Health inspection·October 31, 2024

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to transmit a resident assessment within the required time frame for 1 of 4 discharged residents (Resident #61) reviewed for data encoding and transmission. in that: Residents Affected - Few Resident #61's Discharge MDS was not encoded or transmitted as of 07/22/2024. This failure affected residents who have been discharged in the last 30 days at risk of not having their assessments transmitted timely. The findings included: Record review of Resident #61's face sheet revealed the resident admitted to the facility on [DATE] and discharged on 07/12/2024 home. Resident #61's admitting diagnoses included intervertebral disc disorder with radiculopathy in the lumbar region (symptoms that occur when a spinal nerve root is compressed) other lower back pain, and hypo-osmolality and hyponatremia (a condition of having low levels of electrolytes (including sodium), proteins, and nutrients). Record review of Resident #61's EMR revealed the resident's admission MDS was completed and accepted, but the Discharge MDS assessment was not initiated to where the assessment would be visible, coded, or transmitted as of 07/26/2024. Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated October 2023, revealed OBRA Discharge assessments -Return Not Anticipated (A0310F = 10) Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). In an interview on I0/30/2024 at 2:39 PM the MDS coordinator stated she was out for personnel reasons and Resident #61's Discharge MDS was not encoded or timely transmitted as of 07/22/2024. The MDS coordinator said she was responsible for the encoding of this record in a timely manner. Facility MDS policy dated 02/08/2021 reflected it is the policy of this facility that MDS Page 1 of 19 676487 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0640 assessments, discharge and reentry records will be completed and electronically encoded into our facilities MSDS information system and appropriate assessments will be transmitted to CMS. Level of Harm - Minimal harm or potential for actual harm Procedures: Residents Affected - Few 1. All staff members will be responsible for completion of the MSDS and transmission process in accordance with the MDS RAI instruction manual. 2. MDS electronic submissions shall be conducted in accordance with current OBRA regulation governing the transmission of such data. 3. The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. 676487 Page 2 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

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 observations, interviews, and record review, the facility failed to implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 3 (Resident #235, Resident #242, and Resident #289) of 6 residents reviewed for care plans. The facility failed to complete an accurate comprehensive care plan for Resident #235, Resident #242, and Resident #289 by not including assistance required during transfer. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided during transfers leading to falls and hospitalizations. Resident #235 Record review of Resident #235's undated face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included nondisplaced fracture of the base of neck of right femur (right hip fracture), malaise (weakness), muscle weakness, and unsteadiness on feet. Record review of Physical Therapy Progress Report dated 10/10/2024 reflected resident #235 had a weight bearing status precaution (restrictions) on his right lower extremity of 10-20% related to his right femoral neck fracture. Record review of Resident #235's Comprehensive Care Plan dated 10/09/2024 reflected resident #235 needed assistance with transfers/toileting related to impaired mobility secondary to weakness and debility. Interventions on the care plans did not indicate how much assistance was needed. Record review of Resident #235's admission MDS dated [DATE] reflected he had a BIMS score of 10 indicating he had cognitive impairment. Resident #235 required substantial assistance with activities of daily living such as dressing and grooming. He was dependent for transfers meaning to complete the activity the helper does all the effort, and the resident does none of the effort. Or the assistance of 2 (two) or more helpers was required for the resident to complete the activity. In an interview on 10/29/2024 at 10:04 AM with Resident #235, he stated he was able to get into his wheelchair with assistance of 1 staff but could not stand too long or put weight on his hip and knee. Resident #235 stated he was very weak when standing. Resident #242 Record review of Resident #242's face sheet dated 10/30/2024 reflected she was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (paralysis after a stroke), facial weakness following cerebral infarction (stroke), muscle weakness, and history of falling. Record review of Baseline Care plan dated 10/08/2024 reflected resident #242 required 2-person 676487 Page 3 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0656 assistance with transfers. Transfer status with the use of the Hoyer (mechanical lift) was not marked. