Health inspection·September 9, 2022

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** . Residents Affected - Few Based on observation, interview and record review, the facility failed to have an accurate assessment for one resident (Resident #3) out of 12 residents reviewed for accurate assessments in that: Resident #3 received oxygen therapy that was not reflected on her MDS assessment. This deficient practice could place residents at risk of missed care. The findings were: Record review of Resident #3's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat) and cardiac pacemaker (device attached to the heart that generates electrical impulses to the heart to help it pump properly). Record review of Resident #3's MDS, an admission assessment dated [DATE], revealed her BIMS score was 14 out of 15, indication her cognitive skills for daily decision making were intact; and under Section O, it was not checked Resident #3 received oxygen. Record review of Resident #3's electronic physician orders from 06/01/22 to 09/07/22 revealed there was no order for Resident #3 to receive oxygen. Record review of Resident #3's care plans, initiated 06/01/22 and revised on 06/27/22, revealed there was no care plan for oxygen therapy. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/01/22 indicated oxygen had been administered to the resident at 3 LPM via nasal cannula (a tubing device used to deliver supplemental oxygen that has two prongs at an end which are inserted into the nostrils). Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/01/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Page 1 of 11 745001 745001 09/09/2022 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0641 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/05/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/06/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Residents Affected - Few Record review of Resident #3's clinical record revealed nurses progress note by LVN C dated 06/07/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Observation on 09/06/22 at 10:40 a.m. revealed Resident #3 was sitting in a wheelchair in her room with an oxygen concentrator behind the resident that was not in operation. In an interview on 09/06/22 at 01:49 p.m., Resident #3 stated she used the oxygen at night when she was sleeping and removed the oxygen in the morning. Observation on 09/08/22 at 5:44 a.m. revealed Resident #3 was lying in bed and received oxygen via nasal cannula at 2 LPM. In an interview on 09/08/22 at 6:08 a.m., LVN A stated the nurse would place the nasal cannula on Resident #3 at night to administer oxygen at 2 LPM per the resident's request. LVN A stated Resident #3 needed the oxygen at night when she was first admitted ; the resident's condition improved, and she no longer needed the oxygen, but the resident wanted to have it on at night. In an interview on 09/08/22 at 8:58 a.m., LVN C stated Resident #3 received oxygen continuously when she was admitted to the facility, but the resident weaned herself off the oxygen and only used it at night. In an interview on 09/08/22 at 9:07 a.m., MDS Nurse stated she worked in the facility for only two weeks. The MDS Nurse reviewed Resident #3's nurse's notes for 6/6/22 and 6/7/22, stated it was noted Resident #3 received oxygen at 2 LPM via nasal cannula. The MDS Nurse reviewed Resident #3's admission MDS dated [DATE] and stated it was not coded for oxygen and should had been coded to indicate Resident #3 received oxygen since the nursing progress notes indicated she received oxygen. The MDS Nurse stated the risk of not having the MDS coded correctly could result in an inaccurate assessment and which did not reflect the resident's status. The MDS Nurse stated if the oxygen had been coded on the MDS then it would have triggered a care plan to have been completed for oxygen. In an interview on 09/08/22 at 3:25 p.m. the DON stated the facility would have interdisciplinary team meetings to review care plans to ensure their accuracy along with the MDS. In an interview on 09/08/22 at 3:41 p.m. the Administrator stated the clinical leadership was responsible to ensure the residents' MDS assessments were accurate. Record review of CMS' RAI (Resident Assessment Instrument) Manual 3.0 User's Manual, October 2019, page O-1 to O-3, revealed the treatments, procedures and programs listed in Section O, could have a profound effect on an individual's health status, self-image, dignity, and quality of life. Under Steps for Assessment was 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period .Code continuous or 745001 Page 2 of 11 745001 09/09/2022 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia [low level of oxygen in the blood] . Record review of the policy MDS Error Correction, revised September 2010, revealed The Assessment Coordinator and/or the Interdisciplinary Assessment Team will follow the established processes for making corrections to the MDS. . 