Trinity Nursing And Rehabilitation

F-F695

Immediate Action Taken

Resident Specific

Resident #1 was sent toER on [DATE REDACTED] at 11:54 p.m.

MD was notified of Resident #1's cardiac arrest, CPR, and transport to the emergency roiagnom on [DATE REDACTED].

Family was notified of Resident #1's cardiac arrest, CPR, and transport to the emergency roiagnom on [DATE REDACTED].

Medical Directors were notified of IJ on [DATE REDACTED] at 6:32 p.m

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 675846 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675846 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit Nursing & Rehab of San Augustine 902 E Main St San Augustine, TX 75972

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 System Changes

Level of Harm - Immediate All residents with a tracheostomy or ventilator were assessed on [DATE REDACTED] by Respiratory Therapists. No jeopardy to resident health or issues noted during assessment. Residents were assessed for trach patency/placement, adequate safety oxygenation/ventilation, s/sx of respiratory distress, s/sx of anxiety. Assessment documented on Vent/Trach Resident Assessment (paper form.) Residents Affected - Few All residents with tracheostomy or ventilator will have their care plan reviewed/revised by the MDS Coordinator to ensure that all interventions related to tracheostomy/ventilator status remain adequate and appropriate.

Care plan review to be completed by 12pm on [DATE REDACTED].

Charge Nurse will assess all residents with tracheostomy or ventilator for anxiety at least once per shift and document on the Treatment Administration Record, beginning on [DATE REDACTED]. If s/sx of anxiety exist, Charge Nurse is to intervene appropriately, non-pharmacologically or pharmacologically.

Respiratory Therapist will assess all residents with tracheostomy or ventilator for anxiety, prior to nebulizer treatments and document on the Treatment Administration Record, beginning on [DATE REDACTED]. If s/sx of anxiety exist, Respiratory Therapist is to notify the Charge Nurse for appropriate intervention.

Vents and Alarms are checked by Respiratory Therapist every 4hrs and documented on the Respiratory Treatment Administration Record. (Alarms to be checked are: breath rate, apnea rate, inspiratory pressure, high PEEP, low PEEP and disconnection.)

Education

Director of Nursing provided education to all staff on signs/symptoms of anxiety, and how to intervene appropriately. All staff present in the facility were educated on [DATE REDACTED]. Staff not present for the education will receive education prior to their next shift.

Director of Nursing provided education to nurses and Respiratory Therapists on monitoring for anxiety Q shift, and prior to administering nebulizer treatments. All nurses and Respiratory Therapists present in the facility were educated on [DATE REDACTED]. Nurses and Respiratory Therapists not present for the education will receive education prior to their next shift.

Director of Respiratory Therapy provided education to Respiratory Therapists on vent/alarm checks every 4hrs and to visualize tubing/connections when they are in the room. All Respiratory Therapists present in the facility were educated on [DATE REDACTED]. Respiratory Therapists not present for the education will receive education prior to their next shift.

Director of Respiratory Therapy provided education to Respiratory Therapists on what alarms to check

during the vent/alarm checks. Alarms to be checked are: breath rate, apnea rate, inspiratory pressure, high PEEP, low PEEP and disconnection. All Respiratory Therapists present in the facility were educated on [DATE REDACTED]. Respiratory Therapists not present for the education will receive education prior to their next shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 675846 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675846 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summit Nursing & Rehab of San Augustine 902 E Main St San Augustine, TX 75972

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Director of Respiratory Therapy provided education to nursing staff on notifying Respiratory Therapist immediately if they hear an alarm or see any issues with vent or tubing. All nursing staff present in the facility Level of Harm - Immediate were educated on [DATE REDACTED]. Nursing staff not present for the education will receive education prior to their next jeopardy to resident health or shift. safety Monitoring Residents Affected - Few DON or designee to monitor completion of Anxiety Assessment by Nurses and Respiratory Therapists 5x/week X 4 weeks, then refer to QAPI committee for efficacy of plan and revision of monitoring frequency.

On [DATE REDACTED] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:

Verified 9 other residents were in the facility that required mechanical ventilation and 4 that required trach care with supplemental oxygen therapy.

Record review of care plans for all 13 residents with tracheostomy or ventilator indicated their care plan was reviewed/revised by the MDS Coordinator to ensure that all interventions related to tracheostomy/ventilator status remain adequate and appropriate.

Record review of all 13 residents' orders indicated interventions for Charge Nurse will assess all residents with tracheostomy or ventilator for anxiety at least once per shift and document on the Treatment Administration Record, beginning on [DATE REDACTED]. If s/sx of anxiety exist, Charge Nurse is to intervene appropriately, non-pharmacologically or pharmacologically.

Record Review of all 13 residents' orders indicated Respiratory Therapist will assess all residents with tracheostomy or ventilator for anxiety, prior to nebulizer treatments and document on the Treatment Administration Record, beginning on [DATE REDACTED]. If s/sx of anxiety exist, Respiratory Therapist is to notify the Charge Nurse for appropriate intervention.

Record Review of all 13 residents' orders indicated Vents and Alarms are checked by Respiratory Therapist every 4hrs and documented on the Respiratory Treatment Administration Record. (Alarms to be checked are breath rate, apnea rate, inspiratory pressure, high PEEP, low PEEP and disconnection.)

Record review of Inservice/education sign in sheets dated [DATE REDACTED] indicated the Director of Nursing provided education to 44 staff on signs/symptoms of anxiety, and how to intervene appropriately. Staff not present for

the education will receive education prior to their next shift.

Record review of Inservice/education sign in sheets dated [DATE REDACTED] indicated the Director of Nursing provided education to nurses and Respiratory Therapists on monitoring for anxiety every shift, and prior to administering nebulizer treatments. All nurses and Respiratory Therapists present in the facility were educated on [DATE REDACTED]. Nurses and Respiratory Therapists not present for the education will receive education prior to their next shift.

Record review of Inservice/education sheets dated [DATE REDACTED] ind [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 675846