Health inspection·August 18, 2022

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 that residents received treatment and care in accordance with the comprehensive assessment, professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one resident (Resident #21) out of one resident reviewed for wound assessments. Residents Affected - Few 1. RN A failed to change her gloves after cleaning Resident #21's wound and before applying the new dressing. This failure could place residents at risk of cross contamination, infection, and further deterioration of exiting wound. Findings include: Review of Resident #21's face sheet reflected the resident was a female admitted to the facility on [DATE]. Her diagnosis included a pressure ulcer of the sacral region. Review of Resident #21's Wound care order: Type of wound: pressure ulcer Location of wound: sacrum Cleanse wound w/NS, apply Santyl to wound bed, Soak gauze in Betadine onto either kerlix or 4x4 sponge applied to site. Cover with: Bordered gauze. everyday shift for Wound Care Assess for pain before, during and after dressing change and every 24 hours as needed. On 08/17/2022 at 1:17 p.m. during wound care observation revealed RN A removed Resident #21's wound and cleaned it. She failed to change the gloves and perform hand hygiene before applying the clean wound dressing. During an interview on 08/17/2022 at 1:35 p.m. RN A stated she was not doing the wound care often, she said she was a PRN (as needed) nurse and had to do it for the resident because the wound care nurse was not in the facility that day. She stated failure to change her gloves could contaminate the wound and increase risk of infection for the resident. RN A states she had received infection control training on hand washing, donning and doffing gloves. During an interview with the DON on 08/17/2022 at 1:42 p.m., she stated the failure could cause cross contamination from the dirty gloves to the wound and place the resident at risk for infection. The DON stated they had a series of trainings being offered to the employees. She said they had a check list where they would observe employees performing hand hygiene, donning and doffing gloves, hand washing and they also had online training. Page 1 of 9 676442 676442 08/18/2022 Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521

F 0686 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy titled 'Wound Care (revised May 2022) Steps in the Procedure revealed after removing old dressing and cleaning the wound, employees were to remove gloves and drop them into the appropriate receptacle. The policy reflected employees were to perform hand hygiene followed by wearing clean gloves to perform the wound dressing. Residents Affected - Few 676442 Page 2 of 9 676442 08/18/2022 Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521

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 medications (without adequate indications for use) for 1 (Resident #88) of 16 residents reviewed for unnecessary medications: Residents Affected - Few Resident #88 was receiving anticoagulant Apixaban (reduces risk of blood clots, Eliquis) without an inappropriate indication for its use or diagnosis. This failure could place residents at risk of serious harm due to side effects and adverse reactions from the medication. Findings included: Resident #88 Record review of Resident #88's clinical record revealed an [AGE] year-old female admitted to the facility on [DATE] and a readmission date 7/30/22 with diagnoses which included congestive heart failure (CHF), type 2 diabetes mellitus, chronic respiratory failure, dementia without behavioral disturbance, anxiety disorder and insomnia. Record review of Resident #88's care plan, dated 6/09/22, revealed Resident was receiving anticoagulant therapy. She will have no complications through the review, monitor labs as per MD order and report lab results to MD. Record review of Resident #88's Consolidated Physician's Order, dated August 2022, revealed to give Apixaban 2.5 mg 1 tab twice daily (BID) for anticoagulant, start date 7/31/22. No diagnosis or appropriate indication for use of the anticoagulant. Record review of the MAR, dated August 2022, revealed Resident #88 received Apixaban 2.5 mg 1 tab twice daily (BID) for anticoagulant, start date 7/31/22. No diagnosis or appropriate indication for use of the anticoagulant. In an interview on 8/18/22 11:45 AM the DON stated the MD ordered that all anticoagulant medications to have appropriate indication for its use, and to schedule at every 12 hrs intervals 9:00 AM, 9:00 PM instead of BID. She added she would in-service staff regarding specific time intervals with anticoagulant med administration and with appropriate indication for its use or proper diagnosis. She stated the new unit managers on training will follow-up with reconciliation of monthly consolidated physician's orders and she would be monitoring them. In an interview on 8/18/22 at 3:40 PM the Administrator stated they would follow-up all the medication issues with QAPI. Record review of facility provided policy titled, Pharmacy Services dated April 2007, revealed develop, implement, evaluate and revise (prn) the procedures for the provision of all aspects of pharmacy services (including ordering, delivery, acceptance .administration, documentation and reconciliation of all meds and biologicals . and to identify corrective actions for problems related to pharmacy services and medications including med error. 676442 Page 3 of 9 676442 08/18/2022 Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reevaluate the use of a PRN psychoactive drug, for one Resident (#88) of twelve residents reviewed for psychoactive medications, in that: The facility administered a psychoactive medication (Ativan) PRN (as needed) to Resident #88, for more than 14 days, without an evaluation by Resident #88's Physician for the appropriateness of the medication. This failure could place all residents on psychotropic medications at risk for receiving unnecessary drugs. Findings included: Record review of Resident #88's clinical record revealed an [AGE] year-old female admitted to the facility on [DATE] and a readmission date 7/30/22 with diagnoses which included type 2 diabetes mellitus, chronic respiratory failure, dementia without behavioral disturbance, anxiety disorder, insomnia, and congestive heart failure. Record review of Resident #88's quarterly Minimum Data Set assessment, dated 8/05/22, revealed she was able to make herself understood and usually understands, total BIMS score of 9, with moderately impaired cognitive status. No hallucination or delusions. She received anti-anxiety meds for 7 days. Record review of Resident #88's care plan, dated 6/09/22, revealed the resident with hospice dx CHF. Further review indicated psychological services as needed with dx of anxiety disorder, and to allow the resident to express her feelings. Record review of Resident #88's Consolidated Physician's Orders, dated August 2022, revealed to give Ativan 0.5 mg 1 tab every 2 hrs as needed (PRN), for anxiety, start date 6/07/22. No Stop date order for PRN Ativan after 14 days. Ativan 0.5 mg give 1 tab po three times a day (TID) for anxiety, start date 6/07/22. Record review of the MAR, dated August 2022, revealed Resident #88 received Ativan 0.5 mg 1 tab po three times a day (TID) for anxiety, start date 6/07/22. Ativan 0.5 mg 1 tab every 2 hrs as needed (PRN), for anxiety, start date 6/07/22. No Stop date order for PRN Ativan after 14 days. Record review of facility Consultant Pharmacist recommendation, dated 7/31/22, revealed Resident #88 was newly admitted on a psychotropic medication, Ativan ordered PRN and does not have a stop date after 14 days. Suggest review/discuss with IDT shortly after admission for Pt. assessment that include dx, associated symptoms and meds, determine whether the med can be D/C vs extended or changed. Also, assess for possible consult with psych services and/or psychiatrist evaluation. Per guidelines this is relevant to all residents including those receiving Hospice services. Also, assess for possible consult with psychiatry services and/or psychiatrist evaluation. Per guidelines this is relevant to all residents including those receiving Hospice services. Interview on 8/18/22 11:40 AM the DON stated Resident #88 had an Ativan PRN order since 6/07/22, 676442 Page 4 of 9 676442 08/18/2022 Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521