745001 Page 3 of 11 745001 09/09/2022 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for the resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 12 residents (Residents #3) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan that addressed Resident #3's use of oxygen. This deficient practice could place residents at risk for not receiving the appropriate care and services needed to maintain optimal health. The findings were: Record review of Resident #3's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat) and cardiac pacemaker (device attached to the heart that generates electrical impulses to the heart to help it pump properly). Record review of Resident #3's care plans, initiated 06/01/22 and revised on 06/27/22, revealed there was no care plan for oxygen therapy. Record review of Resident #3's MDS, an admission assessment dated [DATE], revealed her BIMS score was 14 out of 15, indication her cognitive skills for daily decision making were intact; and under Section O, it was not checked Resident #3 received oxygen. Record review of Resident #3's electronic physician orders from 06/01/22 to 09/07/22 revealed there was no order for Resident #3 to receive oxygen. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/01/22 indicated oxygen had been administered to the resident at 3 LPM via nasal cannula (a tubing device used to deliver supplemental oxygen that has two prongs at an end which are inserted into the nostrils). Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/01/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/05/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. 745001 Page 4 of 11 745001 09/09/2022 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/06/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed nurses progress note by LVN C dated 06/07/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Residents Affected - Few Observation on 09/06/22 at 10:40 a.m. revealed Resident #3 was sitting in a wheelchair in her room with an oxygen concentrator behind the resident that was not in operation. In an interview on 09/06/22 at 01:49 p.m., Resident #3 stated she used the oxygen at night when she was sleeping and removed the oxygen in the morning. Observation on 09/08/22 at 5:44 a.m. revealed Resident #3 was lying in bed and received oxygen via nasal cannula at 2 LPM. In an interview on 09/08/22 at 6:08 a.m., LVN A stated the nurse would place the nasal cannula on Resident #3 at night to administer oxygen at 2 LPM per the resident's request. LVN A stated Resident #3 needed the oxygen at night when she was first admitted . She stated the resident's condition improved, and she no longer needed the oxygen, but the resident wanted to have it on at night. In an interview on 09/08/22 at 8:58 a.m., LVN C stated Resident #3 received oxygen continuously when she was admitted to the facility, but the resident weaned herself off the oxygen and only used it at night. In an interview on 09/08/22 at 9:07 a.m., MDS Nurse stated she worked in the facility for only two weeks. The MDS Nurse reviewed Resident #3's nurse's notes for 6/6/22 and 6/7/22, stated it was noted Resident #3 received oxygen at 2 LPM via nasal cannula. The MDS Nurse reviewed Resident #3's admission MDS dated [DATE] and stated it was not coded for oxygen and should had been coded to indicate Resident #3 received oxygen. The MDS Nurse stated the risk of not having the MDS coded correctly could result in an inaccurate assessment which did not reflect the resident's status. The MDS Nurse stated if the oxygen had been coded on the MDS then it would have triggered a care plan to be completed for oxygen. The MDS Nurse reviewed Resident #3's care plans and stated she did not see a care plan for oxygen. The MDS Nurse stated the risk of not having a care plan was that it would not capture the plan of care for the resident. In an interview on 09/08/22 at 3:25 p.m. the DON stated the facility would have interdisciplinary team meetings to review care plans to ensure their accuracy. In an interview on 09/08/22 at 3:41 p.m. the Administrator stated the clinical leadership was responsible to ensure the residents' care plans were accurate. Review of the facility policy Care Plans, Comprehensive Person-Centered, revised December 2021, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial and functional needs is developed and implemented for each residents .1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest 745001 Page 5 of 11 745001 09/09/2022 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0656 practicable physical, mental, and psychosocial well-being; Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few 745001 Page 6 of 11 745001 09/09/2022 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to ensure that one (Resident #82) of one resident reviewed for urinary catheters received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The facility failed to ensure Resident #82 had an order to self-catheterize his intermittent urinary catheter. This deficient practice could place residents at risk for infection and not receiving services as needed. The findings were: Record review of Resident #82's face sheet, dated 09/08/22, revealed he was admitted to the facility on [DATE] with diagnoses which included retention of urine (inability to empty urine from the bladder). Record review of Resident #82's Hospital Discharge summary, dated [DATE], revealed 8. Chronic urinary retention with self-catheterization .self caths [catheterization (a tube inserted into the urinary bladder via the urethra which allows urine to drain from the bladder)] at home. Record review of Resident #82's consolidated electronic Physician Orders, dated 09/08/22, revealed there was no order for self-catheterization of a urinary catheter. Record review of Resident #82's MDS, an admission assessment dated [DATE], revealed his BIMS score was 15 out of 15, indication his cognitive skills for daily decision making was intact; and under Section H, it was checked indicating Resident #82 had an indwelling catheter. Record review of Resident #82's clinical record revealed a nurses' progress note by LVN H dated 08/29/22 which noted res Rresident #82] self [urinary] caths [catheterization] for urinary retention . Record review of Resident #82's clinical record revealed a nurses' progress note by RN G dated 08/29/22 which noted Resident #82 was self [urinary] cath [catheterization] every 4/6 [four to six] hours . Record review of Resident #82's clinical record revealed a nurses' progress note by RN F dated 08/31/22 which noted Resident #82 was self [urinary] cathing [catheterization]. Record review of Resident #82's clinical record revealed a nurses' progress note by RN E dated 09/04/22 which noted Resident #82 was self [urinary] cathing [catheterization]. Record review of Resident #82's clinical record revealed a nurses' progress note by LVN B dated 09/05/22 which noted Resident #82 continues with self [urinary] catheterization. Record review of Resident #82's clinical record revealed a nurses' progress note by LVN A dated 745001 Page 7 of 11 745001 09/09/2022 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0690 09/06/22 which noted Resident #82 continues with self [urinary] catherization. Level of Harm - Minimal harm or potential for actual harm In an interview on 09/06/22 at 2:56 p.m., Resident #82 stated he performed intermittent urinary self-catheterization on himself. Residents Affected - Few In an interview on 09/08/22 at 3:09 p.m., LVN C stated the facility provided Resident #82 with the urinary catheter supplies he needed for urinary self-catheterization. The LVN stated the nurse would assist Resident #82 to the bathroom where the resident would perform the urinary self-catheterization under the supervision of the nurse. LVN C reviewed Resident #82's electronic clinical record and stated she did not see an order for the resident to perform intermittent urinary self-catheterization. In an interview on 09/08/22 at 3:25 p.m., the DON stated if a resident was performing urinary self-catheterization he would expect an order for the self-catheterization and an assessment of the resident's ability to do the task. The DON reviewed Resident #82's electronic clinical record, and stated he did not see an order for urinary self-catheterization. The DON stated the risk of not having the order could result in urinary retention if the resident became incapacitated. The DON stated to ensure the orders were accurate the nurse would read back the order to the physician when the nurse received an order. The DON stated the physicians could review their residents' orders via electronic remote review to ensure they were accurate. In an interview on 09/08/22 at 3:41 p.m. the Administrator stated the clinical leadership was responsible to ensure the residents' orders were accurate. Record review of the facility policy Male Intermittent Self-Catheterization (ISC) revealed Intermittent self-catheterization is a way to empty your bladder using a catheter when your bladder does not empty completely or it does not empty at all. It is the policy of this facility to ensure that any resident who chooses to self-catheterize understands the process and has been identified as safe to do so. Record review of the policy Medication Orders, revised November 2014, revealed The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders .2. A current list of orders must be maintained in chronological order 6. Treatment orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment. Record review of CMS 672 Resident Census and Conditions of Residents, completed by the facility on 9/6/22, indicated there was one resident in the facility with an indwelling or external catheter. . 745001 Page 8 of 11 745001 09/09/2022 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

