Health inspection·May 28, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 3 of 9 residents (Residents #1, #2 and #3) reviewed for care plans in that: Resident #1, Resident #2 and Resident#3's comprehensive care plan did not reflect they used continuous oxygen. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Record review of Resident #1's admission MDS assessment (dated 05/02/24) revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses of unspecified Dementia (loss of cognitive functioning- thinking, remembering, and reasoning, to such an extent that it interfered with a person's daily life and activities), fracture of unspecified part of neck of left femur, anemia (blood produces a lower-than-normal amount of healthy red blood cells), and hypokalemia (low blood potassium levels). No oxygen therapy documented on admission MDS. Record review of Resident#1's orders revealed Resident#1 had an new order (dated 4/26/24) for Oxygen 02 at 2LPM from NC continuously every shift for Hypoxia (low levels of oxygen in body tissues). Record review of Resident#1's care plan (dated 05/02/24) revealed no oxygen therapy documented on admission and was not added to care plan. Record review of Resident #2's admission MDS (dated 05/30/24) revealed, Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses of unspecified Asthma with (acute) exacerbation (episodes of worsening asthma symptoms and lung functions) and chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems). No oxygen therapy documented on admission MDS. Record review of Resident#2's orders revealed, Resident#2 had an new order (dated 5/24/24) for Oxygen 02 at 2LPM from NC continuously every shift for Hypoxia(low levels of oxygen in body tissues). Record review of Resident#2's care plan (dated 05/06/24) revealed no oxygen therapy documented on Page 1 of 7 676452 676452 05/28/2024 Allegiant Wellness and Rehab 724 W. Rendon Crowley Road Crowley, TX 76036

F 0656 admission and was not added to care plan. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's quarterly MDS (dated 07/20/24) revealed Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses of unspecified Dementia (loss of cognitive functioning- thinking, remembering, and reasoning, to such an extent that it interfered with a person's daily life and activities), anxiety disorder (persistent and excessive worry that interferes with daily activities), and Cyclothymic disorder (rare mood disorder). No oxygen therapy documented on quarterly MDS. Residents Affected - Some Record review of Resident#3's orders revealed Resident #3 had an new order (dated 05/24/24) for Oxygen 02 at 2 to 3LPM from NC continuously every shift for Hypoxia (low levels of oxygen in body tissues). Record review of Resident#3's care plan (dated 04/21/24) revealed no revision for oxygen therapy documented. An observation on 05/24/24 at 6:40 AM revealed Resident #2 was hooked up to her oxygen machine and lying in bed. An observation on 05/24/24 at 6:43 AM revealed Resident #3 was hooked up to her oxygen machine and was lying in bed. An observation on 05/24/24 at 6:45 AM revealed Resident #1 did not have her oxygen machine plugged up. An observation on 05/24/24 at 2:15 PM revealed Resident #1 was in her bed with her oxygen machine connected and on. In an interview on 05/24/24 at 7:03 AM with LVN A, revealed Resident #1 would take her oxygen off. LVN A revealed Resident#2 and Resident#3 keep their oxygen on all the time. In an interview on 05/24/24 at 8:04 AM Residen t#1 was not able to answer questions about her oxygen machine. An interview on 05/24/24 at 8:06AM revealed Resident #3 was not able to answer questions about her oxygen machine. In an interview on 05/24/24 at 10:14 AM revealed Resident #2 had to use her oxygen machine all the time or she would have shortness of breath. An interview on 05/24/24 at 2:42 PM with CNA B revealed Resident#1 wore her oxygen in bed when she was in bed. An interview on 05/24/24 at 3:00 PM with MD revealed Resident #1 had not had any adverse reactions at the time from not wearing her oxygen continuous. MD stated that she was not changing her order and she needed to use her oxygen continuously. The MD stated Resident #2 was on continuous oxygen and no reported issues of Resident #2 not wearing oxygen. The MD stated Resident #3 was on continuous oxygen and no reports of her taking off her oxygen. 676452 Page 2 of 7 676452 05/28/2024 Allegiant Wellness and Rehab 724 W. Rendon Crowley Road Crowley, TX 76036

