Health inspection·February 7, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for Resident#197 that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one of one resident (Resident #197) reviewed for baseline care plan. The facility failed to ensure Resident #197's baseline care plan included information related to Resident #197's respiratory needs. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: Record review of Resident #197's face sheet, dated 01/17/2024, revealed an admission date of 01/17/2024 with diagnoses that included: Closed left hip fracture, high blood pressure, dependence on supplemental oxygen, chronic bronchitis (long-term inflammation of the bronchi, It is common among smokers. People with chronic bronchitis tend to get lung infections more easily. They also have episodes of acute bronchitis, when symptoms are worse, anxiety, and chronic obstructive pulmonary disease (COPD) refers to a group of diseases that cause airflow blockage and breathing-related problems. Record review of Resident #197's MDS, dated [DATE], revealed a BIMS score of 12 which suggested moderate cognitive impairment. Further review in Section J, Health Conditions, revealed Resident #197 had shortness of breath with exertion and when lying flat. Record review of Resident #197's baseline care plan, initiated 01/17/2024 with no revision, revealed no focus area for Resident #197's respiratory or therapy needs. Section 13a Special Treatments & Procedures (p) other indicated no other devices and Treatment. Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1 vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. Record review of Resident #197's medication Administration Record, form 1/17/2024 to 02/06/2024, revealed Resident #197 was administered Albuterol Nebulizer every 4 hours and received prn dose once on 2/4/2024 at 0325A.M. Page 1 of 10 676443 676443 02/07/2024 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 02/05/2024 and 02/06/2024 resident #197 was observed with handheld portable nebulizer with medication in chamber, the resident said she can use this nebulizer as needed. During an observation and interview on 02/07/2024 at 10:30 am resident #197 was observed with a vial of Albuterol to instill in her nebulizer, the resident said she always has done this. In an interview with the MDS Coordinator and the Administrator on 02/06/2024 at 11:30 a.m., the MDS Coordinator confirmed Resident #197's respiratory orders had not been addressed on the baseline care plan. The MDS Coordinator revealed the care plan was created from the initial nursing assessment and updated when the MDS assessment was completed. The MDS Coordinator added that respiratory orders and therapy orders were given on admission and should have been in Resident #197's care plan. The MDS Coordinator stated it was the responsibility of the MDS Coordinators to review orders to ensure all resident needs were captured on the care plan , that the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being The care plan must be based on the assessment. Record review of the facility's policy titled, Comprehensive Care Planning, undated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being; and .any specialized services or specialized rehabilitative services . 676443 Page 2 of 10 676443 02/07/2024 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and revise the comprehensive care plan for one of one residents (Resident #197) reviewed for care plans. The facility failed to ensure Resident #197's care plan included information related to Resident #197's respiratory needs was developed within 7 days of the comprehensive assessment and included that the resident was receiving Albuterol for (chronic obstructive pulmonary disease) COPD and shortness of breath. This failure could place residents at risk of not receiving medication as ordered to meet their current Respiratory needs. The findings were: Record review of Resident #197's face sheet, dated 01/17/2024, revealed an admission date of 01/17/2024 with diagnoses that included: Closes left hip fracture, high blood pressure, dependence on supplemental oxygen, chronic bronchitis, anxiety, and chronic obstructive pulmonary disease (COPD). Record review of Resident #197's MDS, dated [DATE], revealed a BIMS score of 12 which suggest moderate cognitive impairment. Further review in Section J, Health Conditions, revealed Resident #197 had shortness of breath with exertion and when lying flat. Record review of Resident #197's baseline care plan, initiated 01/17/2024 with no revision, revealed no focus area for Resident #197's respiratory or therapy needs. Section 13a Special Treatments & Procedures (p) other indicated no other devices and Treatment. Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1 vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. Record review of Resident #197's medication Administration Record, form 1/17/2024 to 02/06/2024, revealed Resident #197 was administered Albuterol Nebulizer every 4 hours and received prn dose once on 2/4/2024 at 0325A.M. During an observation and interview on 02/05/24 and 02/06/2024 Resident #197 was observed with handheld portable nebulizer with medication in chamber, the resident said she can use this nebulizer as she wills. During an observation and interview on 02/07/2024 at 10:30 am Resident #197 was observed with a vial of Albuterol to instill in her nebulizer, the resident said she always has done this. During an interview with the MDS Coordinator and Administrator on 02/06/2024 at 11:30 a.m., the MDS Coordinator confirmed Resident #197's respiratory orders had not been addressed on the care plan. The MDS Coordinator revealed the care plan was created from the initial nursing assessment and updated when the MDS was completed. The MDS Coordinator added that respiratory orders and therapy orders 676443 Page 3 of 10 676443 02/07/2024 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were given on admission and should have been in Resident #197's care plan. The MDS Coordinator stated it was the responsibility of the MDS Coordinators to review orders to ensure all resident needs were captured on the care plan. Record review of the facility's policy titled, Comprehensive Care Planning, undated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being; and .any specialized services or specialized rehabilitative services . 