Health inspection·December 12, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS quarterly assessment was electronically transmitted to the CMS System for 1 of 21 residents records reviewed for MDS assessments. (Residents #82) Residents Affected - Some The facility did not ensure the quarterly MDS assessment was completed and successfully electronically transmitted and accepted as required for Resident #82. This failure could place residents at risk of not having their assessments transmitted and accepted in a timely manner. Findings included: Record review of Resident #82's admission record dated 12/12/23 indicated he was [AGE] years old admitted on [DATE] with diagnosis including chronic kidney disease. Record review of a list of MDSs indicated Resident #82's MDS dated [DATE] was exported and not accepted. The MDS dated [DATE] was exported and accepted. Record review of the MDS for Resident #82 indicated the most recent quarterly MDS assessment was completed on 10/03/23. Record review of the MDS for Resident #82 indicated the quarterly MDS assessment was completed on 07/03/23. During an interview on 12/12/23 at 2:59 p.m., the MDS nurse said she did transmit Resident #82's quarterly MDS assessment dated [DATE]. She said the MDS dated [DATE] was not accepted, and she was unaware of why the MDS was rejected not accepted. The MDS nurse investigated the submission record on her computer and said the MDS had errors. She said she had received training on completing, preparing, signing and transmitting the MDS assessment to CMS. The MDS nurse said she reviews the transmission records after she sends the MDSs to CMS and must have missed this one being rejected for errors. During an interview on 12/12/23 at 3:15 p.m., the DON said Resident #82's MDS assessment should have been transmitted and accepted. She said the MDS nurse was responsible for transmitting and the facility used the RAI manual for their policy. Record Review of the CMS's RAI Version 3.0 Manual obtained on 12/13/23 from the CMS website, Page 1 of 19 676484 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0640 Level of Harm - Potential for minimal harm Residents Affected - Some https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2023.pdf indicated the following: CMS's RAI Version 3.0 Manual indicated . Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). The encoding requirements are as follows: For a comprehensive assessment (Admission, Annual, Significant Change in Status, and Significant Correction to Prior Comprehensive), Assessment Schedule: An OBRA assessment (comprehensive or Quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. An OBRA comprehensive assessment is due every year unless the resident is no longer in the facility. There must be no more than 366 days between comprehensive assessments. 5.3 Validation Edits . validation edits designed to monitor the timeliness and accuracy of MDS record submissions. If transmitted MDS records do not meet the edit requirements, the system will provide error and warning messages on the provider's Final Validation Report. Initial Submission Feedback. For each file submitted, the submitter will receive confirmation that the file was received for processing and editing by iQIES. This confirmation information includes the file submission identification number (ID), the date and time the file was received for processing as well as the file name. Validation and Editing Process. Each time a user accesses iQIES and transmits an MDS file, iQIES performs three types of validation: Fatal File Errors. If the file structure is unacceptable (e.g., it is not a ZIP file), the records in the ZIP file cannot be extracted, or the file cannot be read, then the file will be rejected. The Submitter Final Validation Report will list the Fatal File Errors. Files that are rejected must be corrected and resubmitted. 676484 Page 2 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer residents to the pre-admission screening and resident review (PASARR) program under Medicaid for 1 of 5 residents reviewed for PASRR. (Resident #42) The facility did not submit a new PASRR Screening and refer Resident #42 with newly evident mental disorder. This failure could place residents with mental illness at risk for not receiving appropriate services and decreased quality of life. Findings included: Record review of the face sheet dated 12/11/23 indicated Resident #42 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included delusional disorder, depression, anxiety disorder, and dementia. They all had an onset date of 07/17/23. Record review of a PASRR Level 1 Screening (P1) for Resident #42 dated 07/14/23 indicated Section C C0090 Primary Diagnosis of Dementia was marked no and C0100 Mental Illness was marked no. Record review of an admission MDS dated [DATE] indicated Resident #42 had diagnoses of psychotic disorder and dementia; and she received an antipsychotic medication routinely. Record review of a quarterly MDS dated [DATE] indicated Resident #42 had diagnoses of psychotic disorder, depression, and dementia; and she received an antipsychotic, antianxiety, and antidepressant medication routinely. Record review of a care plan dated 10/20/23 indicated Resident #42 received an antipsychotic medication (quetiapine fumarate) related to delusional