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #242's Comprehensive Care Plan dated 10/08/2024 reflected resident #242 needed assistance with transfers/toileting related to impaired mobility secondary to weakness and debility. Interventions on the care plan did not indicate how much assistance was needed. Residents Affected - Some Record review of Physical Therapy evaluation and plan of treatment dated 10/09/2024 reflected resident #242 was total dependence for transfer status. Record review of Resident #242's admission MDS dated [DATE] reflected she had a BIMS score of 12 indicating she had moderate cognitive impairment. Resident #242 required substantial assistance with activities of daily living such as dressing and grooming. She was dependent for transfers meaning to complete the activity the helper did all the effort, and the resident did none of the effort. Or the assistance of 2 (two) or more helpers was required for the resident to complete the activity. The MDS also reflected Resident #242 required the use of a wheelchair for mobility and had limited range of motion with impairments on one side of both her upper and lower extremities. In an observation and interview on 10/29/2024 at 10:34 AM with Resident #242, she was observed lying in bed on top of a lift sling. Resident #242 stated the staff were going to get her up. She stated the staff used the sling to transfer her with a lift. Resident #289 Review of Resident #289's face sheet, dated 10/31/2024, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included sepsis due to methicillin resistant staphylococcus aureus (a contagious bacterial infection that starts on the skin and is resistant to most common antibiotics. MRSA can spread through cuts, scrapes, and skin-to-skin contact), acute congestive heart failure, type 2 diabetes, acute respiratory failure with hypoxia (a dangerous condition that occurs when the body does not have enough oxygen, which can lead to low oxygen levels in the body's tissues), unsteadiness on feet, and other lack of coordination. Review of Resident #289's initial MDS assessment, dated 10/17/2024, reflected no information regarding resident activities of daily living assistance transfer needs. Review of Resident #289's BIMS assessment dated [DATE] reflected a score of 14, indicating intact cognition . Review of Resident #289's care plan dated 10/17/2024 reflected a focus of, I need assistance with transfers/toileting related to impaired mobility secondary to weakness and debility with a goal dated 10/17/2024, I will cooperate in toileting efforts through the review date and interventions dated 10/17/2024, check frequently and assist with toileting as needed and keep call light within reach and remind me to call for assistance. In an interview on 10/31/2024 at 11:33 AM Resident #289 stated he had been helped from his bed to his wheelchair and from his wheelchair to his bed and to the toilet by sometimes one staff member or sometimes two staff members. He said a male staff member sometimes helped him alone, but pretty much he had two people helping him and he had not felt unsafe when he was transferred. 676487 Page 4 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0656 Level of Harm - Minimal harm or potential for actual harm Observation on 10/30/2024 at 9:02 AM revealed two staff members were present during an attempted transfer of Resident #289 from his bed to his wheelchair. Resident #289 stood up from the bed with a staff member on either side of him each with their hands on one of his arms, but after he achieved a standing position, he said he was in too much pain to be moved to his wheelchair. The staff members held his arms and lowered him to a sitting position on the bed and helped him lay back on his bed. Residents Affected - Some In an interview on 10/30/2024 at 9:03 AM CNA D and CNA E each stated Resident #289 was always a two-person transfer. In an interview on 10/31/2024 at 11:47 AM CNA F stated that Resident #289 was usually a two-person transfer, but at times he had assisted Resident #289 by himself. In an interview on 10/31/2024 at 10:50 AM LVN C stated staff can obtain transfer status by reviewing the care plan. She stated if the care plan just states assistance with transfers then she would assume that would be a 1-person transfer. She stated staff have a beginning of shift verbal report with the nursing assistants and they let them know how much assistance a resident will need with transfers. She stated the nursing assistants should be communicating transfer status in shift report between each other and in the care plan. LVN C stated negative effects for not establishing a transfer status within the care plan would be residents falling. In an interview on 10/31/2024 at 11:00 AM the DON stated transfer status should be on the task bar. The DON stated the nursing assistants get transfer status information in report verbally. The DON stated ultimately the therapist established the transfer status and communicated it to the nurses and nursing assistants. He stated the nurses were responsible for updating the care plan along with the MDS coordinator. He stated the negative effects for not having transfer status on the care plan were that the resident could