676443 Page 4 of 10 676443 02/07/2024 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for (Resident #197) reviewed for Nebulizer therapy. Residents Affected - Few Resident #197's Nebulizer therapy ordered by the physician dated 1/17/2024 Albuterol Sulfate inhalation Nebulization solution, 0.083%, to Inhale orally four times a day for COPD for 30 days administer for 15 minutes. Order date 1/17/2024, there was no order for self-administration. This failure could place residents who receive Nebulization therapy at risk for respiratory distress. The findings were: Record review of Resident #197's electronic face sheet, dated 01/17/2024, revealed an admission date of 01/17/2024 with diagnoses that included: Closed left hip fracture, high blood pressure, dependence on supplemental oxygen, chronic bronchitis, anxiety, and chronic obstructive pulmonary disease (COPD). Review of resident #197's MDS dated [DATE] had not been completed. Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1 vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. A review of Resident #197's physicians orders for January 17,2024 did not indicate any orders for self-administration of medication. It is the policy of this facility that medications are to be administered as prescribed by attending physician. For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer treatment. Nurse must follow physician's orders of administering the nebulizer treatment. During observations Resident #197 was Inhalation Nebulization on the following dates and times: 02/05/2024 at 10:24AM with no staff observation and with her own personal hand-held nebulizer 02/06/2024 at 10 AM opening the Albuterol vial on her own and instilling medication into her personal hand-held nebulizer. 02/07/2024 at 10:30 am with no staff observation as she had been to therapy and returning to room. During an interview on 02/05/2024 at 10:24AM Resident #197 said she can use her personal nebulizer as she needs it, her husband was at the bedside and agreed. During an interview with LVN A on 02/05/2024 at 11:30 am she said that she was to monitor and make sure residents with Nebulizer therapy get their entire treatment, but she knew that resident #197 has her own personal nebulizer and carries it around . 676443 Page 5 of 10 676443 02/07/2024 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/05/2024 at 04:07 pm with DON, she said, residents are to be assessed before and after any inhalation treatment, nurses are to follow the physicians' orders, and no medication is to be left at bedside for residents to administer themselves . During an interview on 02/07/2024 at 4:00pm with the ADON, she said that none of the nurses on staff have had skills training to administer respiratory therapy . A review of the facility's policy on Respiratory Therapy Program dated 1/15/2023: #4 The Services are required and provided by qualified personnel. Nurses administered respiratory therapy will have respiratory therapy training and competency evaluation will reflect proficiency in providing respiratory modalities. A review of the facility's Nebulizer Policy dated 8/16/2022 indicated the following: Purpose: Nebulizer therapy may be provider through various types of supply and delivery systems. Equipment may include the provision of trans-tracheal nebulizer, mask, or handheld. Procedure: For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer treatment. Nurse must follow physician's orders of administering the nebulizer treatment. Patient's door is recommended to be closed during nebulizer treatment. Nurse must rinse the mouthpiece or face mask when completed. 676443 Page 6 of 10 676443 02/07/2024 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 1 resident (Resident #197) reviewed for pharmacy services. LVN A failed to ensure Resident # 197's medications were secure and left physician ordered medications at the bedside. LVN A failed to ensure Resident #197 inhaled her medications. These failures placed Resident #197 at risk of not receiving full dosage and treatment of medication as ordered. Findings included: Record review of Resident #197's electronic face sheet dated 01/17/2023 reflected a[AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included hypertension (elevated blood pressure), left hip fracture, dependence on supplemental oxygen, chronic bronchitis, anxiety, and chronic obstructive pulmonary disease (COPD). Record review of Resident #197's Order Summary Report, dated 01/17/2024, revealed an order for Inhalation Nebulization Solution (Albuterol) to inhale orally four times a day for COPD for 30 days administrator for 15 minutes. Further review revealed an order for Albuterol Sulfate Nebulization Solution, 1 vial inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. Record review of Resident #197's Medication Administration Record for 02/05/2024 reflected LVN A had administered the medications ordered to be given between 08:00, 12:00, and 16:00 over a 15-minute period. Record review of Resident #197's physician orders dated January/February 2024 did not reflect an order for the resident to self-administer medications. Record review of Resident #197s medical records did not reflect an assessment of the residents' ability to self-administer medications safely was completed. Review of Resident #197's Care Plan for January/February 2024 did not reflect Resident #197's was to be allowed to self-administer her own medications. During an observation and interview on 02/05/2024 at 10:24 AM, Resident #197 was noted to be sitting in a wheelchair in her room with an over-the-bed table in front of her. No staff were in the room. The resident's husband was sitting in the room in a bedside chair. The residents' personal hand-held nebulizer was in her hand with medication in the chamber. In an observation and interview on 01/06/2024 at 10 AM, the resident had a vial of Albuterol in her hand ready to open and instill in her personal hand-held nebulizer. The resident and her