disorder, an antidepressant medication (Trazadone) related to depression, and an antianxiety medication (Xanax) related to anxiety disorder. Record review of the EMR from 07/16/23 through 12/12/23 had no indication Resident #42 had another P1 done showing she had a Mental Illness or a PASRR Evaluation (PE) was done. During an interview on 12/12/23 at 03:20 p.m., the MDS Nurse said she was responsible for reviewing PASRRs were done correctly. She said Resident #42 should have had another P1 done with diagnosis of delusional disorder and had a PE done. She said she missed it. She said the outcome of not having a correct P1 and a PE done would be a resident could miss out on services. A PASRR Policy was requested at this time. No PASRR policy was provided before exit. 676484 Page 3 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 the resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 23 residents reviewed for ADL care. (Resident #56) Residents Affected - Few The facility did not ensure Resident #56's fingernails were trimmed. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of the physician orders dated December 2023 indicated Resident #56, admitted on [DATE], was [AGE] years old with diagnoses of hemiplegia (paralysis on one side of body) following cerebral infarction (a pathological process that results in an area of necrotic tissue in the brain) affecting the right non-dominant side and a contracture (a shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints) of his right hand. Record review of the MDS assessment dated [DATE] indicated Resident #56 had a BIMs score of 02 (score indicated resident had severe cognitive impairment). He had functional limitation in range of motion to his upper extremity (shoulder, elbow, wrist, hand) and was dependent for personal hygiene. Record review of a care plan revised 12/08/23 indicated Resident #56 had a self-care performance deficit related to limited mobility, ROM, musculoskeletal impairment, limited mobility, and limited range of motion. The intervention for personal hygiene indicated the resident required total assistance of one staff for personal hygiene and check nail length, trim, and clean on bath day and as necessary. During observation and interview on 12/11/23 at 10:45 a.m., LVN D entered the room and pulled the covers off Resident #56 to reveal the resident's right hand contracted with fingernails approximately 1/2 past the tips of each finger and dark brown in color from the tip of the finger to the end of the nail. The resident's right thumb nail was curled under his other fingers and pushing into his palm. The LVN said his hand had an unclean/musty odor. When the LVN lifted his thumb away from his palm the brown part of his nail broke off. The LVN said the thumb nail was so soft it broke off. The pungent odor became stronger when the LVN opened his hand. The LVN said she never checked the right hand because the nails on his left hand were trimmed and clean. She said it was the nurse's duty to trim Resident #56's nails because he was diabetic. During an observation and interview on 12/11/23 at 10:48 a.m., the DON said Resident #56's nails should have been trimmed or filed. She said she could smell the odor coming from his hand and she checked his palm which appeared reddened with indentions where his nails had been, but the skin was not broken. She said his nails should be filed not trimmed by the LVN because he was diabetic, and his nails would be filed today. She said she was the direct supervisor of all nursing staff. She said not trimming fingernails and cleaning his hand could result in skin breakdown. During and interview on 12/12/23 at 11:45 a.m., the OT said she last worked with Resident #56 May through June 2023. She said that during that time she had requested nursing to trim the fingernails 676484 Page 4 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0677 on his right hand to keep his nails from digging into his palm. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/12/23 at 12:50 a.m., CNA E said washed Resident #56's hand every time she was assigned to do his bath, but it always had an odor. She had not noticed his nails. Residents Affected - Few During an interview on 12/12/23 at 03:56 p.m., the Administrator said residents' nails should be trimmed routinely and as needed. Record review of a Fingernail/Toenails, Care of policy revised February 2018, indicated: . The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 676484 Page 5 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 23 residents reviewed for range of motion. (Resident #56) The facility failed to maintain Resident #56's contractures of the right hand. The resident did not have a hand splint in place 2 hours a day to maintain ROM and prevent a decline. This failure could place the residents at risk for not receiving the care and services to maintain their highest level of well-being. Findings included: Record review of the physician orders dated December 2023 indicated Resident #56, admitted on [DATE], was [AGE] years old with diagnoses of hemiplegia (paralysis on one side of body) following cerebral infarction (a pathological process that results in an area of necrotic tissue in the brain) affecting his right non-dominant side and a contracture (a shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints) of