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview on 05/28/24 at 3:50 PM with the Case Manager revealed, care plans were completed within the first 7 days of a resident being admitted to the facility. The Case Manager revealed that she worked on the care plan with family. The Case Manager revealed she would update the resident's nurse or DON when reporting a change in condition. An interview on 05/28/24 at 4:10 PM with the DON revealed she had been in the facility for 5 days. The DON stated the care plans were completed at admission and at the care plan meetings. The DON stated the residents were not at any risk because the residents received their oxygen treatments. An interview on 05/28/24 at 4:28 PM with the MDS nurse revealed that she was responsible for updating the care plan. The MDS nurse stated she made updates to the care plan when the DON let her know there had been a change in condition. The MDS nurse stated the residents were not at any risk because the orders were still being followed by nursing staff. An interview on 05/28/24 at 4:38 PM with the Administrator revealed the initial care plan should be completed at admission. The Administrator stated acute changes in the residents should be updated on the care plan when the change occurred. The Administrator stated there was no physical risk to the resident if the change of condition was not listed on the care plan. Record review of facility policy titled Change in a Resident's Condition or Status (revised December 2016) revealed, . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 676452 Page 3 of 7 676452 05/28/2024 Allegiant Wellness and Rehab 724 W. Rendon Crowley Road Crowley, TX 76036

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 1 treatment carts reviewed. The facility failed to ensure one facility treatment cart was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: An observation on 05/24/24 at 6:15 AM revealed the facility's treatment cart was unlocked and unattended. The treatment cart was positioned at the far end of hall 100 in front of room [ROOM NUMBER]. The treatment cart top drawer was opened and the drawers were faced outward toward the hallway. All drawers of the treatment cart could be opened, and supplies were easily accessible. No staff were observed within eyesight of the treatment cart. An observation on 05/24/24 at 11:20 AM revealed the facility's treatment cart was unlocked and unattended. The treatment cart was positioned in the middle of the hallway against the wall between 100 and 200 halls. The treatment cart drawers faced outward toward the hallway All drawers of the treatment cart could be opened, and supplies were easily accessible. No staff were observed within eyesight of the treatment cart. An observation on 05/24/24 at 3:30 PM revealed the facility's treatment cart was unlocked and unattended. The treatment cart was positioned at the end of 200 hall. The treatment cart drawer faced outward toward the hallway All drawers of the treatment cart could be opened, and supplies were easily accessible. No staff were observed within eyesight of the treatment cart. An observation on 05/24/24 at 3:32 PM of the treatment cart revealed the following contents: *Diclofenac sodium gel (Temporarily relieves minor to moderate aches and pains caused by arthritis) *Nystatin topical powder (Used to treat fungal (or yeast) infections that affect the skin, mouth, and intestinal tract) *Nystatin topical ointment (Used to treat fungal (or yeast) infections that affect the skin, mouth, and intestinal tract) Gentamicin sulfate ointment 0.1% (Used to treat minor skin infection) *Bacitracin ointment (Used to prevent minor skin infections caused by small cuts, scrapes or burns) *Hydrocortisone cream (A mild corticosteroid that treats various skin conditions such as itching.) 676452 Page 4 of 7 676452 05/28/2024 Allegiant Wellness and Rehab 724 W. Rendon Crowley Road Crowley, TX 76036