husband said they didn't want to get anyone in trouble, but this is what they do all the time with the Albuterol treatment. Resident #197 said Nurses 676443 Page 7 of 10 676443 02/07/2024 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few will give her the vial to put in her nebulizer and maybe check later to see if she needs anything else, but they trust me to take on her own. During an interview with LVN A on 02/05/2024 at 11:30AM, she said she left Resident #197's medications on the over-the-bed table for the resident to take. LVN A said she was supposed to stay/or return within 15minutes with the resident until she had taken all her medications. LVN A said the policy for administering medications was for the nurse to stay with the resident to ensure the medications are taken. LVN A did not respond to being asked if there was a reason for leaving the medications at bedside and not ensuring the resident took her medications , It is the policy of this facility that medications are to be administered as prescribed by attending physician. For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer treatment. Nurse must follow physician's orders of administering the nebulizer treatment. During an interview with the DON on 02/05/2024 at 11:05 AM, she said she expected the nurses to stay with the residents when giving medications and ensure they took them. She said residents who did not take their medications were at risk for not receiving the intended therapeutic effect of their medications. She said residents could hoard their untaken medications and risk overdosing themselves and residents who wander may take unattended medications if it was left sitting out. She said that she had done an employee disciplinary review with LVN A, and the nurse should be following policy . It is the policy of this facility that medications are to be administered as prescribed by attending physician. For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer treatment. Nurse must follow physician's orders of administering the nebulizer treatment. During an interview with LVN B on 02/07/2024 at 11:40 AM, she said the nurses were responsible for administering medications to residents. LVN B said nurses were required to stay with each resident until medications were taken and swallowed . Record review of the facility's general policy titled Medication Administration dated 3/31/2023, including the following: It is the policy of this facility that medications are to be administered as prescribed by attending physician. For a patient receiving a nebulizer treatment, the nurse must ensure that patient completed the nebulizer treatment. Nurse must follow physician's orders of administering the nebulizer treatment. 676443 Page 8 of 10 676443 02/07/2024 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for (Resident #197) resident reviewed for resident records. The facility failed to ensure Resident #197's Medication Administration Record (MAR) reflected documentation of Cleanse Nebulizer mask with soap and water after every use. Allow to dry to air, placed on a paper towel, and taken apart. Once dry and place back together and on hook of nebulizer machine in her Electronic Health Record (EHR). This failure could place all residents who receive nebulizer treatment at risk of having errors in care and treatment. The findings included: Record review of Resident #197's electronic face sheet dated 01/17/2023 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included hypertension (elevated blood pressure), left hip fracture, dependence on supplemental oxygen, chronic bronchitis, anxiety, and chronic obstructive pulmonary disease (COPD). Record review of Resident #197's Medication Administration Record revealed documentation of Cleanse Nebulizer mask with soap and water after every use. Allow to dry to air, placed on a paper towel, and taken apart. Once dry and place back together and on hook of nebulizer machine every shift, in her Electronic Health Record (EHR) had never been done but was being signed as done from 1/17/2024 - 2/6/2024. During an interview with LVN A on 02/06/2024 at 12:30 pm, she stated she never cleaned nebulizer machine on her shift because the resident had her own hand-held nebulizer, she said she just signed the Electronic Health Record (EHR ) Which can Compromised Patient Safety: Missing information can lead to treatment errors, posing a significant risk to patient safety. Delayed Care: Missing or incomplete data can delay care as medical professionals. Each Nurse is responsible to make sure the Electronic Health Record is correct and when signing the task is complete. During an interview with LVN B on 02/07/2024 at 11:40 AM, she said the nurses were responsible for administering medications to residents. She stated she never cleaned nebulizer machine on her shift because the resident had her own hand-held nebulizer, she said she just signed the Electronic Health Record (EHR) Which can Compromised Patient Safety: Missing information can lead to treatment errors, posing a significant risk to patient safety. Delayed Care: Missing or incomplete data can delay care as medical professionals. Each Nurse is responsible to make sure the Electronic Health Record is correct and when signing the task is complete. During an interview with resident on 02/07/2024 at 12:30 pm, she said her, or her husband would clean the nebulizer machine and alternate with her second machine, she said that's what she did at home, and they followed the manufacturer instructions on cleaning. Staff was just signing the Electronic Health Record and not doing the task of cleaning. 676443 Page 9 of 10 676443 02/07/2024 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with ADON on 02/07/2024 at 2:30 pm, who said she would review orders for the Nebulizer, call the physician and make sure staff and resident have respiratory therapy training and competency evaluation that will reflect proficiency in providing respiratory modalities as stated in the centers policy & Procedure. The facility could not produce a policy on resident use of own equipment or policy of staff signage of orders that were not being done. 676443 Page 10 of 10