his right hand. An order dated 12/11/23, after surveyor intervention, indicated to place hand-wrist splint to upper right extremity up to 2 hours as tolerated one time a day for contracture management. Before placing splint proper stretching of the specified area and remove per schedule. Record review of an occupational therapy treatment encounter note dated 05/17/23 indicated and signed by the OT indicated the OT educated Resident #56 and caregivers on range of motion and positioning techniques. Record review of the annual MDS assessment dated [DATE] indicated Resident #56 had a BIMS score of 02 (score indicated resident had severe cognitive impairment). He had functional limitation in range of motion to his upper extremity (shoulder, elbow, wrist, hand) and was dependent for personal hygiene. Record review of a care plan revised 12/11/23, after surveyor intervention, indicated Resident #56 had limited mobility related to contractures to right hand. Interventions included: Hand-wrist splint to RUE up to two hours as tolerated and provide gentle range of motion as tolerated with daily care. The care plan did not indicate any resident refusal of the splint. During observation and interview on 12/11/23 at 10:45 a.m., LVN D entered the room and pulled the covers off Resident #56 to reveal the resident's right hand contracted with fingernails approximately 1/2 past the tips of each finger and dark brown in color from the tip of the finger to the end of the nail. The resident's right thumb nail was curled under his other fingers and pushing into his palm. The LVN said his hand had an unclean/musty odor. When the LVN lifted his thumb away from his palm the brown part of his nail broke off. The LVN said the thumb nail was so soft it broke off. The pungent odor became stronger when the LVN opened his hand. The LVN said she never checked the right hand because the nails on his left hand were trimmed and clean. She said she was unsure if the resident had orders for hand splint, hand roll, or ROM exercises to prevent his right-hand contracture from worsening. 676484 Page 6 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0688 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 12/11/23 at 10:48 a.m., the DON said she said she could smell the odor coming from Resident #56's hand. She checked his palm which appeared reddened with indentions where his nails had been, but the skin was not broken. She said he had a hand splint, but he refused to wear it. She said she was not sure if his refusal to wear the splint was documented in his medical record. She said not positioning his hand correctly could result in worsening contractures. Residents Affected - Few During an interview on 12/12/23 at 11:45 a.m., the OT said she provided therapy with Resident #56 in May and June of 2023. She said during that time she instructed nursing to perform hand hygiene to his hand by washing and drying the inside of his hand and then placing the hand splint in his right hand. She said he was unable to tolerate the hand splint more than 2 hours each time. She said the purpose of the hand splint was to prevent skin breakdown and prevent contractures from worsening. Record review of the Range of Motion Exercises policy revised October 2010 indicated: . The purpose of this procedure is to exercise the resident's joints and muscles. The policy did not address splints or mobility devices. 676484 Page 7 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 6 of 12 months (October 2022 through October 2023) and failed to ensure the DON served as a charge nurse only when the facility had an average daily occupancy of 60 or less residents for 4 of 12 months (October 2022 through October 2023) reviewed for RN coverage. The facility did not have the required eight consecutive hours of RN coverage for 1 day in March 2023, 1 day in April 2023, 2 days in May 2023, 1 day in June 2023, 1 day in July 2023 and 2 days in August 2023. The facility DON served as a charge nurse in March 2023 with an average census of 89, in April 2023 with an average census of 92, in May 2023 with an average census of 94, and in August 2023 with an average census of 90. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings included: 1. Record review of RN time sheets indicated the following: *on 06/04/23 (Sunday) RN H worked from 06:53 p.m. to 10:02 p.m.; a total of 3 hours; *on 07/08/23 (Saturday) RN H worked from 06:02 p.m. to 06:51 a.m.; which had her work 6 hours (06:02 p.m. to 12 midnight) for 07/08; and *on 08/26/23 (Saturday) RN J worked from 06:00 p.m. to 06:13 a.m.; which had her work 6 hours (06:00 p.m. to 12 midnight) for 08/26. There was no indication of another RN working those days for 8 consecutive hours. Record review of the Daily Nursing Assignment Sheets indicated: *on 03/11/23 (Saturday) RN H worked the 6p-6a shift which had her work 6 hours for 03/11 and 6 hours for 03/12; *on 04/01/23 (Saturday) the DON worked the 6p-6a shift which had her work 6 hours for 04/01 and 6 hours for 04/02; *on 05/07/23 (Saturday) the DON worked the 6p-6a shift which had her work 6 hours for 05/07 and 6 hours for 05/08; *on 05/13/23 (Saturday) the DON worked the 6p-6a shift which had her work 6 hours for 05/13 and 6 hours for 05/14; *on 08/05/23 (Saturday) the DON worked the 6a-6p