fall. In an interview on 10/31/2024 at 11:19 AM the ADM stated the facility liked to have therapy evaluate and communicate the transfer status of a resident to the team. Once transfer status was determined it was communicated verbally to the nurses and nursing assistants. The nursing staff pass this information in verbal report. They walk the halls giving bedside report to each other on the residents' status. Within the electronic medical records transfer status should be in the care plan and specialty equipment needed if used. The negative effects of not listing a transfer status would be a resident fall. In an interview on 10/31/2024 at 12:22 PM MDS Coordinator B stated the ADON and the DON will update the care plans with transfer status. She stated use of mechanical lifts, limitations in weight bearing status, and transfer assistance needed would be documented under task bar. She stated the MDS Coordinator has not been defining assistance needed by staff in the care plan. She stated negative effects for the resident may include the nursing assistants may have a problem with the transfer or will have to ask someone for the amount of assistance needed. Record review of facility policy titled Care Plan dated 3/14/24 reflected The center will develop, implement, and provide care in accordance with a comprehensive person-centered care plan for the resident consistent with regulatory requirements. The care plan is to include measurable objectives and timeframes to meet a resident's medical, nursing, psycho-social, and functional needs identified with completion of the comprehensive assessment. To the extent that is practical, the resident and/or family will be involved in the development of their care plan. The care plans will be modified when needed to meet the resident's current needs, problems, and goals. Any revision, additions, or 676487 Page 5 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0656 deletion to the plan of care will be dated and initialed. Revisions involving the care of other disciplines are done through consultative and collaborative efforts. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676487 Page 6 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 residents of 24 residents (Resident #11, Resident #18, and Resident #285) reviewed for activities. Residents Affected - Few 1. Residents #11, Resident #18, and Resident #285 were not engaged in a person-centered activity programs and said they were bored. 2. The group activity calendar for the month of September 2024 listed an entry of books, puzzles, and TV Time for each day, no other activities listed. 3. The group activity calendar of the month of October 2024 listed 16 days of AM (morning) news, puzzles, and books. These failures placed residents at risk of boredom, depression, and a diminished quality of life. Findings included: Review of Resident #11's face sheet, dated 10/31/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a dangerous condition that occurs when the body does not have enough oxygen which can lead to low oxygen levels in the body's tissues), acute congestive heart failure, morbid obesity due to excess calories, and unsteadiness on feet. Review of Resident #11's initial MDS assessment, dated 09/17/2024, section F0500 interview for activity preferences reflected: o How important is it to you to have books, newspapers, and magazines to read - very important o How important is it to you to listen to music you like? - very important o How important is if for you to be around animals such as pets? - very important o How important is it to you to keep up with the news? - very important o 676487 Page 7 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0679 How important is it to you to do thing with groups of people? - very Important Level of Harm - Minimal harm or potential for actual harm o How important is it to you to do your favorite activities? - very important Residents Affected - Few o How important is it to you to go outside to get fresh air when the weather is good? - Very important o How important is it to you to participate in religious services or activities? - very important Review of Resident #11's 09/11/2024 BIMS reflected a score of 13, indicating intact cognition. Review of Resident #11's care plan dated 09/13/2024 reflected a focus of My Preferences dated 09/13/2024, Goal dated 09/13/2024 - my preferences will be met during my stay. Intervention dated 09/13/2024 - preferred time to wake up between 8:00 AM and 9:00 AM and dated 09/16/2024 intervention permission given to wake up to administer medications, therapy or other services dated 09/13/2024. Review of Resident #18's face sheet, dated 10/31/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (a common heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often rapidly), muscle weakness, and steadiness on feet, and need for assistance with personal care. Review of Resident #18's initial MDS assessment, dated 09/20/2024, section F0500 interview for activity preferences was not completed. Review of Resident #18's 09/11/2024 BIMS reflected a score of 13, indicating intact cognition. Review of Resident #18's care plan dated 09/15/2024 reflected a focus