Health inspection·March 7, 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 interview and record review, the facility failed to develop the comprehensive person-centered care plan with services furnished to maintain the resident's highest practicable physical well-being for 1 of 18 residents, (Resident #23), in that: Resident #23's care plan was not updated to reflect the resident's need for a fall mat. these failures placed residents at risk of not receiving adequate care. Findings included: Record review of Resident #23's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with cerebral infarction, dementia and muscle weakness. Record review of Resident #23's MDS, dated [DATE], revealed the resident had a BIMS score of 9 indicating the resident's cognition was moderately impaired. It also documented resident had no falls since prior assessment. Record review of the facility's incident log dated 09/05/2023 - 03/05/2024, revealed Resident #23 had three falls in the past 3 months, recorded on 02/09/2024, 02/11/2024 and 02/28/2024. Record review of Resident #23's nurses notes reflected on 02/09/2024, the resident reported she fell out of bed and hit her head. On 02/28/2024, she reported she fell trying to transfer herself from her wheelchair to bed. Observations and interview with Resident #23 on 03/05/24 10:33AM, revealed the resident was lying in her bed with fall mats on both sides. The resident stated she has fallen in the past because she feels dizzy when getting up. Record review of Resident #23's care plan, undated, revealed under section related to falls, the resident was not care planned for the need of a fall mat. In an interview with CNA H on 03/07/2024 at 12:25PM, she stated she often worked Resident #23 and fall mats were recently implemented at least a week ago due to the resident often attempting to transfer herself and falling in the process. She stated the fall mat being care planned would allow her Page 1 of 5 676412 676412 03/07/2024 Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and other staff to reference and see the resident's need for the fall mat through the [NAME] and other interventions for other residents. In an interview with the DON on 03/07/2023 at 1:03PM, she stated she was in charge of updating care plans had 72 hours to update care plans with new interventions. The residents' care plans are reflected on the [NAME] for staff to refer to and to provide proper care. She stated fall mats help cushion falls and lessen injuries and should be added to the care plan. She said the risk of not documenting fall mats as an intervention was an increased risk of injury to the resident. She stated she missed the opportunity to update Resident #23's care plan likely due to oversight. In an interview with LVN T on 03/07/2024 at 1:45PM, he stated he worked with Resident #23 and she required a fall mat to prevent any possible head trauma from falls. He said the resident had a tendency of transferring herself without help and would slide on the floor. He stated if the intervention of fall mat was not documented on the care plan, it would place the resident at risk of injury in the case a new nursing staff were to work with them and remove the fall mats not knowing the necessity of them. Record review of facilities policy titled, Comprehensive Care Plans, dated April 2023, reflected, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . Record review of facilities policy titled, Fall Prevention, dated January 2023, reflected, . When any resident experiences a fall, the facility will .review the resident's care plan and updated as indicated . 676412 Page 2 of 5 676412 03/07/2024 Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396

F 0692 Provide enough food/fluids to maintain a resident's health. 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 provide 2 of 3 residents (Resident #7 and #39) food in a form to meet their needs: Residents Affected - Some Residents #7 and #39 were not provided a nutritional supplement as ordered. This failure places residents at risk of experiencing nutritional deficiencies. Resident # 7 Record review of Resident #7's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with abnormal weight loss, vitamin deficiency. Record review of Resident #7's care plan, dated 01/08/2024 revealed Resident #7 was triggered for significant /unexpected weight loss due to many food dislikes, diet restrictions and is at risk for further weight fluctuation. The goal associated with this risk was for Resident #7 to have weight stabilized by target date April 3, 2024. Resident #7 will receive adequate nutrition and fluid intake and weight will stabilize through the next review. Interventions to include provide supplements as ordered, provide/offer hydration throughout the day. Serve diet as ordered and offer substitution, if intake less than 50%. Record review of Resident #7's physician order dated 01/18/2024 revealed Resident #7 will receive health shake two times a day for additional nutrition for 90 days with lunch and dinner. Record review of Resident #7's meal ticket read House Shake. Observed on 3/5/24 at 12:32 pm Resident #7 with her lunch tray- noted meal ticket with health shake (a nutritional supplement) as part of her dietary needs to be served with lunch. No health shake present. Inquired from resident does she usually get a health shake supplement and she stated yes. Observed on 3/6/24 at 7:50 am Resident #7 in bed with head of bed at approximately 30°, Breakfast meal ticket shows no health shake to be served with breakfast. No health shake on meal tray noted. Observed on 3/6/243 at 12:36 pm Resident #7 with head of bed at approximately 30°. Lunch meal ticket shows health shake to be served with lunch. Health shake supplement not on lunch meal tray. Observed on 3/7/24 at 12:28 pm with LVN Q and Resident#7, LVN Q looked at lunch tray, LVN Q looked at meal ticket, LVN Q stated she observed health shake on meal ticket. LVN Q stated she did not see health shake on tray. LVN Q stated health shakes should be on the tray when health shakes are on the meal ticket. __________________ Resident # 39 Record review of Resident #39's face sheet revealed an [AGE] year-old female who was admitted into 676412 Page 3 of 5 676412 03/07/2024 Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility on [DATE] and was