Health inspection·April 3, 2024

F 0641 Ensure each resident receives an accurate assessment. 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 assessment accurately reflected the resident's status for 1 (Resident #2) of 3 residents reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure Resident #2 was coded severely visually impaired on his MDS assessment. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #2's face sheet dated 04/01/2024 with an admission date of 08/03/2022 reflected he was a [AGE] year-old male with diagnoses of blindness right eye category 3, blindness left eye category 3, (blindness-presenting visual acuity worse than 3/60 and better than 1/60), unspecified vision loss, and reduced mobility. Record review of Resident #2's quarterly MDS dated [DATE] reflected his BIMS score of 13 which indicated he was cognitive intact. Resident #2 vision impairment was coded as a 1 which indicated he was impaired= sees large print, but not regular print in newspapers/books. Record review of Resident #2's quarterly comprehensive care plan reflected: Problem- Resident #2 has impaired vision function, Interventions- Identify/record factors affecting visual function including physiological, environmental, and choices. An observation on 03/28/2024 at 4:12 p.m., revealed Resident #2 was lying in bed, he had his eyes closed but was awake, he was dressed in his own personal clothing, and was well groomed. His bed was set to the lowest position and call light was within reach. Resident #2's room had a home-like environment. An interview on 03/28/2024 at 4:15 p.m., Resident #2 said he had lost his vision due to glaucoma several years ago. He said he relied on his white cane to get around. He said he would yell out for staff when he needed assistance because he could not see where the call light was. Resident #2 said staff made sure his belongings were kept in the same place and close to him to make it easier for him to find his belongings. An interview on 04/03/2024 at 11:11 a.m., the SW said Resident #2 was considered legally blind. The SW said she had observed Resident #2 being able to grab his utensils during mealtimes and said she Page 1 of 6 676495 676495 04/03/2024 Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few never observed him eating with his hands on several occasions. The SW said she had not coded Resident #2 correctly on his MDS assessment. She said she had coded Resident #2 a 1 and he should have been coded a 4 which indicated he was severely visually impaired. The SW said there were no negative affects to Resident #2 for being coded a 1 since he was getting the assistance he needed with his ADL's. An interview on 04/03/2024 at 2:00 p.m., the MDS LVN said Resident #2 had been coded a 1 on his MDS assessment. She said she did not know Resident #2 was not able to see anything. The MDS LVN said Resident #2 could be negatively affected by not having the correct vision code if there was a new staff (CNA, LVN, RN) as they would not know how to appropriately care for him. An interview on 04/03/2024 at 2:30 p.m., the DON said Resident #2 was coded a 081 on his MDS assessment under vision. He said Resident #2 was considered legally blind and should have been coded a 4 which indicated his vision was severely impaired. The DON said the negative outcome for Resident #2 not being coded correctly could mean he would not get the proper care he needed, and his dignity could be affected. He gave an example, if a staff member read his MDS assessment and saw Resident #2 could read large print he could be offered something to read causing him to be humiliated. An interview on 04/03/2024 at 2:40 p.m., the Administrator referred the state surveyor to facility's corporate DON when requesting policy. An interview on 04/03/2024 at 3:00 p.m., the corporate DON said the facility did not have a policy regarding the MDS. He said they followed the CMS RAI when completing MDS assessments. Record review of CMS's RAI Version 3.0 Manual dated 10/2023 reflected: B-1000: Vision Ability to see adequate light (with glasses or other visual appliances): 0. Adequate- sees fine detail, such as regular print in newspapers/books 1. Impaired-sees large print, but not regular print ni newspapers/books 2. Moderately impaired- limited vision; not able to see newspaper headlines but can identify objects 3. Highly impaired- object identification in question, but eyes appear to follow objects 4. Severely Impaired- no vision or sees only light, colors or shapes; eyes do not appear to follow objects 676495 Page 2 of 6 676495 04/03/2024 Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 2 (Resident #1 and Resident #2) of 3 residents reviewed for care plans. The facility failed to ensure: Resident #1's and Resident #2's care plan reflected their behavior of not using the call light when they needed assistance. Resident #2's ADL's were addressed on his care plan. This failure could place residents for their medical, physical, and psychosocial needs not being met. The findings included: 1. Record review of Resident #1's face sheet dated 03/28/2024 with an admission date of 03/01/2024 and an initial admission date of 01/27/24 reflected she was an [AGE] year-old female with diagnoses of type 2 diabetes, fall on same level, chronic kidney disease, lack of coordination, need for assistance with personal care, and chronic kidney disease. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 03 which indicated Resident #1 was cognitively severely impaired. Record review of Resident #1's quarterly care plan reflected she was at risk for falls related to disease process. Resident #1's interventions were to keep call light within reach and encourage her to use it for assistance as needed, the resident needs prompt response to all request for assistance. An observation on 03/28/2024 at 2:32 p.m., Resident #1 was observed lying in her bed, she was dressed in her own clothing, and well groomed. Her bed was set to the lowest position, fall mats were on both sides in place, the call light within reach, and the room had a home-like environment. An interview on 03/28/2024 at 2:35 p.m., Resident #1 said the times she had fallen was because she tried getting up on her own. Resident #1 said she did not like using the call light because she felt she could still do things on her own. Resident #1 said the nursing staff checked on her regularly and reminded her to use the call light when she needed assistance. Resident #1 said whenever she did not need assistance, she yelled out for help. 2. Record review of Resident #2's face sheet dated 04/01/2024 with an admission date of 08/03/2022 reflected he was a [AGE] year-old male with diagnoses of blindness right eye category 3, blindness left eye category 3, (blindness-presenting visual acuity worse than 3/60 and better than 1/60), unspecified vision loss, and reduced mobility. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score was 13 which indicated he was cognitive intact. Resident #2's vision impairment was coded as a 1 which indicated he 676495 Page 3 of 6 676495 04/03/2024 Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was impaired= sees large print, but not regular print in newspapers/books. Resident #2's functional abilities and goals reflected for eating he required set up and clean up assistance, oral and toileting hygiene he required supervision or touching assistance, for shower/bathe self he required substantial/maximal assistance and for dressing he required partial/moderate assistance. Record review of Resident #2's quarterly care plan reflected he had a moderate risk for falls. The interventions were to anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. An observation on 03/28/2024 at 4:12 p.m., revealed Resident #2 was lying in bed, he had his eyes closed but was awake, he was dressed in his own personal clothing, and was well groomed. His bed was set to the lowest position and the call light was within reach. Resident #2's room had a home-like environment. An interview on 03/28/2024 at 4:15 p.m., Resident #2 said he was blind and could not see anything due to being diagnosed with glaucoma and said he relied on his white cane to get around. He said he would yell out for staff when he needed assistance because he could not see where the call light was. Resident #2 said staff made sure his belongings were kept in the same place and close to him. An interview on 03/28/2024 at 4:30 p.m., LVN E said Resident #1 did not use the call light because she felt she was still able to do things on her own. LVN E said Resident #1 was a fall risk and needed constant supervision. She said Resident #2 did not use the call light but was able to walk to the doorway to call out for help when he needed assistance. LVN E said she had not informed her ADON or DON that Resident #1 and Resident #2 did not like to use the call light. An interview on 04/01/2024 at 12:43 p.m., CNA A said Resident #1 was non-compliant to using the call light. She said Resident #1 had tried to get up on her own several times which resulted in her falling. CNA A said Resident #1 would be kept busy throughout the day to avoid her trying to get up on her own. CNA A said Resident #2 did see very well. CNA A said Resident #2 would call out for help when he needed assistance. CNA A said she had not informed her charge nurse that Resident #1 or Resident #2 did not use the call light. A phone interview on 04/01/2024 at 1:00 p.m., CNA B said Resident #1 would not use the call light and was a fall risk. CNA B said Resident #1 required extra supervision due to her being non-compliant when it came to using the call light and her trying to get up from bed or wheelchair without assistance. CNA B said Resident #2 was visually impaired and used his cane to guide him. He said Resident #2 yelled out for help when he needed assistance. He said he had not notified his charge nurse that Resident #1 and/or Resident #2 did not use the call light. An interview on 04/01/2024 at 1:43 p.m., LVN C said Resident #1 was non-compliant when it came to using the call light and was a fall risk. She said Resident #1 would not call out for assistance. She said she had not notified the ADON or DON that Resident #1 and/or Resident #2 did not use the call light. An interview on 04/01/2024 at 1:50 p.m., LVN D said Resident #1 did not use the call light. LVN D said Resident #1 was a fall risk and needed to be supervised throughout the day because she would try to get up on her own. LVN D said Resident #2 was visually impaired but knew how to get to the bathroom, doorway, and his bed without assistance. LVN D said when Resident #2 needed assistance, he would yell out for help. She said she had not notified the ADON or DON that Resident #1 and/or Resident 676495 Page 4 of 6 676495 04/03/2024 Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582