of My Preferences dated 09/15/2024, Goal dated 09/15/2024 - my preferences will be met during my stay. Intervention dated 09/15/2024 - preferred time to wake up between 8:00 AM and 9:00 AM, and permission given to wake up to administer medications, therapy, or other services. Review of Resident #285's face sheet, dated 10/31/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood that affects brain function), convulsions, acute kidney failure, and unsteadiness on feet. Review of Resident #285's initial MDS assessment, dated 10/16/2024, section F0500 interview for activity preferences reflected: o How important is it to you to have books, newspapers, and magazines to read - very important 676487 Page 8 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0679 o Level of Harm - Minimal harm or potential for actual harm How important is it to you to listen to music you like? - very important o Residents Affected - Few How important is if for you to be around animals such as pets? - very important o How important is it to you to keep up with the news? - very important o How important is it to you to do thing with groups of people? - very Important o How important is it to you to do your favorite activities? - very important o How important is it to you to go outside to get fresh air when the weather is good? - Very important o How important is it to you to participate in religious services or activities? - very important Review of Resident #285's 10/13/2024 BIMS reflected a score of 12, indicating moderate cognitive impairment. Review of Resident #285's care plan dated 10/12/2024 reflected a focus of My Preferences dated 10/12/2024, Goal dated 10/13/2024 - my preferences will be met during my stay. Intervention dated 10/12/2024 - preferred time to wake up between 8:00 AM and 9:00 AM, and permission given to wake up to administer medications, therapy, or other services. Review of Resident #11's Activity Initial Evaluation dated 09/17/2024 reflected: o Activity Involvement preferences - afternoon o Activity Involvement Preferences - group activities o 676487 Page 9 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0679 How important is it to you to have books, newspapers, and magazines to read? - very important Level of Harm - Minimal harm or potential for actual harm o How important is it to you to have music you like to listen to? - very important Residents Affected - Few o How important is if for you to be around animals such as pets? - very important o How important is it to you to keep up with the news? - very important o How important is it to you to do thing with groups of people? - very Important o How important is it to you to do your favorite activities? - very important o How important is it to you to go outside to get fresh air when the weather is good? - Very important o How important is it to you to participate in religious services or activities? - very important o Indicate respondent for daily activities and preferences - resident Review of Resident #18's Activity Initial Evaluation dated 09/20/2024 reflected: o Activity Involvement preferences - morning o Activity Involvement Preferences - Individual activities o Issues, concerns, problems or needs that may affect involvement or engagement in leisure activity included - prefers to stay in own room 676487 Page 10 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0679 o Level of Harm - Minimal harm or potential for actual harm Additional Individual Interests - Watching TV/Movies o Residents Affected - Few Group Activities - social (socials, entertainment, games, moves, pet visits) o How important is it to you to have books, newspapers, and magazines to read? - very important o How important is it to you to have music you like to listen to? - very important o How important is if for you to be around animals such as pets? - very important o How important is it to you to keep up with the news? - very important o How important is it to you to do thing with groups of people? - very Important o How important is it to you to do your favorite activities? - very important o How important is it to you to go outside to get fresh air when the weather is good? - Very important o How important is it to you to participate in religious services or activities? - very important o Indicate respondent for daily activities and preferences - resident Review of Resident #285's Activity Initial Evaluation dated 10/14/2024 reflected: o 676487 Page 11 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0679 Activity Involvement preferences - no specific preference Level of Harm - Minimal harm or potential for actual harm o Activity Involvement Preferences - individual activities and group activities Residents Affected - Few o How important is it to you to have books, newspapers, and magazines to read? - very important o How important is it to you to have music you like to listen to? - very important o How important is if for you to be around animals such as pets? - very important o How important is it to you to keep up with the news? - very important o How important is it to you to do thing with groups of people? - very Important o How important is it to you to do your favorite