diagnosed with Cerebral Infarction (type of stroke in which a cluster of brain cells die when they don't get enough blood). Record review of Resident #39 care plan, dated 01/22/2024 revealed Resident #39 has triggered for significant unexpected weight loss due to cognitive impairment and decreased oral intake. She is at risk for further weight fluctuations. The goal for this is resident will receive adequate nutrition and fluid intake and weight will stabilize through next review target date April 17, 2024. Intervention for this care plan included offer meal substitution/alternative to food/snacks within dietary limits. Serve diet as ordered and offers substitution, if intake less than 50%. Record review of resident #39's physician's order dated 01/19/2024 revealed, house shake with meals for additional nutrition for 90 days. Record review of Resident #39's meal ticket read House Shake. Observed on 3/5/24 at 12:34 pm Resident #39, with her lunch tray- noted meal ticket with health shake (a nutritional supplement) as part of her dietary needs to be served with lunch. No health shake present. Inquired from resident does she usually get a health shake supplement and she stated yes. Observed on 3/6/24 at 7:48 am Resident #39 in bed with head of bed at approximately 30°, Meal ticket shows the health shake to be served with breakfast, no health shake noted on tray. Observed on 3/6/243 at 12:38 pm Resident #39 with head of bed at approximately 30°. Lunch meal ticket shows health shake to be served with lunch. Health shake supplement not on lunch meal tray. Observed on 3/7/24 at 12:28 pm observed with LVN Q, and Resident# 39, LVN Q looked at lunch tray, LVN Q looked at meal ticket, LVN Q stated she observed health shake on meal ticket. LVN Q stated she did not see health shake on tray. Interview on 3/7/24 at 9:31 am with LVN Q stated she is able to locate diet requirements and diet needs in PCC (Point Click Care (an application that is used for documentation in nursing facility)), LVN Q stated the process for passing meals. Kitchen staff prepare meal, dietary manager checks the tray, for correct diet, texture, and supplements. The nurse checks the tray on the hall. LVN Q stated if supplement is not present the Nurse or CNA, will go to kitchen and get the supplement. LVN Q stated the responsibility to assure meal tray is correct is the kitchen staff, dietary manager, nurse in the hall and CNA that delivers the meal. Consequences for not following diet orders, if supplement is not received by resident there is a potential for weight loss and decreased wound healing. Interview on 3/7/24 at 9:40 am with MA. MA stated she is assigned to help in the dining room with feeding residents and checking trays after the nurse checks the trays. CMA stated the kitchen is responsible for setting the trays up, nurses responsible for assuring diet and supplements are on the tray. CMA stated the consequences for not having proper diet and supplementation on trays is weight loss, and delayed wound healing. Interview on 3/7/24 at 9:50 am with CNA U. CNA U stated she is able to locate diet orders for residents on [NAME] (desktop file system that gives brief review of each resident) in PCC and during report with nurse. CNA U stated Kitchen staff prepare meal, dietary manager checks the tray, for correct diet, texture, and supplements. The nurse checks the tray on the hall. CNA U stated if something is missing, she would contact the nurse, and go to the kitchen to get the missing item. CNA U stated 676412 Page 4 of 5 676412 03/07/2024 Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when she checks trays, she looked for the food to match the ticket. CNA U stated when she receives the tray from the kitchen food should be correct and supplements should be in place. CNA U stated loss of weight could be a consequence of not having the correct diet and supplementation. Interview on 3/7/24 at 10:07 am with Dietary Manager (DM). DM stated she reviews menus in PCC. She does a dietary audit between her system and the PCC system twice a week. DM stated she receives dietary orders from nurse, dietitians, and doctors. DM stated dietary changes are brought to kitchen by dietitian or nurses. DM stated the process for trays is the meal trays are created in the kitchen, she oversees as meals being prepared, and checks the trays before they go out. DM stated when checking trays she is looking for everything to be on the tray, supplements, drink, preferences, allergies, texture and their meal tickets match the meal tray prior to leaving the kitchen. DM stated consequences for residents, not receiving correct diet is weight loss, and decreased wound healing. Interview on 3/7/24 at 2:45 pm with Director of Nurse (DON). DON stated the staff are able to locate current diets for resident in PCC. DON stated the process for nursing trays- kitchen creates tray and verifies everything is present by checking meal tray and meal tickets, meal carts go to the hallway, the nurse checks the meal tickets and verifies meal is correct on the tray, if there are items missing either the nurse, or the CNA will go to the kitchen and retrieve it. The reason they are checking trays is to make sure there is correct diet, preferences, consistency, special plates, supplements are present as ordered by MD. Consequences for not having proper diets on resident trays is nutritional needs not being met, weight loss, and decreased wound healing. Record review of the facility's policy on Nutritional and Dietary Supplements, Date implemented 1/2023, Date Reviewed/Revised 4/2023 revealed in part, Policy: It is the policy of this facility that nutritional and dietary supplements will be used to complement a resident dietary needs in order to maintain adequate nutrition status and residence highest practicable level of well-being. Definitions: nutritional supplements refers to products that are used to complement a resident's dietary needs such as calorie or nutrient dense drinks, total parenteral products, enteral products and meal replacement products (e.g., Health Shakes, High Calorie Supplement, etc). Policy Explanation and Compliance Guidelines: 8. Nutritional supplements are to be provided to residents within a timely manner of either a resident's request or less depending on facility's scheduled time for meals. 676412 Page 5 of 5