Health inspection·August 23, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility assessments failed to ensure that the assessment accurately reflected the resident's status for two residents (Resident #42 and #84) of 24 residents reviewed for assessments. Residents Affected - Few 1. Resident #42's cardiac pacemaker was not identified as an active diagnosis on his quarterly MDS assessment with an ARD of 07/09/2024. 2. Resident #84's falls since admission were not reflected on her quarterly MDS assessment with an ARD of 08/09/2024. These failures placed residents at risk for missed or inaccurate care. The findings were: 1.Record review of Resident #42's electronic face sheet dated 08/22/2024 reflected he was admitted to the facility on [DATE]. The resident's diagnoses included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), unspecified atrial fibrillation (a common type of arrhythmia, or irregular heart rhythm, that causes the upper chambers of the heart to beat rapidly and irregularly), anemia (a blood disorder that occurs when the body does not produce enough healthy red blood cells, or the red blood cells do not function properly), atherosclerotic heart disease (a condition that causes arteries to narrow and harden due to plaque buildup) and presence of cardiac pacemaker (a device used to control an irregular heart rhythm). Record review of Resident #42's quarterly MDS assessment with an ARD of 07/09/2024 reflected he was understood and usually able to understand. He scored a 14 out of 15 on his BIMS which signified he was cognitively intact. Review of Section I-Active Diagnoses did not reflect his presence of cardiac pacemaker. Record review of Resident #42's comprehensive care plan revised on 01/31/2024 reflected Focus, has a defibrillator pacemaker, Interventions/Tasks, Apical pulse daily to monitor proper function of the pacemaker, notify MD if pulse is less than 60 or greater than 100. Record review of Resident #42's Active Orders as of: 08/22/2024 reflected APICAL PULSE DAILY TO MONITOR PROPER FUNCTION OF PACEMAKER one time a day related to PRESENCE OF CARDIAC PACEMAKER (Z95.0) NOTIFY MD IF PULSE < 60 BPM > 100 Phone Active 01/27/2022 01/28/2022. Page 1 of 6 676419 676419 08/23/2024 LA Hacienda DE Paz Rehabilitation and Care Center 3333 Bob Rogers Dr Eagle Pass, TX 78852

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #42's TAR dated 08/01/2024-08/31/2024 reflected APICAL PULSE DAILY TO MONITOR PROPER FUNCTION OF PACEMAKER one time a day related to PRESENCE OF CARDIAC PACEMAKER (Z95.0) NOTIFY MD IF PULSE < 60 BPM > 100 Phone Active 01/27/2022 01/28/2022. And nurses initialed off daily that Resident #42's apical pulse was checked and noted the corresponding pulse rate. Observation on 08/22/2024 at 11:32 a.m. of Resident #42 revealed he showed the surveyor a scar on his upper left chest where he had a pacemaker. Interview on 08/22/2024 at 11:34 a.m. with Resident #42, he stated he had the pacemaker since 2007. 2.Record review of Resident #84's electronic face sheet dated 08/21/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: unspecified dementia (a general term for a range of neurological conditions that cause a loss of brain function and impair a person's ability to think, remember, and make decisions), muscle weakness (commonly due to lack of exercise, ageing or muscle injury) and psychotic disorder (a condition that causes people to lose touch with reality) Record review of Resident #84's quarterly MDS assessment with an ARD of 08/09/2024 reflected she scored a 04 out of 15 on her BIMS which signified she was severely cognitively impaired. She required substantial assistance with her ADL's. Review of Section J-Health Conditions reflected Number of Falls Since Admission/Entry or Reentry or Prior Assessment, whichever is more recent, No boxes were coded to indicate, None, One or Two or more. Record review of Resident #84's comprehensive care plan revised date of 07/22/2024 reflected Focus, resident has a hx of falls due to limited mobility, impaired vision, weakness and use of antipsychotic medications and poor safety awareness. Record review of Resident #84's Fall Nurses Note dated 06/04/2024 reflected Resident #84 had a fall with no injury. Record review of Resident #84's Fall-Risk Assessments dated 07/10/2024 reflected she scored a 10 which signified she was High Risk for falls and had 1-2 Falls in the past 3 months. Observation on 08/23/2024 at 10:00 a.m. of Resident #84's room revealed she had a low bed with a fall mat. Interview on 08/23/2024 at 10:00 am with the ADM revealed she was accountable for the MDS's and stated it was important to show residents care as accurate and to be transparent as a provider. She stated care could be missed if the MDS was not accurate and result in demise. Interview on 08/23/2024 at 10:15 a.m. with MDS A revealed a new MDS nurse completed the quarterly MDS for Resident #42, and she started in 04/2024 and was still learning. She stated it was important to have accurate MDS's because care could be missed and she would double check MDS B's work, because she was the RN who signed the MDS's for accuracy. Interview on 08/23/2024 at 10:23 a.m. with MDS B revealed she missed the cardiac pacemaker diagnosis for Resident #42, and she was trained, but still learning. She stated she needed to review the falls for residents. She stated the MDS's for Residents #42 and #84 had since been modified to correct 676419 Page 2 of 6 676419 08/23/2024 LA Hacienda DE Paz Rehabilitation and Care Center 3333 Bob Rogers Dr Eagle Pass, TX 78852