activities? - very important o How important is it to you to go outside to get fresh air when the weather is good? - very important o How important is it to you to participate in religious services or activities? - very important o Indicate respondent for daily activities and preferences - resident In an interview on 10/30/24 at 4:02 PM Resident #11 stated she did not receive an activity calendar; she had not been offered a manicure or pedicure as an activity. She stated she did not know the facility had activities and she was extremely bored, and she was bored over the weekend. She stated there was nothing to do on the weekend. She said that not having had activities affected her attitude and got her down. 676487 Page 12 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0679 Level of Harm - Minimal harm or potential for actual harm In an interview on 10/29/2024 at 10:52 AM Resident #18 stated the staff had not given her the opportunity to demonstrate her intelligence or ability and she had not been given the opportunity to show people that she is not a potato. When asked what she meant by potato, she said she had been regarded an object that just laid there. She stated the only thing she had been out to do was walk with a walker. She stated she did not have enough stimulation. Residents Affected - Few In an interview on 10/31/2024 at 9:38 AM Resident #18 stated she did not recall receiving an activities calendar. She stated she is bored. She stated she stayed in bed all day yesterday because there was, not a damn thing to do otherwise. She did not tell the staff she is bored because she was not a complainer. Resident #18 felt activities should be offered based on the individual needs of each resident and she felt she had been lumped into a category and it had been difficult to express herself. In an interview on 10/31/24 at 9:13 AM Resident #285 stated she had never seen an activity calendar and she was absolutely bored and asked, what the hell is there to do here? When asked how she felt being bored, she replied that that was a stupid question and how would you feel if you were bored? She said she was invited to Bingo, but she did not know one person at the facility. Observation on 10/31/24 at 9:13 AM revealed, the state surveyor, with the permission Resident #285, looked for an activity calendar in the papers in her room and no activity calendar was located in her room. In an interview on 10/31/2024 at 10:15 AM the Activities Director stated she began the job as the activity's director the second week of October 2024. She stated the first thing she began doing was working on the activity calendar. She stated she tried to make sure residents had activities because she wanted them to get out of their rooms and get them motivated. She stated that if residents were closed in their rooms they got depressed. She set up puzzles in a room on the third floor and books were in the library. AM (morning) news was for residents who want to get up and watch the news. She stated she felt an activity was something to get residents active and to get residents to use their hands and feet. She said most residents liked Bingo. She stated an activity assessment was done with each resident. She stated she went to the residents' rooms a little bit after breakfast and explained the activities to them. They currently did not have any religious offerings. She explained the night receptionist was supposed to turn on the TV before she left for the evening. She stated she had been spending time visiting with the residents. She stated she thought residents could get depressed and bored and her goal was to keep them motivated because they were already down and sad. She stated the resident council meeting, and the beauty parlor information should have been on the activity calendar. In an interview on 10/31/2024 at 10:27 AM the Administrator stated resident activities were both for group and individual. Residents were provided with an activity assessment and the facility had activity rooms on both floors that provided coloring books, puzzles, games, and books. The facility was without an activity director from September 2024 until about two weeks ago and no one was acting as an activity director. He stated they did Bingo with residents. He said additional activities were provided to the residents that were not reflected on the September 2024 and October 2024 activity calendar. He said activities could be described as an ongoing patient centered activity program that incorporated the patient's hobbies and culture preferences and he felt like the books, the AM (morning) news, and coloring partially met this description. He stated they could have provided more activates but it was hard when there was not someone in the role as activity director. He said it was the responsibility of the Administrator to make sure that the residents had activities and if residents 676487 Page 13 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0679 Level of Harm - Minimal harm or potential for actual harm do not have activities, it was possible they could decline. He stated the lack of activities could affect their mental health, but he did not know how much it would affect