F 0758 Level of Harm - Minimal harm or potential for actual harm more than 14 days, which should not be given longer than two weeks PRN. She stated moving forward they would ensure PRN psychotropic medication orders had a stop date after 14 days. The DON stated she just asked PCP/ MD and MD told her that he would not agree on psychiatry services as per MRR, for the reason related to family request for Resident's psychotropic Ativan. The DON stated she would follow-up on the MRR issues, and she will be monitoring them. Residents Affected - Few There was no documentation in Resident #88's medical record of an evaluation by resident 's physician for the appropriateness of the use of Ativan PRN for more than two weeks. In an interview on 8/18/22 at 3:40 PM the Administrator stated they would follow-up all the medication issues with QAPI. Record review of the facility's policy titled, Antipsychotic Medication Use dated December 2016 revealed, the need to continue PRN orders for Psychotropic medications beyond 14 days requires that the practitioner document the rationale for extended order. Record review of facility's policy titled, Medication Regimen Reviews, revised date April 2007 revealed: The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. 676442 Page 5 of 9 676442 08/18/2022 Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521

F 0759 Ensure medication error rates are not 5 percent or greater. 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 it was free of medication error rate of five percent or greater. A total of two errors out of 29 opportunities resulting in 6 % error rate. Two of four staff (LVN D and MA C) observed made errors during the medication pass for 2 of 5 residents (Resident #49 and #192) reviewed for medication errors, in that: Residents Affected - Some MA C failed to administer Fluticasone Propionate (Flonase, for allergies) steroid nasal spray to Resident #49 because it was unavailable. LVN D failed to administer Juven packet (for wound healing) mixed in 8 - 10 oz of water as per manufacturer instructions. These failures could affect all residents who take medications and place them at risk of their medications not being administered per physician orders, and at risk of inadequate therapeutic outcomes and decline in health. Findings Included: Resident #49 Record review of Resident #49's clinical record revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, personal history of covid-19, anxiety disorder, depression and dementia without behavioral disturbance. Record review of Resident #49's Physician's Order dated August 2022 revealed an order to give Fluticasone Propionate 50 MCG/ACT Suspension (Flonase) 1 spray in both nostril one time a day for allergies, start date 10/13/21. Record review of Resident #49's MAR dated August 2022 revealed a missed dose of Fluticasone Propionate 50 MCG/ACT Suspension on 08/17/22, (Flonase) 1 spray in both nostrils one time a day for allergies. During observation of medication administration and interview on 08/17/22 at 10:30 AM, revealed Fluticasone Propionate suspension (steroid nasal spray) was not administered to Resident #49. MA C stated she could not administer Resident #49's nasal spray, since the Fluticasone Propionate was unavailable. MA C stated she was new to the facility, and the nurse was informed. In an interview on 08/18/22 at 11:30 AM, the DON stated Resident #49 missed his Fluticasone Propionate yesterday 8/17/22, since it was unavailable, but it was administered today to the resident. She stated they would in-service MAs on notifying nurses timely if medications were not readily available and nurses to follow-up with the pharmacy, and she would like to be notified to elicit assistance. Resident #192 Record review of Resident #192's clinical record revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included protein-calorie malnutrition, adult failure to thrive, 676442 Page 6 of 9 676442 08/18/2022 Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521