shift with handwritten 6am-12pm which had her work 676484 Page 8 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0727 6 hours and LVN K to work 12pm-6pm. Level of Harm - Minimal harm or potential for actual harm There was no indication of another RN working those days for 8 consecutive hours. Residents Affected - Some 2. Record review of the Daily Nursing Assignment Sheets indicated the DON worked the floor as charge nurse: *on 03/11/23 (Saturday) the 6a-6p shift on the 600/700 Halls; *on 04/01/23 (Saturday) the 6p-6a shift on the 300 Hall; *on 05/07/23 (Saturday) the 6p-6a shift on the 200/400 Halls; *on 05/13/23 (Saturday) the 6p-6a shift on the 200/400 Halls; *on 08/05/23 (Saturday) the 6a-6p shift on the 200/400 Halls. Record review of the monthly census reports indicated the following: *in March 2023 the average daily census for the month was 89 residents; *in April 2023 the average daily census for the month was 92 residents; *in May 2023 the average daily census for the month was 94 residents; and *in August 2023 the average daily census for the month was 90 residents. During an interview on 12/12/23 09:12 a.m. the DON said they had issues with RN coverage, and she thought it would be okay for her to work the floor since they were short. She said she had to obtain corporate approval for staffing agency nurses. She said she did not realize the RN working 6p-6a shift would split the day. A policy was requested at this time During an interview on 12/12/23 at 10:10 a.m. the Administrator said they had issues with RN coverage and was cited previously for no RN coverage. He said it was his and the DON's responsibility for RN coverage. He said the DON could not work as a charge nurse for census 60 or more. He said he thought it was okay for the DON to work the floor when they could not get anyone else. He said they did have a contract with a staffing agency and had used agency nurses. No pokicy was provided prior to exit. 676484 Page 9 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

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 interview and record review, the facility failed to ensure residents did not receive medications without an appropriate indication for use for 4 of 5 residents reviewed for unnecessary drugs. (Residents #26, #37, #42, and #74) Residents Affected - Some The facility failed to prevent Residents #26, #37, #42, and #74 from receiving a medication without an appropriate prescribed indication for use. This failure placed the resident at risk of complications related to receiving unnecessary medications. Findings included: 1. Record review of the face sheet dated 12/12/23 indicated Resident #26 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included atrial fibrillation (a type of irregular heartbeat), aortocoronary bypass graft (surgical procedure to place a piece of vein from the main upper body blood vessel to a blood vessel on the heart to bypass a clogged area), cerebral infarction (or cerebrovascualr accident -lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), and myocardial infarction (blood flow decreases or stops in one of the blood vessels of the heart causing tissue death). Record review of physician orders for December 2023 indicated an order dated 11/08/23 for Resident #26 to receive clopidogrel (antiplatelet medication) 75 mg tablet by mouth one time a day for blood thinner. Record review of an MDS dated [DATE] indicated Resident #26 had diagnoses of atrial fibrillation, coronary artery disease (disease of blood vessels of the heart), and high blood pressure; and she received an antiplatelet medication. There was no diagnosis of blood thinner. Record review of a care plan dated 12/07/23 indicated Resident #26 was on antiplatelet therapy clopidogrel related to atrial fibrillation. 2. Record review of the face sheet dated 12/12/23 indicated Resident #37 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), and congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak, becomes stiff, and unable to fill properly). Record review of physician orders for December 2023 indicated an order dated 06/13/23 for Resident #37 to receive clopidogrel (antiplatelet medication) 75 mg tablet by mouth one time a day for anticoagulant. Record review of an MDS dated [DATE] indicated Resident #37 had diagnoses of heart failure, coronary artery disease, and high blood pressure; and he did not receive an anticoagulant medication. Record review of a care plan dated 09/13/23 indicated Resident #37 was on anticoagulant therapy clopidogrel related to CVA. 676484 Page 10 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Record review of the face sheet dated 12/11/23 indicated Resident #42 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included atrial fibrillation (a type of irregular heartbeat) and cerebral infarction (or cerebrovascular accident -lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). Record review of physician orders for December 2023 indicated an order dated 07/17/23 for Resident #42 to receive clopidogrel (antiplatelet medication) 75 mg tablet by mouth one time a day for hematological agents - misc., chemicals. Record review of an MDS dated [DATE] indicated Resident #42 had diagnoses of atrial fibrillation, cerebrovascular accident (also called cerebral infarction), and high