them because the facility was a rehabilitation skilled nursing facility and residents do not live at the facility long term. A review of the facility September 2024 activity calendar reflected: Residents Affected - Few 09/01/2024 through 09/30/2024 - books, puzzles, and TV time. A review of the facility October 2024 activity calendar reflected: 10/01/2024 through 10/12/2024 - AM (morning) news, puzzles 3rd floor, and books, 10/13/2024 AM (morning) news, Sunday Night Football, 10/14/2024 through 10/17/2024 - AM (morning) news, puzzles 3rd floor, and books, 10/198/2024 Bingo 1:30 PM - 3:30 PM, 10/19/2024 - AM (morning) news and college football, 10/20/2024 AM (morning) news and Sunday Night Football, 10/21/2024 Bingo 1:30 PM - 3:30 PM, 10/22/2024 Movie Night 7:00 PM, 10/23/24 Quartet 1:30 PM - 3:30 PM, 10/24/2024 Fall [NAME], 10/25/2024 Bingo 1:30 PM - 3:30 PM and Central Texas Rehabilitation Hospital, 10/26/2024 AM (morning) news and College Football, 10/29/2024 Arts & Crafts, Halloween bags 1:30 PM - 3:30 PM, 10/30/2024 Bingo 1:30 PM - 3:30 PM, 10/31/2024 Halloween Party staff/patient. Review of facilities activities policy dated 02/08/2021 reflected the patient has the right to choose activities and participate in activities, including social, religious, and community activities that do not interfere with the rights of other patients in the facility. The center will ensure and implement an ongoing patient centered activity program that incorporates the patient's hobbies and cultural preferences, which is integral to maintaining and or improving a patient's physical, mental, and psychosocial well-being and independence. The facility will support and create meaningful life by supporting his/her domain of Wellness. The patient will make choices about the activities they would like to participate in. The activity calendar will be provided to all patients. Activities will be provided seven days a week on days and evening. Activity room will have self-directed activities 24 hours a day available to the patient. The patient's interests will be reviewed by activity director with patient. Activities of daily living such as manicures and pedicures and hair styling may be part of an activity program. Validating and respecting patients right to refuse an activity. Promoting one to one visits in patient room as needed. Engagements of exercise and movement. Hands on activities such as crafts, games, etcetera. 676487 Page 14 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

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 review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 1 of 1 Residents (Resident #73) reviewed for tracheostomy care. Residents Affected - Few The facility failed to ensure Resident #73 used aseptic technique (a procedure that healthcare providers use to prevent the spread of germs that cause infection. Placing barriers, using sterile equipment, and following strict guidelines that help create an environment free of germs.) during tracheostomy care. The facility further failed to ensure that Resident #73's tracheostomy tube was free from secretions to ensure a patent airway prior to inserting his inner cannula. This failure could place residents who use respiratory equipment and have tracheostomies at risk for respiratory infections and respiratory distress. Findings included: Review of Resident #73's face sheet dated 10/30/2024 reflected he was admitted on [DATE] with the following diagnoses encephalopathy (a medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion.), human immunodeficiency virus, (a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases.), and tracheostomy status (a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube.). Review of Resident #73's admission MDS dated [DATE] reflected he was assessed to have a BIMS score of 14 indicating he was cognitively intact. Resident #73 was assessed to be independent in all areas of ADL assistance. Resident #73 was assessed to have a multidrug-resistant organism, to receive antibiotics, and to receive tracheostomy care and suctioning. Review of Resident #73's comprehensive care plan reflected a focus area dated 09/19/2024 Antibiotic therapy related infection gangrenous necrosis (is death of body tissue due to a lack of blood flow or a serious bacterial infection.) and acute osteomyelitis of the mandible . Further review reflected a focus area dated 10/29/2024 Tracheostomy interventions included suction as needed. The plan of care did not address tracheostomy care or frequency of care. Review of Resident #73's consolidated physician orders reflected an order dated 09/18/2024 Trach care: Stoma: cleanse peri area with normal start at 12 o'clock to 9am, 3 pm to 6pm, and 12am to 3am. Apply new drain sponge secure in place with new trach tie. Monitor for signs and symptoms of breakdown around stoma as needed. Observation on 10/30/2024 at 11:05 AM LVN F entered Resident #73's room to provide tracheostomy care. LVN F gathered her supplies and opened the sterile trach care kit. LVN F then opened the sterile trach inner cannula and dropped the inner cannula into the trach care kit. LVN F had an unopened bottle of normal saline. LVN F then donned