F 0759 malignant neoplasm (cancer) of esophagus and Parkinson's disease. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #192's Physician's Order dated August 2022, revealed give Juven 1 packet nutritional supplement via GT one time a day, start date 6/17/22. There was no order with the amount of water to mix the Juven packet. Residents Affected - Some Record review of the MAR dated August 2022 revealed Resident #192 received Juven 1 packet nutritional supplement via GT one time a day, start date 6/17/22. There was no order received with amount of water to mix the Juven packet. Observation of medication administration on 8/17/22 a t 11:40 AM revealed LVN D checked Resident #192's GT placement via residual. Further observed LVN D mixed the Juven 1 packet in 4oz of water then administered the Juven via GT. Observed GT was flushed with 30 ml of water before and after medications administered. Observation and interview on 8/17/22 at 11:50 AM revealed LVN D read the Juven packet's manufacturer instructions, which noted to mix in 8 -10 oz of water. LVN D stated she only mixed Resident #192's Juven 1 packet in 4 oz water. LVN D stated the resident's Juven packet order was incomplete, with no administration directions to mix in a minimum of 8 oz water. In an interview on 8/18/22 at 11:35 AM, the DON stated moving forward she would follow-up to ensure residents' medication orders were complete and accurate with administration directions, and she would be monitoring them. Record review of the facility Consultant Pharmacist recommendations, dated 7/31/22, revealed Please be sure that All order entry complete and accurate including med, strength, dosage form and directions .Please be sure that all orders for MiraLAX have mix in a minimum of 4oz water included in the directions .orders for ProStat and Med Pass have the quantity to give . Record review of facility provided policy titled, Pharmacy Services dated April 2007, revealed to develop, implement, evaluate and revise (prn) the procedures for the provision of all aspects of pharmacy services (including ordering, delivery, acceptance . administration, documentation and reconciliation of all meds and biologicals . and to identify corrective actions for problems related to pharmacy services and medications including med errors. 676442 Page 7 of 9 676442 08/18/2022 Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that the facility failed to ensure that-the kitchen floors and walk in refrigerator were kept clean, free of crumbs and debris. -the vent hood was free of grease build up. -the table-mounted can opener blade and the steel base and body were kept clean and free of debris. -failed to thaw ground frozen beef correctly (under running water) -foods were stored, prepared and served under sanitary conditions. -left over food items were properly covered, labeled, and dated. These failures could place residents at risk for food-borne illness and cross contamination. Observation and interview on 08/16/22 at 9:00 AM to 9:15 AM, revealed the kitchen floors were dirty with food particles and used paper towels. The cooking stove had grease build up on top and around the stove. The grill above the stove had grease build up and the vent hood had grease build up. In an interview the Dietary Manager said the vent hood was scheduled for cleaning every quarter, but she would find out the last time it was cleaned. She said she was new to the facility. Observation of one of one table-mounted can opener revealed it had debri on the blade and along the steel base and body. Observation and interview on 08/16/22 at 9:10AM, revealed the counter table by one of two sink areas in the kitchen had, 2- 10Ibs of ground beef in a baking pan. The Dietary manager said the ground beef was for lunch and should be kept under running water. Observation of the walk in-cooler revealed a solidified white build up substance on the floor covering about a 12 by 12 area. The Dietary Manager said it was a milk spill. Observation of the walk-in freezer revealed a frozen apple pile partially covered and dated 04/25/22. The Dietary Manager took it out of the freezer. Further observation revealed an unknown red-looking substance in a large plastic bag undated and unlabeled. The Dietary Manager looked at the substance and said she did not know what it was. She said all left over food products were supposed to be labeled and dated with a used by date. Record review of facility policy titled Food receiving and Storage reflected in part: 1. Food services, or other designated staff will always maintain clean food storage area. 7. All food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 676442 Page 8 of 9 676442 08/18/2022 Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521

F 0812 8. The freezer must be kept frozen solid. Wrappers of frozen foods must stay intact until thawing. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676442 Page 9 of 9