blood pressure; and she received an anticoagulant and an antiplatelet medication. Record review of a care plan dated 10/20/23 indicated Resident #42 was on anticoagulant therapy clopidogrel and apixaban related to atrial fibrillation and CVA. 4. Record review of the face sheet dated 12/11/23 indicated Resident #74 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak, becomes stiff, and unable to fill properly) and atherosclerotic heart disease (a condition where the blood vessels become narrowed and hardened due to buildup of fats in the blood vessel wall). Record review of physician orders for December 2023 indicated an order dated 11/06/23 for Resident #74 to receive clopidogrel (antiplatelet medication) 75 mg tablet by mouth one time a day for blood thinner. Record review of an MDS dated [DATE] indicated Resident #74 had diagnoses of coronary artery disease, heart failure, and high blood pressure; and she received an an antiplatelet medication. Record review of a care plan dated 11/02/23 indicated Resident #74 was on antiplatelet therapy clopidogrel related to congestive heart failure. During an interview on 12/12/23 at 10:45 a.m., LVN L said medications should have a diagnosis as to what they are given for and not their drug classification. During an interview on 12/12/23 at 11:30 a.m., the DON said blood thinner, anticoagulant, and hematological agents were not appropriate indications for medications. She said residents should have a diagnosis for the indication. Record review of the Medication Therapy policy revised April 2007 indicated 3. Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether: a. there is a clear indication for treating that individual with the medication 676484 Page 11 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate residents' food preferences for 1 of 20 (Resident #299) resident reviewed for food preferences. The facility failed to ensure Resident #299 received her preference of a chicken salad sandwich with chips during the lunch meal on 12/10/23. This failure could place residents with food preferences at risk for a decrease in resident choices and diminished interest in meals. Findings included: Record review of Resident #299's face sheet, dated 12/11/23, indicated she was [AGE] years old female was admitted on [DATE] with diagnoses that included: high blood pressure and kidney disease. Record review of Resident #299's physicians orders dated December 2023 indicated a regular diet. Record review of Resident #299's Quarterly MDS assessment, dated 11/06/2023, a BIMS indicated the resident had intact cognition with a score of 15. Record review of Resident #299's tray card indicated a Regular diet. Record review of Resident #299's always available card indicated a chicken sandwich with chips was circled. During an observation and interview on 12/10/23 at 12:30 p.m., Resident #299 said she did not receive the always available chicken salad she marked on her request slip. She said the always available slips were given to her by the activity director. She pointed to the tray and card which indicated always available slip. She said, maybe they ran out of chicken salad, but it was egg salad and she pointed to the sandwich on her tray. The egg salad sandwich only had a few bites taken and French fries were on the tray. During an interview on 12/10/23 at 1:30 p.m., [NAME] F said she did not have time to thaw chicken and make chicken salad for Resident #299. She said she made an egg salad sandwich and served French fries to Resident #299 for lunch today (12/10/23). During an interview on 12/11/23 at 8:00 a.m., the DM said there was an always available menu and chicken salad was always available. He said the chicken was cubed cooked chicken and the staff were to place it in the steamer and then mix with mayonnaise. He said as the DM, he was responsible to ensure his staff honor the request of the residents. 676484 Page 12 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the dish machine reached 120 degrees Fahrenheit. The facility failed to ensure bulk foods were stored in a manner to prevent contamination. This failure could place residents at risk for food contamination and foodborne illness. The findings included: During an observation and interview on 12/10/23 at 9:15 a.m., Dietary Aide G said he had to run the dish machine several times this morning to allow enough time for hot water to reach the dish machine. He ran the dish machine 10 times, and the temperature range was between 110-113 degrees Fahrenheit. The metal label on the side of the dish machine indicated the water temperature should be 120 degrees Fahrenheit. He said he had to call the DM and report the dish machine was not at the right temperature. During an observation and interview on 12/10/23 at 9:20 a.m., the dry storage room contained 2 large bulk food containers, on the shelf. The bulk containers had buildup of powder substance on the inside edges and the lids were covered with dust and powdery substance. [NAME] F said one of the containers was labeled flour dated 03/16/23 with no expiration date or use by date. [NAME] F said the other container had pancake mix and had no label or expiration date or use by date. She said not dating the bulk containers and not being kept clean could cause food born illnesses. She said when items were