gloves and removed Resident #73's old trach gauze from around his trach stoma and she removed his inner cannula. LVN F sanitized her hands and donned she donned sterile gloves. LVN F then opened the non- sterile normal saline and poured into the sterile tray. Resident #73 was observed coughing as she cleaned around the trach stoma producing mucus. Resident 676487 Page 15 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #73 continued to cough and was observed to have a mucus plug visible at the opening of the tracheostomy tube. LVN F then, without clearing the airway inserted the inner cannula through the mucus plug. In an interview on 10/30/2024 at 11:20 am LVN F stated she should have opened the normal saline and placed it in the trach care tray prior to donning the sterile gloves. She stated by not doing so she contaminated her sterile field. She stated should have suctioned Resident #73 or made sure his airway was clear prior to inserting the inner cannula. In an interview on 10/30/2024 at 11:30 AM the DON stated he excepted trach care to be done as an aseptic procedure and LVN F did cross contaminate when she used sterile gloves to open the normal saline which was not sterile to prevent infections. He further stated the resident's airway should be clear prior to inserting an inner cannula to prevent blockage of the airway. Review of the facility's policy Tracheostomy care dated 10/10/2019 reflected Purpose: The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. 1. Aseptic technique must be used: (Aseptic technique is a procedure that healthcare providers use to prevent the spread of germs that cause infection. Placing barriers, using sterile equipment, and following strict guidelines help create an environment free of germs that can make you sick.) a. During cleaning and sterilization of reusable tracheostomy tubes; b. During all dressing changes until the tracheostomy wound has granulated (healed), and c. During tracheostomy tube changes, either reusable or disposable. 2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies . A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times . Review of the website: https://nurseslabs.com/tracheostomy/#h-providing-tracheostomy-care for nursing procedure dated 05/26/2024 reflected .5. Establish the sterile field. Open other sterile supplies as needed, including sterile applicators, a suction kit, and a tracheostomy dressing. 6. Suction the tracheostomy tube, if necessary. Put a clean glove on your nondominant hand and a sterile glove on your dominant hand (or put on a pair of sterile gloves). Suction the full length of the tracheostomy tube to remove secretions and ensure a patent airway. Rinse the suction catheter, wrap it around your hand, and peel the glove off so that it turns inside out over the catheter. 7. Remove the inner cannula. Unlock the inner cannula with the gloved hand. Gently pull it out in line with its curvature and place it in the soaking solution. This moistens and loosens secretions. 8. Remove the soiled dressing. Place the soiled tracheostomy dressing in your gloved hand and peel the glove off so that it turns inside out over the dressing. Discard the glove and the dressing. 9. Put on sterile gloves. Keep your dominant hand sterile during the procedure. Clean the inner cannula. Remove the inner cannula from the soaking solution. 10. Clean the lumen and entire inner cannula thoroughly using the brush or pipe cleaners moistened with sterile normal saline. Inspect the cannula for cleanliness by holding it at eye level and looking through it into the light. Rinse the inner cannula thoroughly in the sterile normal saline. After rinsing, gently tap the cannula against the inside edge of the sterile saline container. Use a pipe cleaner folded in half to dry only the inside of the cannula, leaving a film of moisture on the outer surface to lubricate the cannula for reinsertion. This removes excess liquid and prevents aspiration. 11. Replace the inner cannula, securing it in place. Insert the inner cannula by grasping the outer flange and inserting the cannula in the direction of its curvature. Lock the cannula in place by turning the lock (if present) to secure the flange of the inner cannula to the outer cannula. 12. Clean the incision site and tube flange. Using sterile applicators or 676487 Page 16 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gauze dressings moistened with normal saline, clean the incision site. Handle the sterile supplies with your dominant hand and use each applicator or gauze dressing only once. Hydrogen peroxide may be used (usually in a half-strength solution mixed with sterile normal saline) to remove crusty secretions. Thoroughly rinse the cleaned area using gauze squares moistened with sterile normal saline. This avoids contaminating a clean area and ensures thorough cleaning without irritating the skin. 13. Apply a sterile dressing. Use a commercially prepared tracheostomy dressing or open and refold a 4×4-inch gauze dressing into a V shape. Place the dressing under the flange of the tracheostomy tube while ensuring the tube is securely supported to avoid irritation from excessive movement . 