the staff annually or as needed. She stated the staff were taught to make sure the catheter was secured unless the resident had requested it not to be, and then it should be care planned about their request. She stated the nurse was responsible for ensuring the catheter was secured, but the CNAs should let them know if it had come unsecured . She stated they were taught to keep the bag below the bladder to prevent urine flowing back into the bladder. She stated failing to do this could cause increased risk of urinary tract infections and failing to secure the catheter could lead to the catheter being pulled on or accidently dislodgement. In an interview with Resident #55 on 02/20/24 at 02:40 p.m., he stated he did not mind the catheter being taped to his leg. He stated he had oily skin which caused the tape to come off after about a day or two. He stated he just wanted to make sure it did not get pulled during care, because it was very uncomfortable when that happened. In an interview with LVN A on 02/20/24 at 02:45 a.m., she stated the nurse was responsible for securing the catheter, but stated she relied on the staff to let her know if it had become unsecured. She stated if a resident did not wish to have their catheter secured, it had to be care planned. She stated she would make sure Resident #55's catheter secured. In an interview with the DON on 02/20/24 at 03:00 p.m., she stated any resident with a foley catheter should have it secured, unless the resident requested otherwise, and then it should be care planned, to prevent it from pulling and causing pain or dislodgment. She stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of a urinary tract infection and cross contamination. She stated she would have the Staff development to provide training on positioning of the drainage bag during transfers and the securing the foley catheter tubing. Record review of CNA B's proficiency check off for catheter care revealed she was proficient in care as of 10/11/23. Record review of CNA C's proficiency check off for catheter care revealed she was proficient in care as of 10/06/23. Review of the facility's undated policy titled, Catheter Care , reflected, Purpose: to prevent infection .To reduce irritation .Properly secure catheter .Procedure should be done at least daily . 676390 Page 5 of 5