placed in the bulk containers, it should be labeled with item and date. During an interview on 12/11/23 at 10:00 a.m., the DM said the plastic containers were to be kept clean and dated to prevent food borne illnesses. He said the dish machine had to work properly with time and level of sanitization chemical to prevent food born illnesses. During an interview on 12/11/23 at 3:00 p.m., the administrator said his expectations were for food items to be stored properly and for the kitchen equipment to be maintained and repaired as needed. During an interview on 12/12/23 at 8:00 a.m., the Maintenance Supervisor said he was just told about the dish machine yesterday (12/11/23). He said if the dish machine did not work properly to a temperature of 120 it could affect the sanitization of the dishes. Reference obtained from the internet dated 12/13/23 from Food Code dated 2022 indicated . Good Repair and Proper Adjustment. Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. Record review of the facility's policy dated March 2021 titled Dishwashing Machine Use indicated Food Service staff required to operate the dishwashing machine will be trained in all the steps of 676484 Page 13 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dishwashing machine use by the supervisor or a designee proficient in alll aspects of proper use and sanitation.7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approve long . will report to the supervisor and correct immediately. Record review of the facility's policy titled Food Receiving and Storage dated July 2014 indicated Food shall be received and stored in a manner that complies with food handling practices. 7. Dry foods that are stored in bins will be removed from original package labeled and dated (use by date). 676484 Page 14 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Potential for minimal harm Based on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis for 1 of 1 social worker reviewed for social services. Residents Affected - Many The facility failed to employ a full-time social worker since 09/15/2023. This failure could affect any residents in need of social services and place them at risk of psycho-social decline and poor-quality of life. Findings included: Record review of the undated Facility Summary Report from Tulip printed on 12/06/2023 indicated the facility had a maximum capacity of 124. Record review of the Information For On-Site form completed on 12/10/2023 by the DON, indicated the information for SW and was left blank. During an interview on 12/10/23 at 1:20 p.m., the DON said the facility had not had a SW since September 2023. She said they had been advertising for one in the paper and on job sites. She said she and the ADON had been dividing up the responsibilities for meeting medical needs the SW would normally handle. During an interview on 12/12/23 at 03:45 p.m., the HR staff said the SW's last day was 09/15/23. She said they had not replaced her at this time. 676484 Page 15 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit to CMS accurate direct care staffing information based on payroll and other verifiable and auditable data for 2 of 3 quarters reviewed. (Quarter 2 (January 1 through March 31) and Quarter 3 2023 (April 1 through June 1)). The facility failed to submit accurate RN coverage for 01/08/23, 1/27/2023, 03/11/23, 04/01/23, 05/07/23, and 05/13/23. This failure could place residents at risk for personal needs not being identified and met. The findings included: Record review of the PBJ Reports indicated: *Quarter 2 2023 (January 1 through March 31) there was no RN coverage on 01/08/23 and 03/11/23. *Quarter 3 2023 (April 1 through June 1) there was no RN coverage on 04/01/23, 05/07/23, and 05/13/23. Record review of the facility's Daily Nursing Assignment Sheets indicated: *on 01/08/23 (Sunday) the previous ADON (RN) worked the 6a-6p shift on the 500/600 Halls *on 03/11/23 (Saturday) the DON worked the 6a-6p shift on the 600/700 Halls; *on 04/01/23 (Saturday) the DON worked the 6p-6a shift on the 300 Hall; *on 05/07/23 (Saturday) the DON worked the 6p-6a shift on the 200/400 Halls; and *on 05/13/23 (Saturday) the DON worked the 6p-6a shift on the 200/400 Halls. During an interview on 12/12/23 9:12 a.m., DON said they had issues with RN coverage. She said on 01/28/23 she was the ADON at the time and was on salary so she did not clock in and out therefore her hours would not show on the payroll information. She said as the DON she was on salary and did not clock in and out so her time for 03/11, 04/01, 05/07, and 05/13 would not show on the payroll information. During an interview on 12/12/23 at 3:45 p.m., the HR staff said corporate office submitted the PBJ information. She said she did not realize the information for when salaried staff worked was not included. 