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** . Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 1 resident (Resident #3) reviewed for respiratory therapy, in that: The facility failed to ensure Resident #3 had a physician order for oxygen before providing the resident oxygen. This deficient practice could place residents at risk for inadequate or inappropriate amounts of oxygen delivery and lack of appropriate respiratory care. The findings were: Record review of Resident #3's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat) and cardiac pacemaker (device attached to the heart that generates electrical impulses to the heart to help it pump properly). Record review of Resident #3's MDS, an admission assessment dated [DATE], revealed her BIMS score was 14 out of 15, indication her cognitive skills for daily decision making were intact; and under Section O, it was not checked Resident #3 received oxygen. Record review of Resident #3's care plans, initiated 06/01/22 and revised on 06/27/22, revealed there was no care plan for oxygen therapy. Record review of Resident #3's electronic physician orders from 06/01/22 to 09/07/22 revealed there was no order for Resident #3 to receive oxygen. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/01/22 indicated oxygen had been administered to the resident at 3 LPM via nasal cannula (a tubing device used to deliver supplemental oxygen that has two prongs at an end which are inserted into the nostrils). Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/01/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/05/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 745001 Page 9 of 11 745001 09/09/2022 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0695 06/06/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's clinical record revealed nurses progress note by LVN C dated 06/07/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Residents Affected - Few Record review of Resident #3's clinical record revealed nurses progress note by LVN A dated 09/07/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Observation on 09/06/22 at 10:40 a.m. revealed Resident #3 was sitting in a wheelchair in her room with an oxygen concentrator behind the resident that was not in operation. In an interview on 09/06/22 at 01:49 p.m., Resident #3 stated she used the oxygen at night when she was sleeping and removed the oxygen in the morning. Observation on 09/08/22 at 5:44 a.m. revealed Resident #3 was lying in bed and received oxygen via nasal cannula at 2 LPM. In an interview on 09/08/22 at 6:08 a.m., LVN A stated the nurse would place the nasal cannula on Resident #3 at night to administer oxygen at 2 LPM per the resident's request. LVN A stated Resident #3 needed the oxygen at night when she was first admitted ; the resident's condition improved, and she no longer needed the oxygen, but the resident wanted to have it on at night. LVN A stated Resident #3's oxygen blood levels were within normal limits without the oxygen. In an interview on 09/08/22 at 8:58 a.m., LVN C stated Resident #3 had received oxygen continuously when she was admitted to the facility, but the resident weaned herself off the oxygen and only used it at night. LVN C reviewed Resident #3's electronic clinical record for a physician's order for oxygen, stated she did not see a physician's order for the oxygen. LVN C reviewed Resident #3's discontinued physician orders and stated she did not see any orders for oxygen. LVN C stated there should had been an order for the oxygen. LVN C stated the previous DON would enter all the admission orders for new residents but now the floor nurses entered the admission orders for newly admitted residents. In an interview on 09/08/22 at 9:07 a.m., after the MDS Nurse reviewed Resident #3's nurse's notes from 6/6/22 to 6/7/22, she stated it was noted Resident #3 received oxygen at 2 LPM via nasal cannula. The MDS Nurse stated the risk of not having a physician order for oxygen could result in a significant risk to the resident as the resident could receive too little or too much oxygen than was needed. In an interview on 09/08/22 at 3:25 p.m. the DON stated residents who received oxygen should have an order for oxygen. The DON stated to ensure the orders were accurate the nurse would read back the order to the physician when the nurse received an order. The DON stated the physicians could review their residents' orders via electronical remote review to ensure they were accurate. In an interview on 09/08/22 at 3:41 p.m. the Administrator stated residents who received oxygen via nasal cannula should have a physician order for the oxygen. The Administrator stated the risk of not having an order for the oxygen would depend on if the resident received oxygen continuous or as needed and the rate the oxygen was administered. The Administrator stated the clinical leadership was responsible to ensure the residents' orders were accurate. 745001 Page 10 of 11 745001 09/09/2022 Estates at Shavano Park 4366 Lockhill Selma Shavano Park, TX 78249

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the policy Medication Orders, revised November 2014, revealed The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders .2. A current list of orders must be maintained in chronological order .3. Oxygen Orders - When recording orders for oxygen, specify the rate of flow, route and rationale. Record review of the policy Oxygen Administration, revised October 2018, revealed The purpose of this procedure is to provide guidelines for safe oxygen administration .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Record review of CMS 672 Resident Census and Conditions of Residents, completed by the facility on 09/06/22, indicated there were no residents in the facility who received respiratory treatment [oxygen]. . 745001 Page 11 of 11