F 0761 *Calamine clear lotion (Used to relieve itchiness) Level of Harm - Minimal harm or potential for actual harm *Mupirocin ointment 2% (Antibiotic ointment used to trat certain skin infections) *Ammonium Lactate lotion (Used to treat dry, scaly skin conditions. Residents Affected - Few *Triamcinolone acetonide cream (Used to treat a variety of skin conditions such as eczema, dermatitis, allergies, rash). *Hibiclens (Antibacterial anti microbial skin cleanser) *Povidone iodine 10%Solution (Topical antiseptic to aid in the prevention of infection) An interview on 05/24/24 at 6:30 AM with LVN S revealed the treatment cart should be locked and secured. LVN S revealed stated residents could get into the cart and take something. An interview on 05/24/24 at 7:00 AM with LVN A revealed the treatment carts should be locked. LVN A stated he was not sure of any risk to the resident. An interview on 05/24/24 at 12:36 PM with the ADON revealed the wound care doctor treated residents on 05/24/24. The ADON stated the treatment cart should be locked when it was not in use. The ADON stated the items in the treatment cart would not be harmful to the residents. An interview on 05/28/24 at 4:10 PM with the DON revealed the treatment cart should be locked. The DON stated the residents were not at any risk of being harmed. An interview on 05/28/24 at 4:38 PM with the Administrator revealed nurse staff should have followed the medication/treatment drug storage policy. The Administrator stated the carts should be locked when not in use. The Administrator stated residents could get into the cart. A record review of the policy titled Security of Medication Cart (dated revised on April 2007) revealed, 3 .the cart should be parked in the hallway against the wall with doors and drawers facing the wall 4. Medication cart must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. 676452 Page 5 of 7 676452 05/28/2024 Allegiant Wellness and Rehab 724 W. Rendon Crowley Road Crowley, TX 76036

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 observation, interviews and record reviews the facility failed to maintain medical records that were complete and accurately documented for 1 (Resident #4) of 4 residents reviewed for resident records. The facility failed to accurately document Resident #4's skin tear on the elbow that occurred on 05/24/24. This failure could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care. This failure could place residents at risk for skin tears injuries. The findings were: Record review of Resident #4's initial MDS assessment (dated 05/26/24) reflected Resident #4 was admitted to the facility on [DATE] and had diagnoses of Lobar Pneumonia (affects an entire lobe of the lung), unspecified Glaucoma (eye's optic nerve, which provides information to the brain is damaged), type 2 Diabetes Mellitus (a condition results from insufficient production of insulin, causing high blood sugar) with Diabetic Neuropathy (nerve damage caused by diabetes), unspecified atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat), and combined systolic and Diastolic (Congestive) heart failure. Resident#4 had a BIMS of 14 which indicated cognition was intact. Record review of progress notes from 5/14/24 to 5/24/24 for Resident #4 revealed no documentation of skin tear. Record review of incident reports from 5/14/24 to 5/24/24 for Resident #4 revealed no documentation of skin tear. Record review of skin assessments from 5/14/24 to 5/24/24 for Resident #4 revealed no documentation of skin tears . An observation on 05/24/24 at 7:58 AM revealed four quarter sized spots of blood were noticed on Resident#4's fitted sheet and top sheet that appeared fresh. Resident #4's elbow was observed to still be bleeding. An interview on 05/24/24 at 8:00 AM with Resident #4 revealed Resident #4 had stumbled and scraped his elbow on his bed. Resident #4 stated he told the nurse around 3:00 AM and she put a Band-Aid on his elbow and it came off. Resident #4 could not recall the name of the nurse who assisted him. Resident #4 stated he had not reported to staff that the band-aid had came off. An interview on 05/24/24 at 12:36 PM with the ADON revealed no incident report or progress note were documented about the skin tear. The ADON revealed Resident #4 did not need stitches, and she provided treatment to the skin tear with wound cleaner and applied sterile strips. The ADON revealed she completed a skin assessment and documented in the progress note. The ADON stated Resident #4's family member and the MD were notified. 676452 Page 6 of 7 676452 05/28/2024 Allegiant Wellness and Rehab 724 W. Rendon Crowley Road Crowley, TX 76036

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 05/28/24 at 4:10 PM with the DON revealed the skin tear should have been documented in a progress note and incident report. The DON stated Resident #4's elbow was treated for the skin tear and his family and the doctor had been notified. The DON revealed the overnight staff who initially treated Resident #4's skin tear were not identified. An interview on 05/28/24 at 4:38 PM with the Administrator revealed nurse staff should have followed the skin tear policy and procedures. The Administrator stated nurse staff should have notified the ADON or DON for further assistance with the wound care. The Administrator stated the incident should have been captured so that a risk assessment on Resident #4 could have been completed. Record review of facility policy (Revised September 2013) titled Skin Tears- Abrasions and Minor Breaks Care of reflected Documentation 1.) Completes in-house investigation of causation. 2) Generate non-pressure form 9)When a skin tear is discovered, complete a Report of Incident/Accident 676452 Page 7 of 7