676484 Page 16 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by not screening or testing 3 of 3 newly hired staff, who were reviewed for tuberculosis immunizations. (LVN A, CNA B and CNA C). Residents Affected - Some The facility did not screen or administer a tuberculosis test for 3 newly hired staff. These findings could place the residents at risk of exposure to communicable diseases. Findings included: Record review of facility personnel files indicated the following newly hired staff did not have documentation of TB (tuberculosis is a serious bacterial illness that mainly affects the lungs and can be spread through talking, coughing and sneezing) screening/testing: *LVN A hired 11/27/23; *CNA B hired 11/09/23; and *CNA C hired 11/21/23. During an interview on 12/12/23 at 10:10 a.m., after review of the personnel files, the BOM said LVN A, CNA B and CNA C did not have TB screenings/tests on file. She said the newly hired staff should receive TB testing/screenings upon hire and did not. She said the DON was responsible for ensuring the staff received TB screenings and she was not aware why the staff did not receive them. During an interview on 12/12/23 at 10:35 a.m., the DON said LVN A, CNA B and CNA C were not tested for TB upon hire. She said she did not have a screening record for them either. She said the newly hired staff did not receive their TB screening timely due to her lack of knowledge of the time frame in which the TB tests had to be completed. She said she was trained by her clinical director and was certain the director informed her the TB testing had to be completed upon hire, but she had forgotten. She said the possible negative outcome of not testing and/or screening the new staff could be an outbreak of TB in the facility. During an interview on 12/12/23 at 11:02 a.m., the Administrator said his expectations were for all newly hired staff to be tested/screened for TB upon hire. He said the possible negative outcome could be TB could spread throughout the facility. Record review of a Tuberculosis, Employee Screening for policy revised August 2019 indicated: All employees are screened for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening, prior to beginning employment. The CDC website accessed on 12/27/23 at <https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm> indicated All U.S. health care personnel should be screened for TB upon hire (i.e., preplacement). The local health department should be notified immediately if TB disease is suspected. 676484 Page 17 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record reviews, the facility failed to maintain essential equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment: Residents Affected - Many The facility failed to ensure two of six gas burners, on the stove, lit automatically, when the knob was turned (front and back middle burners). The facility failed to ensure the dish machine reached 120 degrees Fahrenheit. These failures could place residents at risk of foodborne illnesses and injury. Findings included: During an observation and interview on 12/10/23 at 8:55 a.m., [NAME] F turned on and off each gas burner and 2 of the 6 burners (front and back middle burners) did not light with turning the knob. She used a long stem lighter to light those burners. She said those 2-burners had to be lit by the lighter for a couple of months. She said the stove could leak gas if they do not light the burners when turned on. During an observation and interview on 12/10/23 at 9:15 a.m., Dietary Aide G said he had to run the dish machine several times this morning to allow enough time for hot water to reach the dish machine. He ran the dish machine 10 times, and the temperature range was between 110-113 degrees Fahrenheit. The metal label on the side of the dish machine indicated the water temperature should be 120 degrees Fahrenheit. He said he had to call the DM and report the dish machine was not at the right temperature. During an interview on 12/11/23 at 10:00 a.m., the DM said the plastic containers were to be kept clean and dated to prevent food borne illnesses. He said the pilot light should be lit so the burners light immediately. The DM said the staff should not use a lighter to light the burners. He said if the burners did not light immediately, it could allow a gas leak. He said the dish machine should be at the correct temperature of 120 degrees Fahrenheit to prevent food born illnesses. During an interview on 12/11/23 at 3:00 p.m., the Administrator said his expectation was for the kitchen equipment to be maintained and repaired as needed. During an interview on 12/12/23 at 8:00 a.m., the Maintenance Supervisor said he was just told about the dish machine yesterday (12/11/23). He said he just heard about the pilot lights not staying lit; so 2 of the six burners were not working properly on Sunday (12/12/23). He said if burners did not light it could let gas leak out. He said if the dish machine doesn't work properly to a temperature of 120 it could affect the sanitization of the dishes. Record review of the facility's policy dated March 2021 titled Dishwashing Machine Use indicated Food Service staff required to operate the dishwashing machine will be trained in all the steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation.7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approve long . will report to the supervisor and correct immediately. 676484 Page 18 of 19 676484 12/12/2023 Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523

F 0908 Level of Harm - Minimal harm or potential for actual harm Reference obtained from the Internet dated 12/13/23 from Food Code dated 2022 indicated . Good Repair and Proper Adjustment. Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. Residents Affected - Many 676484 Page 19 of 19