F 0657 #2 did not use the call light. Level of Harm - Minimal harm or potential for actual harm An interview on 04/03/2024 at 10:24 a.m., CNA F said Resident #1 was non-compliant when it came to using the call light. CNA F said Resident #1 was a fall risk and needed to be kept busy throughout the day so she wouldn't get up on her own. CNA A said when Resident #2 needed assistance he would yell out for help because he could not see where the call light was. CNA F said she had not notified her charge nurse Resident #1 and/or Resident #2 did not use their call lights. Residents Affected - Few An interview on 04/03/2024 at 10:35 a.m., CNA G said Resident #1 did not use the call light. She said Resident #1 would be kept busy throughout the day to avoid her from trying to get up and falling. CNA G said Resident #2 would yell out CNA when he needed assistance. CNA G said she had not notified her charge nurse Resident #1 and/or Resident #2 did not use their call lights. An interview on 04/03/2024 at 2:00 p.m., the MDS-RN said she had not been informed by the nursing staff, ADON's, or the DON that Resident #1 was non-compliant in using her call light. She said that would be something that needed to have been care planned because it would place Resident #1 at risk of not getting the attention she needed and was at risk of falling. The MDS-RN said she had not been informed Resident #2's could not and/or would not use his call light. She said Resident #2's could be negatively affected if staff were not near his room when he would yell out for help and ran the risk of not getting the attention he needed. The MDS-RN said Resident #2' care plan should have included ADL's. She said it must have been deleted when it was being updated but was not sure when they were deleted. She said if ADL's were not included in the care plan, staff would not know how to properly care for him. An interview on 04/03/2024 at 2:30 p.m., the DON said he had not been informed by his nursing staff that Resident #1 and Resident #2 did not/could not use their call light. The DON said Resident #1 and Resident #2 could be negatively affected if staff were not near their rooms when they needed help. The DON said if Resident #2's care plan did not include his ADL's, staff would not know how to care properly care for him. Record review of facility's policy on Care Plan Revisions Upon Status Change dated 10/24/2022 reflected: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary,, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change. a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and 676495 Page 5 of 6 676495 04/03/2024 Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582

F 0657 collaborate on intervention options. Level of Harm - Minimal harm or potential for actual harm d. The care plan will be updated with the new or modified interventions. Residents Affected - Few 676495 Page 6 of 6