F 0641 the errors. She stated it could have resulted in missed care. Level of Harm - Minimal harm or potential for actual harm Interview on 08/23/2024 at 10:36 a.m. with the DON revealed MDS's trigger components and are the base of the care plan, so they must be accurate. She stated important care could be misinterpreted or missed and result in harm. Residents Affected - Few Record review of the facility policy and procedure titled Minimum Data Set (MDS) policy for MDS assessment Data Accuracy 2.2021 (undated) reflected The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status. 676419 Page 3 of 6 676419 08/23/2024 LA Hacienda DE Paz Rehabilitation and Care Center 3333 Bob Rogers Dr Eagle Pass, TX 78852

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident (Resident #42) out of 24 residents reviewed for quality of care. Residents Affected - Few RN C did not perform an apical pulse for Resident #42 in August 2024 as ordered to check the function of his cardiac pacemaker. This deficient practice could affect residents with cardiac pacemakers and could result in dysrhythmias (irregular heartbeats). The findings included: Record review of Resident #42's electronic face sheet dated 08/22/2024 reflected he was admitted to the facility on [DATE]. The resident's diagnoses included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), unspecified atrial fibrillation (a common type of arrhythmia, or irregular heart rhythm, that causes the upper chambers of the heart to beat rapidly and irregularly), anemia (a blood disorder that occurs when the body does not produce enough healthy red blood cells, or the red blood cells do not function properly), atherosclerotic heart disease (a condition that causes arteries to narrow and harden due to plaque buildup) and presence of cardiac pacemaker (a device used to control an irregular heart rhythm). Record review of Resident #42's quarterly MDS assessment with an ARD of 07/09/2024 reflected he was understood and usually able to understand. He scored a 14 out of 15 on his BIMS which signified he was cognitively intact. Review of Section I-Active Diagnoses did not reflect his presence of cardiac pacemaker. Record review of Resident #42's comprehensive care plan revised on 01/31/2024 reflected Focus, has a defibrillator pacemaker, Interventions/Tasks, Apical pulse daily to monitor proper function of the pacemaker, notify MD if pulse is less than 60 or greater than 100. Record review of Resident #42's Active Orders as of: 08/22/2024 reflected APICAL PULSE DAILY TO MONITOR PROPER FUNCTION OF PACEMAKER one time a day related to PRESENCE OF CARDIAC PACEMAKER (Z95.0) NOTIFY MD IF PULSE < 60 BPM > 100 Phone Active 01/27/2022 01/28/2022. Record review of Resident #42's TAR dated 08/01/2024-08/31/2024 reflected APICAL PULSE DAILY TO MONITOR PROPER FUNCTION OF PACEMAKER one time a day related to PRESENCE OF CARDIAC PACEMAKER (Z95.0) NOTIFY MD IF PULSE < 60 BPM > 100 Phone Active 01/27/2022 01/28/2022. And nurses initialed off daily that Resident #42's apical pulse was checked and noted the corresponding pulse rate. Observation on 08/22/2024 at 11:32 a.m. of Resident #42 revealed he showed the surveyor a scar on his upper left chest where he had a pacemaker. Interview on 08/22/2024 at 11:34 a.m. with Resident #42, he stated he had the pacemaker since 2007. 676419 Page 4 of 6 676419 08/23/2024 LA Hacienda DE Paz Rehabilitation and Care Center 3333 Bob Rogers Dr Eagle Pass, TX 78852