676487 Page 17 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and 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 and follow accepted national standards for one of one resident reviewed for tracheotomy care (Resident #73). Residents Affected - Few The facility failed to ensure LVN F used aseptic technique during tracheotomy care for Resident #73. These failures could place residents at risk for developing wound and upper respiratory infections. Findings included: Review of Resident #73's face sheet dated 10/30/2024 reflected he was admitted on [DATE] with the following diagnoses encephalopathy (A medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion.), human immunodeficiency virus, (a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases.), and tracheostomy status (a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube.). Review of Resident #73's admission MDS dated [DATE] reflected he was assessed to have a BIMS score of 14 indicating he was cognitively intact. Resident #73 was assessed to be independent in all areas of ADL assistance. Resident #73 was assessed to have a multidrug-resistant organism, to receive antibiotics, to receive tracheostomy care and suctioning. Review of Resident #73's comprehensive care plan reflected a focus area dated 09/19/2024 Antibiotic therapy related infection gangrenous necrosis (is death of body tissue due to a lack of blood flow or a serious bacterial infection.) and acute osteomyelitis of the mandible . Further review reflected a focus area dated 10/29/2024 Tracheostomy interventions included suction as needed. The plan of care did not address tracheostomy care or frequency of care. Review of Resident #73's consolidated physician orders reflected an order dated 09/18/2024 Trach care: Stoma: cleanse peri area with normal start at 12 o'clock to 9am, 3 pm to 6pm and 12am to 3am. Apply new drain sponge secure in place with new trach tie. Monitor for signs and symptoms of breakdown around stoma as needed. Observation on 10/30/2024 at 11:05 AM LVN F entered Resident #73 room to provide tracheostomy care. LVN F gathered her supplies and opened the sterile trach care kit. LVN F then opened the sterile trach inner cannula and dropped the inner cannula into the trach care kit. LVN F had an unopened bottle of normal saline. LVN F then donned gloves and removed Resident #73 old trach gauze from around his trach stoma and she removed his inner cannula. LVN F sanitized her hands and donned she donned sterile gloves. LVN F then opened the non- sterile normal saline and poured into the sterile tray. Resident #73 was observed coughing as she cleaned around the trach stoma producing mucus. Resident #73 continued to cough and was observed to have a mucus plug visible at the opening of the tracheostomy tube. LVN F then, without clearing the airway inserted the inner cannula through the mucus plug. 676487 Page 18 of 19 676487 10/31/2024 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 10/30/2024 at 11:20 am LVN F stated she should have opened the normal saline and placed it in the trach care tray prior to donning the sterile gloves. She stated by not doing so she contaminated her sterile field. In an interview on 10/30/2024 at 11:30 AM the DON stated he excepted trach care to be done as an aseptic procedure and the LVN F did cross contaminate when she used to sterile gloves to open the normal saline which was not sterile to prevent infections. Review of the facility's policy Tracheostomy care dated 10/10/2019 reflected Purpose: The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. 1. Aseptic technique must be used:( Aseptic technique is a procedure that healthcare providers use to prevent the spread of germs that cause infection. Placing barriers, using sterile equipment, and following strict guidelines help create an environment free of germs that can make you sick.) a. During cleaning and sterilization of reusable tracheostomy tubes; .Sterile gloves must be used during aseptic procedures 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies . Review of the website: https://nurseslabs.com/tracheostomy/#h-providing-tracheostomy-care for nursing procedure dated 05/26/2024 reflected .5. Establish the sterile field. Open other sterile supplies as needed, including sterile applicators, a suction kit, and a tracheostomy dressing. 6. Suction the tracheostomy tube, if necessary. Put a clean glove on your nondominant hand and a sterile glove on your dominant hand (or put on a pair of sterile gloves) .8. Remove the soiled dressing. Place the soiled tracheostomy dressing in your gloved hand and peel the glove off so that it turns inside out over the dressing. Discard the glove and the dressing. 9. Put on sterile gloves. Keep your dominant hand sterile during the procedure . Using sterile applicators or gauze dressings moistened with normal saline, clean the incision site. Handle the sterile supplies with your dominant hand and use each applicator or gauze dressing only once .Thoroughly rinse the cleaned area using gauze squares moistened with sterile normal saline. This avoids contaminating a clean area and ensures thorough cleaning without irritating the skin. 13. Apply a sterile dressing. 676487 Page 19 of 19