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few When asked by the surveyor if nurses listen to his heart, he stated the only one that listened to his heart was the doctor. He stated the nurses used a cuff to take his vital signs. Interview on 08/22/2024 at 11:45 a.m. with RN C who was assigned to Resident #42, she stated she took his vital signs with a machine and a cuff, and it was important because he was on cardiac medications. When shown the by the surveyor she initialed off on the apical pulse check, she stated she did not read it and marked it off. She stated she did not know he had a cardiac pacemaker. She stated she had a stethoscope and knew how to take an apical pulse, but she did not do it. She stated she did not get assigned to that hall much. Interview on 08/23/2024 at 10:36 a.m. with the DON, she stated she in-serviced her nurses on the apical pulse, and she was not aware normal vital signs were taken. She stated nurses were trained and knew how to take an apical pulse. She stated it was an older but thorough way of listening to any irregularity in the heartbeat which was important with a resident who had a pacemaker. She stated she was responsible for overseeing resident care, and checked that physician orders were followed. Record review of RN C's Nurse Proficiency Audit dated 11/5/2023 reflected she was signed off as s or satisfactory for Cardiovascular Assessment Skills. Record review of the facility policy and procedure titled Permanent Pacemaker revised February 13, 2007, reflected The resident will experience correct functioning of the pacemaker. Record review of Resident #42's cardiac follow-up dated 05/4/2024 reflected Normal Pacemaker Examination. Record review of the facility policy and procedure titled Pulse, Apical dated 2003, reflected Auscultate for the sound (lub-dub) of the heartbeat and count beats for 60 seconds with each lub-dub signifying a single beat and note rhythm and quality and any deviations from baseline values. 676419 Page 5 of 6 676419 08/23/2024 LA Hacienda DE Paz Rehabilitation and Care Center 3333 Bob Rogers Dr Eagle Pass, TX 78852

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, interviews and record reviews, the facility failed to establish and maintain an infection 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 1 resident (Resident #8) of 4 observed for peri care and wound care in that: Residents Affected - Few CNA D and RN C failed to sanitize their hands between glove changes while performing peri care and wound care for Resident #8. These failures could result in cross contamination of germs and could result in an infection or hospitalization. The findings were: Record Review of Resident #8's face sheet dated 08/20/2024 revealed she had an original admission on [DATE] and a re-admission on [DATE], with diagnoses of: cerebral infarction (a stroke), chronic atrial fibrillation (irregular heart rhythm), heart failure (heart does not pump enough blood), and dysphasia (difficulty swallowing). Record Review of Resident #8's quarterly MDS assessment with an ARD of 08/13/2024 revealed Resident #8 had frequent incontinent bowel and bladder. Further review of the MDS revealed Resident #8's SAMS score was a 3, indicating rarely/never understood. Observation on 08/21/2024 at 9:21 a.m. of CNA D performed peri care for Resident #8, during peri care, CNA D did not sanitize her hands in-between glove changes. Interview on 08/21/2024 at 9:37 a.m. with CNA D stated not sanitizing her hands between glove changes could cause cross contamination and could result in the resident getting an infection or being hospitalized . Observation on 8/21/2024 at 9:45 am of RN C performed wound care for Resident #8, during wound care, RN C did not sanitize her hands in-between glove changes. Interview on 8/21/2024 at 10:00 am with RN C stated she should have sanitized her hands in-between gloves changes to prevent cross-contamination. Interview on 8/21/2024 at 10:15 am with the DON stated the nurse and CNA should have sanitized their hands in-between glove changes to prevent any infections from cross-contamination. Record Review of CNA D's Nurse Aide Incontinence Care Proficiency Assessment (not dated) revealed they were checked off for completing incontinent care which included washes hands/changes gloves. Review of the facility policy and procedure guide titled Perineal Care dated 4/27/2022, revealed Always perform hand hygiene before and after glove use. 676419 Page 6 of 6